Preoperative Evaluation Before General Anesthesia: A Complete Guide

Preoperative Evaluation Before General Anesthesia: A Complete Guide

Question. Evaluation for the case of general anesthesia.
Or
Write a short note on evaluation for the case of general anesthesia.

Answer.

Preoperative Evaluation Before General Anesthesia: A Complete Guide

History of Patient

• A detailed history of the patient is taken about any major ailment in the past and recently.
  Confirm the type of treatment given and if any residual effects of the disease are persisting.
• The history of alcohol intake and addiction to other narcotic agents is taken.
• Some patients are allergic to certain drugs and general anesthesia.
  It must be thoroughly ascertained if the person is allergic to any of these drugs.
• If a patient is a chronic smoker, he/she is likely to have a chronic cough, and this has to be considered when giving general anesthesia.
• If there is a presence of hypertension, the drugs being taken must be ascertained and recorded.
  Anesthetist should assess the degree of hypertension and its effect on the heart as well as any interaction of the anti­hypertensive drugs with the anesthetic agents.
• If the patient is suffring from cardiac insuffiency the heart must be evaluated and certain emergency drugs must be kept at hand during operative procedure.
  A detailed history about all drugs the patient is on anticoagulants,digoxin, nitrates, diuretics or any other drug must be enquired and recorded.

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Physical examination

• A detailed general physical examination must be done preoperatively.
• Look for anaemia and state of nutrition. Patient who is severely anemic is not fi for general anesthesia. Anemia must be corrected before. If emergency operation is to be done, blood transfusion is given.
• Pulse rate should be in between 60–80 beats per minute. If the pulse rate is either high or slow, cause must be found out, and if possible it should be corrected.
• Blood pressure must be evaluated carefully.
  Neither high or low blood pressure is desirable.
  An hypertensive must be treated before going for general anesthesia and blood pressure levels brought to normal or near normal levels.
  But if complications are present such as cardiomegaly,renal or lung complications or features of left heart or congestive failure, then great caution has to be employed.
• Lungs are examined for evidence of chronic bronchitis with or without emphysema and other lung diseases.
  Look for clubbing, cyanosis and emphysema. Patient’s respiratory functions must be evaluated.
  A chronic smoker is likely to be at disadvantage.
  For this breadth holding test is done.
  In such patients, it is desirable to institute breathing exercises for at least a week before operation and the patient is encouraged to continue with these exercises as soon as he regains consciousness. In this way, many pulmonary complications are avoided.
  Breathing exercises program must be carried out under the guidance of a physiotherapist with advice from the physician.

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• Abdomen should be examined for hepatomegaly,splenomegaly, ascites and any organomegaly.
  Lymph glands in the body should be palpated for evidence of any disease of reticuloendothelial system.
• Bleeding tendencies must be looked into. History of bleed from any source after any simple injury or bruising should be considered.
• Oral cavity must be carefully examined, and if any loose teeth are present or if there is any great degree of sepsis these should be taken care of before operation.
  In patients using dentures these must be removed before administering premedication since failure to do this may choke the patient.
• Patient color should be carefully examined and if any signs of anemia or polycythemia are present they must be attnded to.
• Urine should be carefully tested, and if any evidence of diabetes is present, blood sugar estimations be done.
  Urine be examined not only for sugar but also for albumin and ketone bodies.
  Diabetes must be controlled before hand with insulin. In the presence of ketone bodies, it is usual to institute 10 % glucose drip neutralizing with 25 units of soluble insulin in each botte.
  This infusion is given till urine is ketone free

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• It is preferable in any diabetic patient who is on oral antidiabetic drugs to switch on to soluble insulin 48 hours before operation.
  On the day of operation, patient is put on 5% or 10% glucose drip neutralized with soluble insulin.
  After operation, patient has to be continued on insulin injections till the wound has healed.
  This may have to be carried out for 10–14 days. Once recovery is complete and patient is ambulatory he can be switched on to oral antidiabetic drugs.
• If urine contains considerable amount of albumin, this indicates renal pathology and anesthetist in consultation with the physician must evaluate the risks and the type of anesthesia.
• Heart size must be evaluated. Position of apex beat,presence of abnormal pulsations over the precordium and cardiac murmurs must be assessed.
• Look for patient veins especially over the ankles and antecubital fossa. Suitable veins must be identifid for intravenous purposes.

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Investigations

In every patient due for general anesthesia following investigations be carried out:

• Hemoglobin to assess anemia.
• Total and diffrential leucocyte count.
• Bleeding time (BT) and clottng time (CT) for bleeding disorders.
• Platelet count: Low platelet count indicates thrombocytopenia.
• Complete urine examination for albumin, sugar, ketone bodies and presence of any casts and cells.
• Blood sugar (fasting and postprandial) to exclude diabetes.
• Prothrombin time for bleeding disorders.
• X-ray heart (PA view) for heart size: It shall also assess any pathology in the lungs.
• Electrocardiogram for any myocardial damage or insuffiency or presence of any arrhythmia.
• Pulmonary function tests to evaluate the lung functions.

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Patient preparation before giving general anesthesia

• On the day of surgery, patient should be empty stomach.
• Litte bowel enema is given to patient so that his / her bowels are empty.
• Breathing exercises are performed a week before.
• Smokers should stop smoking 2 to 3 weeks before general anesthesia for preventing pulmonary complications during and after anesthesia.
• Sleeping pill is given to a patient in night so that proper sleep is taken
• Preanesthetic medication is given which helps in induction of general anesthesia.