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Pre anaesthesia checkup-history.pptx
- 1. Pre Anaesthesia Evaluation Presented by: Dr Sushma Moderator : Dr Harshal Consultant Anaesthetist , KIMS
- 2. PREOP EVALUATION • Aprocess of clinical assessment that precedes the delivery of anesthesia for surgical and non surgical procedures. • Guides the anesthetic plan An opportunity for the anesthesiologist to: • Describe the proposed anesthetic plan • Psychological support to the pt • Obtain informed consent
- 3. Preop Evaluation • Inadequatepreoperative planning and incomplete patient preparation are commonly associated with anesthetic complications.
- 4. Purpose of effectivepre op evaluation • To identify those few patients whose outcomes will be improved by implementation of a specific medical treatment eg: 60 y/o patient scheduled for elective total hip arthroplasty who also has unstable angina from left main coronary artery disease would more likely survive if coronary artery bypass grafting is performed before the elective procedure
- 5. Purpose of effectivepre op evaluation • To identify patients whose condition is so poor that the proposed surgery might only hasten death without improving the quality of life . eg, a patient with severe chronic lung disease, end-stage kidney failure, liver failure, and heart failure likely would not survive to derive benefit from an 8-hour, complex, multilevel spinal fusion with instrumentation.
- 6. Purpose of effectivepre op evaluation • To identify patients with specific characteristics that likely will influence the proposed anesthetic plan eg: the anesthetic plan may need to be reassessed for a patient whose trachea appears difficult to intubate, one with a family history of malignant hyperthermia, or one with an infection near where a proposed regional anesthetic would be administered.
- 7. • To providethe patient with an estimate of anesthetic risk . However, the anesthesiologist should not be expected to provide the risk- versus-benefit discussion for the proposed procedure(responsibility of the surgeon)
- 8. Elements of thePreoperative History Patients presenting for elective surgery and anesthesia typically require a focused preoperative medical history emphasizing • Cardiac • Pulmonary function • Kidney disease • Endocrine and metabolic diseases • Musculoskeletal • Anatomic issues relevant to airway management and regional anesthesia • Responses and reactions to previous anesthetics.
- 10. History Taking • Demographicdetails • Present medical history (Presenting complaint/ History of presenting complaint) • Past medical history • Surgical history / Previous anesthetic history • Drug history(allergies/present medications) • Family history • Social history
- 11. Demographic Details Date &time of examination Patient’s name Age Sex Weight
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- 13. Goals • To ensurethat the patient is in the 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.
- 14. Cardiovascular Issues Preoperative cardiacassessment: • Whether the patient’s condition need to be improved prior to the sx • Need for any further cardiac evaluation prior to the surgery
- 15. CVS Symptoms of thefollowing problems Active Cardiac Conditions • Unstable coronary syndromes • Unstable or severe angina • Recent MI • Decompensated HF • Significant arrhythmias • Severe valvular disease
- 16. Specific enquiries mustbe made about Coronary Artery Disease Determine • Type • Severity • Functional limitation
- 17. RISK FACTORS OFCAD • Age over 45 • Obesity • Angina • Prior MI or CHF • Dysrrhythmias
- 18. Angina • Chest painat rest/with mild exercise, Freq and duration • Incidence , precipitating factors, duration of use of anti-anginal medications, e.g. Glyceryl trinitrate (GTN) oral or sublingual ) • Stable angina – proceed wd sx • Unstable angina- em sx only
- 19. Ischemic Heart Disease Thereis a high incidence of both silent MI and myocardial ischaemia in diabetics. High risk : • MI wd in past 6m • CHF Extremely high risk • Signs: orthopnea sweating palpitations night coughing
- 20. H/o previous myocardialinfarction and subsequent symptoms indicating heart failure /MI are at a greater risk of perioperative reinfarction . • Elective surgery postponed until at least 6 months after the event
- 21. Valvular Heart Disease •Prosthetic valves - on anticoagulants • Acs need to be stopped or changed (bridging therapy)prior to surgery • Antibiotic prophylaxis Heart Failure • Symptoms : fatigue ,palpitations ,sweating ,dyspnea ,chest pain, syncope • worsened by the depressant effects of anaesthetics impairing the perfusion of vital organs
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- 24. HYPERTENSION • How long •Tx • Compliance with tx • How well it is controlled
- 25. Severe HTN • Systolic>195 • Diastolic>100 • Delay non urgent sx • Obtain approp consultation and Rx Mild HTN • Systolic <165 • diastolic<100 • Evaluate other risks • Proceed with caution • Obtain approp followup
- 26. HYPERTENSION • Untreated andpoorly 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.
