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Pbl 1   preop assesment
Pbl 1   preop assesment
Pbl 1   preop assesment
Pbl 1   preop assesment
Pbl 1   preop assesment
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Pbl 1   preop assesment
Pbl 1   preop assesment
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Pbl 1 preop assesment

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  • 1. History, examination and relevant investigations
  • 2. <ul><li>Such an assessment has four goals:- </li></ul><ul><li>to acquire the relevant information about the patient's state </li></ul><ul><li>to educate the patient </li></ul><ul><li>to diminish anxiety </li></ul><ul><li>to obtain informed consent from the patient for the proposed procedure. </li></ul>
  • 3. <ul><li>The assessment should determine:- </li></ul><ul><li>the nature and extent of the relevant surgical pathology </li></ul><ul><li>the nature and extent of any disease which might affect the conduct of the operation and postoperative course </li></ul><ul><li>Any specific problems that might affect choice of anaesthesia and postoperative care </li></ul>
  • 4. History <ul><li>Present illness (including age, sex, complaint, planned procedure, elective/ emergency?) </li></ul><ul><li>Past Medical History:- </li></ul><ul><li>List of medical problems </li></ul><ul><li>Medications, allergies, drug history, recreational drug use </li></ul><ul><li>Past surgeries, type of anesthetic used, anesthetic related problems </li></ul>
  • 5. <ul><li>Family History:- </li></ul><ul><li>Any anesthetic related problems </li></ul><ul><li>Social History:- </li></ul><ul><li>Smoking, alcohol, STDs, HIV etc </li></ul>
  • 6. Systemmic Review <ul><li>General:- </li></ul><ul><li>Vital signs </li></ul><ul><li>Exercise tolerance, weakness, fatigue, fever, weight changes, frequent headaches </li></ul><ul><li>Skin:- </li></ul><ul><li>Rashes, sores, lesions </li></ul><ul><li>Eyes:- </li></ul><ul><li>Double vision, blurring, glaucoma, cataract </li></ul>
  • 7. <ul><li>Ear:- </li></ul><ul><li>Tinnitus, vertigo, discharge </li></ul><ul><li>Mouth:- </li></ul><ul><li>Bleeding gums, dentures, loose teeth </li></ul><ul><li>Cardiovascular system:- </li></ul><ul><li>HPT, MI, CCF, RF, murmurs, angina, palpitations </li></ul><ul><li>PND, peripheral oedema </li></ul>
  • 8. <ul><li>Respiratory system:- </li></ul><ul><li>Cough, sputum, haemoptysis, asthma, TB </li></ul><ul><li>GI:- </li></ul><ul><li>Hiatus hernia, GERD, diarrhoea, constipation, haematemesis, maleana, jaundice, hepatitis </li></ul><ul><li>Urinary system:- </li></ul><ul><li>Frequency, urgency, nocturia, dysuria, haematuria, incontinence </li></ul>
  • 9. <ul><li>Female:- </li></ul><ul><li>LMP, likelihood of current pregnancy </li></ul><ul><li>Neurologic:- </li></ul><ul><li>Claudication, thrombophlebitis, seizure, stroke </li></ul><ul><li>Haematologic:- </li></ul><ul><li>Anaemia, past transfusions </li></ul><ul><li>Endocrine:- </li></ul><ul><li>Thyroid abnormalities, diabetes </li></ul>
  • 10. <ul><li>Psychiatric illness </li></ul><ul><li>Prosthetics </li></ul>
  • 11. <ul><li>The most common general assessment of fitness used by anaesthetists is the American Society of Anesthesiologists' (ASA) Physical Status Classification </li></ul>
