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Give me important points from these pages so that I don't have to read them.

Here is a structured summary of all 9 pages from Chapter 2: Pre-operative Evaluation & Management:

Chapter 2 - Pre-operative Evaluation & Management

GOALS OF PRE-OPERATIVE ASSESSMENT

Reduce surgical/anesthetic morbidity and mortality
Document conditions needing surgery, assess overall health, uncover hidden problems
Determine perioperative risk and optimize patient's condition
Educate patient about surgery, anesthesia, and pain management
Reduce costs, shorten hospital stay, reduce cancellations

A. PRE-OPERATIVE HISTORY (Most Important Component)

Key areas to cover:

Cardiovascular: MI (<6 weeks), hypertension, ischemic heart disease, arrhythmias - patients who can climb stairs without breathlessness have lower risk
Respiratory: COPD, asthma
GI: Hepatitis, peptic ulcer, GERD, chronic liver disease, obstructive jaundice
Neurological: CVA, epilepsy, psychiatric illness
Renal: Renal dysfunction, UTIs
Endocrine: Diabetes, thyrotoxicosis, phaeochromocytoma
Other: Previous surgery/anesthesia, malignancy, medications, smoking, alcoholism, bleeding disorders, drug allergies

B. PHYSICAL EXAMINATION

Must include assessment of airway, lungs, heart + vital signs
Abnormal findings must be investigated before elective surgery

Mallampati Airway Grading (patient seated, mouth open, tongue out):

Grade I: Soft palate, fauces, uvula, pillars visible
Grade II: Soft palate + part of uvula visible
Grade III: Only soft palate seen
Grade IV: Only hard palate seen
Higher grade = higher risk of difficult intubation

Other predictors of difficult intubation:

Long upper incisors, prominent overbite
Cannot protrude mandibular incisors past maxillary incisors
Inter-incisor distance <3 cm
Uvula not visible when tongue protruded
Highly arched/narrow palate
Thyromental distance <3 fingerbreadths
Short/thick neck, limited neck movement

C. INVESTIGATIONS

Routine labs in healthy patients are NOT cost-effective
Order based on history, age, surgery complexity

Test	Indications
CBC	Major ops, anemia, ongoing blood loss, chronic disease, malignancy, sickle cell trait
Electrolytes/Creatinine	Major surgery, age >60, CVS/renal/endocrine disease, diuretics/digoxin/antihypertensives
ECG	Age >60, cardiovascular/renal/respiratory disease, diabetes
Clotting screen	Bleeding diathesis, liver disease, eclampsia, anticoagulation therapy
Chest X-ray	Cardiac history, respiratory symptoms, COPD, pulmonary cancer/metastasis/effusion
Pregnancy test	All women of childbearing age
Blood glucose/HbA1c	Diabetes, endocrine problems
LFTs	Jaundice, hepatitis, cirrhosis

Advanced tests (coronary angiogram, cardiac perfusion scan, PFTs, ABGs, CT brain) if indicated.

ASA PHYSICAL STATUS CLASSIFICATION

Class	Description
ASA 1	No organic/physiologic/biochemical/psychiatric disturbance
ASA 2	Mild-moderate systemic disturbance (e.g., controlled HTN, diabetes, mild COPD)
ASA 3	Severe systemic disturbance limiting activity (e.g., poorly controlled HTN, angina, prior MI)
ASA 4	Life-threatening systemic disturbance (e.g., CHF, advanced organ failure)
ASA 5	Moribund patient - last resort surgery
ASA 6	Brain-dead patient for organ donation
"E" suffix	Emergency operation

SPECIFIC PRE-OPERATIVE PROBLEMS

Cardiovascular

Risk predictors (ACC/AHA):

Major predictors: MI <6 weeks, unstable/severe angina (class III-IV), decompensated CHF, significant arrhythmias, severe valvular disease, CABG/PTCA <6 weeks
Intermediate predictors: MI >6 weeks, mild angina, silent ischemia, compensated CHF (EF <0.35), diabetes, renal insufficiency
Minor predictors: Family history, age >70, ECG abnormalities, low functional capacity, stroke history, uncontrolled HTN, hypercholesterolemia, smoking

Myocardial Infarction:

Risk of perioperative MI decreases with time since infarction:
- 6 months: 5% | 4-6 months: 10-20% | <3 months: 20-30%
Delay elective surgery 6 months post-MI
After coronary stenting: delay until dual antiplatelet therapy completed (6 weeks)

Angina: Unstable angina has 25% perioperative MI risk - refer for angioplasty/stenting/bypass

CHF: EF <35% carries 19.5% mortality vs 2.2% with EF >55%

Hypertension: Control BP to <160/90 mmHg before elective surgery; allow 2 weeks stabilization for new antihypertensive