- 27. HTN • Controversy regardingdelay or cancel a sx in a patient with untreated or inadequately treated hypertension. • In patients with blood pressure above 180/100 mm hg , in the absence of end organ changes, such as renal insufficency , LVH with strain the benefits of optimizing BP must be weighed against the risk of delaying surgery.
- 28. REVISED CARDIAC RISKINDEX (cardiac pts undergoing elective major non cardiac procedures)
- 29. Surgical Risk Stratification(for cardiac pt undergoing non cardiac sx)
- 30. Clinical Predictors OfIncreased Perioperative CVS Risk(MI,CHF,death) MAJOR • Unstable coronary syndromes • Recent MI with evidence ischaemic risk by clinical symptoms or noninvasive study • Unstable or severe angina • Decompensated CHF • 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.
- 31. Clinical Predictors OfIncreased Perioperative CVS Risk INTERMEDIATE • Mild angina • Prior MI by history or pathological Q waves • Compensated or prior CHF • Diabetes mellitus
- 32. Clinical Predictors OfIncreased Perioperative Cvs Risk MINOR • Advanced age • Abnormal ECG (LVH,LBBB, ST-T abnormalities) • Arrhythmias (e.g- AF) • Low functional capacity (e.g- inability to climb one flight of stairs ) • History of stroke • Uncontrolled systemic HTN
- 33. Functional Capacity –(MET )Metabolic equivalents • A unit of functional activity • Expressed as a multiple of current metabolic rate to the resting metabolic rate • It is the rate of energy consumption where 1met is the basic metabolic consumption • 1met =3.5mloxygen/kg/min(resting metab consumption) • Lowest met =0.9(sleeping)
- 34. METS • To withstandthe stress of sx pts should achieve 4mets of functional capacity • Perioperative cardiac and long-term risks are elevated in patients unable to obtain 4-MET demand • Able to climb 2flights of stairs without getting tired indicates good reserve - FC>4mets
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- 37. CENTRAL NERVOUS SYSTEM Problems •Ischemia/vasospasm • Embolism/thrombosis • Tumor • Aneurysm/haemorrhage • Seizures - well controlled or not • stroke • Correlate h/o with physical findings
- 38. CNS Signs and symptoms •Nausea /vomiting • Vertigo • Headache /vision disturbances • Htn/brady • Focal sensory/motor defecits • Slurred speech • Confusion/disorientation • Coma
- 39. Peripheral Neuropathy Signs andsymptoms • Weakness or loss of function • Tingling/numbness • Cold/pale extremities • Diminished reflexes
- 40. Peripheral Neuropathy Causes: • Autonomicdysfunction • Dm • Drug induced neuropathy • Nerve compression Get neuro consultation for new symptoms Evaluation prior to regional anaesthesia
- 41. HEPATIC SYSTEM • H/ojaundice/hepatitis Viral hepatitis • Easily transmitted • Nonsp symptoms like fatigue, malaise, vague abd pain • Symptoms of hepatitis: spider navi , ascites, generalised tremor ,confusion /disorientation
- 42. HEPATIC SYSTEM Coexsisting diseases •Obesity • Fatty liver • Alcohol abuse • Multiple blood transfusions • Recreational drug use • Coagulation disorders
- 43. RENAL SYSTEM • Probswd urination • Chronic cystitis • Prostatitis • Renal calculi • ARF/CRF • Electrolyte abnormalities • Hypervololemia HTN Hyperkalemia
- 44. RENAL ARF/CRF • Get accurateh/o dialysis schedule , last dialysis, RFT& electrolytes after dialysis Chronic renal failure • Anaemia • Electrolyte abnormalities • Altered drug excretion restricts the choice of anaesthetic agents
- 45. RESPIRATORY SYSTEM • DetailedHistory of recent URTI, sorethroat , productive cough, dyspnea(exertion/rest), allergies(hay fever),sleep apnea • Acute disease: URTI/Asthma/Bronchitis/Pneumonia • Chronic disease: COPD/TB • Asthma: duration ,last episode, hospitalisation ,tx (bronchodilators) • COPD-productive cough , smoking packs perday
- 46. RESPIRATORY SYSTEM Pulmonary complicationsoccurs more frequently than cardiac complications (5-10% incidence ) • Perioperative complications includes: 1. Aspiration 2. Atelectasis 3. Pnuemonia 4. Bronchitis 5. Bronchospasm 6. Hypoxemia 7. AE COPD 8. Respiratiory failure requiring mechanical ventilation
- 47. Cases where thereis markedly increased risk of pulmonary complications • ASA class 3 and class 4 patients ( compared to class 1) • Cigarette smoking • Longer surgeries(>4 h) • Certain types of surgeries: Abdominal Thoracic Aortic aneurysm Head and neck Emergency surgery • General anesthesia (compared with cases in which GA was not used)
- 48. Efforts required forprevention of pulmonary complications • Cessation of smoking prior to surgery • Lung expansion techniques (eg, incentive spirometry) after surgery in patients at risk. • Patients with asthma, have a greater risk for bronchospasm during airway manipulation. • Appropriate use of analgesia and monitoring are key strategies for avoiding postoperative respiratory depression in patients with obstructive sleep apnea.
