Preoperative Evaluation


Published on

Published in: Education, Health & Medicine

Preoperative Evaluation

  2. 2. POLICY OF MISSED WORK (ATTENDENCE REQUIREMENT)<br />FINAL EXAM<br />CONTACT INFORMATION<br /> DEPARTMENT 71597<br /> Dr walid tel 71816<br /> Dr osama bleep 2158<br />QUESTIONS<br />
  3. 3. Clinical Objectives for Medical Students in (044) Anesthesia and CPR Course<br />At the end of the course the student will be able to understand and practice: <br />1- Pre-anesthesia assessment and evaluation<br />Able to take history from patient<br />Able to open PAC System to get information and investigation.<br />Interpretation of preoperative data relevant to anesthetic plan.<br />Consultations<br />
  4. 4. 2- Orientation with anesthesia equipment in O.R.<br />Anesthesia machine<br />Anesthesia circuits<br />Laryngoscopes – tubes – LMA – Airways<br />Epidural set Spinal set<br />Monitors - Anesthesia Record <br />Anesthetics Drugs : I.V. drugs Inhalational & Muscle Relaxants<br />Resuscitation Drugs During Anesthesia<br />Crystalloids & Colloids Fluids<br />
  5. 5. 3- Post-operative Care Unit Orientations<br />Case Scenarios: Interactive Case Discussion <br />
  6. 6. 4- Surgical ICU Rounds & Discussions about<br />Management of critically I’ll patient<br />Monitoring of critically I’ll patient<br />Ventilators<br />Common Cases in ICU<br /> Head injury management<br /> Sepsis management<br />
  7. 7. Role Of Anesthesiologist In pre-Opertiveperiod<br />
  8. 8.
  9. 9. Anesthesia<br />The word is derived from the Greek words an, which means “without” and aithesia which means “feeling”<br />The use of medical anesthesia was first reported in 1846<br />The development of anesthesia has made today’s modern surgical techniques possible<br />
  10. 10. Basic Principles of Anesthesia<br />“Triad of General Anesthesia”<br />need for unconsciousness<br />need for analgesia<br />need for muscle relaxation and loss of reflexes<br />
  11. 11. Anesthetic assessment andpreparation for surgery<br />
  12. 12. Purposes of the Preoperative Evaluation<br />Obtain medical history<br />Review current physical status<br />Order additional tests / consultation<br />Answer questions<br />
  13. 13. Overview.<br />The preanesthetic evaluation has specific objectives including:<br />- Establishing a doctor-patient relationship, <br />- Becoming familiar with the surgical illness and coexisting medical conditions, <br />
  14. 14. Developing a management strategy for perioperative anesthetic care, <br />- Obtaining informed consent for the anesthetic plan. <br /> The overall goals of the preoperative assessment are to reduce perioperative morbidity and mortality and to allay patient anxiety.<br />
  15. 15. Stages of the Peri-Operative Period<br />Pre-Operative<br />From time of decision to have surgery until admitted into the OR theatre.<br />
  16. 16. Stages of the Peri-Operative Period<br />Intra-Operative<br />Time from entering the OR theatre to entering the Recovering Room or Post Anesthetic Care Unit (PACU)<br />
  17. 17. Stages of the Peri-Operative Period<br />Post-Operative<br />Time from leaving the RR or PACU until time of follow-up evaluation (often as out-patient)<br />
  18. 18. Purposes of thePreoperative Evaluation <br />Reassure patient / allay anxiety<br />Order preoperative medications<br />Obtain informed consent<br />Document the record<br />Develop anesthetic care plan<br />
  19. 19. Medical History<br />Review the chart<br />Review previous records<br />Interview the patient<br />
  20. 20. The Chart Review<br />Demographic Data<br />Height / weight<br />Vital signs<br />Diagnosis<br />
  21. 21. The Chart Review<br />History and Physical Exam<br />Note any abnormalities<br />Don’t assume that all problems are listed<br />
  22. 22. The Chart Review<br />Medications<br />Routine medications at home<br />Meds ordered in hospital<br />Lab / x-ray results<br />Consultations<br />
  23. 23. Old Hospital Records<br />Available in same institution<br />Previous diagnosis<br />Previous treatment<br />
  24. 24. Old Hospital Records<br />Review prior anesthesia record<br />Induction doses<br />Airway difficulty<br />Work-up<br />
  25. 25. Benefits from surgery ←-> Risk of complications<br />
  26. 26. Age <br />Obesity<br />Smoking<br />General health status<br />Chronic obstructive pulmonary disease (COPD)<br />Asthma<br />Patient related risk factors(pulmonary)<br />
  27. 27. Smoking<br />Important risk factor<br />Smoking history of 40 pack years or more->↑risk of pulmonary complications<br />stopped smoking &lt; 2 months : stopped for &gt; 2 months4:1(57% : 14.5%) <br />quit smoking &gt; 6 months : never smoked = 1:1 (11.9% : 11%)<br />
  28. 28.
