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Pbl 1 preop assesment

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