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PREOPERATIVE ASSESS

ME

NT

Two main goals are:

1) Evaluate and optimize patient's medical conditions

2) Anticipate, minimize, and plan for possible complications
The Anaesthetic History and Examination
Anaesthesia is a compromise between patient medical problems, drug
interactions, surgical disease and procedure, the hospital system, and social
factors. A thorough knowledge of each of these components is required to
offer a safe perioperative course. History and examination are used to identify
disease processes that need to be explored, defined and optimized. Newly
discovered signs and symptoms should not merely be documented and then
ignored. The pursuit of patient optimization takes time, and may need to delay
surgery. Occasionally, optimization is compromised by need for surgery,
social and hospital system pressures.

Previous Exposure to Anaesthesia

Check date, place and reason for previous anaesthetics. Specifically enquire
and review charts, looking for adverse reactions or events - E.g. Difficult
intubation, response to anaesthesia, pain requirements, adverse reactions,
and awareness. Be aware that side effects such as nausea and vomiting are
frequently wrongly reported as allergies.
A family history of anaesthetic problems should also be obtained, since some
disorders are inherited E.g. Plasma cholinesterase deficiency (don't
metabolise suxamethonium), malignant hyperthermia, coagulation
abnormalities.

Fasting
Gastric contents are more likely to be aspirated under anaesthesia. Patients
should consume no solids after 6 hours, and no clear fluids after 2 hours
before the start of any sedative or anaesthetic procedure. These times for
gastric emptying will be prolonged by pain and opioid use.
Emergency situations may require an unfasted patient to undergo
anaesthesia. ln this circumstance, a Rapid Sequence lntubation is used to
occlude the oesophagus until the airway is protected by a cuffed tube.

Medication
Some medications interact with those used in anaesthesia. Over-the-counter
and alternative drugs, tobacco, alcohol, and illicit drugs all can have serious
implications.
Medications can also expose illnesses that the patient may have neglected to
reveal.

Allergies
A history of known allergies, and the actual drug effect, is essential before
prescribing or administering any drug. The difference between an allergy and
a side effect is important, othenvise a best choice drug may be unnecessarily
avoided.

Dentition
The teeth are at risk of damage during ainruay instrumentation. Pre-existing
damage should be noted for medico-legal reasons. The presence of caps,
crowns, and loose or unhealthy teeth (especially in front) should be noted,
and the risk of damaged discussed with the patient. Loose teeth can be
dislodged into the lungs, and may need preoperative dental review.

Gastro-oesophageal Refl ux
The extent of reflux should be determined. Reflux of gastric contents (usually
acid secretions in the fasted) is worse under anaesthesia, and a Rapid
Sequence lnduction may be required. (This type of induction is not used for all
anaesthetics, mainly because of the side effects of suxamethonium.)

Concurrent lllness
Many medical illnesses may complicate the course of anaesthesia and
surgery. All systems should be considered in the patient assessment. Most
consideration goes to cardiac and respiratory diseases, as they play the major
role in contributing to perioperative morbidity and mortality.
Exercise tolerance is a good indicator of cardio-respiratory reserye (ability to
cope with the perioperative insult). The ability to climb stairs, play golf, do the
gardening - all without symptoms, are good indicators of sufficient reserve for
fairly major surgery.
Concurrent disease and patient age guide the surgical intern and anaesthetist
in the choice of which preoperative investigations are required. CXR, ECG,
U&E, FBC, Group, x-match, coags should not be done as routine, but as
indicated. More advanced investigations (ECHO, stress tests, spirometry,
sleep studies, CT, MRI) may also be required. The end result of the
investigation process is that a change may need to be made to the patient's
medical care before surgery is attempted. (See the'Pre Admission Screening'
questionnaire for suggested investigations.)
Sufficient time must be allowed preoperatively to undertake and report on
these tests, and institute any therapies. lt is the responsibility of the surgical
team to identify more complicated patients and commence the preparation
process early, hence avoiding unnecessary delays to surgery.
Defining the disease process, its extent, and the impact on the patient will
help determine the anaesthetic technique and agents used. For example, a
patient with severe respiratory disease may be better served with a spinal for
Iower body surgery. A patient with a poorly functioning heart will need invasive
monitoring and the least cardiac depressant drugs available.

