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2. Dr. Mansoor Aqil Associate Prof. and Consultant Department Of Anaesthesia King Saud University Riyadh 2

3. History and physical examination To determine medical risk factors, relevant tests and consultations Decision regarding optimization Choose anesthetic plan in discussion with patient Informed consent Educate patient about anesthesia, pain management and perioperative care 3

4.  Patient history and records  Patient interview  Physical examination  Laboratory tests  Consultations  Preparation 4

5. Days before schedule date in preoperative clinic Day before schedule date as inpatient Re-evaluation on admission and before anesthesia 5

6.  Patient  Patient attendant  Medical records 6

7. Approx 1:26,000 anaesthetics One third of deaths are preventable 7 Causes in order of frequency Inadequate patient preparation Inadequate postoperative management Wrong choice of anaesthetic technique. Inadequate crisis management

8.  Inadequate postoperative management you have to assess to see if the patient s having intra abdominal bleeding, or any concealed bleeding or nausea and vomiting.  Wrong choice of anesthetic technique. Local regional anesthesia is better in general but especially in C-section because it reduces the risk of aspiration 8

9. Why does the patient need an operation now? Is it acute/chronic illness? e.g. anaemia, cachexia, pain, seizures etc What are the pathophysiological consequences? Presenting symptoms? e.g. thyroid mass Local - stridor, SVC obstruction Systemic - hypo/hyperthyroidism 9

10.  All comorbidities should be controlled before surgery  We do not operate on hypo/hyperthyrodism it should be euthyroid except in acute cases in which there is difficulty in breathing with stridor then you should operate regardless the state of the thyroid.  Always keep in mind the urgency of the surgery. 10

11. Other problems that may affect Perioperative morbidity and mortality?  Cardiac disease  Respiratory disease  Arthritis  Endocrine disorders - diabetes, obesity etc What is the patients functional capacity? Must be assessed. 11

12.  Asthma  COPD HISTORY ◦ Onset ◦ Duration ◦ Progress ◦ Dyspnoea I.II.III.IV 12

13.  RISK FACTORS  Smoking increases the risk of coughing, bronchospasm, or other airway problems during the operation.  Ideally should be stopped 6 weeks before surgery but in emergency cases we can accept it 13

14. RISK FACTORS  Chest wall deformity intubation will not help unlike in asthmatics  Major abdominal surgeries  Thoracic surgery  Morbid obesity 14

15.  H/O Angina  H/O dyspnoea  Repeated hospital admissions  Look for risk factors  Diabetes Mellitus  Hypertension  Syncopal attacks  Peripheral Vascular disease 15

16. 1–4 METS (Eating, dressing, walking around house, dishwashing) 4–10 METS (Climbing stairs—1 flight, walking level ground 6.4 km/hr, running short distance, game of golf) ≥10 METS (Swimming, singles tennis, football) MET=metabolic equivalent. 1 MET = 3.5 mL of O2/Kg/min 16

17. Class I: Angina with strenuous or prolonged exertion Class II: Angina with moderate exertion Class III: Can only lightly exert oneself Class IV: Angina with ANY activity or at rest 17

18.  Other systems  Renal  Liver  Diabetes  Psychiatric problem  FAMILY HISTORY 18

19.  Previous surgical procedure  Anesthesia Type  Difficult airway  Difficult IV access Any Complications  Allergy  PONV  Malignant hyperpyrexia 19

20. Best done by an anaesthetist Certain features of concern ◦ Small mouth ◦ Poor dentition ◦ Limited neck mobility ◦ Scars/surgery/anatomical abnormalities ◦ Obesity 20

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22. Why would this man’s airway be difficult to manage? 22

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26. 26 Grade 1 Grade 2 Grade 3 Grade 4

27.  Class 1:pillars, glottis and vocal cords are seen. Easiest intubation.  Class 4: only the hard palate can be seen. The most difficult intubation. 27

28. Preoperative tests should not be ordered routinely Preoperative tests may be ordered, required, or performed on a selective basis for purposes of guiding or optimizing perioperative management. This may result in unnecessary OR delays, cancellations, and potential patient risk through additional testing and follow-up. 28

29. 29 P1. Normal healthy patient. (Mortality 0.06-0.08%). P2. Patient with mild systemic disease. (Mortality0.27-0.4%). P3. Patient with severe systemic disease. (Mortality 1.8-4.3%). P4. Patient with severe systemic disease that is life-threatening. E.g. MI (Mortality 7.8-23%). P5. Moribund (dying) patient who is not expected to survive without an operation. (Mortality 9.4-51%). P6. Brain-dead patient whose organs are being removed for donation. For emergent operations, you have to add the letter ‘E’ after the classification

