preoperative evaluation

COURSE OUTLINESTHE FORMAT OF THE COURSEKNOWLEDE AND SKILLS THAT CAN BE

GAINED.COURSE PROGRAMECOURE OBJECTIVESREQUIRE MATERIALS:TEXT BOOKS

Anesthesia Rotation bookASSESSMENT

POLICY OF MISSED WORK (ATTENDENCE REQUIREMENT)

FINAL EXAMCONTACT INFORMATION DEPARTMENT 71597 Dr walid tel 71816 Dr osama bleep 2158QUESTIONS

Clinical Objectives for Medical Students in (044) Anesthesia and CPR Course

At the end of the course the student will be able to understand and practice:

1- Pre-anesthesia assessment and evaluation Able to take history from patient Able to open PAC System to get information and

investigation. Interpretation of preoperative data relevant to

anesthetic plan. Consultations

2- Orientation with anesthesia equipment in O.R. Anesthesia machine Anesthesia circuits Laryngoscopes – tubes – LMA – Airways Epidural set Spinal set Monitors - Anesthesia Record Anesthetics Drugs : I.V. drugs Inhalational &

Muscle Relaxants Resuscitation Drugs During Anesthesia Crystalloids & Colloids Fluids

3- Post-operative Care Unit OrientationsCase Scenarios: Interactive Case Discussion

4- Surgical ICU Rounds & Discussions about Management of critically I’ll patient Monitoring of critically I’ll patient Ventilators Common Cases in ICU

Head injury management

Sepsis management

Role Of Anesthesiologist In pre-Opertive period

Anesthesia

The word is derived from the Greek words an, which means “without” and aithesia which means “feeling”

The use of medical anesthesia was first reported in 1846

The development of anesthesia has made today’s modern surgical techniques possible

Basic Principles of Anesthesia

“Triad of General Anesthesia”need for unconsciousnessneed for analgesianeed for muscle relaxation and loss of

reflexes

Anesthetic assessment andpreparation for surgery

Purposes of the Preoperative Evaluation1. Obtain medical history

2. Review current physical status

3. Order additional tests / consultation

4. Answer questions

Overview.

The preanesthetic evaluation has specific objectives including:

- Establishing a doctor-patient relationship,

- Becoming familiar with the surgical illness and coexisting medical conditions,

Developing a management strategy for perioperative anesthetic care,

- Obtaining informed consent for the anesthetic plan.

The overall goals of the preoperative assessment are to reduce perioperative

morbidity and mortality and to allay patient anxiety.

Stages of the Peri-Operative Period

Pre-Operative

From time of decision to have surgery until

admitted into the OR theatre.

Stages of the Peri-Operative Period

Intra-Operative

Time from entering the OR theatre to entering

the Recovering Room or Post Anesthetic Care

Unit (PACU)

Stages of the Peri-Operative Period

Post-Operative

Time from leaving the RR or PACU until time of

follow-up evaluation (often as out-patient)

Purposes of thePreoperative Evaluation

1. Reassure patient / allay anxiety2. Order preoperative medications3. Obtain informed consent4. Document the record5. Develop anesthetic care plan

Medical History

1. Review the chart

2. Review previous records

3. Interview the patient

The Chart Review

Demographic DataHeight / weightVital signsDiagnosis

The Chart Review

History and Physical ExamNote any abnormalitiesDon’t assume that all problems are listed

The Chart Review

1. Medications Routine medications at home Meds ordered in hospital

2. Lab / x-ray results

3. Consultations

Old Hospital Records

1. Available in same institution

2. Previous diagnosis

3. Previous treatment

Old Hospital Records

Review prior anesthesia recordInduction dosesAirway difficultyWork-up

Benefits from surgery ←→ Risk of complications

Age ObesitySmokingGeneral health statusChronic obstructive pulmonary disease

(COPD)Asthma

Patient related risk factors(pulmonary)

Smoking

Important risk factor Smoking history of 40 pack years or more →↑risk of

pulmonary complications stopped smoking < 2 months : stopped for > 2

months 4:1(57% : 14.5%) quit smoking > 6 months : never smoked = 1:1

(11.9% : 11%)

Risk Stratification

Revised Cardiac Risk Index High risk surgery (vascular, thoracic) Ischemic heart diseaseCongestive heart failureCerebrovascular disease Insulin therapy for diabetesCreatinine >2.0mg/dL

Active Cardiac Conditions

Unstable coronary syndromesUnstable or severe anginaRecent MI

Decompensated HFSignificant arrhythmiasSevere valvular disease

Minor Cardiac Predictors

Advanced age (>70)Abnormal ECG

LV hypertrophyLBBBST-T abnormalitiesRhythm other than sinus

Uncontrolled systemic hypertension

Surgical Risk Stratification

High Risk Vascular (aortic and major vascular)

Intermediate Risk Intraperitoneal and intrathoracic, carotid, head and

neck, orthopedic, prostateLow Risk

Endoscopic, superficial procedures, cataract, breast, ambulatory surgery

Risk Stratification

ASA physical statusASA 1 – Healthy patient without organic

biochemical or psychiatric disease.ASA 2- A Patient with mild systemic disease. No

significant impact on daily activity. Unlikely impact on anesthesia and surgery.