Medications to Hold
ln general terms, hold aspirin and clopidegrel for 1 week, most other NSAIDS
24-48 hours, and warfarin 3-4 days to a normal lNR. The indications for these
medications need to be considered before ceasing vs risk of bleeding during
the procedure. Long acting heparins E.g. Clexane should not be given within
the 12 hours before surgery - they exclude the possibility of spinal and
epidural anaesthesia, which may be essential to the patient.
Diabetic medication - hold oral hypoglycaemics on the day of surgery and the
preceding night. The non insulin diabetic would rarely need a sliding scale,
and can be kept hydrated with non dextrose containing lW. The fasting
insulin dependent should have regular BSL checks, be early on the operating
list, and usually a sliding scale with dextrose IVT (to avoid hypoglycaemia).
The anaesthetist should be aware of insulin dependent diabetics to contribute
to the preoperative management.
Antihypertensives would rarely be held. Missing a dose will often lead to
unstable blood pressures and an increased risk of cardiac events.
Give other medications as usual. "Fasting" does not include medication!
lf concerned or unsure, always contact an anaesthetist.

The Emergency
This poses multiple compromises to optimizing for surgery. There is little time
for patient preparation, so only essential tasks are performed (bloods,
invasive monitoring, fluids).
ldeally a patient is resuscitated and cardiovascularly stabilized before
administration of anaesthetic agents, but this may not be possible and is
performed intraoperatively (E.g. a ruptured AAA) ln such situations,
anaesthetic techniques need to be dramatically altered.

Prepared by Dr. Anthony Fisher.

Classification of Patient Fitness

Patient fitness is classified according to their ASA status (American Society of
Anesthesiologists). This has some correlation to risk.

Class 1
Class 2
Class 3
Class 4
Class 5
"E" added to

fit and healthy

mild systemic illness (such as hypertension)
severe systemic illness which is not incapacitating
incapacitating illness/constant threat to life
moribund/not expecting to live more than 24 hours
above if operation is an emergency

Premedication
Premedication should only be prescribed by the anaesthetist. The exception
would be an 'on call'Ventolin/Atrovent nebule prescribed by the surgical team
where indicated. Premedication is a separate issue from the patient's usual
drugs.
o Benzodiazepines may be used for an overly anxious patient. Sedatives
are avoided where fast awakening from anaesthesia is desired, in the
non-consented, where conscious state is altered, and in the
airway/respi ratory comprom ised.
. Children are most commonly ordered EMLA cream (takes t hour to
work) and sedatives (midazolam).
. Ventolin + Atrovent nebs are often given immediately before
anaesthesia for respiratory disease. This prevents perioperative
bronchospasm.
. Antacids (ranitidine, sodium citrate) are used to reduce gastric acidity
in the patient at risk of aspiration. This reduces respiratory
complications.
. Any frail patient should be well hydrated by lW whilst fasting. This is
also an idealfor all patients. Diabetics should also receive dextrose
solutions if receiving insulins whist fasting.
. Beta blockers are some times commenced in patients at risk of
myocardial ischaemia.

,:
A-

Sumame

-7

U.R.No.

Given Names

TOWNSVILLE HEALTH SERVICE DISTRICT

PRE ADMISSION SCREENING

Proposed Operation:

Date of Birth

(Affix Patient Identification Label Here)

Surgeon

Previous GA Problems

Lung or breathing problems

COAD /

SI

Angina or regular chest pain

Anv other heart condition

Bruising or bleeding easi

A
D

blood thinners

I
S

Diabetes: 1. Diet controlled

I
o

2. Take tablets
3. IIse insulin

Reflux / indisestion / heartbum / Hiatus Hernia

Ulcers (peptic / duodena

Anv other stomach / intestinal disorder

R
E
E

failure / kidnev disease /

I
N
G

.Iaundice in the last

Anv other liver condition

Alcohol Habits / Hx Alcohol Abuse

recent blackouts or faintin

Any Other Health Problems

eg. severe arthritis, dental

Poor exercise tolerance

Any Infectious Diseases

Comments:

Criteria for Anaesthetic Review

Authorised by:

. 0ver 75 years
. History ofAnaesthetic problem
. BMI > 35
. For major surgery
. Any 'Yes' answer to above assessment

Date:

Medications
(including over-the-counter medications: Aspirin, Oral Contraceptives, Inhalers, Topicals, Eye Drops, Hypnotics & Herbals)
Note if Steroids used in last 3 months.
Drug (Name)

Why do you take it

When

Dose

2.
3.
4.
.5.

