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PRE OPERATIVE ASSESSMENT

Presented by

Moderator

INTRODUCTION
Anesthesia and surgery are physiologically
stressful, invasive interventions which may
exacerbate or uncover underlying disease
processes.

Aim
Problem Identification
Risk Assessment
Preoperative Preparation
Plan Anesthetic Technique

Problem identification
Identify unrecognized co-morbid disease and
risk factors for medical complications of
surgery
Optimize preoperative medical condition
Understand, recognize, and treat potential
complications.

History
Reason the patient is having surgery /
procedure.
How the condition developed and related
therapies
Concurrent past/present medical problems
Previous surgeries
History of past anaesthesia and related
complications

Prescription /over the counter medications


Allergies to drugs /substances
Use of tobacco , alcohol,illicit substances
System wise approach to illicit information

Cardiovascular : hypertension ; ischemic ,


valvular or congenital heart disease; CHF or
cardiomyopathy, , arrhythmias

Respiratory : smoking; COPD; restrictive lung


disease; altered control of breathing
(obstructive sleep apnea, CNS disorders, etc.)
Elderly , Children, Pregnancy

Neuromuscular : raised ICP ; TIA's or CVA's; seizures; spinal


cord Injury; disorders of NM junction e.g myasthenia
gravis, muscular dystrophies ,MH.
Endocrlne : DM; thyroid disease; pheochromocytoma;
steroid therapy
GI - Hepatic : hepatic disease; gastresophageal reflux

Renal : renal failure


Hematologic : anemias; coagulopathies

Physical examination

General examination
Local examination
Airway assessment
Systemic examination
Laboratory tests
Other tests

Airway assessment

Condition of teeth
Incisors
Tongue size
Facial hair
Thyromental distance
Length of neck
Neck circumference
Range of motion of head and neck

If the patient accommodates his/her 3


finger after widely opening the mouth

Protrusion of mandible
Patient maximally protrudes mandible, with
assessment of the relative position of lower teeth
to upper teeth.
Inability to protrude lower incisors beyond the
upper incisors is associated with difficult
intubation(B ,C).
CLASS A- Lower incisors protruded anterior.
CLASS B- Teeth level (edge to edge).
CLASS C- Lower incisors can not even be
brought at level.

Thyro mental distance


Distance from the mentum to the thyroid
notch.
It helps to determine how readily the
laryngeal axis will fall in line with the
pharyngeal axis.
Roughly it should be 3 finger width.

STERNO MENTAL DISTANCE


Measured from the sternum to the tip of the mandible with
the head extended.
A sternomental distance of 12.5cm predicts a difficult
intubation.

Mallampatti grading

CORMAC AND LEHANE GRADING


This test is performed during direct
laryngoscopy
One of four grades is assigned to the airway
based on what is viewed.

GRADE 1 INCLUDES
VISUALIZATION OF ENTIRE
GLOTTIC APERTURE;
GRADE 2 INCLUDES
VISUALIZATION OF ONLY POST
ASPECTS OF
GLOTTIC
APERTURE;
GRADE 3 IS VISUALIZATION OF TIP
OF EPIGLOTTIS;
GRADE 4 IS VISUALIZATION OF NO
MORE THAN SOFT PALATE

ATLANTO-OCCIPITAL NECK EXTENSION


Patient is asked to extent the head maximally and
the examiner estimates the angle traversed by
the occluded surface of upper teeth.
GRADE I - >35
GRADE II - 22 - 34
GRADE III - 12- 21
GRADE IV- < 12
(NORMAL ANGLE OF
EXTENSION IS 35 OR MORE)

RISK ASSESSMENT

EVALUATION OF PATIENTS WITH CO


EXISTING DISEASE
CARDIOVASCULAR SYSTEM
HTN
IHD
HEART FAILURE
VALVULAR ABNORMALITIES
RHYTHM ABNORMALITIES

HTN
Defined as two or more B.P. readings>140/90
mm
Cause
Other risk factors
End organ damage
Therapy

Co arctation of aorta
Hyperthyroidism
Pheochromocytoma
Steroid usage
Illicit drugs

Elective surgery be delayed if


Systolic > 200mm
Diastolic > 115 mm
Until B.P. < 180/110 mm
If end organ damage present , to normalize
B.P. as much as possible

Investigations

ECG
BUN
Electrolytes
Stress testing
2 D ECHO

Therapy
Beta blockers
Calcium channel blockers
Diuretics electrolytes?

