The document discusses guidelines for pre-anesthetic evaluation. It outlines the objectives of pre-anesthetic evaluation as assessing the patient's medical condition, optimizing risks for anesthesia, and obtaining informed consent. Key components of evaluation include medical history, physical exam assessing airway and cardiovascular/respiratory systems, lab tests, and ASA physical status classification. Guidelines are provided for pre-op fasting, medication management, documentation, and conducting evaluations via interview or questionnaires.
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This presentation shows the steps required in submental intubation and the advantages of the procedure. The author thinks that submental intubation is an effective way to manage airway in cases of panfacial trauma with concomitant naso orbito ethmoidal fractures and skull base fractures.
A basic overview on the management of intra-operative bronchospasm: the risk factors, triggers, diagnosis, prevention and management. Includes a case scenario – discussion.
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Anaesthesia-Critical Care.
Preanesthetic evaluation of patients in oral and maxillofacial surgeryPunam Nagargoje
The word is derived from the Greek words an, which means “without” and aithesia which means “feeling”
The use of medical anesthesia was first reported in 1846
The development of anesthesia has made today’s modern surgical techniques possible
• Basic Principles of Anesthesia
• “Triad of General Anesthesia”
need for unconsciousness
need for analgesia
need for muscle relaxation and loss of reflexes
• Preoperative Evaluation
• The preanesthetic evaluation has specific objectives including:
- Establishing a doctor-patient relationship,
- Becoming familiar with the surgical illness and
- coexisting medical conditions,
- Anticipating potential complication
Developing a management strategy for perioperative anesthetic care,
- Obtaining informed consent for the anesthetic plan.
The overall goals of the preoperative assessment are to reduce perioperative morbidity and mortality and to allay patient anxiety.
• Pre-operative
This applied both in evaluation & investigations
• General
This include the following:
1-General condition of the patient.
2-Psychological condition. ( Specially in major operations).
• Specific
This include the following:
1-Related to anaesthesia.
2-Related to the surgery.
• Medical History
1. Review the chart
2. Review previous records
3. Interview the patient
• Demographic Data
Height / weight
Vital signs
Diagnosis
History and Physical Exam
Note any abnormalities
Don’t assume that all problems are listed
• Steps of the preoperative visit :
• Preoperative testing should be performed on a selective basis for purposes of guiding or optimizing perioperative management.
• Pre-op Testing Schema Example
• Preoperative Laboratory Testing:
• only if indicated from the preoperative history and physical examination.
• "Routine or standing" pre operative tests should be discouraged
• -CBC anticipated significant blood loss, suspected hematological disorder (eg.anemia, thalassemia, SCD), or recent chemotherapy.
• -Electrolytes diuretics, chemotherapy, renal or adrenal disorders
• -ECG age >50 yrs ,history of cardiac disease, hypertension, peripheral vascular disease, DM, renal, thyroid or metabolic disease.
• -Chest X-rays prior cardiothoracic procedures ,COPD, asthma, a change in respiratory symptoms in the past six months.
• -Urine analysis DM, renal disease or recent UTI.
• -tests for different systems according to history and examination
• Disease-based indications
Alcohol abuse
CBC, ECG, lytes, LFTs, PT
Anemia
CBC
Bleeding disorder
CBC, LFTs, PT, PTT
Cardiovascular
CBC, creatinine, CXR, ECG, lytes
• Disease-based indications
Cerebrovascular disease
Creatinine, glucose, ECG
Diabetes
Creatinine, electrolytes, glucose, ECG
Hepatic disease
CBC, creatinine, lytes, LFTs, PT
• Disease-based indications
Pregnancy (controversial)
Serum B-hCG- 7 days, Upreg 3 days
Pulmonary disease
CBC, ECG, CXR
Renal disease
CBC, Cr, lytes, ECG
RA
CBC, ECG, CX
The presentation deals with the basics of pre anesthetic checkups, its only for the educations purpose!
Any kind of replication, modifications and republication is strictly prohibited.
All Rights reserved to the Author. 2016
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ASA GUIDELINE
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Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
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Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
2. Introduction
is a requisite component to administering any
anaesthetic.
a rapid transformation in hospital practices
from admission on previous night to the
morning of day of surgery.
new approach where anaesthesiologist take
a lead role in assessing and optimising the
patient.
3% of peri-operative adverse events are
attributed to inadequate PAE.
3. • Evaluate the patient’s medical condition
• Optimise the patient’s medical condition for
anaesthesia and surgery.
• Determine and minimise risk factors for anaesthesia.
• Plan anaesthetic technique and perioperative care.
• Develop a rapport with the patient to reduce anxiety
and facilitate conduct of anaesthesia.
• Inform and educate the patient about anaesthesia,
perioperative care and pain management
• Obtain informed consent for anaesthesia
Objectives
4. Benefits
• More selective ordering of lab tests.