6.
7.
8

9.
10.

Allergic Reactions

(please note all forms of reactions and their cause)

Substance

Reaction

2.

3.
4.
5.

Other Drugs

Marijuana

Amphetamine

Hepatitis

o IV drug use

Heroin

Other

Social Risks

HIV

o Other

Religious / Cultural issues that may impact on this procedure:

Physical Examination
Patient Age

Height

Weight

(cm)

(Ke)

BMI

Blood
Pressure

Pulse

Peak Flow

Oxygen

(L/min)

Saturation

Urinalysis

PROPOSED OPEMTION:

oRl

v\1./t S

& EXAMINATION:

ro

- Na

loo

ny]'PI

WEIGHTn,

ESULTS:

IC PLAN:

Medicotion

/ lnstructions

NBM From: f"\,r'^'An,i

THE TOWNSVILLE HOSPITAL

ACUTE PAIN SERVICE

TNTERMITTENT SUBCUTANEOUS OPIOIDS

Administration Guidelines for Acute Pain Management
These guidelines are intended for ward use in patients with moderate-severe acute pain, not warranting PCA or PCEA.
IV opioid administration on the wards is not recommended unless via PCA, or directly supervised by a medical officer
in an emergency.

Standard orders
Morphine is the standard strong analgesic agent used at TTH. Subcutaneous administration through an indwelling
'butterfly' or 24G cannula is the preferred route as this limits the potential exposure of nursing staff to needle-stick
injury and is less uncomfortable for the patient than repeated IM injections. Alternatives for patients with morphine
allerry include fentanyl or tramadol. Pethidine must NOT be administered subcutaneously, however, as it is painful and
unpredictably absorbed.
Recommended initial prescriptions
The initial dose requirements vary considerably. With the exception of Paediatrics, the best predictor of morphine dose
is AGE*, not weight. A 2-hrly interval with small doses is safer than large doses less frequently.

Initial

Patient has pain,

SC orders 2 hourly PRN

(years)l Morphine I

Fentanyl
Fentanyl I Tramadol
(mg) | Dose range (mcg)
lmcg) | Dose range (mg)
1s-3e I z. s- tz.s I roo - lso I 7s - t2s
40-s9 I 5.O - 10.O I 75- t25 I 50 - 100
tJ
-z.s II ou-ruu
zs - zs
zJot_r-o:,
6o-6s II z.o
z.s -t.o
so - roo II

requests analgesia

Age

Range
lDose
ttt

Is t-here an appropriate opioid order?

e.g. dose as per table, 2-hr1y PRN

zo-zs
tw-tY
Itz.o-ar.L,
z.s - s.o

80+ lz.o-s.o
.
.
.

-zs I
I so-so
zs
zJ-ro

zs - so
zJ-Jv

zo-so

First dose in middle of range

Subsequent dose titrated to response
Upper limit can be increased by RMO fl..
sedation score

Is the sedation
score <2, resp

I
I

(2

and respiratory rate >8 and analgesia is inadequate

Seek medical review

rate >8/min ?

Sedation Score
0 Fully alert
I Mild, occasionally drowsy, easy to rouse
2 Moderate, constantly or frequently drowsy, easy to rouse
3 Severe, somnolent, difficult to rouse

Is the sedation
score <2, resp

rate >S/min

NO

Patient stiil in
pain? Requesting

>

2 hours

(*Average dailv morphine dose requirement

Oxygen at 6 L/min via mask

Notify RNIO
if no improvement consider IV naloxone 80mcg
Smaller opioid dose next time.

NO
Reassess

analgesia?

