PRE-OPERATIVE VISIT

Preoperative Evaluation of Patients An anesthetic plan should be formulated that will optimally accommodate the patient's baseline physiological state, including any medical conditions, previous operations, the planned procedure, drug sensitivities, previous anesthetic experiences, and psychological makeup. Inadequate preoperative planning and errors in patient preparation are the most common causes of anesthetic complications. To help formulate the anesthetic plan, a general outline for assessing patients preoperatively is an important starting point. This assessment includes a pertinent history (including a review of medical records), a physical examination, and any indicated laboratory tests. Classifying the patient's physical status according to the ASA scale completes the assessment. Anesthesia and elective operations should not proceed until the patient is in optimal medical condition. Assessing patients with complications may require consultation with other specialists to help determine whether the patient is in optimal medical condition for the procedure and to have the specialist's assistance, if necessary, in perioperative care. Following the assessment, the anesthesiologist must discuss with the patient realistic options available for anesthetic management. The final anesthetic plan is based on that discussion and the patient's wishes.

The Preoperative History The preoperative history should clearly establish the patient's problems as well as the planned surgical, therapeutic, or diagnostic procedure. The presence and severity of known underlying medical problems must also be investigated as well as any prior or current treatments. Because of the potential for drug interactions with anesthesia, a complete medication history including use of any herbal therapeutics should be elicited from every patient. This should include the use of tobacco and
1

alcohol as well as illicit drugs such as marijuana, cocaine, and heroin. An attempt must also be made to distinguish between true drug allergies (often manifested as dyspnea or skin rashes) and drug intolerances (usually gastrointestinal upset). Detailed questioning about previous operations and anesthetics may uncover prior anesthetic complications. A family history of anesthetic problems may suggest a familial problem such as malignant hyperthermia. A general review of organ systems is important in identifying undiagnosed medical problems. Questions should emphasize cardiovascular, pulmonary, endocrine, hepatic, renal, and neurological function. A positive response to any of these questions should prompt more detailed inquiries to determine the extent of any organ impairment. Physical Examination The history and physical examination complement one another: The examination helps detect abnormalities not apparent from the history and the history helps focus the examination on the organ systems that should be examined closely. Examination of healthy asymptomatic patients should minimally consist of measurement of vital signs (blood pressure, heart rate, respiratory rate, and temperature) and examination of the airway, heart, lungs, and musculoskeletal system using standard techniques of inspection, eg, auscultation, palpation, and percussion. An abbreviated neurological examination is important when regional anesthesia is being considered and serves to document any subtle preexisting neurological deficits. The patient's anatomy should be specifically evaluated when procedures such as a nerve block, regional anesthesia, or invasive monitoring are planned; evidence of infection over or close to the site or significant anatomic abnormalities may contraindicate such procedures. The importance of examining the airway cannot be overemphasized. The patient's dentition should be inspected for loose or chipped teeth and the presence of caps, bridges, or dentures. A poor anesthesia mask fit should be expected in some edentulous patients and those with significant facial abnormalities. Micrognathia (a
2

short distance between the chin and the hyoid bone), prominent upper incisors, a large tongue, limited range of motion of the temporomandibular joint or cervical spine, or a short neck suggests that difficulty may be encountered in tracheal intubation. Laboratory Evaluation Routine laboratory testing for healthy asymptomatic patients is not recommended when the history and physical examination fail to detect any abnormalities. Such routine testing is expensive and rarely alters perioperative management; moreover, abnormalities often are ignoredor result in unnecessary delays. Nonetheless, because of the current litigious environment in the United States, many physicians continue to order a hematocrit or hemoglobin concentration, urinalysis, serum electrolyte measurements, coagulation studies, an electrocardiogram, and a chest radiograph for all patients. To be valuable, performing a preoperative test implies that an increased perioperative risk exists when the results are abnormal and a reduced risk exists when the abnormality is corrected. The usefulness of a screening test for disease depends on its sensitivity and specificity as well as the prevalence of the disease. Sensitive tests have a low rate of false-negative results, whereas specific tests have a low rate of false-positive results. The prevalence of a disease varies with the population tested and often depends on sex, age, genetic background, and lifestyle practices. Testing is therefore most effective when sensitive and specific tests are used in patients in whom the abnormality might be expected. Accordingly, laboratory testing should be based on the presence or absence of underlying diseases and drug therapy as suggested by the history and physical examination. The nature of the procedure should also be taken into consideration. Thus, a baseline hematocrit is desirable in any patient about to undergo a procedure that may result in extensive blood loss and require transfusion.

