PAC 19.07 seminar.pptx

seminar no. 11 date- 19/07/22
topic:
PREANAESTHETICCHECKUP ANDDOCUMENTATION
MODERATOR :
Dr. UMA MANDAL
SPEAKER :
Dr.KRISHANU MAJUMDAR

It is also known as Pre- Operative Evaluation
goals and benefits of pre- anaesthetic evaluation:
 To ensure,pt. can safely tolerate anaesthesia
 Mitigate perioperative risks.
 Documenting comorbid illness.
 Reducing the patient’s ( and family’s) anxiety
 Optimisation of previous medical condition and selective
referrals to specialists.
 Inteventions intended to decreae risk and arrange
appropriate levels of post-op care.

components of pre anaesthetic checkup :
 COMPLETE HISTORY
 PHYSICAL EXAMINATION
 GENERAL SURVEY
 SYSTEMIC EXAMINATION
 AIRWAY EXAMINATION

completehistory
 DEMOGRAPHIC DETAILS( name,age,sex,address &
ID)
CHIEF COMPLAINTS
PRESENT H/O
PAST MEDICAL HISTORY( required to optimise the pt.
before surgery)
PERSONAL H/O
FAMILY H/O

 PAST SURGICAL H/O
 MENSTRUAL H/O
 IMMUNIZATION H/O

DRUGS TO BE DISCONTINUED BEFORE SURGERY :

ANTI PLATELET DRUGS shouldnot be interupted in pt.
with coronary stents without consultation
 Low dose Aspirin should be continued to prevent cardiovascular
 thrombtoic events in the following cases :
1) pts. with prior PCI
2) pts. with coronary artery disease
3) pts, with stroke in the past 9 months
also,
aspririn should be continued in pts, requiring
CABG

Unfractionated Heparin 6 hours
LMWH- prophylactic
dose
12 hours
LMWH - therapeuitc
dose
24 hours
Minimal interval between the last doseand surgery

When to stop WARFARIN?
Pts. with high risk for thrombosis-- warfarin should be
stopped 4-5 days pre-op and LMWH is used till the day
before (24hours) surgery
Pts. with lower risk for thrombosis may have warfarin
discontinued 4-5 days pre-op and then reinitiated after
succesful surgery
warfarin may be continued in pts. posted for cataract
surgery without bulbar block

DRUGS THAT CAN BE CONTINUED ON THE DAY OF SURGERY

PERSONAL HISTORY :
SMOKING - Should be discontinued atleast 6-8 weeks before
operation

> ALCOHOL : Acts as an enzyme inducer
STOP 24-48 hours prior to surgery
>TOBACCO CHEWING : Restricted mouth opening
difficulty in intubation
>DRUG ABUSE : (eg : heroine,LSD they acts as an exciting agent )
STOP atleast 2Months prior to surgery

FAMILY HISTORY :
MALIGNANT HYPERTHERMIA :
> rare disease
> sustained muscle contraction
Presents as LOCKED JAWS
> Family H/O of massive cardiac arrest and death on surgery
table
ALLERGY HISTORY :
It can cause ANAPHYLACTIC SHOCK

PRE-OPERATIVE FASTING RECOMMENDATIONS :
ABOVE 1 YEAR OF AGE INFANTS / NEONATES
1. 2Hrs - CLEAR FLUIDS 1. 4Hrs - BREAST MILK
2. 6Hrs - LIGHTER MEAL/ MILK 2. 6Hrs - SOLIDS/FORMULA
FEEDS/COW’S MILK
3. 8Hrs - FRIED/ FATTY FOOD

ASSESSMENT OF FUNCTIONAL
CAPACITY :
Done by using MET (METABOLIC
EQUIVALENT OF TASK )
1MET Amount of 02 consumed
while sitting at rest,
equivalent to O2 consumption
of 3.5 ml/min/kg BW

>DASI
estimated METS (0.43* DASI) + 9.6
3.5
>6 min walk test /incremental walk
test
>ECG EXCERCISE TESTING
> CPET

PHYSICAL EXAMINATION :
1. GENERAL SURVEY
• Spine (kyphoscoliosis etc )
• Perpheral venous access
• Neck glands/thyroid gland etc
• Dentition,
• Oedema,JVP
• Auscultation & inspection of Pulomnary system.
• Basic neurological examination
2.ARTERIAL BLOOD PRESSURE
3. HR,RR
5. OXYGEN SATURATION
6. HEIGHT, BODY WEIGHT,BMI
7. BASIC ANATOMY

AIRWAY examination:
ASSESSMENT OF CERVICAL AND
ATLANTO-OCCIPITAL JOINT FUNCTION :
 Assess the neck flexion movement
 For atlanto occipital joint extension
( Reduction of A-O extension : No reduction,1/3rd,2/3rd, complete
reduction)

ASSESSMENT OF TEMPOROMANDIBULAR JOINT (TMJ) FUNCTION
1) if done , this is >5 cm and is adequate
for direct laryngoscopy
2) sliding function of the mandible
CALDER TEST -MANDIBLE
PROTRUSION TEST

ASSESSMENT OF MANDIBULAR SPACE :
THYROMENTAL DISTANCE -
distance between thyroid notch and mental
symphisis when neck is fully extended
>6.5cm - No problem
6-6.5cm - difficult but possible
<6.0cm - laryngoscopy may be impossible
HYOMENTAL DISTANCE
distance between mentum and hyoid bone :
GRADES I - >6CM
II - 4-6cm
III - <4cm

ASSESSING THE ADEQUACY OF OROPHARYNX:
1. MALLAMPATI GRADING ( SAMSOON & YOUNG’S MODIFICATION)
GRADE I - faucial pillars,uvula,soft and
hard palate visible
GRADE II - uvula,soft palate and hard
palate visible
GRADE III - base of the uvula or
none,soft and hard palate visble
GRADE IV - only hard palate visble
2.NARROWNESS OF THE PALATE : a very narrow,high arched palate
offers very little space for laryngoscopy and simultaneous
endotracheal intubation

