Lecture Title: Lecture Title: Role of anesthesiologist in pre-operative period Lecturer name: Dr. Jumana Baaj Lecture Date: 19/10/2014

Lecture Objectives.. Students at the end of the lecture will be able to: 1)learn pre-anesthetic patient evaluation and risk stratification. 2)Obtain a full history and physical examination including allergies, current medications, past anesthetic history, family anesthetic history 3)The medical student will understand how patient co-morbidities can affect the anesthetic plan. 4)The medical student will be able to understand potential anesthetic options for a given surgical procedure. 5)The medical student will be able to plan an anesthetic for a basic surgical procedure. 6)The student will understand risk stratification of a patient undergoing anesthesia.

Stages of the Peri-Operative Period Pre-Operative From time of decision to have surgery until admitted into the OR theatre.

Stages of the Peri-Operative Period Intra-Operative Time from entering the OR theatre to entering the Recovering Room or Post Anesthetic Care Unit (PACU)

Stages of the Peri-Operative Period Post-Operative Time from leaving the RR or PACU until time of follow-up evaluation (often as out-patient)

Preoperative visit. To educate about anesthesia, perioperative care and pain management to reduce anxiety. To obtain patient's medical history and physical examination. To determine which lab test or further medical consultation are needed. To choose care plan guided by patient's choice and risk factors

Benefits from surgery ←→ Risk of complications

Preoperative Evaluation: A thorough history and physical exam. Complete review of systems. – Organ specific issues. – Functional Status. – Habits (smoking, alcohol, drugs). Medications (herbals) and allergies. Anesthesia history. Pre-op labs: one size does not fit all.

Patient related risk factors (pulmonary) Age Obesity Smoking General health status Chronic obstructive pulmonary disease (COPD) Asthma

Smoking Important risk factor Smoking history of 40 pack years or more →↑risk of pulmonary complications stopped smoking 2 months 4:1(57% : 14.5%) quit smoking > 6 months : never smoked = 1:1 (11.9% : 11%)

Risk Stratification Revised Cardiac Risk Index – High risk surgery (vascular, thoracic) – Ischemic heart disease – Congestive heart failure – Cerebrovascular disease – Insulin therapy for diabetes – Creatinine >2.0mg/dL

Active Cardiac Conditions Unstable coronary syndromes – Unstable or severe angina – Recent MI Decompensated HF Significant arrhythmias Severe valvular disease

Minor Cardiac Predictors Advanced age (>70) Abnormal ECG – LV hypertrophy – LBBB – ST-T abnormalities – Rhythm other than sinus Uncontrolled systemic hypertension

Surgical Risk Stratification High Risk – Vascular (aortic and major vascular) Intermediate Risk – Intraperitoneal and intrathoracic, carotid, head and neck, orthopedic, prostate Low Risk – Endoscopic, superficial procedures, cataract, breast, ambulatory surgery

Risk Stratification ASA physical status – ASA 1 – Healthy patient without organic biochemical or psychiatric disease. – ASA 2- A Patient with mild systemic disease. No significant impact on daily activity. Unlikely impact on anesthesia and surgery. – ASA 3- Significant or severe systemic disease that limits normal activity. Significant impact on daily activity. Likely impact on anesthesia and surgery.

Risk Stratification ASA 4- Severe disease that is a constant threat to life or requires intensive therapy. Serious limitation of daily activity. ASA 5- Moribund patient who is equally likely to die in the next 24 hours with or without surgery. ASA 6- Brain-dead organ donor “E” – added to the classifications indicates emergency surgery.

Step 2: Determine Presence of Active Cardiac Conditions If none are present, proceed with surgery Presence of one of these delays surgery for evaluation Many patients need a cardiac cath

Step 2 Unstable coronary syndromes Decompensated heart failure Significant arrhythmias Severe valvular disease

Step 3: Surgery Low Risk? Low risk surgery includes: 1.Endoscopic procedures 2.Superficial procedures 3.Cataract surgery 4.Breast surgery 5.Ambulatory surgery Cardiac risk <1%

The Nervous System 1.Problems may be central or peripheral 2.Thorough history is essential 3.Correlate history with physical finding 4.Sources of Problems Ischemia, Vasospasm, Embolism Thrombosis Tumor,Aneurysm, Hemorrhage,Seizures, Stroke 5.Signs and Symptoms : Nausea / Vomiting Vertigo, Headache, Visual problems, Sensory abnormalities Motor weakness

Renal System Acute / Chronic Renal Failure – Total body disease – Electrolyte abnormalities – Coagulation disorders – Hypervolemic, hypertensive, hyperkalemic

