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PRE-ANESTHETIC EVALUATION
- 1. Presenter Dr NeethuRita Jose Moderator Dr Swetha Kamath
- 2. Introduction Conduct Benefits Present scenario Guidelines History
- 3. Airway assessment Other examination Investigations Pre op drug therapy and modification Premedication Fasting guidelines References
- 4. Basic elementof anaesthesia care PERIOPERATIVE MEDICAL SPECIALISTS Assessment and optimisation of patients who are being prepared for surgery
- 5. Joint commissionmandates documentation of history and physical examination for any surgical patients WITHIN 30 DAYS before the planned procedure Reassessment WITHIN 48 HRS preceding surgery
- 6. Personal interview inthe ward, operating theatre or PAE clinic or Preset questionnaires assisted by trained nursing or paramedical staff under the supervision of an anaesthesiologist
- 7. Emergency surgery- PAEdone and risks documented
- 8. More selectiveordering of lab tests. Reduced patient anxiety. Improved acceptance of regional anaesthesia.
- 9. Shorter durationof hospitalisation. Lower hospital costs. Fewer case cancellations on the day of surgery
- 10. Every patientshould be considered as COVID 19 positive and anaesthetists should wear MASK(N 95) all the time WASH hands –soap and water/alcohol based sanitizer frequently
- 11. Wear cap,gown&shoe cover, GLOVES FACE SHIELD/GOGGLES Maintain SOCIAL DISTANCING Restrict NUMBER of attendants to PAC Prevent CROWDING in PAC
- 12. History ofFEVER,COUGH,SORE THROAT Record body TEMPERATURE before entering PAC clinic
- 13. Patients shouldalso wear MASKS Detailed PAC to be taken-TRAVEL international/domestic to affected areas in last 14 days Careful chest auscultation
- 14. All reusableequipments (steth,BP apparatus)SANITISED frequently At the end of day , clean by wiping surfaces of furniture and floor with 2-3% hydrogen peroxide Correct method of using and disposing surgical masks
- 15. Introduction ofthe medical practitioner performing the consultation. Confirmation of the patient’s identity , procedure including site and side
- 16. Medical assessmentof the patient - History −Review patient records − Clinical examination ( Systemic and Airway) − Medications − Relevant investigations - Previous anaesthesia records
- 17. Specialist consultation, if required Informed consent Instructions regarding fasting
- 18. Information regardingpain management Information regarding modification of current medications
- 19. Requirement ofassistance after the procedure Educate patient regarding modifiable health factors
- 20. Rapport withpatient and family- reduce anxiety Clear and detailed documentation
- 21. Name, Age,Sex Date & time of examination Source of history: patient, relative, care taker. Occupation and social status
- 22. Community /Religion Atypical pseudocholinesterase in Shetty community HPI- indication for surgery and planned procedure Mode of onset, cause of onset, progress and treatment received
- 23. History ofrecent respiratory infections Menstrual history History of allergy
- 24. History pertaining tovarious symptoms a. Cardiovascular system b. Respiratory system c. Central Nervous system d. Gastrointestinal tract e. Genito-Urinary system f. Musculoskeletal g. Hematological system h. Endocrine system
- 25. History ofmedications- especially OTC History of addictions History of previous surgery History of previous anesthesia
- 26. Any treatmentfor cancer Family history of any adverse events related to anesthesia History of snoring
- 27. Antenatal history Term/pre term Birth weight Mode of delivery- indication History of ICU admission
- 28. Developmental delay Immunisation history Congenital disorders Recent respiratory infections
- 29. CVS complicationsare common perioperative adverse events 50% of peri-op deaths
- 30. Identify riskfactors Severity of the disease Need for pre-op interventions Risk of peri-op adverse events
- 32. Evaluated bythe estimated energy requirement for various activities Graded in metabolic equivalents (METS) on a scale defined by the Duke Activity Status Index One MET represents the oxygen consumption of a resting adult (3.5 ml/kg/min)
- 36. Risk factorsfor post-op pulmonary complications Procedure-related risk factors: − how close the surgery is to the diaphragm (i.e. upper abdominal and thoracic surgery are the highest risk procedures).
- 37. Length ofsurgery (> 3 hours) and general anesthesia Emergency surgery. Underlying chronic pulmonary disease or symptoms of respiratory infection Smoking.