THYROID - FLOOR OF MOUTH DISTANCE :
>larynx is normally placed
if pt. can place 2 fingers between top of
thyroid artilage and floor of the mouth
Ratio of the pt. height to thyromental distance :
if < 23.5, an easy laryngoscopy may be anticipated
STERNOMENTAL DISTANCE :
Measured with head in full extension and
mouth closed
sternomental distance of <12.5cm - predicts
difficult laryngoscope intubation

PRE-OP ASSESSMENT IN GERIATRIC POPULATION :
• FRAILTY
• ANXIETY,DEPRESSION,SUBSTANCE
ABUSE,SOCIAL ISOLATION etc

PRE-OP LABORATORY INVESTIGATIONS :
INVESTIGATIONS Ref. Intervals INVESTIGATIONS Ref Intervals
1 Hb 13-17g/dl 8 Na 135-145 mmol/l
2 TLC 4000-10000/cu.mm K 3.5-4.5mmol/l
3 DLC :N 40-80 % Mg 0.6-1 mmol/
L 20-40% HCO3 24-28 mmol/l
E 2-10% Cl 96-106mmol/l
B 0-1% 9 Platelet count : 1.5-4 lakhs/cu.mm
4 ESR 25 mm/hr 10. BT
CT
2-8mins
3-8mins
5 Glucose Fasting 70-100mg/dl 11 PT time 11-14sec
Post Pranadial upto 140mg/dl APTT 30-34 sec
HbA1c 5-5.7% 12 INR 1.2
Ur,Cr 12-40,0.7-1.2mg/dl 13 C XRAY
6 TSH 0.4-4 mIU/L 14 ECG
7. T3,4 0.8-2.8,100-200ng/dl 15 other relevant
inv

SYSTEMIC EXAMINATION :
1.CARDIOVASCULAR SYSTEM

PRE-OP CARDIAC RISK ASSESSMENT

 CORONARY STENTS/ PROSTHETIC HEART VALVES
 HEART FAILURE

CHA2DS2-VASc SCORE (RISK OF STROKE IN AF )

PULMONARY
DISORDERS
 ASTHMA
 COPD
 PULMONARY
HYPERTENSION
 SMOKERS AND
 SECOND HAND
SMOKERS
 URTI
 CYSTIC FIBROSIS
 OBSTRUCTIVE SLEEP
APNEA

ENDOCRINE DISORDERS
DIABETES
MELLITUS
TYPE 1 DIABETES TYPE 2 DIABETES
ONSET Usually during
chilhood ;
develops rapidly
Frequently after 35 ;
develops gradually
DEFECT b cells are
destroyed
INSULIN resIstance +
inabilty of beta cells to
produce appropirate
quantity of insulin
PLASMA
INSULIN
Low to absent high early in disease ;
low in disease of long
duration
T/T WITH
OHA
UNRESPONSIVE RESPONSIVE
COMPLICA
TION
KETOACIDOSIS HYPEROSMOLAR COMA
OBESITY UNCOMMON COMMON

THYROID DISORDERS
> HYPO/HYPERTHYROIDISM
>If pre-op testing is indictaed : TSH> T4,T3
>If mod/severe hypothyroidism( TSH free T4 )
postpone surgery until the pt. is euthyroid
>If overt hyperthyroidism ( TSH T4 or T3 )
postpone surgery until the pt. is euthyroid

> MULTIPLE ENDOCRINE NEOPLASIA
> PHEOCHROMOCYTOMA
> KIDNEY DISEASE
PAC TESTS : UREA,CREATININE
> HEPATIC DISORDERS :
PAC TESTS : ALT,AST,ALBUMIN
DISORDERS - HEPATITIS
OBSTRUCTIVE JAUNDICE
ELEVATED LFT
CIRRHOSIS
MISCELLANEOUS

PREDICTORS OF POOR PERI-OP OUTCOME IN
PTS.WITH LIVER DISEASE

HEMATOLOGICAL DISORDERS
> PAC tests : CBC , PT,INR,BT,CT
> DISORDERS : ANEMIA
SICKLE CELL DISEASE
G-6 PHOSPHATE DEHYDROGENASE DEF
COAGULOPATHIES
HEMOPHILIAS
THROMBOCYTOPENIA
VON WILLIBRAND DISEASE
POLYCYTHEMIA
THROMBOEMBOLISM
THROMBOCYTOPENIA

NEUROLOGICAL DISEASE :
> SEIZURE DISORDER
> MULTIPLE SCLEROSIS
> PARKINSON DISEASE
> NMJ DISORDERS
> MUSCLE DYSTROPHIES AND MYOPATHIES
> CNS TUMOURS
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDER :
>RA
>ANKYLOSING SPONDYLITIS
> SLE
>SYSTEMIC SCLEROSIS ETC

CANCERS AND OTHER CONDITIONS :
> PTS. WITH CANCER
> MEDIASTINAL MASSES
> VON HIPPEL LINDAU
> CARCINOID TUMOURS
> PSEUDOCHOLINESTERASE DEF
> TRANSPLANT CASES
> PT WITH ALLERGIES
> HIV
> PT WITH SUBSTANCE ABUSE

NEED FOR DOCUMENTATION ;
 To facilitate appropriate plannong before the surgery.
 Provides guidance for future encounter of the patient.
 Assess the quality of care that was given.
 To provide risk adjustment of outcomes.
 To justify the cost and duration of hospitalisation .
 For research and thesis purpose.
 Documentation supports a potential defense case /Medicolegal.

(8)Intraoperative monitoring
& documentation
Moderator:-
Dr. Nandita Biswas
Presented by:-
Dr. Madhabi roy

Subtopics:-
 Definition & importance of intraoperative
monitoring.
 ASA monitors
 Special monitoring (systemic monitoring)
 Monitored Anesthetic Care (MAC)
 Post Anesthesia Care Unit (PACU)
 Documentation of Intraoperative monitoring

Definition:-
 Intraoperative monitoring is the measurement
repeated regularly of patient’s physiological
status and the disturbances with regard to
normal functioning of several body systems
that he/she is going through during a surgical
procedure.