  29. 29. Risk Stratification<br />Revised Cardiac Risk Index <br />High risk surgery (vascular, thoracic)<br />Ischemic heart disease<br />Congestive heart failure<br />Cerebrovascular disease<br />Insulin therapy for diabetes<br />Creatinine &gt;2.0mg/dL<br />
  30. 30. Active Cardiac Conditions<br />Unstable coronary syndromes<br />Unstable or severe angina<br />Recent MI<br />Decompensated HF<br />Significant arrhythmias<br />Severe valvular disease<br />
  31. 31. Minor Cardiac Predictors<br />Advanced age (&gt;70)<br />Abnormal ECG<br />LV hypertrophy<br />LBBB<br />ST-T abnormalities<br />Rhythm other than sinus<br />Uncontrolled systemic hypertension <br />
  32. 32.
  33. 33. Surgical Risk Stratification<br />High Risk <br />Vascular (aortic and major vascular)<br />Intermediate Risk<br />Intraperitonealand intrathoracic, carotid, head and neck, orthopedic, prostate<br />Low Risk<br />Endoscopic, superficial procedures, cataract, breast, ambulatory surgery<br />
  34. 34. Risk Stratification<br />ASA physical status<br />ASA 1 – Healthy patient without organic biochemical or psychiatric disease.<br />ASA 2- A Patient with mild systemic disease. No significant impact on daily activity. Unlikely impact on anesthesia and surgery.<br />ASA 3- Significant or severe systemic disease that limits normal activity. Significant impact on daily activity. Likely impact on anesthesia and surgery.<br />
  35. 35. Risk Stratification<br />ASA 4- Severe disease that is a constant threat to life or requires intensive therapy. Serious limitation of daily activity.<br />ASA 5- Moribund patient who is equally likely to die in the next 24 hours with or without surgery.<br />ASA 6- Brain-dead organ donor<br />“E” – added to the classifications indicates emergency surgery.<br />
  36. 36. Step #1:Is the surgery emergent?<br />yes<br />Is the surgery emergent?<br />Operating room*<br />no<br />(Next Step)<br />Consider beta-blockade, pain control<br />and other peri-operative management<br />
  37. 37. Step 2: Determine Presence of Active Cardiac Conditions<br />If none are present, proceed with surgery<br />Presence of one of these delays surgery for evaluation<br />Many patients need a cardiac cath<br />
  38. 38. Step 2<br />Unstable coronary syndromes<br />Decompensated heart failure<br />Significant arrhythmias<br />Severe valvular disease<br />
  39. 39. Step #2: Active Cardiac Conditions<br />Evaluate and treat per current guidelines<br />yes<br />Active Cardiac conditions<br />no<br />Consider Operating Room<br />(Next Step)<br />
  40. 40. Step 3: Surgery Low Risk?<br />Low risk surgery includes:<br />Endoscopic procedures<br />Superficial procedures<br />Cataract surgery<br />Breast surgery<br />Ambulatory surgery<br />Cardiac risk &lt;1%<br />Testing does not change management<br />
  41. 41. Step #3: Surgery Low Risk?<br />yes<br />Operating room<br />Low risk surgery<br />No<br />(Next Step)<br />
  42. 42. Airway Evaluation<br />Take very seriously history of prior difficulty<br />Head and neck movement (extension)<br />Alignment of oral, pharyngeal, laryngeal axes<br />Cervical spine arthritis or trauma, burn, radiation, tumor, infection, scleroderma, short and thick neck<br />
  43. 43.
