Presentation on theme: "PREOPERATIVE ASSESSMENT"— Presentation transcript:
1 PREOPERATIVE ASSESSMENT Hossam M. AjabnoorAnesthesia & ICU Asistant ConsultantAnd LecturerSchool of Medicine, Taibah University
2 INTRODUCTION Importance Reduce patient risk and morbidity associated with surgery and coexisting diseasesPromote efficiency and reduce costsPrepare the patient medically and psychologically for surgery and anesthesia
3 ASA basic standards for preanesthetic care Determining the pt. medical statusDeveloping an anesthetic care planReviewing with the pt. or a responsible adult this plan
4 Who should perform the preoperative evaluation? Ideally, the preoperative evaluation is performed by the person who will administer the anesthetic.
5 Goals:Inform the pt. of the risk → informed consentEducate the pt. regarding anesthesia PlanAnswer pt. Q.s & reassure the pt. & familyProhibition of ingesting foodInstruct the pt. about which medications to take or to stop on the day of surgery
6 PREOPERATIVE EVALUATION It is important for the evaluation to be complete, accurate, and clear, not only to allow the information to be relayed to others who may care for the patient perioperatively, but also for medico legal purposes
7 COMPONANTS HISTORY PHYSICAL EXAMINATION LAB TESTS CONSULTATIONS (if needed)PLANDISCUSSION WITH PATIENT
8 HISTORY State of health of pt. especially their exercise tolerance Present illnessMental statusMedication and substances use(e.g., cigarettes, alcohol)Previous anesthesia and any complicationsDrug allergies and family Hx of MHreview of medical records
9 SPECIFIC AREAS IN Hx CNS Strokes - seizures CVS Angina - old MI – HTN – rheumatic fever – claudication – arrhythmiasPULMONARYSOB – cough/sputum – asthma – smoking – recent UTI – pneumoniaGIGERD – alcohol – hepatitis
12 AIRWAY Cervical spine mobility Short thick neck Temporomandibular mobilityLarge tongueProminent central incisorsDiseased or artificial teethThyromental distance and tissue complianceAbility to visualize the uvula (Mallampati classification)
13 Mallampati classification Mallampati found a correlation between higher oropharyngeal class and decreased glottic exposure at laryngoscopy. A higher oropharyngeal class combined with a mental space < 2 fingerbreadths may better predict increased difficulty with intubation Performed by having patients in sitting position with their mouth widely open and protruding the tongue completely forward. (A tongue depressor is not used)
14 DIRECT VISUALIZATION, PATIENT SEATED LARYNGOSCOPIC VIEWDIRECT VISUALIZATION, PATIENT SEATEDEntire glotticclass I → soft palate, fauces, uvula, and pillarsPosterior commissureclass II → soft palate, fauces, and a portion of the uvulaTip of epiglottisclass III → soft palate and base of the uvulaNo glottal structuresclass IV → hard palate only
16 LAB TESTS No evidence supports the use of routine laboratory testing Use selected laboratory analysis based on the patient's preoperative history, physical examination, and proposed surgical procedure
17 Test Indications Electrocardiogram Chest radiograph Cardiac and circulatory disease, respiratory disease, advanced age†Chest radiographChronic lung disease, history of congestive heart diseasePulmonary function tests, including blood gas analysis and spirometryReactive airway disease, chronic lung disease, restrictive lung disease (e.g., scoliosis)Hemoglobin/hematocritAdvanced age,† anemia, bleeding disorders, other hematologic disordersCoagulation studiesBleeding disorders, liver dysfunction, anticoagulantsSerum chemistries (Na+, K+, Cl-, CO2, glucose)Endocrine disorders, medications, renal dysfunctionPregnancy testUncertain pregnancy history, history suggestive of current pregnancy
18 CONSULTATIONSPreoperative consultations fall into two general categories:Those cases that need more information or expertise to establish or quantify a diagnosis that has implications for anesthetic management. An example is asking a cardiologist to evaluate a 50-year-old man with recent onset of exertional chest pain.Patients in whom the diagnosis is known, but further evaluation and treatment are needed to optimize their medical condition prior to surgery. Referring patients with poorly controlled diabetes, hypertension, or asthma to an internist are examples.