Why do we need IOM??
 To maintain the normal patient physiology & homeostasis throughout
anaesthesia & surgery.
 To combat surgery induced stress in terms of sympathetic stimulation
& assess the functioning of specific parts of nervous system.
 To smoothen the anaesthetic drugs induced hemodynamic instability,
myocardial depression, hypotension, arrhythmia etc.
 To recognize intraoperative blood loss & the subsequent need for
blood transfusion.
 To take care of the hypo or hyperventilation as well as the airway
patency.

Parameters of ASA monitoring:-
1.Pulse oximetry:
 Based on BEER-LAMBERTS LAW.
 A typical pulse oximeter utilizes an electronic
processor & a pair of small LEDs facing a
photodiode through a transluscent part of
pt’s body, usually a fingertip or earlobe.
 Normal SpO2 :- 97-100%

Limitations:-
 Pulse oximeter only measures the percentage of bound
hemoglobin.
 Erroneously high/low reading is seen in case hemoglobin
binds to something else other than oxygen, e.g. CO,
Cyanide & Methemoglobin etc.
 Other causes of erroneously low readings are –
Hypoperfusion of extremity d/t cold or vasoconstriction,
incorrect sensor application, highly calloused skin or may be
due to shivering.

2.Capnography:-
 It is the monitoring of end tidal (expired) CO2
which reflects fundamental physiological
process.
 Luft developed principle of capnography in
1943.
 2 types – Sidestream & Mainstream.
 Normal End-tidal CO2 :- 35-45 mmHg.
 Normal shape :- Tophat shape.
 Principle used :- Infra-red spectrography.

Phase 1- Exhalation of dead space gases.
Phase 2 – Sharp rise in CO2 concentration,
signifies transition b/w airway & alveoli.
Phase 3 – Plateau phase with slight upstroke,
due to ventilation- perfusion mismatch.
Phase 4 /0 – Inspiratory phase, inspiration of
fresh gas into the sampling site.
Phases in capnographic curve:-

Clinical uses of EtCO2 :-
1.Surest sign of intubation.
2.Intraoperative displacement & disconnection of ET tube,
cardiac arrest – flat capnograph.
3.Venous air embolism-decreased CO2.
4.Malignant hyperthermia, exhausted soda lime- increased
CO2.
5.Bronchospasm – Shark-fin wave.
6.Monitoring performace CPR.

3.Blood pressure monitoring:-
 Non-invasive BP-
 By Sphygmomanometry
• Palpatory
• Oscillatory
• Auscultatory
 Mean blood pressure – indicates
perfusion of different organs.
 MAP= Diastolic BP+ 1/3 (SBP-DBP)

Invasive BP monitoring:-
Indications –
• Major surgeries
• Ionotrope infusion
• For repeated ABG sampling
Sites for monitoring –
• Radial – easily accessible (Allen’s test is mandatory)
• Ulnar – if multiple failure of radial artery cannulation
• Brachial – good collaterals distally
• Axillary – comfort mobility & mimics central waveform
• Femoral – largest vessel for cannulation.
• Dorsalis pedis, post.tibial & sup.temporal – paediatric age.

Lead 2 is along the cardiac axis – to detect
Arrhythmia.
Lead V5 – to detect Ischaemia.
5.Pulse Rate:
 Pulse rate can be monitored with the help of
pulse oximeter as well as the ECG monitor & it
represents the number of heart beats per minute.
 Normal adult PR ranges b/w 60-100 bpm.
4.ECG monitoring:

6.Temperature monitoring:-
 Sites for core temperature:-
• Pulmonary artery (most accurate)
• Tympanic membrane (most accurate for brain temp.)
• Nasopharynx
• Lower esophagus (best for core body temp.)
• Oral cavity, Axilla, Rectal, Bladder, skin

Hypothermia
 Most common thermal abnormality during anaesthesia is
Hypothermia.
 Causes of Hypothermia:-
• Vasodilatation by Anaesthetics
• Decrease room temp.
• Evaporation
• Cold i/v fluids

Rx of intra-op Hypothermia:-
• Warm i/v fluids
• Blankets
• Forced air by Bair-hugger
 Induced Hypothermia:-
• For brain protection
• Protection against tissue ischaemia during cardiac surgery

Special monitoring:-
1.NIRS & ICP monitoring:
 Used for number of neurological conditions & intracranial
surgeries.
 Invasive: EVD, IPM a/k/a Bolts & continuous brain tissue
oxygen tension(PbO2).
 Non-invasive: Transcranial doppler(TCD) & Optic nerve
sheath diameter (ONSD).
 Cerebral oximetry uses Near Infra-red
Spectroscopy(NIRS)which reflects the absorption of venous
hemoglobin.

 CNS monitoring:-
 To assess the depth of anaesthesia.
 Signs of Light anaesthesia:
• Movement response
• Increase in BP, Tachycardia, Sweating, Lacrimation
• Tachypnoea , eye lash response
• Patent reflexes (can be preserved in case of ketamine)

Electrophysiological monitors:-
a.Evoked responses:-
Persistent evoked responses
indicates light anaesthesia.
b.EEG:- Beta waves indicate
light anaesthesia.

c.Bispectral index:-
 The bispectral index is a statiscally based
parameter.
 It analyses EEG waves & helps to monitor the
depth of anaesthesia.
 It gives a numerical value b/w 0 to 100, where
0 is  Deeply anaesthetized & 100 is  Fully
awake.
 Score of 40-60 is considered as adequate
depth.

d. Entropy monitoring:-
 It is a relatively new method of assessing
anaesthetic depth.
 It relies on a method of assessing the
degree of irregularity in EEG signals.

2.Central venous pressure
monitoring:-
Tells about functioning of right heart
(cardiac filling pressure)
Technique – Seldinger technique.
Site of injection – Right IJV (most
common), Left IJV, Subclavian v.,
Femoral v.,Axillary v.,PICC line etc.

Indications of CVP:-
 CVP monitoring for major surgeries
 PCWP monitoring
 Pacing
 Dialysis
 Aspiration of emboli in case of intracranial surgery
 Repeated sampling in ICU patients
 Drug trauma etc.