  • 12. ASA Classification <ul><li>A normal healthy patient </li></ul><ul><li>A patient with mild systemic disease </li></ul><ul><li>A patient with severe systemic disease </li></ul><ul><li>A patient with severe systemic disease that is a constant threat to life </li></ul><ul><li>A moribund patient who is not expected to survive without the operation (E) </li></ul><ul><li>A declared brain-dead patient whose organs are being removed for donor purposes. </li></ul>
  • 13. Other Points to Consider Other than the ASA Classification <ul><li>To predict:- </li></ul><ul><li>operative risk </li></ul><ul><li>age and obesity of the patient </li></ul><ul><li>the nature and severity of the operative procedure </li></ul><ul><li>selection of anesthetic techniques </li></ul><ul><li>the competency of the surgical team (surgeon, anesthesia providers and assisting staff) </li></ul><ul><li>duration of surgery or anesthesia </li></ul><ul><li>availability of equipment, medicine, blood, implants and especially the level of post-operative care etc. </li></ul>
  • 14. APACHE II (&quot;Acute Physiology and Chronic Health Evaluation II&quot;) <ul><li>is a severity of disease classification system (Knaus et al., 1985) </li></ul><ul><li>A general measure of disease severity based on </li></ul><ul><ul><li>Current physiologic measurements </li></ul></ul><ul><ul><li>Age </li></ul></ul><ul><ul><li>Previous health condition. </li></ul></ul><ul><li>Scores range from 0-71 </li></ul><ul><li>Increasing score associated with an increasing risk of hospital death. </li></ul>
  • 15. <ul><li>APACHE II score = (acute physiology score) + (age points) + (chronic health points) Acute Physiology Score </li></ul><ul><li>1= Rectal temp (C) </li></ul><ul><li>2 = Mean arterial pressure (mmHg) </li></ul><ul><li>3 = Heart rate (bpm) </li></ul><ul><li>4 = Respiratory rate (bpm) </li></ul><ul><li>5 = Oxygen delivery (ml/min) </li></ul><ul><li>6 = PO2 (mmHg) </li></ul><ul><li>7 = arterial pH </li></ul><ul><li>8 = Serum sodium (mmol/l) </li></ul><ul><li>9 = Serum potassium (mmol/l) </li></ul><ul><li>10 = Serum creatinine (mg/dl) </li></ul><ul><li>11 = Haematocrit (%) </li></ul><ul><li>12 = White cell count (10 3 /ml) </li></ul>
  • 16.  
  • 17. Age Points <44 0 45-54 2 55-64 3 65-74 5 >75 6 History of severe organ insufficiency Points Non-operative patients 5 Emergency postoperative patients 5 Elective postoperative patients 2
  • 18.  
  • 19. Investigations
  • 20. Before Requesting Investigations <ul><li>Does the investigation detect conditions not found on history taking and physical examination which will affect perioperative management? </li></ul><ul><li>Do the investigations give a useful baseline for comparison in the postoperative phase? </li></ul><ul><li>What are the specificities and sensitivities of the investigation? </li></ul><ul><li>Are there medicolegal considerations for performing the investigations? </li></ul><ul><li>If the result is not available, will the operation be affected? </li></ul>
  • 21. <ul><li>A full blood count (FBC) is generally requested to detect anaemia, which may place the individual at risk from a general anaesthetic </li></ul><ul><li>Coagulation profile if necessary </li></ul>
  • 22. <ul><li>Full blood count </li></ul><ul><li>Major surgery. </li></ul><ul><li>Chronic bleeding. </li></ul><ul><li>History of anaemia. </li></ul><ul><li>Renal disease. </li></ul>Clotting screen 1 Clinical evidence of liver disease including a history of hepatitis. 2 Bleeding disorder. 3 Anticoagulants.
