The presentation deals with the basics of pre anesthetic checkups, its only for the educations purpose!
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2. ANESTHESIA
Anesthesia (from Greek an “without” aesthesis
“sensation”)The components of the anesthetic
state include
• unconsciousness
• loss of memory
• lack of pain
• immobility and attenuation of autonomic
responses to noxious stimulation.
3. PREOPERATIVE EVALUATION
• Defined as the process of clinical assessment that
precedes the delivery of anesthesia for surgery
and for non surgical procedures.
• It consists of the consideration of information of
multiple sources that may include the patient’s
interview, medical records, physical examination
and findings from medical tests and evaluations.
4. GOALS
• To ensure that the patient is in the best(optimal)
condition.
• Patients with unstable symptoms should be
postponed for optimization prior to elective
surgery.
• Anesthetic drugs and techniques have profound
effects on human physiology. Hence, focused
review of all major organ system should be done
prior to elective surgery.
8. Phase 1: History taking
• Demographic details,
• Presenting complaint (PC),
• History of presenting complaint (HPC),
• Past medical history (PMH),
• Previous anesthetic history-any h/o difficult intubation,any h/o allergy at
that time
• Drug history (DH),
• Family history (FH),
• Social history (SH),
• Systemic enquiry (SE),
8
9. Demographic details
• Date & time of examination,
• Patient’s name, DOB, Age, weight & address,
• Source of referral,
• Doctor’s name,
• Source of history: patient, relative, care taker
9
12. Airway
• Incidence of difficult
intubation reported to
range between 0.13 – 5.9%
• It can be predicted and
expert anaesthsiologist is
called for the case.
• Evaluation is the first step in
management of difficult
intubation.
13. AIRWAY CLASSIFICATION SYSTEM
MALLAMPATI SCORE
CLASS DIRECT VISULAISATION OF
AIRWAY
1 Full view of Soft Palate, fauces,
uvula, tonsillar pillars
2 Soft palate, fauces ,upper
portion of uvula
3 Soft palate ,uvular base
4 Hard palate only.
LARYNGOSCOPIC VIEW
Cormack lehane
CLASS LARYNGOSCOPIC VIEW
1 Entire glottic
2 Posterior commisure
3 Tip of epiglottis
4 No glottic structure.
14.
15. Airway evaluation
• Mentothyroid distance : normal 6 cm.
• Mentosternal distance : normal 15 cm
• Mentohyoid distance : normal 3 FB
• Neck movement: flexion and extension of
neck, history of radiation
• Nasal cavity
18. Difficult intubation
• Mouth opening less than 3 cm.
• Limitation of neck movement
• Micrognatia
• Macroglossia
• Protusion of teeth
• Short neck
• Morbid obesity
19.
20.
21. Airway Examination
Normal
– Opens mouth normally (Adults: greater than 2 finger widths or 3
cm)
–
– Able to visualize at least part of the uvula and tonsillar pillars with
mouth wide open & tongue out (patient sitting)
–
– Normal chin length (Adults: length of chin is greater than 2 finger
widths or 3 cm)
– Normal neck flexion and extension without pain / paresthesias
22. Airway Examination
Abnormal
– Small or recessed chin
–Inability to open mouth normally
–Inability to visualize at least part of
uvula or tonsils with mouth open &
tongue out
–High arched palate
–Tonsillar hypertrophy
–Neck has limited range of motion
–Low set ears
–Signficant obesity of the face/neck
23. Airway assessment: predictive tests
Sensitivity = 50-60%
• Mallampati modified test:
Visibility of pharyngeal structures.
• Patil test:
Thyro-mental distance <6.5cm
• Mandibular protrusion:
Class C : inability to protrude lower incisors beyond the upper.
• Wilson test.
• Radiological assessment of the mandible and cervical spine.
25. medical status mortality
ASA I normal healthy patient without organic, biochemical,
or psychiatric disease
0.06-0.08%
ASA II mild systemic disease with no significant impact on
daily activity e.g. mild diabetes, controlled
hypertension, obesity .
Unlikely to have
an impact
0.27-0.4%
ASA III severe systemic disease that limits activity e.g. angina,
COPD, prior myocardial infarction
Probable impact
1.8-4.3%
ASA IV an incapacitating disease that is a constant threat to
life e.g. CHF, unstable angina, renal failure ,acute MI,
respiratory failure requiring mechanical ventilation
Major impact
7.8-23%
ASA V moribund patient not expected to survive 24 hours e.g.
ruptured aneurysm
9.4-51%
ASA VI brain-dead patient whose organs are being harvested
ASA Physical Status Classification System
For emergent operations, you have to add the letter ‘E’ after the classification.