Pulmonary artery
catheterization is done with Swan-
Ganz catheter.
Helps to assess the functioning
of left side of the heart specially
left atrial pressure.
PCWP > 25 mmHg, leads to –
Left atrial failure, Pulmonary
edema.
3.PCWP:-

Clinical uses:-
 Cardiac pressure chamber monitoring
 For mixed venous oxygen saturation
 For cardiac output/ cardiac index
 For fluid titration

4.Echocardiography:-
 Transesophageal ecgocardiography:
• Most sensitive for wall motion
abnormality(ischaemia) & air embolism
• Most sensitive monitor for cardiovascular
monitoring.
• Has a very high sensitivity to locate a blood clot
inside the LA.
• May require sedation or general anaesthesia &
fasting.

5.ABG :-
 Usually the sample is
taken from Radial
artery preferably in a
heparinized glass
syringe.

 Neuromuscular monitoring:-
 It is done to assess the muscle power.
 It involves the application of electrical stimulation to
nerves & recording of muscle response, by
measuring the amplitude of contraction.
 Indicate muscle paralysis on administration of
muscle relaxant, no contraction even after
stimulation of nerve.
 Most common nerve used – Ulnar nerve.

Train of four stimulation:-
• 4 supramaximal stimuli of 2 Hz
every 0.5sec are applied over
2sec interval, repeated every 10-
12 sec.
• The ratio b/w 4th & 1st response
is called the TOF count or TOF
ratio.

Normal TOF ratio is 1
TOF ratio >0.9 is the
objective sign of
adequate reversal &
patient can be
extubated.
TOF can differentiate
b/w DMR & NDMR.

Monitoring of patient positions:
No
Image
Proper positioning during
intra-op.avoids injuries &
facilitates surgical exposure.
Intra-op monitoring of
patient position is critical in
terms of various nerve
injuries related to
inappropriate positioning &
avoidance of many
debilitating outcomes.

Monitored anaesthesia care
 Previously called conscious sedation.
 It is a combination of local/regional anaesthesia with i/v
sedation & analgesic drugs under monitor by the
anaesthetist.
 Generally done for short, minor, day care procedures.
 Pre-op assessment:-
• Fasting status, detailed history & examination, ability of the
patient to remain motionless & if necessary to actively
cooperate.

Specialized unit to provide care to
patients who have undergone
anaesthesia for any procedure.
To ensure successful & faster
recovery as well as to reduce post-
op mortality rate.
PACU:

Intra operative documentation:
 Pre-op check of anaesthesia machine & other relevant equipments
 Re-evaluation of patient prior to induction of anaesthesia
 Time of administration, route & dosage of drugs given intra-op
 Intra-op estimation of blood loss & urinary output
 Results of lab reports obtained during operation
 i/v fluid & any blood products administered
 Pertinent procedure notes, e.g. ET intubation, invasive monitors etc.
 Any specialized intra-op technique such as hypotensive anaesthesia,one lung ventilation
etc.
 Timing & conduct of intra-op events
 Unusual events or complications
 Condition of the patient at the time of hand-off to postanaesthesia or ICU unit.

SEMINAR NO: 9 date :10/06/22
TOPIC: ASSESSMENT OF AIRWAY & CAUSES OF DIFFICULTAIRWAYS :
DI/DV/DI + DV
MODERATOR :
Dr. D. SARKAR
SPEAKER :
DR. KRISHANUMAJUMDAR

q.what is an airway?
It is the passage through which air/gas passes
during respiration.It may be divided into upper and
lower airway
UPPER AIRWAY-
> MOUTH (extends from mouth opening to Ant.
tonsillar pillars )
>NOSTRILS ( the dist from alae nasi to various
points on the ext. ear are used to estimate the
length of airway devices )
> NASAL CAVITY -FLOOR,ROOF,LAT AND MEDIAL
WALL ( fracture of roof leads to rhinorrhea,is a C/I
for nasal intubation and ryle’s tube )

>PHARYNX : extends from skull base to
loweborder of cricoid cartilage
>NASOPHARYNX : from post. turbinates to post.
pharyngeal wall above the soft palate
>OROPHARYNX : from soft palate above to
epiglottis below,anteriorly from tonsillar pillar
to post.pharyngeal wall.
>LARYNX : extends from laryngeal inlet to
lower border of cricoid cartilage
LOWER AIRWAY includes the trachea,
bronchi, bronchioles which
terminates into alveoli

DIFFICULT AIRWAY :
acc to ASA,the clinical situation in which a conventionally trained
anaesthesiologist experiences difficulty with mask
ventilation,difficulty with tracheal intubation or both .
DIFFICULT MASK VENTILATION :
the ASA Task Force defined it as occuring when,
It is not possible for an unassisted anaesthesiologist to maintain 02
saturation >90% using 100% O2 and post. pressure mask ventilation
in a pt. whose oxygen saturation was >90% before anaesthetic
intervention; and/or it is not possible for the unassisted
anaesthesiologist to prevent or reverse signs of inadequate
ventilation during PPMV

DIFFICULT LARYNGOSCOPY :
acc to ASA Task Force,
It is not possible to visualise any portion of the vocal cords with
conventional laryngoscope,usually corresponds to Cormack &
Lehane’s Grade IV laryngoscope view.
DIFFICULT ENDOTCHEAL INTUBATION :
acc to ASA Task Force :
Proper insertion of the tracheal tube with conventional laryngoscopy
requires >3 attempts or >10 mins.
CANADIAN AIRWAY FOCUS GROUP

PATIENT EVALUATION FOR DIFF MASK VENTILATION :
during any excercise of airway management, the ability to ventilate
a pt remains one of the most crucial events.
Ability to ventilate ,failure to intubate the trachea doesnot end up in
disaster since the pt. can always be woken up .
factors for difficult mask ventiltion :
INDIVIDUAL INDICES GROUP INDICES

INDIVIDUAL INDICES
1.BEARD : creates difficulty in creating
an effective seal by mask.Spreading
opsite film over the beard or vasoline
has been recommended to improve
mask seal
2. OBESITY : Pts. with BMI ( >26kg/m2) are often at a greater risk of
difficult mask ventilation, they also require larger force during
ventilation and have functional residual capacity.
3. ABNORMALITY OF TEETH :Pts. with irregular/artifical denture or
who are edentulous offer poor fit for the connventional mask vent.
4. ELDERLY : pts. with age >55yrs may be difficult to mask ventilate

5.SNORERS : Pts. with h/o of snoring may pose problems during face
mask ventilation.
Application of gentle but continous Postv airway pressure (5-10 cm
H20 ) while ventilating may help in keeping airway patent
6.HAIRBUN : placing pts with bun in sinffing postition is
difficult as it prevents extension of
atlanto occipital joint
7. JEWELRY AND FACIAL PIERCING : It is recommended
to remove them prior to the procedure and restore
them at the end,if requested .