  • 23. Biochemistry <ul><li>All patients should have a dipstick urinalysis to measure glucose, bilirubin, protein and ketones. </li></ul><ul><li>In patients aged under 60 years, this is sufficient </li></ul>
  • 24. <ul><li>Serum sodium and potassium </li></ul><ul><li>hyperkalaemia can predispose to cardiac arrest, particularly if suxamethonium is given </li></ul><ul><li>hypokalaemia can lead to cardiac arrhythmias. </li></ul>
  • 25. <ul><li>Urea and electrolytes </li></ul><ul><li>Clinical evidence of renal disease. </li></ul><ul><li>Symptomatic cardiovascular disease. </li></ul><ul><li>Diabetes. </li></ul><ul><li>Drugs-Diuretics, digoxin, steroids </li></ul>
  • 26. <ul><li>Liver function tests </li></ul><ul><li>Clinical evidence of liver disease. </li></ul><ul><li>Chronic liver disease, including a history of hepatitis. </li></ul>
  • 27. Preoperative Chest X Ray <ul><li>to confirm or establish a diagnosis and </li></ul><ul><li>evaluate the extent of pathology </li></ul><ul><li>to establish a baseline for comparison with postoperative films </li></ul>
  • 28. <ul><li>Cardiorespiratory disease. </li></ul><ul><li>Possible pulmonary malignancy (primary or secondary). </li></ul><ul><li>Severe trauma. </li></ul><ul><li>Immigrants from countries with endemic TB. </li></ul>
  • 29. ECG <ul><li>Abnormalities are relatively common, between 47% and 52% and correlate with increasing age, male gender and physical status score (ASA). </li></ul><ul><li>According to Gold et al. of the patients with abnormal preoperative ECGs, only 1.6% experienced a perioperative adverse cardiovascular event </li></ul><ul><li>In only half of these was the preoperative ECG helpful. </li></ul>
  • 30. <ul><li>Patients older than 60 years undergoing major surgery. </li></ul><ul><li>Symptoms and signs of cardiovascular disease, including ischaemic heart disease or hypertension. </li></ul><ul><li>Symptomatic respiratory disease. </li></ul>
  • 31. Airway Assessment
  • 32. <ul><li>Difficult tracheal intubation accounts for 17% of the respiratory related injuries and results in significant morbidity and mortality. </li></ul><ul><li>Up to 28% of all anaesthesia related deaths are secondary to the inability to mask ventilate or intubate </li></ul>
  • 33. Difficult Airway <ul><li>Where there is a problem in establishing or maintaining gas exchange via a mask, an artificial airway or both </li></ul><ul><li>Anaesthetic factors which could predispose to a difficult airway are:- </li></ul><ul><li>oedema, burns, bleeding </li></ul><ul><li>tracheal/oesophageal stenosis </li></ul><ul><li>compression or perforation, pneumothorax </li></ul><ul><li>aspiration of gastric contents. </li></ul>
  • 34.  
  • 35.  
  • 36.  
  • 37. <ul><li>A global assessment should include the following: </li></ul><ul><li>Patency of nares : look for masses inside nasal cavity (e.g. polyps) deviated nasal septum, etc. </li></ul><ul><li>Mouth opening of at least 2 large finger breadths between upper and lower incisors in adults is desirable. </li></ul>
  • 38. <ul><li>Teeth : Prominent upper incisors, or canines with or without overbite, can impose a limitation on alignment of oral or pharyngeal axes during laryngoscopy </li></ul><ul><li>especially in association with a large base of tongue, they can compound the difficulty during the direct laryngoscopy or bag-mask ventilation. </li></ul><ul><li>An edentulous state, on the other hand, can render axis alignment </li></ul><ul><li>hypopharyngeal obstruction by the tongue can occur. </li></ul><ul><li>Palate : A high arched palate or a long, narrow mouth may present difficulty. </li></ul><ul><li>Assess patient’s ability to protrude the lower jaw beyond the upper incisors (Prognathism). </li></ul>
  • 39. <ul><li>Temporo-mandibular joint movement : It can be restricted ankylosis/fibrosis, tumors, etc. </li></ul><ul><li>Measurement of submental space (hyomental/ thyromental length should ideally be > 6 cm). </li></ul><ul><li>Presence of hoarse voice/stridor or previous tracheostomy may suggest stenosis. </li></ul><ul><li>Any systemic or congenital disease requiring special attention during airway management (e.g. respiratory failure, significant coronary artery disease, acromegaly, etc.). </li></ul>
  • 40. Hyomental Distance – 3 finger breadths Thyrohyoid distance – 2 finger breadths
  • 41. Six standards in the evaluation of airway <ul><li>Temporomandibular mobility – One finger </li></ul><ul><li>Inspection of mouth, oropharynx – Mallampati classification – Two fingers </li></ul><ul><li>Measurement of mento-hyoid distance (4 cm) in adult - three fingers. </li></ul><ul><li>Measurement of distance from chin to thyroid notch – (5 to 6 cm) – Four fingers </li></ul><ul><li>Ability to flex head towards chest, extend head at atlanto-occipital junction and rotate head, turn right and left (five movements). </li></ul><ul><li>Symmetry of nose and patency of nasal passage. </li></ul>
  • 42. Mallampatti Classification <ul><li>correlates tongue size to pharyngeal size. </li></ul><ul><li>Class I : Visualization of the soft palate, fauces; uvula, anterior and the posterior pillars. </li></ul><ul><li>Class II : Visualization of the soft palate, fauces and uvula. </li></ul><ul><li>Class III : Visualization of soft palate and base of uvula. </li></ul><ul><li>Class IV: Only hard palate is visible. Soft palate is not visible at all. </li></ul>
  • 43.  