- 49. GASTRO INSTESTINAL SYSTEM •Nutritional status • Obese/anorexic • Wt gain/loss • Gastric reflux • Evaluate aspiration risk
- 50. GASTRO INTESTINAL SYSTEM Therisk of aspiration is increased in certain groups of patients • Morbidly Obese • Pregnant women in the second and third trimesters • Hiatus hernia • Full stomach (em sx / trauma) • Serious gastroesophageal reflux disease (GERD).
- 51. Severe GERD: Treat patientswith consistent symptoms (multiple times per week) with • Medications (eg, nonparticulate antacids such as sodium citrate) • Techniques (eg, tracheal intubation)
- 52. Pharmacological Agents toReduce 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 content • Proton pump inhibitors: supress gastric acid secretion by binding proton pump of the parietal cell • Prokinetic agents : Metoclopramide (Dopamine antagonist)
- 53. COAGULATION ISSUES • Howto manage patients who are taking warfarin on a long-term basis(anticoagulants) • How to manage patients who are taking clopidogrel and related agents(antiplatelets) • How to safely provide regional anesthesia to patients who either are receiving long-term anticoagulation therapy or who will receive anticoagulation perioperatively.
- 54. ANTICOAGULANTS Patients at highrisk for thrombosis: Mechanical heart valve implants Atrial fibrillation Prior thromboembolic stroke Bridging Therapy
- 55. ANTICOAGULANTS • Patients atlower risk for thrombosis may have warfarin discontinued and then reinitiated after successful surgery. • Decisions regarding bridging therapy often require consultation with the physician who initiated the warfarin therapy
- 56. ANTIPLATELETS Aspirin • Consider selectivelycontinuing 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 in patients who have drug eluting coronary stents until they have completed 12 months of dual anti platelet therapy.
- 57. ANTIPLATELETS Thienopyridines (clopidogrel andticlopidine) • Cataract Surgery –no need to stop • If reversal of platelet inhibition is necessary, then clopidogrel must be stopped 7 days before & Ticlopidine – 14 days before surgery • Do not discontinue them in Pts who have drug eluting stents before 1 year
- 58. Endocrine And MetabolicIssues • Blood glucose measurement on the morning of elective surgery • Adequacy of longterm blood glucose control - Hba1c . • Abnormally elevated Hba1c - referral to a diabetology service for education ,diet modification and medications to improve metabolic control may be beneficial.
- 59. Endocrine And MetabolicIssues • Elective surgery should be delayed in patients presenting with marked hyperglycemia • Rearranging the order of scheduled cases to allow insulin infusion to bring the blood glucose concentration closer to the normal range before surgery begins .
- 60. Endocrine And MetabolicIssues Type1 IDDM End organ disease is common • Retinopathy • Nephropathy • Autonomic dysfunction T2- NIDDM
- 61. Endocrine And MetabolicIssues Diabetes patients have an increased incidence of • Ischaemic heart disease • Renal dysfunction • Autonomic and peripheral neuropathy • Intra- and postoperative complications
- 62. Dm - goalsof Mx • Maintain blood glucose 100-250mg/dl • Provide adequate fluid volume
- 63. Endocrine And MetabolicIssues • Hyperthyroid: excessive t3t4 secretion; low TSH • Signs and symps: hypermetab exophthalmous tx propylthiouracil betablockers • Hypothyroid; low t3t4 ; high TSH • Signs and symptoms: low metabolism large tongue • Tx eltroxine
- 64. Endocrine And MetabolicIssues Hyperparathyroidism: • Hypercalcemia • Increased bone resorption • Reduced renal excretion • Diagnosis; high sr calcium high pth
- 65. Endocrine And MetabolicIssues Pheochromocytoma: • Tumor of chromaffin tissue • Inc production & release of epinephrine & norepi • S&S: intermittent HTN, headache, sweating, tachy • Diagnosis: inc sr epi , nor epi / Inc urine vinylmandelic acid & metanephrine
- 66. Endocrine And MetabolicIssues Carcinoid tumors • Slow growing gi tumors • Release vasoactive amines & polypeptides 5hydroxytryptamine • Diarrhoea • Abd cramps • Respi distress/bronchospasm • HTN Histamine abd bradykinin release • Paroxysnal hypotension • Cutaneous flushing • Bronchospasm