GROUP INDICES
1. BONES : 5 individual predictors have been grouped together
B- BEARDED INDIVIDUAL
O- OBESITY (BMI>26 kg/m2)
N- NO TEETH
E- ELDERLY ( AGE > 55yrs)
S- SNORER
Pts. having >/= 2 of these predictors are likely to have difficult mask
ventilation

2. MOANS : nearly identical to BONES except it includes all possible
anatomical features which may make mask fit difficult
M - Mask seal may be difficult/impossible in pts with receding
mandible, syndromes with facial abnormalities,burn strictures etc
O - OBESITY ( BMI >26kg/m2) or upper airway obstruction
A - Advanced age
N - no teeth
S - Snorer

PREDICTING DIFFICULT PLACEMENT OR POOR VENTILATION IN
RELATION TO USE OF SUPRAGLOTTIC DEVICE :
RODS :
R - RESTRICTED MOUTH OPENING
O -OBSTRUCTION OF UPPER AIRWAY
D -DISRUPTED UPPER AIRWAYS ( TRAUMA,BURNS etc)
S -STIFF LUNG ( POOR LUNG OR THORACIC COMLIANCE )

PREDICTING DIFFICULTY IN CREATING SURGICAL AIRWAY :
BANG
B BLEEDING TENDENCY INHERENT OR AS A RESULT OF
ANTICOAGULANTS
A AGITATED PATIENT
N NECK SCARRING, NECK FLEXION DEFORMITY
G GROWTH OR VASCULAR ABNORMALITIES IN THE REGION OF
SURGICAL AIRWAY

FACTORS RESPONSIBLE FOR DIFFICULT AIRWAY IN PEDIATRIC
POPULATION
1.ANATOMICAL
> Smaller size
> Vocal cord between C1-C4 with an anterior
angulation
>Large and floppy epiglottis
>Large occiput
2. PHYSIOLOGICAL
> Frequent upper airway obstruction under GA
> higher metabolism,smaller FRC, faster desaturation during
period of apnea
3.Pre-op assessment difficulties especially in children <3 years
4. Awake fibreoptic intubation is usually not an option
5. Regional anaesthesia is often not an option

SYNDROMES ASSOCIATED WITH DIFFICULT AIRWAY MANAGEMENT
IN CHILDREN
1. PIERRE ROBIN SYNDROME
2. TREACHER COLINS SYNDROME
3. GOLDENHAAR SYNDROME
4.DOWNS SYNDROME
5. EDWARD SYNDROME
6.CRI DU CHAT SYNDROME
7. MUCOPOLYSCCHARIDOSIS
8. KENNY- CAFFEY SYNDROME
9.SCHWARTZ JAMPEL SYNDROME
10.FREEMAN- SHELDON SYNDROME

why do we needairway assessment ?
The purpose of undertaking airway assessment is to diagnose the
potential for difficult airway for :
 1. Optimal patient preparation
 2. Optimal selection of equipment and technique
 3. Participation of the personnel experienced in the difficult
airway management
 4. Also, it avoids time consuming,invasive and potenially more
traumatic methods of securing the airway

componenets of airway assessment ?
1.HISTORY TAKING
> Previous anaesthesia record may reveal a h/o of
difficult airway
> H/O of prevs surgery, burns,trauma or tumour in
and around the neck,oral cavity or cervical spine
should be asked
2.GENERAL EXAMINATION
> Anatomic factors that cause difficult laryngoscopy and intubation
> identify physiological and pathological factors that may impair
laryngoscopy and intubation
3. Specific tests/ indices

airway assessment
INDIVIDUAL INDICES GROUP INDICES
 Physical examination indices
 Radiological indices
 Advanced indices

INDIVIDUALINDICES
physical examination indices :
ASSESSMENT OF CERVICAL AND
ATLANTO-OCCIPITAL JOINT FUNCTION :
1.Direct Assessment :
 Assess the neck flexion movement by asking the pt. to touch his
manubrium sterni with his chin(If done- assures neck flexion of 25-
35’)
 For atlanto occipital joint extension, ask the pt. to look the ceiling
without raising the eyebrows.
 ( Reduction of A-O extension : No reduction,1/3rd,2/3rd, complete
reduction)
 DELIKAN’S TEST

2. INDIRECT ASSESSMENT :
 Approx. 1/3rd of long term juvenile diabetic pts. present with
laryngoscopic difficulties due to “stiff joint syndrome”
 to assess difficulties in such pts, PALM PRINT TEST is used :

ASSESSMENT OF TEMPOROMANDIBULAR JOINT (TMJ) FUNCTION
1. Ask the pt. to open his mouth wide
and place his three fingers in the
opening
( if done , this is >5 cm and is adequate
for direct laryngoscopy )
2. Place index finger in front of the
tragus and thumb in front of lower part
of mastoid process .Ask the pt to open
his mouth, as the condyle of the mandible slides forward,index finger
can be indented in this space ( if done suggests good sliding function
of the mandible )
CALDER TEST

ASSESSMENT OF MANDIBULAR SPACE :
space ant. to larynx can be expressed as:
1. THYROMENTAL DISTANCE -
distance between thyroid notch and mental
symphisis when neck is fully extended
>6.5cm - No problem
6-6.5cm - difficult but possible
<6.0cm - laryngoscopy may be impossible
2. HYOMENTAL DISTANCE
distance between mentum and hyoid bone :
GRADES I - >6CM
II - 4-6cm
III - <4cm

