1. Role of Anesthesiologist Peri-Operative Period

2. Lecture Objectives.. Students at the end of the lecture will be able to: a) Obtain a full history and physical examination including allergies, current medications, past anesthetic history, family anesthetic history b) Understand how patient co-morbidities can affect the anesthetic plan c) Able to plan an anesthetic for a basic surgical procedure d) Understand risk stratification of a patient undergoing anesthesia

3. An Anesthesiologist or Anaesthetist is a physician trained in anesthesia and perioperative medicine. They are physicians who provide medical care to patients in a wide variety of (usually acute) situations. Anesthesiologists are responsible for ensuring the delivery of anesthesia safely to patients in virtually all health care settings, including all major medical and tertiary care facilities.

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

6. Intra-Operative Time from entering the OR theatre to entering the Recovering Room or Post Anesthetic Care Unit (PACU)

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

8. 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

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

10. 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 Functional Status Assessment 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. METs = metabolic equivalents.

11. Patient Related Risk Factors Age Obesity Smoking General health status Chronic obstructive pulmonary disease (COPD) Asthma

12. e.g Smoking Smoking history of 40 pack / year 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%)

13. Risk Stratification (1) Cardiac

14. This is a multi-factorial index of cardiac risk in the non-cardiac surgical setting. It was developed for preoperative identification of patients at risk from major perioperative cardiovascular complications. The data were derived retrospectively in 1977 from 1001 patients undergoing non-cardiac surgery. Patients with scores >25 had a 22% incidence of death, with a 56% incidence of severe cardiovascular complications. Patients with scores <26 had a 4% incidence of death, with a 17% incidence of severe cardiovascular complications. Patients with scores <6 had a 0.2% incidence of death, with a 0.7% incidence of severe cardiovascular complications. Multifactorial index of cardiac risk in noncardiac surgical procedures Goldman L, Caldera DL, Nussbaum SR N Engl J Med 1977; 297: 845-50N Engl J Med 1977; 297: 845-50

15. Cardiac (Cont.) Revised (Lee`s) Cardiac Risk Index High risk surgery (vascular, thoracic) Ischemic heart disease Congestive heart failure Cerebrovascular disease Insulin therapy for diabetes Creatinine >2.0mg/dL Risk for cardiac death, nonfatal myocardial infarction, and nonfatal cardiac arrest: 0 predictors = 0.4%, 1 predictor = 1%, 2 predictors = 2.4%, ≥3 predictors = 5.4%

16. * Clinical Predictors of Increased Perioperative Cardiovascular Risk* Major Predictors Unstable coronary syndromes Acute or recent MI with evidence of important ischemic risk by clinical symptoms or noninvasive study Unstable or severe angina (Canadian Class III or IV) Decompensated heart failure Significant arrhythmias High-grade atrioventricular block Symptomatic ventricular arrhythmias in the presence of underlying heart disease Supraventricular arrhythmias with uncontrolled ventricular rate Severe valvular disease * Myocardial infarction, heart failure, death. Circulation 1976;54:522-523. Cardiac (Cont..)

17. Intermediate Predictors Mild angina pectoris (Canadian Class I or II) Previous MI by history or pathologic Q waves Compensated or prior heart failure Diabetes mellitus (especially insulin-dependent type) Renal insufficiency Cardiac (Cont…)

18. Minor Predictors Advanced age > 70 Abnormal ECG (e.g., left ventricular hypertrophy, left bundle branch block, ST-T abnormalities) Rhythm other than sinus (e.g., atrial fibrillation) Low functional capacity (e.g., inability to climb one flight of stairs with a bag of groceries) History of stroke Uncontrolled systemic hypertension ECG, electrocardiogram; MI, myocardial infarction. Cardiac (Cont….) Major predictors of risk need extensive investigation and postponement or cancellation of elective surgery. Intermediate risk need careful assessment to decide on the need for noninvasive cardiac testing. Minor predictors of risk are not known to influence the perioperative course of patients.