• Reduced health care costs by specialists referrals
rather than primary care physicians.
• Reduced level of patient anxiety.
• Improved acceptance of regional anaesthesia.
• Shorter duration of hospitalisation.
• Lower hospital costs.
• Clear role of medical consultants to optimise the
medical condition and also co-manage the pt
postoperatively.
5. Pre-anaesthetic assessment
May be conducted
– as a personal interview in the ward, operating
theatre or pre-anaesthetic clinic or
– using preset questionnaires assisted by trained
nursing or paramedical staff under the supervision
of an anaesthesiologist.
In the case of emergency surgery where early
consultation is not always possible, the anaesthesiologist
is still responsible for the preanaesthetic assessment. If
surgery cannot be delayed in spite of increased anasthetic
risks, documentation to that effect should be made.
6. 6
DETECTING DISEASE AND ASSESSING
SEVERITY
• Medical history
– medical problems
– current medication and allergies
– previous anaesthesia
– family history of anaesthetic complications.
– System review
– Menstrual
• Physical examination
– cardiovascular and respiratory systems (including the
airway)
– other systems i.e. the renal, hepatic and central nervous
systems
13. UPPER LIP BITE TEST (ULBT)
• Class 1:
Lower incisors can bite upper lip
above vermillion line.
• Class 2:
Lower incisors can bite upper lip
below vermillion line.
• Class 3:
Lower incisors cannot bite the upper lip.
14. Less than or equal to 4.5 cm is
considered a potentially
difficult intubation.
Generally greater than 2.5 to 3
fingerbreadths (depending on
observers fingers)
INTERINCISOR DISTANCE (IID)
15. – Upright
– Full neck extension
– Distance from upper border of
thyroid cartilage (laryngeal prominence), to the
bony point
of the mentum.
– Distance < 6.5cm may be difficult
THYROMENTAL DISTANCE
20. Physical Examination - Risk Factors for Difficult Intubation
Risk Factor Detail Level of Risk
Weight < 90 kg 0
90-110 kg 1
> 110 kg 2
Head & Neck Movement > 90 o 0
Approx 90 o 1
< 90 o 2
Jaw movement
IG = Interincisor gap
Slux = mandibular subluxation
IG > 5 cm or Slux > 0 0
IG < 5 cm or Slux = 0 1
IG < 5 cm or Slux < 0 2
Receding Mandible Normal 0
Moderate 1
Severe 2
Protruding maxillary teeth Normal 0
Moderate 1
Severe 2
21. Evaluating Cardiac Disease
• Cardiovascular complications are very common serious peri--op adverse
events.
• Accounts for nearly 50 % of all peri-op deaths.
• 8% of patients have serious Myocardial injury during major surgery.
• Goals are to identify the risk factors,severity of the disease,determine the
need for pre –op interventions and modify the risk of peri –op adverse
events.
• In addition to this also categorise the surgery into Low risk,Intermediate
risk and High risk.
22. NYHA Functional Class
Class I No limitation of physical activity; ordinary activity does not cause fatigue,
palpitations or syncope
Class II Slight limitation of physical activity; ordinary activity results in fatigue,
palpitations or syncope
Class III Marked limitation of physical activity; less than ordinary activity results in
fatigue, palpitations or syncope; comfortable at rest
Class IV Inability to do any physical activity without discomfort; symptoms at rest
23. Arrhythmias/ECG abnormalities
• Further work-up or therapy needed
– New onset AF
– Symptomatic bradycardia
– High-grade heart block (2nd or 3rd degree)
– Uncontrolled AF
– VT
– Prolonged QT
– New LBBB
– RBBB with right precordial ST elevation (Brugada)
24. Revised Cardiac Risk Index
• Predicts the cardiac risk in non- cardiac
surgery.
Components of Revised Cardiac Risk
Index
Points Assigned
•High-risk surgery (intraperitoneal,
intrathoracic, or suprainguinal
vascular procedure)
•Ischemic heart disease (by any
diagnostic criteria)
•History of congestive heart failure
•History of cerebrovascular disease
•Diabetes mellitus requiring insulin
•Creatinine >2.0 mg/dL (176 μmol/L)
Revised Cardiac Risk Index
0
1
2
≥3
1
1
1
1
1
1
Score Risk of Major Cardiac Events
0.4%
1.0%
2.4%
5.4%
25. Evaluating Respiratory Disease
established risk factors for pulmonary complications
Patient factors like h/o cigarete smoking, BMI>30, age >70,
partially or fully dependent ,COPD, Heart failure
Procedure related factors like
neck, thoracic, upper abdominal, aortic or neurological surgery
prolonged procedures (> 2 hours), planned for anesthesia with
ETT tube, emergency surgery
Lab factors like
hypo-albuminaemia (< 30 g/l),Urea >21 ,abnormal CXR
26. URTI & anaesthesia
• Mild symptoms - can usually proceed
– huge inconvenience to patient if cancelled
• Severe symptoms or underlying disease
– postpone
• Intermediate severity - ?