19 PLAN Type of anesthesia Awake Sedation Local Regional General anesthesiaTransfer postopHomeHospital room (day care / ward)ICUPain control postop
20 Discussion With The Pt. Preop 1. Risks related to anesthesiaNausea and vomitingMyalgiaDental injuryPeripheral neuropathyCardiac dysrhythmiasAtelectesisAspirationStrokeAllergic drug reactionsDeath (very unlikely)
21 2. Preop insomnia and its treatment 3 2. Preop insomnia and its treatment 3. Time, route of administration & effects of preop meds 4. Time of transport to OR 5. Duration of surgery
22 6. Awakening after surgery in PACU 7 6. Awakening after surgery in PACU 7. Probable presence of catheters on awakening 8. Time to expected discharge from PACU 9. Magnitude of postop discomfort and it treatment
23 ASA PHYSICAL STATUS CLSSIFICATION Created in 1940purposes of statistical studies and hospital recordsIt is useful both for outcome comparisons and as a convenient means of communicating the physical status of a patientUnfortunately, it is imprecise, and a patient often may be placed in different classes by different anesthesiologiststhe higher ASA class only roughly predicts anesthetic riskClass 1: Healthy patient, no medical problemsClass 2: Mild systemic diseaseClass 3: Severe systemic disease, but not incapacitatingClass 4: Severe systemic disease that is a constant threat to lifeClass 5: Moribund, not expected to live 24 hours irrespective of operationAn e is added to the status number to designate an emergency operation. An organ donor is usually designated as Class 6.
24 How long should a patient fast before surgery? Healthy adults with no risk factors for aspiration include no solid food for a minimum of 6 hours, clear liquids up to 2 hours prior to an elective procedure, and oral preoperative medications up to 1-2 hours before anesthesia with sips of water.Pediatric patients are as follows:clear liquids up to 2 hours preoperativelybreast milk up to 4 hours preoperativelysolid foods, including nonhuman milk and formula, up to 6 hours preoperatively.
25 How long before surgery must A smoker patient quit smoking? Carbon monoxide (CO) from cigarette smoking diminishes oxygen delivery to tissuesNicotine increases heart rate and can cause peripheral vasoconstrictionWithin hours of discontinuing cigarettes, CO and nicotine levels return to normalBronchociliary function improves within 2-3 days of cessationsputum volume decreases to normal levels within about 2 weeksHowever, there may not be a significant decrease in postoperative respiratory morbidity until after 6-8 weeks of abstinence.
26 List the major goals of premedication Sedation and anxiolysisAnalgesia and amnesiaAntisialagogue effectTo maintain hemodynamic stability, including decrease in autonomic responseTo prevent and/or minimize the impact of aspirationTo decrease postoperative nausea and vomitingProphylaxis against allergic reaction
27 What factors should be considered in selecting premedication for a patient? Patient age and weightPhysical statusLevels of anxiety and painPrevious history of drug use or abuseHistory of postoperative nausea or vomiting or motion sicknessDrug allergiesElective or emergency surgeryInpatient or outpatient status
28 List the most commonly used preop medications Diazepam Oral 5-20 SedationMidazolam IV SedationMorphine IM 5-15 AnalgesiaMeperidine IM AnalgesiaRanitidine Oral, IV 150 mg and 50 mg, respectively Decrease gastric pHMetoclopramide Oral, IM, IV 5-20 GastrokineticGlycopyrrolate IM, IV Weak sedative, antisialagogueScopolamine IM, IV Sedative, antisialagoguePromethazine IM AntiemeticKetamine IM, oral 1-2 mg/kg and 6 mg/kg, respectively Sedation
29 A 3-year-old child presents for an elective tonsillectomy A 3-year-old child presents for an elective tonsillectomy. His mother reports that for the past 3 days he has had a runny nose. Should you postpone surgery?
30 Viral URI alters the quality and quantity of airway secretions and increases airway reflexes to mechanical, chemical, or irritant stimulationSome clinical studies have shown associated intraoperative and postoperative bronchospasm, laryngospasm, and hypoxiaThere is evidence that the risk of pulmonary complications may remain high for at least 2 weeks, and possibly 6-7 weeks, after a URIInfants have a greater risk than older children, and intubation probably confers additional risk
31 However, as a practical matter, young children can average 5-8 URIs per year, mostly from fall through springIf a 4- to 7-week symptom-free interval were rigorously followed, an elective surgery might be postponed indefinitelyTherefore, most anesthesiologists distinguish uncomplicated URI with chronic nasal discharge from nasal discharge associated with more severe URI with or without lower respiratory tract infection (LRI)Chronic nasal discharge is usually noninfectious in origin and caused by allergy or vasomotor rhinitisAn uncomplicated URI is characterized by sore or scratchy throat, laryngitis, sneezing, rhinorrhea, congestion, malaise, nonproductive cough, and temperature > 38°C
32 More severe URI or LRI may include severe nasopharyngitis, purulent sputum, high fever, deep cough, and associated auscultatory findings of wheezes or ralesIt is generally agreed that chronic nasal discharge poses no significant anesthesia riskIn contrast, children with severe URI or LRI almost always have their elective surgery postponedProbably most anesthesiologists will proceed to surgery with a child with a resolving uncomplicated URI, unless the child has a history of asthma or other significant pulmonary disease