Preanaesthetic assessment and management in the context of the district hospital

Preanaesthetic assessment and management allow for the systematic identification of perioperative risks and the implementation of interventions to mitigate them, such that the patient’s physiological state is optimised for surgery or other procedures. This is a crucial activity for good perioperative outcomes, as patients not assessed are at a higher risk of unanticipated adverse perioperative events and are more likely to receive suboptimal management. The district hospitals in South Africa perform minor and moderately complex surgical procedures that require anaesthesia, administered mostly to healthy patients and those with stable diseases without functional limitations. A significant proportion of anaesthesia-related deaths reported in the district hospitals can be linked to poor risk assessment and management. In this article, we highlight the key clinical imperatives for optimal preanaesthetic assessment and management from the district hospital perspective.


Introduction
Preanaesthetic assessment is the process of clinical evaluation that precedes the administration of anaesthetics for surgical and non-surgical procedures. 1 Apart from providing an opportunity to build good doctor-patient rapport, it allows for the systematic identification of the patient at risk of adverse perioperative events and the implementation of targeted interventions to optimise favourable perioperative outcomes. 2 Achieving the above is a clinical and policy imperative in South Africa district hospitals, where according to the 2017 Saving Mothers report, 65.5% of all anaesthetic deaths were reported. 3 Furthermore, preanaesthetic assessment reduces patient anxiety about perioperative care, the rate of surgery cancellation or postponement and the length of hospital stay. 4 In line with international standards, the Society of Anaesthesiologists of South Africa (SASA) affirms that every patient presenting for anaesthesia should have a preanaesthetic medical assessment; 5,6 however, the extent to which this is true in South Africa is not known. It should be noted that patients who are not assessed preoperatively are at risk of suboptimal anaesthetic management.
The following are the objectives of the preanaesthetic assessment: 7,8 • to build a good rapport between the anaesthetist and the patient, which enables shared understanding of the anaesthetic plans and perioperative care. This reduces patient's anxiety • to identify and assess risks associated with the administration of anaesthesia • to eliminate or ameliorate risks by optimising patient's health status. This may involve referral to other specialists • to obtain consent for anaesthesia • to order tests, premedication and other indicated interventions.
This continued professional development article considered the norms and standards for the South African 9 district hospital surgical services package, and the recommendations of the SASA for the General practitioner Anaesthesiologist, including Diplomates. To this end, patients to be anaesthetised in South African district hospitals should mainly be American Society of Anaesthesiology (ASA)-1 and -2 (E) risk categories. Some ASA-3 risk category patients may be anaesthetised by an experienced Diplomate in Anaesthesia depending on the urgency and nature of the surgery, the availability or unavailability of supporting specialist anaesthetist and adequacy of clinical support services. 6

Responsibility and timing for the preanaesthetic assessment
The responsibility for preanaesthetic assessment lies with the anaesthetist. Whilst it should be preferably performed by the anaesthetist who is delivering the anaesthetics, 6 it may be conducted by a peer anaesthetist in settings where there are dedicated preanaesthetic assessment clinics. 10 Although there is no conclusive evidence that one approach is superior to the other in terms of outcomes, 5 the former allows for building of rapport between the anaesthetist and the patient and/or next of kin, ensures continuity of care and minimises opportunities for missed findings. 11 The use of a standardised health questionnaire and forms may assist in reducing variations in the quality of documentation of information during the assessment. 12 Self-administered, electronic questionnaires have also been found to be acceptable to patients. 13 The timing of assessment is influenced by complexity of the anticipated procedure, whether the procedure is an emergency, and the patient's health status. In order to avoid unnecessary postponement and cancellation in elective procedures, patients who are at extremes of ages, have a poor health status and who are undergoing major and complicated procedures should be assessed as early as possible (preferably a few days before) to allow time for optimisation. For reasons of limited knowledge, skills and supportive equipment, patients at extremes of ages and those for complicated surgical procedures are not appropriate candidates for anaesthesia at the district hospital. In emergencies, the time of assessment and intervention is guided by the nature of the pathology and the urgency of surgical intervention.