- 38. Age >60years. Obesity. Presence of obstructive sleep apnea. (STOP BANG questionnaire) Poor exercise tolerance or poor general health status
- 40. Documentation regarding previousairway difficulty? Impact of surgery on the airway? Difficult BMV Difficult SADs Difficult intubation
- 41. Difficult infraglottic airway Aspiration risk Altered cardio-respiratory physiology? Ease of extubation
- 42. Previous historyof any previous anaesthesia issues including difficult intubation GER OSA BMI
- 43. Mouth openingand interincisor gap (IIG) Modified Mallampati score Teeth examination
- 44. Upper lipbite test (ULBT)/Mandible protrusion test Thyromental distance (TMD) Cervical spine movement
- 45. Pierre Robins- Micrognathia, macroglossia, cleft soft palate Treacher – Collins - Auricular and ocular defects, malar and mandibular hypoplasia
- 46. Goldenhaar -Auricular and ocular defects, malar and mandibular hypoplasia Downs - Poorly developed or absent bridge of the nose, macroglossia
- 47. Klippel Fiel- Congenital fusion of a variable number of cervical vertebrae, restriction of neck movement Acquired : − Infections : Abscess, Croup Arthritis , Benign tumors , Acromegaly ,Burns
- 49. It isthe distance between the upper and lower incisors. Normal is 4.5 cm or more; < 3.5 cm predicts difficult airway
- 51. Distance fromthe mentum to the thyroid notch while the patient’s neck is fully extended. TMD< 3 finger breadths or < 6 cm in adults
- 53. Distance fromthe suprasternal notch to the mentum with the head fully extended on the neck with the mouth closed. Less than 12 cm
- 55. Measurement ofmandibular length from chin (mental) to hyoid At least 4 cm or 3 finger breadths
- 58. Flexion ofneck Atlanto occipital (AO) joint extension Normally more than 35 degrees Turn right and left Rotate head
- 59. L -Look externally (facial trauma, large incisors, beard or moustache, large tongue) E - Evaluate the 3-3-2 rule (IIG>3fb, HMD > 3FB and TMD>2fb)
- 60. M -Mallampati (Mallampati score > 3). O - Obstruction (presence of any condition like epiglottitis, peritonsillar abscess, trauma). N - Neck mobility (limited neck mobility)
- 61. Beard ObesityBMI>26kg/m2 No teeth Elderly >55yrs Snorer
- 62. Restricted mouthopening Obstruction upper airway Disrupted airway-burns,trauma Stiff lung
- 63. Height Weight BMI(kg/m2) PICCLE SPO2 Vitals-temperature,PR,BP
- 64. System examination IV access Positioning of patient Teeth Spine Assess the pain score
- 66. Complete blood count Major surgery Chronic CVS,renal,pulmonary or hepatic d/s or malignancy Known or suspected anemia,bleeding diathesis,myelosuppression Less than one year of age
- 67. Hb lessthan 8g%-transfuse and repeat Hb on day of sx Serology INR, aPTT Anticoagulant therapy Bleeding diathesis Liver disease
- 68. Fasting glucose DM GRBS monitoring Q6H
- 69. Electrolytes andcreatinine HTN,DM,Renal disease, Pituitary/adrenal disease, Digoxin/diuretic therapy LFT Urine pregnancy test(menstrual age group)
- 70. ECG Heart disease,HTN,DM Other factors for cardiac disease(age) SAH/ICH, CVA, head trauma All ASA>II –above 30yrs ASA I- above 35yrs <30yrs if symptomatic
- 71. CXR cardiac/pulmonary disease Malignancy Covid 19 Not in pediatrics,pregnancy Recent LRTI in adults RTPCR for COVID 19
- 72. >60yrs UncontrolledDM ASA II Uncontrolled HTN ASAII All major SX h/o CAD or symptoms Abnormal ECG
- 73. CKD,CLD Sepsis Poorly mobilised Unable to assess effort tolerance
- 74. Administration ofmost drugs should be continued up to and including the morning of operation
- 75. Stop 6weeks before – OCP Stop 2-3 weeks before – MAO inhibitors, Herbal supplements Stop 1 week before – Clopidogrel
- 76. Stop 4-5 days before – Oral anticoagulants Stop 24 – 48hrs before – NSAIDS Stop on day of surgery – − OHA /Insulin − ACEI & ARBs − Diuretics-unless severe heart failure
- 78. Unfractionated Heparin-stop 6 hours prior LMWH- Stop 12hours prior prophylactic dose Stop 24hours prior therapeutic dose
- 79. Rivaroxaban,apixaban(FTI)- 72hrs Dabigatran(DTI) - 5 days Prasugrel 7-10 days Ticagrelor- 5-7 days Cangrelor – 3 hours
- 80. Fibrinolytics likestreptokinase- 10days Abciximab – 24-48hours Eptifibatide,tirofiban- 4-8hours
- 81. Alleviate anxiety/ sedation/ amnesia : Benzodiazepines(NOT in pediatric,pregnant,geriatric and very sever copd) Patient already on antianxiety drugs needn’t give
- 82. Antiaspiration prophylaxis: PPI, H2RB Antiemetics- ondansetron,metoclopramide
- 83. Fasting priorto procedure is to decrease the risk of peri- operative regurgitation, which may result in aspiration syndrome. Before any anesthetic procedure.
- 84. Prescribed medicationsmay be taken with a sips of water less than two hours prior to anaesthesia unless otherwise directed
- 85. Ask tostart IVF @ 50-75ml per hour from 6am For cases posted noon or later Caution in CKD,low EF patients
- 87. Informed consent Blood arrangement( open abdominal Sx,hysterectomy,LSCS,hip dx, neuro sx,major head and neck sx,any major sx,anemic patient)
- 88. A –Allergies M – Medical history P – Previous surgery L – Last meal E – Events leading up to the surgery
- 89. A minimumpre anesthetic physical examination should include 1. Airway examination 2. Pulmonary examination to include auscultation of the lungs 3. Cardiovascular examination
- 90. Miller’s anesthesia9th edition IJA,year 2020,volume-64,pages 267-274 ASRA and pain medicine April 2018 guidelines