IHD

IDENTIFY RISK OF HEART DISEASE


Severity of features
Need for preoperative interventions
Modify risk factors

MAJOR
Unstable coronary syndromes
Acute (<7d) or recent MI (<1mth) with evidence of
ischemic risk
Unstable or severe angina
Decompensated heart failure
Significant arrhythmias
High-grade AV block
Symptomatic ventricular arrhythmia
SVT with uncontrolled rate
Severe valvular disease

INTERMEDIATE
Mild angina pectoris
Previous myocardial infarction (>1mth) by
history of pathological Q waves
Compensated or prior heart failure
Diabetes mellitus (particularly insulin
dependent)
Renal insufficiency (creatinine >2.0)

MINOR
Advanced age
Abnormal ECG (LVH, LBBB, ST-T abnormalities)
Rhythm other than sinus (e.g. a fib)
Low functional capacity (e.g. inability to climb
one flight of stairs with a bag of groceries)
History of stroke
Uncontrolled systemic hypertension

Functional Capacity
Metabolic equivalents

Surgery-specific risk
High (Reported risk >5%)
Emergent major operations, particularly in
elderly
Aortic and other major vascular surgery
Surgical procedures associated with large fluid
shifts and/or blood loss

Intermediate (Reported risk <5%)


Carotid endarterectomy
Head and neck surgery
Intraperitoneal and intrathoracic procedures
Orthopedic surgery
Prostate surgery

Low (Reported risk <1%)


Endoscopic procedures
Superficial procedures
Cataract surgery
Breast surgery

5 step approach

1. urgency
2. active cardiac condition?
3. surgical risk/ severity
4. functional capacity
5. for poor / intermediate functional capacity

Applying Classification of
Recommendations and Level of
Evidence (LOE)

Class I- Evidence that procedure is beneficial,


useful, and effective
Class II- Conflicting Evidence
Class IIa- Weight is in favor of
usefulness/efficacy
Class IIb- Efficacy is less well established
Class III- Evidence that procedure is not useful
and may be harmful

Applying Classification of
Recommendations and Level of
Evidence

Level of Evidence A- Data from multiple,


randomized, clinical trials
Level of Evidence B- Data from singlerandomized trial or non-randomized trial
Level of Evidence C- Only consensus opinion
of experts, case studies, or standard-of-care

Pre op ecg?
Class I & II
0-1 clinical risk factor & vasc surgery (LOE: B)
1 risk factor & intermediate risk surgery (LOE:
B)
Class III
Not indicated in asymptomatic persons & low
risk procedure (LOE: B)

Recommendation for Eval of LV


function
Class IIa
Dyspnea of unknown origin (LOE: C)
Current or prior HF with worsening dyspnea or
other change in clinical status (LOE: C)
Class IIb
Stable cardiomyopathy may not need (LOE: C)
Class III
Routine echo in pts not recommended (LOE: B)

Recommendatons for Noninvasive


Stress Testing
Class I
Active cardiac conditions should be treated
prior to surgery (LOE: B)
Class IIa
3+ clinical risk factors & < 4 METS who require
vascular surgery (LOE: B)

Recommendations for Pre-op


Revascularization with CABG or PCI

Class I
Stable angina & left main stenosis
Stable angina & 3 vessel disease
Stable angina & 2 vessel disease (prox LAD
stenosis) & either EF < 50% or ischemia on
stress test
High risk unstable angina or NSTEMI
Acute STEMI

PCI: angioplasty
Delay surgery for > 14 days to allow healing of
vessel injury
Should continue aspirin perioperatively

PCI: bare-metal stent


Delay surgery for 4-6 wks to allow for at least
partial endothelialization
Clopidogrel usually not needed after 4 wks
Should continue aspirin perioperatively (vs
bleeding risk)

PCI: Drug-eluting stents


Delay surgery for 12 months due to risk of instent thrombosis
Should continue aspirin perioperatively
Thrombosis may occur up to 1.5 years after
implantation, particularly in the context of
discontinuing antiplatelet agents before
surgery

thank you