Details of the preanaesthetic assessment
The evaluation is based on multiple information sources that may include medical interview(s) with the patient and/or next of kin, physical examination, medical record appraisals, ordering and reviewing of test results, and as necessary, consultation with other healthcare professionals involved in the perioperative care. 1,7,10,14 At the end, patients should be assigned an ASA risk category, and a management plan should be developed.

Medical history
• Past and present medical histories need to be fully explored.
Several perioperative complications and adverse outcomes are linked to co-morbidities such as diabetes mellitus, chronic pulmonary diseases, hypertension, heart failure, past myocardial infarction, and cerebrovascular and peripheral vascular diseases. 7,14 Other issues to pay attention to include bleeding disorders, thyroid dysfunctions, smoking history, alcohol-use disorders and high body mass index. Previous hospitalisations, exercise intolerance, dyspnoea at rest and orthopnoea may indicate poor cardiovascular reserve. Table 1 shows the peri-anaesthetic implications of some uncontrolled medical conditions. Whilst controlling medical conditions may require postponement or delay in elective procedures, it may not be feasible to do so in emergencies. Uncontrolled medical conditions with functional limitations constitute at least ASA-3/3E risk category, and anaesthesia in such patients is best delivered in secondary or tertiary levels of care, where there are specialists and more advanced monitoring and management resources.
Particular attention should be paid to any history of difficulty in opening the mouth, swellings and dental problems in head and neck surgery; snoring or sleep apnoea, hypertension, obesity, nausea and vomiting in ear, nose and throat (ENT) surgery; symptoms of gastroesophageal reflux, nausea, vomiting, features suggesting bowel obstruction and anaemia in gastrointestinal surgery; and nausea, reflux and anaemia in obstetric and gynaecological surgery.
Autoimmune diseases, such as rheumatoid arthritis, ankylosing spondylitis, scleroderma and degenerative osteoarthritis in the elderly, may affect the temporomandibular joints (TMJs) and cervical and lumbar spines, thereby limiting mouth opening, neck and back movements, and making airway management and axial blocks difficult.
• Explore for a positive family history of adverse reactions to anaesthetics, such as malignant hyperthermia, scoline

Physical examination
Physical examination should augment history in identifying risks that may negatively affect intra-and post-operative outcomes. 7,14,16,18,19 The focus of physical examination should be on the cardiorespiratory system. The need for other system examination is dictated by the type of surgery, patient's health status and anticipated anaesthetic technique (general, regional block, sedation or monitored or balanced). At minimum, physical examination should include the following: • measurement of vital signs (blood pressure, heart rate, temperature, weight and body mass index) • examination of airways, lungs, heart, musculoskeletal system including any neurological deficit, when regional or peripheral nerve block is being contemplated.

Airway assessment
This is aimed at determining the ease of airway management during anaesthesia. The SASA Airway guideline (2014) recommends the following five pertinent questions to be answered for adequate airway management assessment: 20 rheumatoid arthritis and ankylosing spondylitis) may affect the ability to maintain the airway. The latter may affect the cervical spines and TMJ, restricting mouth opening and neck flexion. Arthritis affecting the vertebrae may also distort the anatomy and make lumbar epidural and spinal block more difficult to perform. • Children: Airway control may be challenging because of their small sizes, more cephalad and anterior vocal cords, and large tongues and heads in comparison with their bodies. Considering the highly specialised skills required, neonates and children weighing < 10 kg should not be anaesthetised in the district hospital. 7