  44. 44. Airway Evaluation<br />Jaw Movement<br />Both inter-incisor gap and anterior subluxation<br />&lt;3.5cm inter-incisor gap concerning<br />Inability to sublux lower incisors beyond upper incisors<br />Receding mandible<br />Protruding Maxillary Incisors (buck teeth)<br />
  45. 45. Airway Evaluation<br />Oropharyngeal visualization<br />Mallampati Score<br />Sitting position, protrude tongue, don’t say “AHH”<br />
  46. 46. Preoperative Testing<br />Routine preoperative testing should not be ordered.<br />Preoperative testing should be performed on a selective basis for purposes of guiding or optimizing perioperative management.<br />
  47. 47. Preoperative Testing5<br />Procedure based.<br />Low risk<br />Baseline creatinine if procedure involves contrast dye.<br />Intermediate risk<br />Base line creatinine if contrast dye or &gt;55yr of age.<br />High risk<br />CBC, lytes & S, creatinine as above.<br />PFTs for lung reduction surgery.<br />
  48. 48. Preoperative Testing<br />Disease-based indications<br />Alcohol abuse<br />CBC, ECG, lytes, LFTs, PT<br />Anemia<br />CBC<br />Bleeding disorder<br />CBC, LFTs, PT, PTT<br />Cardiovascular<br />CBC, creatinine, CXR, ECG, lytes<br />
  49. 49. Preoperative Testing<br />Disease-based indications<br />Cerebrovascular disease<br />Creatinine, glucose, ECG<br />Diabetes<br />Creatinine, electrolytes, glucose, ECG<br />Hepatic disease<br />CBC, creatinine, lytes, LFTs, PT<br />Malignancy<br />CBC, CXR<br />
  50. 50. Preoperative Testing<br />Disease-based indications<br />Pregnancy (controversial)<br />Serum B-hCG- 7 days, Upreg 3 days<br />Pulmonary disease<br />CBC, ECG, CXR<br />Renal disease<br />CBC, Cr, lytes, ECG<br />RA<br />CBC, ECG, CXR, C-spine (atlantoaxialsubluxation)<br />AP C-spine, AP odontoid view and lateral flexion and extention.<br />
  51. 51. Preoperative Testing<br />Disease-based <br />Sleep apnea <br />CBC, ECG<br />Smoking &gt;40 pack year<br />CBC, ECG, CXR<br />Systemic Lupus<br />Cr, ECG, CXR<br />
  52. 52. Preoperative Testing<br />Therapy-based indications<br />Radiation therapy<br />CBC, ECG, CXR<br />Warfarin<br />PT<br />Digoxin<br />Lytes, ECG, Dig level<br />Diuretics<br />Cr, lytes, ECG<br />Steroids<br />Glucose, ECG<br />
  53. 53. Obtaining a Consult<br />Ask specific questions which you want answered<br />Talk directly to the consultant<br />
  54. 54. Informed Consent<br />Frequently questioned in malpractice cases<br />Risks / benefits<br />Alternatives<br />Answer all questions<br />Do not deceive the patient<br />
  55. 55. Risks of Anesthesia<br />Determine what the patient wants to know - Do not frighten patients<br />Start with minor risks<br />Proceed to serious risks<br />
  56. 56. Risk associated with anesthesiaand surgery<br />The question that patients ask<br />is ‘Doctor, what are the risks of having an anaesthetic?’<br />These can be divided into two main groups.<br />
  57. 57. Minor<br />These are not life threatening and can occur even when anaesthesia has apparently been uneventful. They include:<br />• failed IV access;<br />• cut lip, damage to teeth, caps, crowns;<br />• sore throat;<br />• headache;<br />• postoperative nausea and vomiting;<br />• retention of urine.<br />
  58. 58. Major<br />These may be life-threatening events. They include:<br />• aspiration of gastric contents;<br />• hypoxic brain injury;<br />• myocardial infarction;<br />• cerebrovascular accident;<br />• nerve injury;<br />• chest infection<br /> Death<br />
  59. 59. Document the Visit<br />Complete the evaluation form<br />Enter progress notes<br />Have patient sign consent<br />Write appropriate orders<br />
  60. 60. Preanesthesia Clinic<br />
  61. 61. Questions?<br />