Testing fertile women for an undiagnosed early pregnancy may be justified by the potentially teratogenic effects of anesthetic agents on the fetus; pregnancy testing involves detection of chorionic gonadotropin in urine or serum. Routine testing for AIDS (detection of the HIV antibody) is highly controversial. Routine coagulation studies and urinalysis are not cost effective in asymptomatic healthy patients. ASA Physical Status Classification In 1940, the ASA established a committee to develop a "tool" to collect and tabulate statistical data that would be used to predict operative risk. The committee was unable to develop such a predictive tool, but instead focused on classifying the patient's physical status, which led the ASA to adopt a five-category physical status classification system for use in assessing a patient preoperatively. A sixth category was later added to address the brain-dead organ donor. Although this system was not intended to be used as such, the ASA physical status generally correlates with the perioperative mortality rate. Because underlying disease is only one of many factors contributing to perioperative complications, it is not surprising that this correlation is not perfect. Nonetheless, the ASA physical status classification remains useful in planning anesthetic management, particularly monitoring techniques. ASA GRADING American Society of Anesthesiologists (ASA) grade is the most commonly used grading system ASA accurately predicts morbidity and mortality 50% of patients presenting for elective surgery are ASA grade 1

ASA Grade I II III IV V Informed Consent

DEFINITION Healthy individual with no systemic disease Mild systemic disease not limiting activity Severe systemic disease that limits activity but is not incapacitating Incapacitating systemic disease which is constantly life-threatening Moribund, not expected to survive 24 hours with or without surgery

MORTALITY % 0.05 0.4 4.5 25 50

The preoperative assessment culminates in giving the patient a reasonable explanation of the options available for anesthetic management: general, regional, local, or topical anesthesia; intravenous sedation; or a combination thereof. The term monitored anesthesia care (previously referred to as local standby) is now commonly used and refers to monitoring the patient during a procedure performed with intravenous sedation or local anesthesia administered by the surgeon. Regardless of the technique chosen, consent must always be obtained for general anesthesia in case other techniques prove inadequate. If any procedure is performed without the patient's consent, the physician may be liable for assault and battery. When the patient is a minor or otherwise not competent to consent, the consent must be obtained from someone legally authorized to give it, such as a parent, guardian, or close relative. Although oral consent may be sufficient, written consent is usually advisable for medicolegal purposes. Moreover, consent must be informed to ensure that the patient (or guardian) has sufficient information about the procedures and their risks to make a reasonable and prudent decision whether to consent. It is generally accepted that not all risks need be detailed only risks that are realistic and have resulted in complications in similar patients

with similar problems. It is generally advisable to inform the patient that some complications may be life-threatening. The purpose of the preoperative visit is not only to gather important information and obtain informed consent, but also to help establish a healthy doctor patient relationship. Moreover, an empathically conducted interview that answers important questions and lets the patient know what to expect has been shown to be at least as effective in relieving anxiety as some premedication drug regimens.

PRE-SCREENING QUESTIONNAIRE (This form to be posted to patient with appointment for screening)
6

Patients Identification Details Name: Address: Postcode: DoB: Admitting Consultant: Proposed Operation: the hospital. It will help us to make plans for your care. It will be treated as confidential medical information. A Parent, Guardian or Carer may answer on the patient's behalf. What would you like us to call you? (for example, as Mr or Mrs, or by your first name) Have you ever suffered from any of the following? (if 'yes', please give details) Heart disease of any sort Chest pain, palpitations or blackouts High blood pressure Rheumatic fever Asthma, bronchitis or other chest disease Breathless on exertion or at night Diabetes or sugar in the urine Kidney or urinary trouble Convulsions or fits Anaemia or other blood disorders Bruising or bleeding problems Blood clots in the legs or lungs YES / NO YES / NO YES / NO YES / NO YES / NO YES / NO YES / NO YES / NO YES / NO YES / NO YES / NO YES / NO
7