Is DOSE intewal

Normal sleep

after

hour

NO
from Medical Officer
Consider higher dose next time
Seek advice

= l00mg - age in yearsl if over 2O years old ) Reviewed APS 3/O3

THE TOWNSVILLE HOSPITAI

ACUTE PAIN SERYICE (APS)

PATIENT CONTROLLED ANALGESIA

Intravenous PCA
For children < 60kg; use paediatric PCA
USE 50ml SYRINGE TIADE UP

To 69Iil

Surname:
Given Names:
Unit Record No:
Date of Birth:

Sex:MiF

(Affix label)

WTTH 0.9% SALINB

PRESCRTBERS; STRII(E TEROUGH EXISTING ORDER BEFORE WRITING NEW ORDERS/ CEASING PCA
SCHEDULE

A
I

DATE/TIME
OPIOIDDRUG

OPIOID
CONCENTRATION

RECIPE

at

MORPHINE
T

MG/TUL

60mg morphine

H
PCADOSE

LOCKOIIT PERIOD
CONTINOUS RATE

LOADING DOSE

0.9% s.aline
to total volume 60rnl
lmg (l ml)

EYDROIVIORPIIONE
200r}lcG/r\{L

l2mg Hydromorphone
0.9% saline
to total volume 60ml
200pcg

(l

Z*ro

Zeto

STAT

STAT

DOCTORNAil{E

rnl)

F
E
N
T

A
N

at

FENTAI{YL
20

MCG/ML

l200mce Fentaavl
0.9% saline
to total volume 60nd
20pcg (lml)

Zem

at

Z,ero

PCA DELIVERY

5 mins

5 mim

3 mins
Zero

Zero

STAT

DOCTOR SIGN

N
E

MODIHED SCIIEDULES TO BE COMPLETED IN FULL BY TIIE PRESCRIBER

.I{ODIFIED

SCHEDULE

DATE/TIME

at

.MODIFIED

.MODIFIED

at

at

OPIOID DRUG
OPIOID CONCENTRATION
RECIPE

0.9% saline
to total volume 60ml

0.9% saline
to total volume 60ml

0.9% saline
to total volume 60ml

PCA DOSE
LOCKOUT PERIOD
CONTINOUS RATE

LOADING DOSE
PCA DELIVERY

DO

TOR NATVIB

DOTTOR SIGN

PCA orders ceased on

Revised April 2006

at

I name

sign

THE TO\,\TNSVILLE HOSP ITAL

Sumame:

ACUTE PAII{ StrRYICE (APS)

Given Names:
Unit Record No:
Date of Birth:

PATIENT CONTROLLED EPIDURAI ANALGESIA

Epidural (PCEA)

Sex: M

/F

(Affix label)

Epidural catheter inserted by Pr..

......cm

Level inserted............Space identified at

Bloody tap Y/i.l

Catheter fixed ......cm at skin

Dural tap YA.I

Pain/paraesthesiae YAI

Other technical details...

USE PCAM SCHEDULE E FOR EPIDURAL INFUSION OF AITIY MEDICATION

INFUSIONS MUST USE 100mI SyRhacES IVIADE UP To 100MLs

AIL EPQURAL

WITII 0.9% SALINE

MODMIED SCIIEDULES TO BE COMPLETED IN FI}LL BY THE PRESCRTBER

PRESCRIBERS; STRIIG THROUGE EXISTING OR}ER BEFORE WRTTING NEW ORDERS/ CNASING PCEA

SCHEDULE

DATSTIME

E
P

D
U

at

OPIOID

FENTANYL 3NICG/TUL

DRUG /CONCIiNTRATION
LOCAL ANAESTHE'TIC
DRUG/CONCENTRATION
ADDITIONAL
DRUG/CONCENTRATION

LEVOBUPIVACAINE I MG'UL

RECIPE

Levobupivacainc l00mg

at

at

300 mcg (6ml) fcnunyl

0,9% salhe up to a tolal volumc

E.IVIODIFIED

CONCENTRATTON
(onioid)

PCEA DOSE

12

lfi)ml

0.9% saline up to a lotal volume l00ml

0.9% saline up to a lota[ volume l00m:

mc/ml

mcg (4 ml)

LOCKOUTPERIOD

l5 mins

CONTINOUS RATE

lE mcg (6 ml/lu)

LOADING DOSE

7*ro

PCA DELIVERY

STAT

DOCTORNA-I\4E

DOCTOR SIGN

PATIENT RECEIYING CLEXANE, HEPARIN

oT OTHER

BLOOD THINNING AGENTS

tr Withhold morning heparin/ clexane/

dose on
I I
tr Epidural catheter not to be renroved before.............hrs on_ _t __l _^
tr Delay the next dose of Clexane / Heparin/_
for minimum 2 hours after removal

PCEA orders ceased

on

name

Epidural catheter removed and intact: signed (nurse)

Revised April 2006

sign

^t

Date I

Time