ASA 3- Significant or severe systemic disease that limits normal activity. Significant impact on daily activity. Likely impact on anesthesia and surgery.

Risk Stratification

ASA 4- Severe disease that is a constant threat to life or requires intensive therapy. Serious limitation of daily activity.

ASA 5- Moribund patient who is equally likely to die in the next 24 hours with or without surgery.

ASA 6- Brain-dead organ donor“E” – added to the classifications indicates

emergency surgery.

Step #1:Is the surgery emergent?

Is the surgery emergent? Operating room*yes

(Next Step)

no

Consider beta-blockade, pain controland other peri-operative management

Step 2: Determine Presence of Active Cardiac Conditions

If none are present, proceed with surgery

Presence of one of these delays surgery for

evaluation

Many patients need a cardiac cath

Step 2

Unstable coronary syndromes

Decompensated heart failure

Significant arrhythmias

Severe valvular disease

Step #2: Active Cardiac Conditions

Active Cardiac conditionsyes Evaluate and treat per current

guidelines

Consider Operating Room

no

(Next Step)

Step 3: Surgery Low Risk?

Low risk surgery includes:1. Endoscopic procedures

2. Superficial procedures

3. Cataract surgery

4. Breast surgery

5. Ambulatory surgery Cardiac risk <1% Testing does not change management

Step #3: Surgery Low Risk?

Low risk surgery

No

Operating roomyes

(Next Step)

Airway Evaluation

Take very seriously history of prior difficulty

Head and neck movement (extension) Alignment of oral, pharyngeal,

laryngeal axes Cervical spine arthritis or

trauma, burn, radiation, tumor, infection, scleroderma, short and thick neck

Airway Evaluation

Jaw Movement Both inter-incisor gap and

anterior subluxation <3.5cm inter-incisor gap

concerning Inability to sublux lower

incisors beyond upper incisors Receding mandible Protruding Maxillary Incisors

(buck teeth)

Airway Evaluation Oropharyngeal visualization Mallampati Score Sitting position, protrude tongue, don’t say “AHH”

Preoperative Testing

Routine preoperative testing should not be ordered.

Preoperative testing should be performed on a selective basis for purposes of guiding or optimizing perioperative management.

Preoperative Testing5

Procedure based.Low risk

Baseline creatinine if procedure involves contrast dye. Intermediate risk

Base line creatinine if contrast dye or >55yr of age.High risk

CBC, lytes & S, creatinine as above.PFTs for lung reduction surgery.

Preoperative Testing

Disease-based indicationsAlcohol abuse

CBC, ECG, lytes, LFTs, PTAnemia

CBCBleeding disorder

CBC, LFTs, PT, PTTCardiovascular

CBC, creatinine, CXR, ECG, lytes

Preoperative Testing

Disease-based indicationsCerebrovascular disease

Creatinine, glucose, ECGDiabetes

Creatinine, electrolytes, glucose, ECGHepatic disease

CBC, creatinine, lytes, LFTs, PTMalignancy

CBC, CXR

Preoperative Testing

Disease-based indicationsPregnancy (controversial)

Serum B-hCG- 7 days, Upreg 3 daysPulmonary disease

CBC, ECG, CXRRenal disease

CBC, Cr, lytes, ECGRA

CBC, ECG, CXR, C-spine (atlantoaxial subluxation) AP C-spine, AP odontoid view and lateral flexion and extention.

Preoperative Testing

Disease-basedSleep apnea

CBC, ECGSmoking >40 pack year

CBC, ECG, CXRSystemic Lupus

Cr, ECG, CXR

Preoperative Testing

Therapy-based indications Radiation therapy

CBC, ECG, CXR Warfarin

PT Digoxin

Lytes, ECG, Dig level Diuretics

Cr, lytes, ECG Steroids

Glucose, ECG

Obtaining a Consult

1. Ask specific questions which you want

answered

2. Talk directly to the consultant

Informed Consent

1. Frequently questioned in malpractice cases

2. Risks / benefits3. Alternatives4. Answer all questions5. Do not deceive the patient

Risks of Anesthesia

1. Determine what the patient wants to know - Do not frighten patients

2. Start with minor risks

3. Proceed to serious risks

Risk associated with anesthesiaand surgery

The question that patients ask

is ‘Doctor, what are the risks of having an anaesthetic?’

These can be divided into two main groups.

MinorThese are not life threatening and can occur even

when anaesthesia has apparently been uneventful. They include:

• failed IV access;• cut lip, damage to teeth, caps, crowns;• sore throat;• headache;• postoperative nausea and vomiting;• retention of urine.

MajorThese may be life-threatening events. They include:• aspiration of gastric contents;• hypoxic brain injury;• myocardial infarction;• cerebrovascular accident;• nerve injury;• chest infection Death

Document the Visit

1. Complete the evaluation form

2. Enter progress notes

3. Have patient sign consent

4. Write appropriate orders

Preanesthesia Clinic

Questions?