Hospital No: Specialty: Screening clinic date:

Please complete this questionnaire at home and bring it with you when you come to

Jaundice (yellowness) Indigestion or heartburn Any other serious illnesses Do you smoke, or have you stopped recently? (if 'yes' how many a day?) Do you drink alcohol (if 'yes' how much a week?) Do you have false, capped or crowned teeth? Do you have a pacemaker or any implants? Do you wear contact lenses or a hearing aid? Women; Could you be pregnant? Are you on the Pill/HRT? What is your approximate weight? What is your approximate height? Are you taking any medicines or drugs? (including inhalers, eyedrops, creams,or herbal remedies, whether prescribed by your doctor or not) Are you allergic to any drugs or materials? Please list any previous operations or anaesthetics . . . Year: Year: Year:

YES / NO YES / NO YES / NO YES / NO YES / NO YES / NO YES / NO YES / NO YES / NO YES / NO

YES / NO

YES / NO

Have you, or any member of your family, had any problems with anaesthetics? Is there anything else which your anaesthetist or surgeon should know? Do you have particular cultural or religious needs Do you understand that you must not drink alcohol, drive or operate any machinery for 48 hours after your anaesthetic? YES / NO
8

YES / NO YES / NO YES / NO

Do you need the services of an interpreter For Day Surgical Patients only: Will you have someone to take you home by car? Will you have a responsible adult at home to look after you overnight? Will you have easy access to a telephone? Signature: PAEDIATRIC DAY CARE UNIT PRE-OPERATIVE ASSESSMENT Patient label: DATE OF SURGERY: DIAGNOSIS: PROPOSED PROCEDURE: PAST MEDICAL HISTORY YES/NO DETAILS -Has your child been admitted to,or frequently attends hospital? -Has your child attended a doctor in the last 4 weeks? -Has your child had any of the following symptoms in the last 4 weeks: high temperature,rash, cough, cold, sore throat? -Has your child been in contact with an infectious disease in the last 4 weeks? -Has your child any heart problems? -Does your child have a history of asthma or

YES / NO

YES / NO YES / NO YES / NO Date:

chest problems? -Has your child any kidney problems? -Has your child ever been jaundiced? -Does your child bruise easily? -Has your child ever had any convulsions or seizures? -Does your child have any other medical conditions? -Was your child born prematurely (i.e before 37 weeks)?

ASA (American Society of Anesthesiologists) membuat klasifikasi berdasarkan status fisik pasien pra anestesi yang membagi pasien kedalam 5 kelompok atau kategori sebagai berikut: ASA 1, yaitu pasien dalam keadaan sehat yang memerlukan operasi. ASA 2, yaitu pasien dengan kelainan sistemik ringan sampai sedang baik karena penyakit bedah maupun penyakit lainnya. Contohnya pasien batu ureter dengan hipertensi sedang terkontrol, atau pasien apendisitis akut dengan lekositosis dan Universitas Sumatera Utara febris. ASA 3, yaitu pasien dengan gangguan atau penyakit sistemik berat yang diaktibatkan karena berbagai penyebab. Contohnya pasien apendisitis perforasi dengan septi semia, atau pasien ileus obstruksi dengan iskemia miokardium. ASA 4, yaitu pasien dengan kelainan sistemik berat yang secara langsung mengancam kehiduannya. ASA 5, yaitu pasien tidak diharapkan hidup setelah 24 jam walaupun dioperasi atau tidak. Contohnya pasien tua dengan perdarahan basis krani dan syok hemoragik karena ruptura hepatik. Klasifikasi ASA juga dipakai pada pembedahan darurat dengan mencantumkan tanda darurat (E = emergency), misalnya ASA 1 E atau III E.

10