- 67. Endocrine And MetabolicIssues Adrenocortical dysfunction – cushing syndrome • Tx- correct fluid vol status /electrolyte abnorm/ steroids
- 68. HEMATOLOGIC SYSTEM Anemia • Hbfor o2 delivery • Causes acute/chronic anemia • Any benefit from delay of sx • Acute bl loss-poorly tolerated
- 69. MUSCULOSKLETAL SYSTEM Rheumatoid arthritis •Duration, tx h/o - aspirin /nsaids/ steroids • Chronic anemia • Severely limited movement of their joints makes positioning for surgery and airway maintenance difficult. • Tendency for dislocation of atalnto-occiptal joint • Osteoarthritis • Muscular dystrophies
- 70. MUSCULOSKLETAL SYSTEM Neuromuscular disorders •Care with muscle relaxants • Coexisting heart disease • Restrictive pulmonary disease
- 71. OBESITY Determine Ideal bwtand BODY MASS INDEX Ideal bwt (kgs): • Broca Index = ht(cms)-105 women ht(CMS) -100 men BMI=Wt(kg)/Ht(m2)
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- 75. Obstructive sleep apnea •OSA is episodic upper airway narrowing during sleep. • During sleep, the activity of the upper airway dilator muscles decreases in a sleep-stage-dependent manner • This leads to narrowing of the upper airway, loud snoring, and reduction in airflow • Can either be partial (a hypopnoea), or complete (an apnoea). • Apnoea Hypopnoea Index (AHI) The total number of apnoeas and hypopnoeas per hour of sleep Used to describe the severity of OSA
- 76. Obstructive sleep apnea •OSA severity -AHI No OSA- AHI < 5/h, Mild OSA - AHI 5–15/h, Moderate OSA- AHI 15–30/h Severe OSA- AHI > 30/h • Gold standard - Polysomnography or multi- channel respiratory polygraphy (“sleep study”) • Questionnaires to assess OSA risk - to screen for OSA and to assess the prevalence of OSA
- 77. STOP BANG questionarre-Screening tool for OSA
- 78. FAMILY HISTORY • Inheritedconditions in the family • History of prolonged apnoea , unexplained death
- 79. Surgical History &Previous Anaesthesia Exposure Difficulties with previous anaesthetics • Procedure difficulties • Nausea • Vomiting • Dreams • Awareness • Postoperative jaundice
- 80. Surgical History &Previous Anaesthesia Exposure History of difficulty with venous access • Thrombosis of vein • Look for tattooing
- 81. DRUG HISTORY ANDALLERGIES • Identify all medications • Prescribed/self-administered • Allergies to- drugs /topical preparations (e.g.iodine)/adhesive dressings/ food
- 82. SOCIAL HISTORY Alcohol :duration / frequency • Alcohol induction of liver enzymes • Tolerance Smoking: number of cigarettes /amount of tobacco • Nicotine stimulates the sympathetic nervous system causing tachycardia ,hypertension ,coronary artery narrowing, hyperactive airways • Look for withdrawal symptoms
- 83. Preparation For Anesthesia •Continuing current medications/ treatment of coexisting diseases • Responsibility of the anesthesiologist to instruct patients regarding which medications to continue and which to hold preoperatively
- 84. Instruct Patients totake the medications with small sips of water, even if fasting! Medications to be Continued on the day of Surgery • Antihypertensives except ACEI is and ARBs • Cardiac medications e.g beta- blockers, digoxin ,antianginal • Antidepressants, anxiolytics and other psychiatric medications • Antiparkinson drugs • Thyroid medications • Birth control pills • Eye drops • Heartburn or reflux medications • Narcotics • Anticonvulsants • Asthma medications • Steroids • Statins
- 85. Medications to bediscontinued • Topical medications e.g creams and ointment • Oral hypoglycemic agents -on the day of sx • Insulin -on the day of sx • Diuretics (except Thiazides for bp or severe HF) - on the day of sx • Sildenafil(similar drugs )-24 hrs before Sx. • NSAIDS –48 hrs before Sx. • Warfarin ( Coumadin) 4 days before Sx • Anticoagulants/antiplatelets
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- 92. Summary The anesthesiologist whotakes the time to adequately prepare the patient medically and psychologically for anesthesia and surgery will find that their job of caring for the patient intraoperatively becomes easier, and they are more likely to have a positive outcome as well as a satisfied patient.