ASSESSMENT FOR QUALITY OF GLOTTIC VIEWING:
1.INDIRECT MIRROR LARYNGOSCOPIC VIEW
> Complete vocal cords visble
> Posterior commisure visible
>Epiglotis visible
>No glottic structures visible
2. DIRECT LARYNGOSCOPY “AWAKE LOOK” :
COOK’S
GRADING

3. GRADING EASE OF INTUBATION :
GRADE I- No extrinsic larynx manipulation required
II- External manipulation of larynx is necessary to intubate
III- Intubation possible only when added with stylet
IV- Failed intubation
4. PERCENTAGE OF GLOTTIC OPENING(POGO) :
seen while directly visualising through scope
POGO 33% - if only lower third of vocal cords and arytenoids are
visible

THYROID - FLOOR OF MOUTH DISTANCE :
> tells about the position of larynx in neck
>larynx is normally pklaced if pt. can place 2 fingers between top of
thyroid artilage and floor of the mouth
Ratio of the pt. height to thyromental distance :
if < 23.5, an easy laryngoscopy may be anticipated
STERNOMENTAL DISTANCE :
Measured with head in full extension and
mouth closed
sternomental distance of <12.5cm - predicts
difficult laryngoscope intubation

GROUP INDICES:
1. WILSON’S SCORING SYSTEM :
SCORE
</= 5 - easy
laryngoscopy
6-7 -moderate
difficulty
8-10 -severe
difficulty

2.BENUMOF’S 11 PARAMETER ANALYSIS :

3. ROCKE ET AL (1992) COMBINED
MALLAMPATI GRADING :
>/= 2 risk factors if present are multiplied to give the actual
risk probability

4. ARNE’S SIMPLIFIED
SCORE MODEL (1998) :

5.RAPID AIRWAY ASSESSMENT : Im an emergency situation, 1-2-3
finger assessment may be rapidly performed to assess TMJ function,
mouth opening & mandibular space
> 1 Finger test
> 2 Finger test :if done,
this is >3cm and adequate
for 2 cm flange of direct
laryngocope
> 3 Finger test

radiological indices :
Lateral xray of head neck along with distance marking between bony
landmarks has been used to predict diff laryngoscopy
1. Ratio of effective mandibular length to its
post depth <3.6
predicts diff intubation/laryngoscopy
2.Reduced dist between occiput and spinous
process of C1 <5mm
3. post. depth of mandible >2.5cm poses
problem during intubation/laryngoscopy

ADVANCEDINDICES:
1.FLOW VOLUME LOOP 2.ACOUSTIC RESPONSE 3. MRI
Relies on the pattern of
sound wave reflection
from the upper airway in
respponse to incident
sound wave, based on this
Vocal cord ( zone I)
Thyroid isthmus (zone II)
Suprasternal notch
( zone III)
Saggital MRI of
the upper
airways may be
valule in
specialised
cases

AIRWAYASSESSMENTIN PEDIATRICPOPULATION:
1. HISTORY
>C/O snoring,apnea,day time somnolence,stridor,hoarse voice &
prior sx. or radiation t/t to face/neck
>review of prevs. anaesthetic record with H/O of
injury,postponement of sx. following an anesthetic etc.
2.PHYSICAL EXAMINATION :
Evaluate the anatomy
Presence of retractions( suprasternal/sternal/infrasternal/intercostal)
BREATH SOUNDS - Crowing on inspiration indicates extrathoracic whereas Noise on
exhalation is due to intrathoracic lesions,whereas Noise on both insp and exp
indicates thoracic inlet lesions
Obtaining blood gas and O2 saturation

COPUR SCALE
PREDICTION POPINTS :
5-7 - Easy,normal intubation
8-10 - laryngeal pressure may help
12 - inc difficulty, fibreroptic may be
used
14 - difficult intubation, fiberoptic/
other devices should be used
16 - Dangerous airway, consider
awake intubation,potential
tracheostomy

LEMONLAW
Represents 5 simple,reproducible and rapid assessment methods on
uncooperative and cooperative patients
l look for anatomic features suggestive of potential difficulties (short
neck, facial hairs,edentuloussss pt,high larynx,buck
teeth,small/large chin, high arched palate, big tongue,facial/oral
trauma & tumor )
E examination of the airway anatomy
ASSESS ORAL OPENING MEASURE THE ABILITY OF
MANDIBLE TO
ACCOMODATE TONGUE
EXTERNALLY ASSESS FOR
HIGH LARYNX
SHOULD BE ABLE TO
ACCOMODATE 3 FINGERS
SHOULD BE ABLE TO FIT 3
FINGERS BETWEEN
MENTUM AND HYOID
BONE
SHOULD BE ABLE TO GET
2 FINGRS BETWEEN TOP
OF THYROCARTILAGE AND
MANDIBLE ( FLOOR OF
MOUTH )

M - MALLAMPATI GRADING OF OROPHARYNGEAL VIEW
O - OBSTRUCTION OF AIRWAY
> location of obstruction
> is the obstruction fixed or mobile ?
> how rapidly is the obstruction progressing ?
N - NECK MOBILITY ( NORMAL extension >80-85’ ,
flexion >25-30’ ,rotation >70-75’ )
>can th pt flex the neck and extend the head at atlanto axial joint
> assess the above by doing it yourse in non trauma pt
> cervical spinal collar must be removed when c spine is
immobilised

magboul’s 4 m for
assessingdifficult airway

SEMINAR NO.(10)
MANAGEMENT OF DIFFICULT AIRWAY
ALGORITHM (INTUBATION/VENTILATION)
& DEVICES
Moderator: Dr.Madhumita Ray
Presented by: Dr.Madhabi Roy

SUBTOPICS:
Definition of difficult airway
Conditions predisposing to difficult airway
ASA DIFFICULT AIRWAY ALGORITHM
DAS DIFFICULT AIRWAY ALGORITHM
DIFFICULT AIRWAY ALGORITHM FOR PAEDIATRIC
How to avoid difficult airway situations
Airway devices

WHAT IS A DIFFICULT AIRWAY??
ASA defines a difficult airway as “The clinical situation in
which a conventionally trained anaesthesiologist
experiences difficulty with mask ventilation, tracheal
intubation or both.”
Difficult mask ventilation: Not possible to maintain SpO2
>90% using 100% oxygen & PPMV.
Difficult laryngoscopy: Not possible to visualize any portion
of the vocal cords with conventional laryngoscope,
corresponds to Cormack & Lehane’s Grade 4.