• ? risk of increased bronchial reactivity
27. Sleep-disordered Breathing
• 24% of middle aged men (< 15% diagnosed!)
• OSA - complete obstruction for 10s +
• OH (obstructive hypopnoea) > 4% drop in sats
• Severe OSA have >30 episodes of apnoea/hr
• CVS disease common
• Berlin Questionnaire(STOP BANG)
• Snoring
• Daytime sleepiness
• Hypertension
• Obesity
2 or more = high
risk for OSA
28. RECOMMENDED PREANAESTHETIC
INVESTIGATIONS
ECG
• Age above 50 (female)
• Age above 40 (male)
• Cardiovascular disease
• Diabetes Mellitus
• Renal disease
Subarachnoid/Intracrania
l Bleed, CVA, Head
Trauma
Chest X-ray
• Age above 60
• Significant respiratory
disease
• Cardiovascular disease
Malignancy Major
Thoracic/Upper Abdominal
Surgery
29. RECOMMENDED PREANAESTHETIC
INVESTIGATIONS
FBC
• Age above 60
• Clinical anaemia
• Haematological
disease
• Renal disease
• Chemotherapy
• Procedures with
blood loss > 15%
RP
• Age above 60
• Renal disease
• Liver disease
• Diabetes Mellitus
• Cardiovascular
disease
• Procedures with
blood loss > 15%
Coagulation
profile
• Haematological
disease
• Liver disease
• Anticoagulation
• Intra-
thoracic/Intra-
cranial
procedures
30. Random Blood
Sugar
• Age above 60
• Diabetes Mellitus
• Liver dysfunction
Liver Function
Tests
• Hepato-biliary
disease
• Alcohol abuse
31. ASA Minimum Pre-op Visit Components
• Medical, anaesthesia and medication history
• Appropriate physical examination
• Review of diagnostic data (ECG, labs, x-rays)
• Assignment of ASA physical status
• Formulation and discussion of anesthesia plan
32. The ASA Physical Status Classification
ASA 1 Normal healthy patient Mortality
ASA 2 Mild systemic disease - no impact on daily life 0.1%
ASA 3 Severe systemic disease - significant impact on daily life 0.2%
ASA 4 Severe systemic disease that is a constant threat to life 1.8%
ASA 5 Moribund, not expected to survive without the operation 7.8%
ASA 6 Declared brain-dead patient - organ donor 9.4%
E Emergency surgery
33. DOCUMENTATION
• A written summary of the pre-anaesthetic
assessment, orders or arrangements should
be explicitly and legibly documented in the
patient’s anaesthetic record.
34. Hold on day of surgery
• Diuretics
• unless thiazide for hypertension
• unless severe heart failure
• Insulin & OHA
• Vitamins & iron
• ACEI’s or ARB’s depends on procedure/risk of
hypotension
• MAOI inhibitors
35. PREOP MEDICINES MANAGEMENT
Stop 48 hours pre-op
NSAIDs
Stop 4 days pre-op
Warfarin (convert to enoxaparin)
Stop 7 days pre-op
Clopidogrel
Aspirin 75 mg usually continued (check with consultant)
Herbal remedies
HRT Estrogens 1 month
36. Premedication
• Alleviate anxiety/sedation/amnesia
• e.g. midazolam pre-induction
• Reduce risk of reflux
• e.g. ranitidine/lansoprazole/citrate/metoclopramide
• Manage pain
• e.g. paracetamol, gabapentin, topical LA
• Control peri-operative risk
• e.g. blockade, -2 agonists
• Dry secretions
• e.g. glycopyrollate
• Decrease anaesthetic requirements
• e.g. clonidine
37. FASTING GUIDELINES
Time before anaesthesia Food or fluid intake
Up to 8 hours Unrestricted
Up to 6 hours Light meal/Formula milk
Up to 4 hours Breast milk
Up to 2 hours Clear liquids only (no solids, no
fat)
2 hours pre-anaesthesia Nothing permitted
• Primary goal of pre-op fasting is to reduce occurence of Pulmonary aspiration.
•In addition to the recommended guidelines,always assess the airway pre-op
for difficult intubation and increased risk of aspiration.
38. Conclusion
• Anaesthesia /surgical risk can be significantly reduced by
combined skill of
– Surgeon
– Anaesthesiologist
– Primary care physician
– Nursing officers and Paramedics
– Patient (follow instructions ).
anesthesia
administration
surgeon
nursing