  • 44. LEMON airway assessment <ul><li>The score with a maximum of 10 points is calculated by assigning 1 point for each of the following LEMON criteria: </li></ul><ul><li>L = Look externally (facial trauma, large incisors, beard or moustache, large tongue) </li></ul><ul><li>E = Evaluate the 3-3-2 rule (incisor distance-3 finger breadths, hyoid-mental distance-3 finger breadths, thyroid-to-mouth distance-2 finger breadths) </li></ul><ul><li>M = Mallampati (Mallampati score > 3). </li></ul><ul><li>O = Obstruction (presence of any condition like epiglottitis, peritonsillar abscess, trauma). </li></ul><ul><li>N = Neck mobility (limited neck mobility) </li></ul>
  • 45. Direct Laryngoscopy <ul><li>Grade I – Visualization of entire laryngeal aperture. </li></ul><ul><li>Grade II – Visualization of only posterior </li></ul><ul><li>commissure of laryngeal aperture. </li></ul><ul><li>Grade III – Visualization of only epiglottis. </li></ul><ul><li>Grade IV – Visualization of just the soft palate. </li></ul><ul><li>Grade III and IV predict difficult intubation. </li></ul>
  • 46.  
  • 47. Indicators of difficult intubation <ul><li>The classic signs altering the operator to difficulty of intubation may be summarised as follows: </li></ul><ul><li>Poor flexion–extension mobility of the head on neck. </li></ul><ul><li>A receding mandible and presence of prominent teeth. </li></ul><ul><li>A reduced atlanto-occipital distance, a reduced space between C1 and the occiput. </li></ul><ul><li>Large tongue size – related more to the ratio of the anterior length of the tongue to the length of the chin or mandible </li></ul>
  • 48. Preoperative Fasting Guidelines
  • 49. Preoperative  fasting guidelines <ul><li>The volume of liquid ingested is less important than the type of liquid ingested. </li></ul><ul><li>Intake of water up to 2 hrs before induction of anaesthesia. </li></ul><ul><li>Other clear fluids *, clear tea and coffee without milk up to 2 hrs before induction of anaesthesia. </li></ul><ul><li>Tea and coffee with milk are acceptable up to 6 hrs before induction of anaesthesia. </li></ul><ul><li>The volume of administered fluids does not appear to have an impact on patient’s residual gastric volume and gastric pH, when compared to a standard fasting regimen. </li></ul><ul><li>Therefore, patients may have unlimited amounts of water and other clear fluid up to two hours before induction of anaesthesia. </li></ul><ul><li>* In practice, a clear fluid is one through which newsprint can be read. </li></ul>
  • 50. <ul><li>The intake of solid foods </li></ul><ul><li>A minimum pre-op fasting time of 6hrs is recommended for food (solids and milk). </li></ul><ul><li>Fried or fatty meal 8hrs is recommended before induction of anaesthesia. </li></ul><ul><li>Chewing gum and sweets </li></ul><ul><li>Chewing gum should not be permitted on the day of surgery. </li></ul><ul><li>Sweets are solid food. A minimum of 6hrs pre-op fasting time is recommended. </li></ul>
  • 51. <ul><li>Higher-risk patients should follow the same pre op fasting regime as healthy adults, unless contraindicated. </li></ul><ul><li>Adults undergoing emergency surgery should be treated as if they have a full stomach. </li></ul><ul><li>If possible, the patient should follow normal fasting guidance to allow gastric emptying. </li></ul><ul><li>*High risk of regurgitation and aspiration; patients include those with obesity, gastro-oesophageal reflux and diabetes. </li></ul>
  • 52. Ingested Material Minimum Fasting Period Clear liquids 2hrs Breast Milk 4hrs Infant Formula 6hrs Non-human milk 6hrs Light meal 6hrs

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