Gastric reflux Get accurate history Evaluate risk of aspiration Consider gastric prep Proton inhibiter or H2 blockers (ranitidine ) Metoclopramide Antacid Gastric reflux Rapid sequence induction, Cricoid pressure Gastrointestinal System

Endocrine System Diabetes Mellitus – Type I -- Insulin dependent End organ disease is common hypertension, coronary artery disease, neuropathy, retinopathy, nephropathy, autonomic dysfunction – Type II -- Non-insulin dependent Onset usually after pregnancy or excessive weight gain controlled with diet and exercise

Endocrine System (con’t) Diabetes Mellitus – Goals of Management – Maintain glucose in range – Provide adequate fluid volume – Individualize care plan – Consider diabetic complication( dibetic nephropathy,diabetic retinopathy, diabetic neuropathy )

Endocrine System (con’t) Pheochromocytoma – Tumor of chromaffin tissue Increased production and release of epinephrine and norepinephrine – Signs and symptoms Intermittent hypertension Headache Sweating Tachycardia

Endocrine System (con’t) Pheochromocytoma (con’t) – Secondary problems Hyperglycemia Myocarditis Cardiomyopathy M.I. with CHF Intracerebral hemorrhage, heart failure

Hematologic System Anemia – 3 key questions What is the cause? Is it acute or chronic? Will the patient benefit from delay? – Acute blood loss poorly tolerated – Chronic renal failure Anemia and platelet dysfunction Tolerate anemia well Platelet dysfunction corrected with dialysis

Hematologic System (con’t) Disorder of hemostasis – Congenital Hemophilia – Acquired Thrombocytopenia Hepatic dysfunction Platelet dysfunction Drugs induce

Airway Evaluation  Take very seriousl history of prior difficulty  Head and neck movement (extension) ◦ Alignment of oral, pharyngeal, laryngeal axes ◦ Cervical spine arthritis or trauma, burn, radiation, tumor, infection, scleroderma, short and thick neck

Airway Evaluation Jaw Movement – Both inter-incisor gap and anterior subluxation – <3.5cm inter-incisor gap concerning – Inability to sublux lower incisors beyond upper incisors Receding mandible Protruding Maxillary Incisors (buck teeth)

Airway Evaluation Oropharyngeal visualization Mallampati Score Sitting position, protrude tongue, don’t say “AHH”

Preoperative Testing Routine preoperative testing should not be ordered. Preoperative testing should be performed on a selective basis for purposes of guiding or optimizing perioperative management.

Preoperative Testing Procedure based. – Low risk Baseline creatinine if procedure involves contrast dye. – Intermediate risk Base line creatinine if contrast dye or >55yr of age. – High risk CBC, lytes & S, creatinine as above. PFTs for lung reduction surgery.

Preoperative Testing Disease-based indications – Alcohol abuse CBC, ECG, lytes, LFTs, PT – Anemia CBC – Bleeding disorder CBC, LFTs, PT, PTT – Cardiovascular CBC, creatinine, CXR, ECG, lytes

Preoperative Testing Disease-based indications – Cerebrovascular disease Creatinine, glucose, ECG – Diabetes Creatinine, electrolytes, glucose, ECG, HbA1C – Hepatic disease CBC, creatinine, lytes, LFTs, PT – Malignancy CBC, CXR

Preoperative Testing 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, CXR, C-spine (atlantoaxial subluxation) – AP C-spine, AP odontoid view and lateral flexion and extention.

Preoperative Testing Disease-based – Sleep apnea CBC, ECG – Smoking >40 pack year CBC, ECG, CXR – Systemic Lupus Cr, ECG, CXR

Preoperative Testing Therapy-based indications – Radiation therapy CBC, ECG, CXR – Warfarin PT – Digoxin ElectrolyteLytes, ECG, Dig level – Diuretics Cr,electrolytes, ECG – Steroids Glucose, ECG

Informed Consent 1.Frequently questioned in malpractice cases 2.Risks / benefits 3.Alternatives 4.Answer all questions 5.Do not deceive the patient

Risks of Anesthesia 1.Determine what the patient wants to know - Do not frighten patients 2.Start with minor risks 3.Proceed to serious risks

ASA Physical Status 1.Risk indicators 2.Developed for statistical studies 3.Used to compare outcomes

ASA Physical Status Classification ASA 1 – normal, healthy patient ASA 2 – patient with mild, well-controlled systemic disease ASA 3 – patient with severe systemic disease that limits activity ASA 4 –patient with severe, life-threatening disease ASA 5 – moribund patient not expected to survive for 24 hours with or without surgery

Document the Visit 1.Complete the evaluation form 2.Enter progress notes 3.Have patient sign consent 4.Write appropriate orders

 Q & A

Dr. T hank You T hank You