Difficult ET intubation( by ASA Task Force) : Proper
insertion of ET tube with conventional laryngoscopy
requires > 3 attempts or > 10 mins.
Canadian Airway Focus Group : “ When an experienced
laryngoscopist, using direct laryngoscopy, requires 
>2 attempts with same blade, or change in blade or using an
adjunct to DL (e.g. Bougie) or use of an alternative device.

BASIC AIRWAY MANAGEMENT PROBLEMS:
1. Difficulty with patient cooperation.
2. Difficult mask ventilation.
3. Difficult SGA device placement.
4. Difficult laryngoscopy.
5. Difficult intubation.
6. Difficult surgical airway access.

ASA DIFFICULT AIRWAY ALGORITHM

ANATOMIC DIFFERENCES B/W PEDIATRIC &
ADULT AIRWAYS
Larynx  proportionately smaller in child
Narrowest portion of airway Cricoid cartilage in case of children,
Vocal cord for adults.
Relative vertical location  C3, C4, C5 in infant/child, C4, C5, C6 in
adults.
Epiglottis  Longer, narrower & stiffer in child.
Aryepiglottic folds closer to midline.
Pliable laryngeal cartilage.
Mucosa more vulnerable to trauma.
Vocal cords anteriorly placed with respect to larynx.

DIFFICULT AIRWAY ALGORITHM FOR
PAEDIATRIC PATIENT

UNANTICIPATED DIFFICULT PAEDIATRIC AIRWAY
ALGORITHM

HOW TO AVOID DIFFICULT AIRWAY SITUATION
5 questionnaire method &
plan accordingly (as shown
in the table):-
 Take home messages:-
1.If suspicious secure the
airway awake.
2.If can ventilate, but cannot
intubate awaken the
patient.
3.If CVCI employ CVCI
plan
4.Always keep an alternative
plan think ahead.

AIRWAY DEVICES:
Face masks:-
1.Adult face masks-
 Transparent face mask allows
observation for vomitus, secretions,
blood, lip colour & exhaled moisture.
 Parts:-
 Body/shell/dome
 Seal/Rim
 Connector/collar/mount

2.Rendell –Baker –Soucek mask:-
 Designed for paediatric patient.
 Has a triangular, shallow body.
 Minimal dead space for efficient
ventilation.
 Used for patients with
tracheostomy & acromegaly or
sometimes used to cover only the
nose.

3.Endoscopic mask:-
 Designed to allow mask ventilation
while an endoscope is being used.
 Has a port/diaphragm in the body
to allow a fiberscope into the nose
or mouth.

 OROPHARYNGEAL AIRWAYS:-
1.Guedel Airway-
 Has a large flange, a reinforced
bite portion & a tubular
channel.
2.Berman Airway-
 Has a centre support & open
sides.
 Side openings allow to engage
or disengage a ET tube.
3.Ovassapian fibreoptic airway-
 Designed to deliver a fiberscope
as close to larynx as possible.

4.Williams airway intubator-
 Was designed for blind
orotracheal intubations.
 Can also be used to aid
fibreoptic intubations or as an
oral airway.
 Provides better view of larynx
than an ovassapian airway.

 NASOPHARYNGEAL AIRWAY:-
 Intact airway reflexes.
 Loose teeth or poor dentition.
 H/o trauma, oral pathology or when the
mouth cannot be opened.
 Contraindications:-
 Base of skull fracture
 Anticoagulation
 Pathology of nose or nasopharynx
 h/o nose bleeding.

TYPES OF NASOPHARYNGEAL AIRWAYS:
Linders NPA Binasal NPA
Wei’s nasal jet airway

 SUPRAGLOTTIC AIRWAY DEVICES:
1. Laryngeal Mask airway family-
 These devices sit outside the
trachea but provides a handsfree
means of achieving gas-tight
airway.
 Classification based on sealing
mechanism given by Miller’s
classification.
 Cook divided SAD into first &
second generation.

FIRST GENERATION SGA:
LMA classic LMA flexible- it has a flexible,
wire-reinforced tube & can be
bent at any angle without
kinking.

LMA Fastrach
LMA Proceal LMA Supreme
LMA Ctrach

OTHER SGA DEVICES:
Softseal LMA
LMA
protector
I-Gel SGA
Ambu Auragain
combitube

LARYNGOSCOPES:
Rigid laryngoscopes:-
Curved : Macintosh Straight: Miller

Commonly used
Laryngoscopes (handles &
blades 
Flexible fibreoptic
laryngoscopes:

 VIDEO LARYNGOSCOPES:
 Types :-
A.Glidescope
B.C-MAC
C.McGrath
D.Airtraq

7) SEMINAR TOPIC :
1) MECHANISMOF COAGULATION
2) ASSESSMENT
3) ANTI COAGULANT DRUGS
Moderator :
Dr. A. Mazumdar
Speaker :
Dr. Krishanu Majumdar
03/06/2022

1) HEMOSTASIS:
 It is a physiologic process that
keeps blood within damaged
vessels, the opposite of
hemorrhage
 It is a complex inflammatory
process thta provides host defence
mechanism to prevent excessive
blood loss following trauma, injury
and /or surgery

2) STEPS OF COAGULATION:
INITIATION
AMPLICATION
PROPAGATION
STABILISATION

3) INTIATIONOF COAGULATION:
Initiation of coagulation by
procoagulant activities has
been traditionally divided into :
> intrinsic
> extrinsic
> common pathways

3a) extrinsic:
Folllowing tissue injury and
vascular disruption
activation of hemostasis by
tissue factor(TF) expression on
the subendothelial vascular
basement membrane
TF is a transmembrane receptor
expressed by perivascular/
vascular cells that binds VII a
Initiation of clotting

 Activated factor VIIa allows for the
formation of factor VIIa-TF complex
 conversion of factor X Xa
generates trace amount of THROMBIN
 Thrombin generation is subsequently
amplified by other coagulation factors
from intrinsic cascade

3B) INTRINSIC:
Intrinsic cascade begins when XII
is exposed to subendothelial
collagen, kallikrein,HMWK and
activated to XIIa
XI XIa
(Ca2+)
IX IXa
Factor IXa,VIIa,Ca2+ forms a
complex to activate factor X

3c) common pathway:
Prothrombinase complex
(Xa,Va,Ca2+)
II IIa(thrombin)
Fibrinogen FIbrin( Ia)
 Factor XIIIa binds with calcium to then create fibrin crosslinks to
stabilize the clot.