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31.  Low risk surgeries (<1% cardiac risk)  Endoscopic procedures  Superficial biopsies  Cataracts  Breast surgery 31

32.  Intermediate risk (<5% cardiac risk)  Intraperitoneal and intrathoracic  Carotid endarterectomy  Head and neck  Orthopedic  Prostate 32

33.  High risk (>5% cardiac risk)  Emergency major operations  Especially in the elderly  Aortic or major vascular surgery  Craniotomy  Extensive operations with large volume shifts or blood loss. 33

34.  Minor predictors  Advanced age  Abnormal ECG  Rhythm other than sinus  Low functional capacity  Uncontrolled hypertension 34

35.  Intermediate predictors  Mild angina pectoris (class 1 or 2)  Prior MI more than 6 months ago  Compensated or prior heart failure  Diabetes mellitus  Renal insufficiency 35

36.  Major predictors  Acute or recent MI less than 2 months before surgery  Unstable or severe angina  Decompensated heart failure  High-grade A-V block  Severe valvular disease  Arrhythmias 36

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38. 38 Emergency surgery Proceed surgery. Optimize medical management yes

39. Emergency surgery No Active cardiac condition Treat the cardiac condition Severe angina, recent MI, decompensated heart failure, significant arrythmia, severe valvular heart disease yes

40. 40 Emergency surgery No Active cardiac condition No Low risk surgery Proceed surgery. yes Low risk surgeries (<1% cardiac risk) Endoscopic procedures Superficial biopsies Cataracts Breast surgery

41. 41 Emergency surgery No Active cardiac condition No Low risk surgery Intermediate risk (<5% cardiac risk) Intraperitoneal and intrathoracic Carotid endarterectomy Head and neck Orthopedic Prostate High risk (>5% cardiac risk) Emergency major operations Especially in the elderly Aortic or major vascular surgery Craniotomy Extensive operations with large volume shifts or blood loss. Low risk surgeries (<1% cardiac risk) Endoscopic procedures Superficial biopsies Cataracts Breast surgery No Good functional status >4 MET Good functional status >4 MET Proceed surgery. yes

42. 42 Emergency surgery No Active cardiac condition No Low risk surgery Intermediate risk (<5% cardiac risk) Intraperitoneal and intrathoracic Carotid endarterectomy Head and neck Orthopedic Prostate High risk (>5% cardiac risk) Emergency major operations Especially in the elderly Aortic or major vascular surgery Craniotomy Extensive operations with large volume shifts or blood loss. Low risk surgeries (<1% cardiac risk) Endoscopic procedures Superficial biopsies Cataracts Breast surgery No Good functional status >4 MET Good functional status >4 MET No All other situations Clinical risk factors Diabetes IHD CHF CVA CRF Assess number of risk factors 0= Proceed with surgery 0-2= Consider risk modification, Consider perioperative beta blockers, Consider non invasive stress testing if change in management >3 = Consider non invasive stress testing + consider perioperative beta blockers Consider coronary revascularization

43. TAKE CONSCENT EXPLAIN RISKS OFFER CHOICES OF ANESTHESIA AND PAIN MANAGEMENT NPO orders Premedication: drugs that decrease gastric secretions to decrease the risk of aspiration especially in obese, patients with a history of heartburn or pregnant ladies (due to progesterone and increased intraabdominal pressure) or vagolytics to decrease oral secretions for easier intubation or analgesics to decrease the dose of anaesthetics. 43

44.  Take all usual medications ◦ Anti-hypertensives ◦ Beta blockers ◦ Statins  Think about discontinuing/replacing ◦ Aspirin ◦ Anticoagulants ◦ Diabetic medications ◦ MAOIs ◦ Note in obese patients, patients with a history of heartburn or pregnant ladies 44

45. Ingested Material Minimum Fasting Period Clear liquids 2hrs Breast Milk 4hrs Infant Formula 6hrs Non-human milk 6hrs Light meal 6hrs 45

46. 46 PURPOSE : To allay anxiety, Reduce anesthetic drugs requirements Causes retrograde and ante grade amnesia Reduce need of intraoperative analgesia Drugs : Benzodiazepines, Narcotics, Antiemetic etc

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48. History and physical most important assessors of disease and risk ASA and functional status good predictors of risk Lab tests have some usefulness Lab tests add little in low risk patients May add false + ves Add expense 48

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