Valvular Heart Disease: Stop warfarin 5 days pre-op; bridge with unfractionated heparin when INR <1.5 (APPT 1.5x normal); stop heparin 2 hours before surgery

Pacemakers: Avoid monopolar diathermy

Anemia

Treat with iron and vitamins
Hb <8 g/dL before major surgery - consider transfusion

Respiratory Diseases

Vital capacity <3x tidal volume = likely respiratory insufficiency post-laparotomy/thoracotomy
Asthma: Use bronchodilators/steroids pre-op; patients on >10 mg prednisolone need perioperative steroid cover
Smoking cessation: Nicotine levels normalize in 12-24 hours; ciliary function improves in 2-3 days; full lung function returns after 3 months abstinence
Chest infections: Postpone elective surgery; reschedule after 4-6 weeks of antibiotics + physiotherapy

Coagulation Disorders

Thrombophilia: Provide thromboprophylaxis; stop OCP/HRT 6 weeks before surgery
Anticoagulation (warfarin): Stop 5 days pre-op; bridge with heparin (stop 2 hours pre-op); Vitamin K for emergency reversal (24-48 hrs); FFP/prothrombin complex for rapid reversal
Haemophilia A: Factor VIII deficiency; Haemophilia B: Factor IX deficiency - infuse respective factor perioperatively

Obstructive Jaundice

Risk of: hepatorenal shutdown, bleeding diathesis, cholangitis, sepsis
Give Vitamin K pre-op (deficiency of fat-soluble clotting factors II, V, VII, IX, X)
Maintain adequate hydration; prophylactic antibiotics

METABOLIC DISORDERS

Diabetes Mellitus

Risks: sepsis, delayed wound healing, CVA, diabetic ketoacidosis
Check HbA1c; close monitoring required

Non-insulin dependent (oral hypoglycemics):

Schedule first on operating list
Stop morning oral hypoglycemics; regular 1-2 hourly sugar checks
IV cannula with slow dextrose saline infusion
Moderate hyperglycemia is acceptable (hypoglycemia is more dangerous)

Insulin dependent:

Admit day before surgery; stop long-acting insulin the night before
Check glucose/electrolytes morning of surgery; switch to sliding scale
Afternoon list patients: give half normal insulin dose with breakfast

Sliding scale (Alberti regime): IV insulin + glucose + potassium as single mixed infusion - continue until patient resumes normal diet

Long-Term Corticosteroids

Normal adrenal output: 30 mg cortisol/day (= 7.5 mg prednisolone or 30 mg hydrocortisone)
Surgery stress doubles/triples cortisol need; suppressed adrenals can cause acute adrenocortical insufficiency (hypotension, bradycardia, confusion, hypoglycemia)

Steroid supplementation guidelines:

Surgery Type	Protocol
Minor	1.5-2x usual prednisolone on morning of surgery
Moderate	2x usual dose orally + 25mg hydrocortisone IV pre-op, 75mg IV during op, 50mg IV after; taper over 48h
Major	2x usual dose + 50mg IV pre-op, 100mg IV during op, 100mg IV q8h x24h post-op; taper over 48-72h

Thyrotoxicosis

Carbimazole 30-40 mg is drug of choice; once euthyroid (8-12 weeks) reduce to 5 mg 8-hourly
Beta-blockers (propranolol 40 mg TDS) can control toxic state rapidly (ready for surgery within 1-2 weeks)
In pregnancy: use propylthiouracil (carbimazole crosses placenta - causes fetal hypothyroidism)

Hypothyroidism

Treat before surgery to avoid hypotension, shock, hypothermia, hypoventilation, CO2 retention
Myxoedema coma if patient fails to wake from anesthesia
Use levothyroxine (IV in emergencies)

Dehydration/Renal Failure

Dehydration (e.g., intestinal obstruction, peritonitis): fluid resuscitation mandatory before surgery
Renal failure patients on dialysis: dialyze 24 hours before surgery; delay postoperative dialysis 24 hours if possible

Obesity

BMI >30% above ideal weight increases cardiovascular and pulmonary risk
Delay elective surgery while patient loses weight

PRE-OPERATIVE FASTING

Adults - "2-6 Rule":

Water: up to 2 hours before induction
Food/milk/solids: minimum 6 hours before induction

Children - "2-4-6 Rule":

Water/clear fluids: up to 2 hours before
Breast milk: up to 4 hours before
Formula/cow's milk/solids: 6 hours before

EMERGENCY SURGERY

Same assessment principles apply but time is limited
Some risks can be reduced; others must be explained to patient

CONSENT

Discuss diagnosis, procedure, complications with patient and relatives
Written consent required; two treatment options should be described if available
Valid consent = voluntary, by a competent person, fully informed
Document everything

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