19. Cardiac Risk* Stratification for Noncardiac Surgical Procedures High Risk (reported cardiac risk often >5%) Emergent major operations, particularly in older patients Aortic and other major vascular surgeries Peripheral vascular surgery Anticipated prolonged surgical procedures associated with large fluid shifts, blood loss, or both Intermediate Risk (reported cardiac risk generally <5%) Carotid endarterectomy Head and neck surgery Intraperitoneal and intrathoracic surgery Orthopedic surgery Prostate surgery Low Risk (reported cardiac risk generally <1%)† Endoscopic procedures Superficial procedure Cataract surgery Breast surgery * Combined incidence of cardiac death and nonfatal myocardial infarction. †Does not generally require further preoperative cardiac testing. (2) Surgical ( ACC & AHA)

20. (3) ASA Physical Status ASA 1 Healthy patient without organic biochemical or psychiatric disease. ASA 2 A Patient with mild systemic disease (controlled hypertension or diabetes without systemic effects). No significant impact on daily activity. Unlikely impact on anesthesia and surgery. ASA 3 Significant or severe systemic disease that limits normal activity (controlled congestive heart failure (CHF), stable angina, old heart attack, poorly controlled hypertension, morbid obesity, chronic renal failure). Significant impact on daily activity. Likely impact on anesthesia and surgery. ASA 4 Severe disease that is a constant threat to life or requires intensive therapy (symptomatic COPD, symptomatic CHF, hepatorenal failure). Serious limitation of daily activity. ASA 5 Moribund patient who is equally likely to die in the next 24 hours with or without surgery (multiorgan failure, sepsis syndrome). ASA 6 Brain-dead organ donor “E” Added to the classifications indicates emergency surgery. **Mortality rates of the individual classes showed considerable variation, with 0-0.3% for ASA I, 0.3-1.4% for ASA II, 1.8-4.5% for ASA III, 7.8-25.9% for ASA IV and 9.4- 57.8% ASA V ( Br J Anaesth 2004;93:393–399.)

21. #1: Surgery Low Risk* Low risk surgery confirmed Operating room 1.Endoscopic procedures 2.Superficial procedures 3.Cataract surgery 4.Breast surgery 5.Ambulatory surgery *Cardiac risk <1% Testing does not change management

22. #2: Is the surgery emergent? Emergent?Operating Room* Yes (Next Step) No * Consider beta-blockade, pain control and other peri-operative management

23. #3: Active Cardiac Conditions Active Cardiac conditions Yes Evaluate and treat per current guidelines ( Many patients need a cardiac cath.) Consider Operating Room No (Next Step) 1- Unstable coronary syndromes 2- Decompensated heart failure 3- Significant arrhythmias 4- Severe valvular disease

24. Airway Evaluation

25. Airway Evaluation (cont.)  Take very seriously 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

26. 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 (cont..)

27. Mallampati Score Sitting position, protrude tongue, don’t say “AHH” Class 1: Full visibility of tonsils, uvula and soft palate Class 2: Visibility of hard and soft palate, upper portion of tonsils and uvula Class 3: Soft and hard palate and base of the uvula are visible Class 4: Only Hard Palate visible

28. Airway Evaluation (cont…) Laryngoscopy view: Cormack and Lehane Grade I: complete glottis visible Grade II: anterior glottis not seen Grade III: epiglottis seen, but not glottis Grade IV: epiglottis not seen

29. Preoperative Lab. 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.

30. Procedure based indications Low risk Intermediate risk Base line creatinine High risk CBC, Electrolytes PFTs for lung reduction surgery Preoperative Lab. Testing (Cont.)

31. Disease-based indications Anemia CBC Bleeding disorder CBC, LFTs, PT, PTT Cardiovascular CBC, creatinine, CXR, ECG, lytes Diabetes Creatinine, electrolytes, glucose, ECG Hepatic disease CBC, creatinine, lytes, LFTs, PT Malignancy CBC, CXR Preoperative Lab. Testing (Cont..)

32. 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. Sleep apnea CBC, ECG Smoking >40 pack year CBC, ECG, CXR Preoperative Lab. Testing (Cont..)

33. Therapy-based indications Radiation therapy CBC, ECG, CXR Warfarin PT Digoxin Lytes, ECG, Dig level Diuretics Cr, lytes, ECG Steroids Glucose, ECG Preoperative Lab. Testing (Cont…)

34.  Q & A

35. dr. essam manaa Assistant professor & consultant Anesthesia dept., kkuh e_manaa@yahoo.com