Cardiovascular system
The blood pressure (BP), heart rate (HR) and pallor should be checked. Pulses should be palpated for rate, regularity and collapsing pulse. Whilst irregular pulse may indicate atrial fibrillation or ventricular ectopics, a collapsing pulse may indicate aortic incompetence. The jugular vein should be assessed for any elevated venous pressure that may suggest heart failure.
The precordium should be palpated for thrills (that may indicate clinically significant murmur of at least 4/6) and lower parasternal heave (that may indicate a hyperdynamic right ventricle), and percussed for heart size to exclude cardiac hypertrophy. Auscultate cardiac sounds to exclude clinically significant murmurs. If you suspect any pathology, perform further investigations such as electrocardiography (ECG), chest radiograph (CXR) and Echocardiograph as appropriate, including referring for specialist evaluation. Significant cardiac pathology, presence of effort intolerance, history of myocardial infarction, and signs of heart failure and cardiac arrhythmias all suggest high perioperative, cardiovascular risk and should prompt referral of such patients to a regional or tertiary centre for specialist anaesthetic management. Even in emergencies, patient should be stabilised and referral arranged.

Respiratory system examination
Respiratory system examination includes checking for the respiratory rate, oxygen saturation rate, central and peripheral cyanosis, signs of upper airways obstruction -stridor, drooling, submandibular or oral or neck masses, and tracheal deviation.
Inspect the chest. An increased anteroposterior diameter may indicate underlying obstructive airway disease. Kyphosis or scoliosis presents with significant alteration of respiratory mechanics and gaseous exchange, and may require advanced anaesthetic management and critical care postoperatively. Such patients should not be anaesthetised in the district hospital.
Palpate and percuss the chest and auscultate lungs for good bilateral air entry in all lobes, and added breath sounds. If any problem is suspected, a chest radiograph is performed, and if necessary, the patient is referred to a physician consult.

Musculo-skeletal and neurological system
• Cervical spine: check for ranges of movements and tenderness. In trauma cases, do not remove rigid collar before c-spine fracture is excluded. • Thoracic spine: Check for kyphoscoliosis. • Lumbar spine: Check for kyphoscoliosis, spina bifida, degenerative diseases and other deformities. • Muscles: Check for wasting and fasciculation • A brief neurological examination should check for muscle bulk, tone, power and reflexes, especially when a neurological problem is suspected, and before nerve blocks. Document the findings and avoid nerve and regional blocks.

Risk assessment and categorisation
After history and examination (and when appropriate, test result reviewed), the patient should be classified into a risk category: • Functional status or exercise tolerance: This is perhaps the single most useful risk index. It is commonly measured in metabolic equivalents (METS). One MET is the energy  https://www.safpj.co.za Open Access consumed by the body at rest (3.5 mL of oxygen consumed per kilogram body weight per minute). The capacity to climb a flight of stairs corresponds to a moderate exercise capacity and is equivalent to four METS. This is easily measured, takes less than 70 s to complete and is a sensitive cardiovascular risk index. Patients with an exercise capability of four METS or greater present with a lower risk of cardiovascular morbidity. 21 It should be noted that some view the stair-climbing test as a test of anaerobic rather than aerobic capacity. It is therefore better tests lung function than cardiovascular function. Fatigue on a stair-climb is thus worrying; however, the ability to complete one may be falsely reassuring. For this reason, some anaesthetists prefer a 6-min walk test on the flat, which is a sub-maximal exercise test used to assess aerobic capacity and endurance. 22 • American Society of Anaesthesiology physical status classification ( Table 2) 16,19 : The ASA physical status classification was originally intended to predict operative risk and generally correlates well with the perioperative mortality rate; however, underlying disease is only one of many factors that contribute to perioperative complications, and therefore, the correlation is not perfect. 19

Clinical investigations
Most surgeries performed in the district hospitals are minor or moderately complex, and up to ASA-3 risk category patients, where there is an experienced Diplomate. 23,24,25,26,27 Routine laboratory tests are therefore not warranted, except when indicated by findings on history and examination, and the complexity of surgery. The incidence of abnormal test results is extremely low, and the need for tests should balance risk and costs against benefits. The use of point of care tests should also be considered. Figure 2 provides some guidance on investigations that can be performed in exceptional cases.