26. Cardiovascular system
• Pulse: rate, rhythm, character and volume,
• Blood pressure (BP),
• Jugular venous pulse (JVP): height and
character,
• Ankle edema: presence or absence,
Dr Resham B Rana, MD 26
27. Continue
• Inspection:
– any scar, abnormal vessels, lumps, chest shape, apex beat-
position,
–
• Palpation (localize technique):
– confirm apex beat, character, presence of thrills &
peripheral pulses on both sides,
• Percussion (technique):
– precordium- size of heart,
• Auscultation (technique):
– heart sounds, murmur,
28. H/O TO REVIEW OF THE ORGAN
SYSTEM
CVS
Symptoms of the following problems sought
in all patients.
Ischaemic heart disease
HTN
Heart failure
Conduction defect and arrythmia
Peripheral vascular disease
29. Patient with h/o of MI are greater risk of perioperative
reinfarction, the incidence of which is related to the time
interval between surgery and infarct.
The presence of unstable angina has been associated with a
high perioperative risk of MI.
The presence of active congestive heart failure has been
associated with an increased incidence of perioperative
cardiac morbidity.
30. REVISED CARDIAC RISK INDEX
(UNDERGOING ELECTIVE MAJOR NON CARDIAC
PROCEDURES)
1. High risk type of surgery
2. History of ischaemic heart disease
3. History of congestive heart failure
4. History of cerebrovascular disease
5. Preoperative treatment with insulin
6. Preoperative serum creatinine>2mg/dl
Rates of major complications with 0,1,2 or 3 of
these factors are 0.5,1.3,4 and 9% respctively.
31. The American heart association /American College of
cardiology task force on perioperative evaluation
of cardiiac patient undergoing noncardiac surgery
has definded three risk groups-
1 Major
2 Intermediate
3 Minor
They indicate that recent MI(<30 days)places patients in
the group of highest risk,after that period ,a prior MI
places the patient in the group at intermediate risk.
32. CLINICAL PREDICTORS OF INCREASED
PERIOPERATIVE CVS RISK(MI,CHF,DEATH)
• MAJOR
Unstable coronary sydromes
Recent MI with evidence of important ischaemic risk by clinical
symptoms or noninvasive study.
Unstable or severe angina
Decompensated congestive heart failure
Significant arrythmias
High grade AV block
Symptomatic ventricular aarythmias in the presence of underlying heart
disease.
Supraventricular arrythmias with uncontrolled ventricular rate.
Severe valvular disease.
33. • INTERMEDIATE
Mild angina pectoris
Prior MI by history or pathological Q wave
Compensated or prior CHF.
Diabetes mellitus.
34. • MINOR
Advanced age
Abnormal ECG (Left ventriculay hypertrophy,LBBB,ST-T
abnormalities)
Rhythm other than sinus(e.g- AF)
Low functional capacity (e.g- inability to climb one
flight of stairs )
History of stroke
Uncontrolled systemic HTN
35. Clinical Predictors of Increased
Perioperative Cardiovascular Risk
• Functional Capacity
– Metabolic equivalents
– 1 MET – Can you take care of yourself? Eat, dress,
use the toilet? Walk a block or two on level
ground 2-3 MPH
– 4 METs – Do light work around the house like
dusting or washing the dishes? Climb a flight of
stairs?
– >10 METs – Participate in strenuous sports like
swimming, singles tennis, football?
36. Clinical Predictors of Increased
Perioperative Cardiovascular Risk
• Functional Capacity
– Perioperative cardiac and long-term risks are
elevated in patients unable to obtain 4-MET
demand
– www.1000takes.com
37. HYPERTENSON
Untreated and poorly controlled HTN may lead
to exaggerated cardiovascular responses
during anesthesia.
Both HTN and hypotension can be
precipitated,which increase the incidence of
both mycardial and cereberal ischaemia.
38. BLOOD PRESSURE
CATEGORY SBP(MM HG) DBP(MM HG)
Optimal <120 and <80
Normal <130 and <85
High Normal 130-139 or 85-89
Hypertension
Stage 1 140-159 or 90-99
Stage 2 160-179 or 100-109
Stage 3 ≥180 or ≥110
39.
40. There is controversy regarding a trigger to delay or
cancel a surgical procedure in a patient with untreated
or inadequately treated hypertension.
It is less clear in patients with blood pressure above
180/100 mm hg ,although no absolute evidence exists
that postponing surgery will reduce risk.
In the absence of end organ changes,such as renal
insufficency left ventricular hypertrophy with strain,the
benfits of optimizing BP must be weighed against the
risk of delaying surgery.
41. • Aggressive treatment of BP is associated wih
increased reduction in long term risk,although
the effect diminishes in all but in diabetic patient
diastolic pressure is reduced to 90mmhg.
• Patient with BP of >180 mm hg systolic or 110 hg
diastolic are prone to develope perioperative MI,
venticular dysarrythmias, and lability in BP.
42. CORONARY ARTERY DISEASE
For those patients without overt symptoms or history the
probability of CAD varies with the type and number of
atherosclerotic risk factor present.
Pheripheral arterial disease has been associated with CAD
in multiple studies.
There is a high incidence of both silent MI and myocardial
ischaemia in diabetics.
