1. Aim:
   1. 1: identify high risk patient for Sx
   2. 2: reduce post-op complication
2. consider;
   1. undelying diagnosis
   2. overall fitness for op
   3. type of anest
   4. type of ope
   5. consent
3. ASA CLASSIFICATION
   1. Class I Healthy individual
   2. Class II Mild systemic disease
   3. Class III Limiting, but not incapacitating, systemic disease
   4. Class IV Incapacitating systemic disease
   5. Class V Moribund (pre-terminal)
4. CVS
   1. Hx of Cardiac Dz
      1. Angina, MI
      2. Arrhythmia
      3. Prev. intervention
      4. current medications
   2. physical Exam
   3. Ix
      1. U+E
      2. ECG
         1. all males > 40 yrs
         2. Females > 50 yrs
      3. CXR
      4. others : depend on Hx
5. Respi
   1. Hx
      1. resp co-morbidities
      2. medication
         1. steroid?
            1. increase steroid requirement
      3. smoking
         1. smoking cessation improve outcome for GA
         2. increase airway hyperactivity --> bronchospasm
         3. increase sputum production + reduce sputum clearance --> post op infection
   2. Physical Exam
   3. CXR
      1. generally performed over 60 yr
   4. Ch. Lung Dz
      1. PFTs
      2. ABG
   5. resp compromised?
      1. pre & post-op chest physio
6. Main Topic 6
7. Diabetes
   1. risk of hypo& ketoacidosis
   2. infection
      1. gangrene
      2. ulceration
   3. Hx
      1. established severity
         1. poorly controlled
            1. : endocrinologist advice
         2. moderate dz
            1. insuline > 40 units/day
            2. increase post-op risk
   4. procedure
      1. admit 48hrs before Sx
      2. FBC,U+E,glucose
      3. ECG, CXR
      4. 1st list
      5. omit morning dose insulin
         1. 15 units/L soluble insulin wit 5% dextrose, 2 hr before sx
      6. check blood glucose prior Sx
8. Rheumatoid Arthritis
   1. lateral Cervical Spine Xray
      1. to assess any atlanto-axial subluxation
         1. can compromise blood supply/ compress spinal cord
9. general pre-op measure
   1. Blood test
      1. 1. FBC
         1. investigate if anemic
      2. 2.U+E
      3. 3. Coag
         1. if prolong PTT --> vit K
            1. in liverdz, jaudice
      4. 4. group &cross match
   2. DVT prophyl
      1. thromboembolic deterrent stockings
      2. subcutaneous LMWH
      3. pelvic/hip sx
      4. obese
      5. malignant dz, DM
      6. previous Hx
      7. HRT/OCP
   3. Discontinuing medications
      1. aspirin/clopidogrel
         1. 10 days before admission for elective Sx
         2. if for stent patency, consult cardiologist
      2. OCP
         1. 1 month before
   4. fasting 6 hrs before
      1. minimize aspiration
   5. elective bowel Sx
      1. bowel preparation
         1. oral
         2. retrograde purgative
            1. picolax
      2. pre-op antibiotic prophyl
      3. stoma bag marked
   6. side of operation marked by surgeon
   7. prosthetic metal heart
      1. early admission
      2. discon warfarin --> IV Heparin
         1. heparin discont 4 hrs before operation
      3. antibiotic prophylaxis