Preanaesthetic management and premedication
The management plan will depend on the health status of the patient and the type of surgery.
• Consent: The findings of the risk assessment and the anaesthetic plan should be discussed with the patient for shared understanding. Enough information should be given to ensure that informed written consent can be said to have been obtained. • Fasting: This is to prevent bronchial aspiration of gastric content. All patients must be fasted before anaesthesia, except in emergencies where this risk is managed along with the surgery. Guides on periods of fasting in different circumstances and the factors that may delay gastric emptying are shown in Table 3. New evidence suggests that up to 3 mL/kg clear fluids may be allowed up to 1 h before surgery in children. 15,16,17 Premedication • Although not always routinely used, premedications are still prescribed for anxious patients (Table 4) 16,17,18,19,28,29,30 . However, a good doctor-patient rapport and a clear explanation of the anticipated anaesthetic events provide more anxiolysis than drugs. 8,16 • Intestinal prokinetic and antiemetic drugs such as metoclopramide are prescribed to facilitate gastric emptying and prevent and reduce the risk of aspiration. Proton pump inhibitors and sodium citrate are prescribed  to reduce gastric acid production and increase pH, respectively. • Prophylactic antibiotics are used preoperatively according to the South African Antibiotic Stewardship Programme guidelines. Special attention should be given to the need to prevent infective endocarditis in applicable patients with damaged or artificial heart valves, intravenous drug users, and dental, urogenital, gastrointestinal and instrumentation procedures. 31 • Intravenous line ensures access for rapid administration of drugs and fluids. Dehydration is undesirable in any form of anaesthesia and should be avoided. The administration of a pre-load/ co-load of 10 mL/kg -20 mL/kg of warm crystalloid before spinal block mitigates hypotension from the spinal block. Any fluid deficit from fasting should be estimated (4 mL/kg per hour for the first 10 kg of body weight, plus 2 mL/kg per hour for the next 10 kg of body weight plus 1 mL/kg per hour for the remaining weight in kilograms). For example, in a 40 kg young woman who has been fasted for 8 h without any fluid, the deficit is estimated as (4 × 10 × 8) + (2 × 10 × 8) + (1 × 20 × 8) = 640 mL of crystalloid. This Holliday-Segar formula may overestimate fluid requirements in the adults, and about one-half to two-third of the estimated amount is given. Any ongoing and third space loss should be added.

Record keeping and documentation
The documentation of the findings of preanaesthetic assessment just like other medical records is crucial for quality control and medico-legal reasons. However, the rate of documentation has been shown to vary depending on the criteria assessed, with airway assessments and peri-anaesthetic visit findings and incidents or accidents reportedly documented in less than 50% of patients. 32 It is important to note that 'if not documented, the assessment or intervention is assumed not done!'.

Conclusion
The preanaesthetic assessment is an essential component of anaesthetic practice and allows for the systematic identification, categorisation and management of perioperative risks. The anaesthesiologists should discuss the findings with the patients and/or next of kin in an environment that is culturally appropriate and respectful, advise the patient on available anaesthetic choices and obtain informed consent. Considering the limitations of skills and equipment, primary care doctors in district hospitals should provide anaesthetic care within the scope of ASA-1 to 2. When there is an experienced Diplomate in anaesthesia, the scope may be extended to ASA 3 (E). In addition, all details of anaesthetic care should be documented in the medical records in accordance with professional and regulatory standards for optimal service outcomes.  Note: Causes of delayed gastric emptying: metabolic causes, for example, diabetes mellitus, renal failure, sepsis; decreased gastric motility, for example, head injury and trauma; bowel obstruction; raised intra-abdominal pressure, for example, pregnancy and obesity; drugs, for example, opioids; severe trauma and pain; and gastro-oesophageal reflux, may be associated with delayed emptying of solids but not liquids.