REGULATORS:
 TFPI inhibits the TF-activated factor VII
(FVIIa) complex in an activated factor X
(FXa)-dependent manner, helping to
control thrombin generation and
ultimately fibrin formation.
 Anti thrombin ( anti thrombin III)

3) propagationOF COAGULATION:
 Thrombin is also a potent
agonist for platelets by
stimulating Protease activated
receptors PAR -1 ,PAR-4
 Platelet -gp Ib receptors bind to
XI,also localises VIII to the site
of endothelial disruption via
vWF

 Fibrinogen binds to platelets via gp IIb/IIIa receptors to
facilitate clot formation
 also, it facilitates the cross linking and network
formation of clot and subsequent fibrin polymerization

tests in hemostasis/ assessment:
 Protocols for coagulation studies :
1) always take the sample in plastic syringe
2) platelet poor plasma for study
3)Anti-coagulant used : 3.2% trisodium citrate (vials with
blue coloured cap)
4) within 2 hrs of blood coagulation, test has to be done
5)sample is stored at room temperature

1) platelet count :
 Normal - 1.5 - 4 lakhs/cu mm
 decrease in platelets - THROMBOCYTOPENIA
Production Destruction
bone marrow supression ( Idiopathic
( ex : Aplastic Anemia ) thromboctyic purpura)

2) bleeding time (bt):
DUKE METHOD : patient is pricked with special needle on
earlobe/fingertip after wiping out the surface with alcohol, the test is
completes when the bleeding is ceased
Normal - 2-8 mins
Increase in BT :
 platelet count Functional defect of platelets

3) clotting time :
 def : it is the interval between the moment the bleeding
starts and the moment when the fibrin thread is first
seen.
 Normal : 2-7 mins
 Increase in CT:
Hemophilia A & B
Vit K def, liver disease
Overdose of anticoagulants

4) prothombintime (PT) :
 Test for extrinsic pathway of coagulation and common pathway
 Normal : 12-16 seconds
 Prolonged PT
 Inherited cause Acquired cause
( Factor VII def) > Mild Vit K def
> Liver disease
> Warfarin

6) activatedpartial thromboplastintime(aPtT):
 tests for intrinsic pathway and common pathway
 Normal : 26-34 sec
 prolonged aPTT :
INHERITED CAUSE ACQUIRED CAUSE
factors VIII, IX,XI def Heparin, lupus anticoagulant,Acq vWD
factor XII,prekallikerin
or HMWK def
von Willebrand disease

Prolonged PT + Prolonged aPTT
 evalautes common pathway factors
INHERITED CAUSE ACQUIRED CAUSE
Def of Prothombin (II),
Fibrinogen (I),
factor V and factor X
Disseminated intravascualr
coagulation
Severe liver disease
Severe Vit K def
Direct thrombin inhibitors
Direct factor Xa inhibitors

Minimal interval between the last doseand surgery :
Unfractionated Heparin 6 hours
LMWH- prophylactic
dose
12 hours
LMWH - therapeuitc
dose
24 hours

VITK ANTAGONISTS --- WARFARIN
 Derivative of 4 hydroxy coumarin
 Mechanism of action :
Warfarin inhibits VIT K epoxide reductase that converts VitK
dependent coagulation proteins( II,VII,IX,X) to their active form, a
post translational modification
Pharmacokinetics :
rapidly and completely absorbed ,97% bound to albumin and
contributes to neglible renal elimination ang long t1/2 of 24-36 hours
after oral adminstration.
Laboratory Evaluation :
Prothombin time , INR

 Clinical uses:
prevention of Venous Thromboembolism, prevention of systemic
embolisation and resultant stroke in pt. with prosthetic heart
valves or Atrial fib.
When to stop ?
Pts. with high risk for thrombosis-- warfarin should be stopped
4-5 days pre-op and LMWH is used till the day before (24hours)
surgery
Pts. with lower risk for thrombosis may have warfarin
discontinued 4-5 days pre-op and then reinitiated after succesful
surgery
warfarin may be continued in pts. posted for cataract surgery
without bulbar block

CANGRELOR :
ATP analogue that blocks P2Y212 receptor mediated platelet
activation
only IV P2Y212 inhibitor availble for clinical use

CONCERNS in pt. taking ASPIRIN AND CLOPIDOGREL
In case of regional anaesthesia procedures(blind)
patient bleeds enormously in a closed cavity space
forms spinal/epidural hematoma
leading to permanent disability
therefore, bridge the pts. with LMWH
Only if the risk of bleeding is very high aspirin shgould be
discontinued

 Low dose Aspirin should be continued to prevent cardiovascular
thrombtoic events in the following cases :
1) pts. with prior PCI
2) pts. with coronary artery disease
3) pts, with stroke in the past 9 months
also,
aspririn should be continued in pts, requiring CABG

FIBRINOLYTICS :
PLASMINOGEN
( tissue plasminogen activator )
PLASMIN
Breaks fibrin
STREPTOKINASE
 binds with plasminogen and uncovers or exposes tpA binding site
 Clot NON specific fibrinolytics
 high risk of bleeding and hypotension
 high dose required

recombinant TPA:
 more acceptable
 Alteplase,Reteplase,Duteplase and Tenecteplase
 clot specific fibrinolytics
 lesser bleeding risk
 maxm. clot specificty in tenecteplase
 C/I:
 Brain tumour/ aneurysm
 recurrent surgery or trauma
 aortic dissection
 h/o of intracranial bleed
 non compressive vascualr puncture

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