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a slide presentation giving a layout ofperioperative assessment. Identify potential high risk case, and to minimize the risk for lowering intraoperative morbidity and mortality
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CONTENTS
1. Objectives
2. Preop assessment, where & when?
3. Recommended preoperative investigations
4. Fasting guidelines
5. Premedication
6. Medications
7. Summary
OBJECTIVES
1. Confirmation of pt identification, review of diagnosis & proposed procedure
2. Thorough history: - medical history e.g: IHD, HPT, DM - surgical related history - anaesthetic - drug
OBJECTIVES
PREVIOUS ANAESTHETIC HISTORY difficult airway PONV Malignant hyperthermia allergies difficult IV access awareness death following anaesthesia in the family
OBJECTIVES
DRUG HISTORY
- very useful, often forgotten Current medications Smoking/alcohol history History of allergy Medic alert bracelets Other drugs abuse
OBJECTIVES
3. Thorough Physical Examination: i) General examination:- General – mental status, body weight
- CVS – blood pressure, heart murmur
- RS - abnormal breathing sounds
- GI - abnormal masses, previous scar
OBJECTIVES
Musculoskeletal – kyphoscoliosis
Skin – local skin infection especially at thoracolumbar area
Neurological – peripheral neuropathy
OBJECTIVES
ii) Specific examination
- directed to the disease
e.g: cardiovascular disease
young HPT – look for sign for secondary
causes
OBJECTIVES
4. Optimization of patient’s medical condition for anaesthesia
-e.g: uncontrolled blood sugar/hypertension in diabetic patients
OBJECTIVES
5. Airway assesment
- certain features of concern
obesity
limited mouth opening
poor dentition
limited neck mobility
FEATURES OF DIFFICULT INTUBATION
OBJECTIVES
6. Classify physical status
ASA grading (American Society of Anesthesiologists)
Functional capacity
ASA GRADING
• Medical co-morbidity increases the risk associated with anaesthesia and surgery
• ASA grading is the most commonly used grading system
• ASA accurately predicts morbidity and mortality
ASA Grade
Definition Mortality (%)
I Normal healthy individual 0.05
IIMild systemic disease that does not limit activity 0.4
IIISevere systemic disease that limits activity but is not incapacitating 4.5
IVIncapacitating systemic disease which is constantly life-threatening
25
V Moribund, not expected to survive 24 hours with or without surgery
50
Application of ASA Grading
Cardiovascular disease
ASA Grade 2 ASA Grade 3
Angina Occasional use of GTN.
Regular use of GTN or unstable angina
HypertensionWell controlled on single agent
Poorly controlled. Multiple drugs
Diabetes Well controlled. No complications
Poorly controlled or complications
Respiratory disease
ASA Grade 2 ASA Grade 3
COPD Cough or wheeze. Well controlled
Breathless on minimal exertion
Asthma Well controlled with inhalers
Poorly controlled limiting lifestyle
• This is a measure of the metabolic demands of various daily activities on the heart
• For e.g: a patient who was breathless at rest, or after walking a short distance, would have a low functional capacity, which is a predictor of increased risk
Functional Capacity
• Poor functional capacity is associated with increased cardiac complications in noncardiac surgery.
• A patient's functional capacity can be expressed in metabolic equivalents (METs).
• One MET equals the oxygen consumption of a 70-kg, 40-year-old man in a resting state
Functional Capacity
Functional Status Assessment
Excellent (>7 METs)
Moderate (4 to 7 METs) Poor (<4 METs)
Squash Jogging (10-minute mile) Scrubbing floors Singles tennis
Cycling, Climbing a flight of stairs Golf (without cart)Walking 4 mph Yardwork (e.g., raking leaves, weeding, pushing a power mower)
Vacuuming Activities of daily living (e.g., eating, dressing, bathing) Walking 2 mph Writing
OBJECTIVES
7. Planning of anaesthetic technique, perioperative care & pain management
8. Clarification with surgeon if required
9. Obtain consent
- anaesthesia
- surgical
- blood transfusion
ANAESTHETIC DISCLOSURE AND CONSENT
- Planned anaesthetic procedure- Anaesthetic options if applicable - Possible risks & complications pertaining to
anaesthesia- Benefit vs risks of each technique- High risk consent with possible ICU admission
ANAESTHETIC CONSENT
- For underaged patient, obtain from parent/ guardian
- Discussion should be documented
OBJECTIVES
10. Establishment of rapport
- reduce anxiety & facilitate conduct of anaesthesia
11. Give instruction on medications, time of fasting
12. Prescription of premedicant drugs
PREOPERATIVE ASSESSMENTWhere & when ?
1. Elective surgery
- assessment done either in pre-anaesthetic clinic or ward
- advantages of early referral• Allows preoperative optimization• Reduces risk of unnecessary cancellation• Appropriate lab investigation can be done &
reviewed
2. Emergency surgery ill patient will be assessed in the ward
prior to surgery
May need ICU admission preoperatively for stabilization
RECOMMENDED PREOPERATIVE INVESTIGATIONS FBC- Age above 60- Clinical anaemia- Haematological disease- Renal disease- Chemotherapy- Procedures with blood loss > 15%
Renal profile- Age > 60- Renal ds- Liver ds- DM- Cardiovacular disease- Procedures with blood loss >15%
RECOMMENDED PREOPERATIVE INVESTIGATIONS ECG- Age > 50- Cardiovascular disease- DM- Renal disease
CXR- Age > 60- Signs of significant respiratory disease- Cardiovascular disease
RECOMMENDED PREOPERATIVE INVESTIGATIONS Coagulation profile- Haematological disease- Liver disease- Anticoagulations- Intrathoracic/ intracranial procedures
RBS- Age > 60- DM- Liver dysfunction
RECOMMENDED PREOPERATIVE INVESTIGATIONS
OTHER SPECIFIC INVESTIGATIONS
1. ABG
2. Lung function test
3. Thyroid function test
PREMEDICATION
1. NO SEDATIVE PREMED
- ill, septic, elderly
- potential diff airway
- day care surgery
- most neurosurgical pts
- neonates & infants < 6 month
PREMEDICATION
3. PAED PTS- Omit premed in ill babies, neonates & infants
< 6 month esp prem babies- Syrup midazolam 0.2 mg/kg- EMLA cream
PREMEDICATION
4. OBSTETRIC PTS- Oral ranitidine 150mg ON & morning of op- 0.3M sodium citrate 30 ml- Iv metoclopramide 10 mg
5. PTS AT RISK OF ASPIRATION
Prophylaxis vs acid aspiration- H2 receptor antagonist e.g ranitidine- Proton-pump Inhibitor e.g omeprazole
PREMEDICATION
- Non particulate antacids e.g 0.3M sodium citrate
- Gastrokinetic agents e.g metoclopramide
MEDICATIONS
Take all usual medications- Antihypertensives- β blocker- Statins
Think about discontinuing/ replacing- Aspirin- Anticoagulants- Diabetic medications- MAOIs