43. CARDIAC RISK STRATIFICATION FOR NONCARDIAC
SURGICAL PROCEDURES IN PATIENTS WITH KNOWN
CORONARY ARTERY DISEASE
• HIGH
Reported cardiac risk often> 5%
1. Emergency major operations,particularly in the
elderly
2. Aortic and major vascular
3. Peripheral vascular
4. Anticipated proloned surgical procedures
associated with large fluid shifts and/or blood
loss.
44. • INTERMEDIATE
Reported cardiac risk gnerally <5%
1. Carotid endarterectomy
2. Head and neck
3. Intraperitoneal and intrathoracic
4. Orthopedic
5. prostate
45. • LOW
Reported cardiac risk generally < 1%
1. Endoscopic procedures
2. Superficial procedures
3. Cataract Surgery
4. Breast Ambulatory procedures
46. • Coronary Angiography
• Evidence of adverse outcome from non-invasive test
• Angina unresponsive to therapy
• Unstable angina, especially with intermediate or high
risk surgery
• Equivocal noninvasive test in high clinical risk patient
undergoing high risk surgery
50. Preparation For Anesthesia
• Continuing Current Medications/ Treatment of
Coexisting Diseases
It is the RESPONSIBILITY of the anesthesiologist
to instruct patients regarding which medications
to take and which to hold preoperatively.
51. Instruct Patients to take the medications with
small sips of water, even if fasting!
Medications to be Continued on the day of Surgery
1. Antihypertensives except ACE Is and ARBs
2. Cardiac medications e.g ᵦ- blockers, digoxin
3. Antidepressants, anxiolytics and other
psychiatric medications
4.Thyroid medications
5.Birth control pills, eye drops, heartburn or reflux
medications, narcotics, anticonvulsants, asthma
medications, Steroids, Statins,
52.
53. Aspirin
Consider selectively continuing aspirin in
patients where the risk of cardiac events is felt
to exceed the risk of major bleeding.
if reversal of platelet inhibition is necessary,
stop aspirin at least 3 days before surgery.
Do not discontinue aspirin if patients who
have drug eluting coronary stents until they
have completed 12 months of dual anti
platelet therapy.
54. Thienopyridines (Clopidogrel and Ticlopidine)
• Patients having Cataract Surgery – Do not need
to stop.
• If reversal of platelet inhibition is necessary,
then clopidogrel must be stopped 7 days
before surgery (Ticlopidine – 14 days)
• Do not discontinue Thienopyridines in Pt. who
have drug eluting stents before 1 year.
55. Medications to be discontinued
• Topical medications e.g creams and ointments
• Oral hypoglycemic agents ( on the day of Sx)
• Diuretics (on the day of Sx except Thiazide)
• Sildenafil ( Viagra) of similar drugs –
discontinue 24 hrs before Sx.
• NSAIDS – discontinue 48 hrs before Sx.
• Warfarin ( Coumadin) discontinue 4 days
before Sx
57. Pharmacological Agents to Reduce the
risk of Pulmonary Aspiration
• Histamine – 2 Receptor Antagonist : block the
ability of histamine to induce secretion of gastric
fluid with high hydrogen concentrations e.g.
Cimetidine, Ranitidine, Famotidine
• Antacids – neutralize the acid in gastric contents
• Proton pump inhibitors: supress gastric acid
secretion by binding proton pump of the parietal
cell
• Gastrokinetic Agents : Metoclopramide-
Dopamine antagonist.
58. Psychological Preparation
• Preoperative visit and interview with the patient
and family members,
• The anesthesiologist should explain anticipated
events and the proposed anesthetic
management in an effort to reduce anxiety and
diminish apprehension.
59. Pharmacological preparation
• To relief anxiety and production of sedation
• Prophylaxis against allergic reactions e.g. to
latex
• Prevention of Autonomic reflexes mediated
through the vagus nerve.
• Prevention of nausea and vomiting.
60. Benzodiazepines
• Produces anxiolysis, amnesia and sedations e.g.
Diazepam, Midazolam, Lorazepam
Diphenhydramine : histamine-1 receptor
antagonist, blocks the peripheral effects of
histamine, it has sedative, anticholinergic and
antiemetic activity.
Anticholinergics : (Atropine, glycopyrolate,
scopolamine)
1. Antisialogogue effect
2.sedation and amnesia
3. Vagolytic effect
61. Antibiotic Prophylaxis
• Cephalosporins are the most popular antibiotics
because they cover skin microbes,
• For intestinal Sx, anaerobic and Gram negative
coverage is needed.
• Antibiotics must be administered within 1 hr
prior to incision except :
Vancomycin should be given 2hr prior to incision
when tourniquet is used, the antibiotics should
be adminstered prior to its inflation.
62. Summary of the Patient Preparation
• The anesthesiologist who takes the time to
adequately prepare the patient medically and
psychologically for anesthesia and surgery will
find that their job of caring for the patient
intraoperative becomes easier, and they are
more likely to have a positive outcome as well
as a satisfied patient.
