Download - Pre-operative evaluation and management
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By Ronald Ombaka
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Anesthetic drugs and techniques have profound effects on human physiology. Hence, a focused review of all major organ systems should be completed prior to surgery.
The goals of preoperative evaluation are to reduce patient risk and the morbidity of surgery
(with the premise that it will modify patient care and improve outcome)
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This ultimately allows the anaesthesiologist to formulate an appropriate anaesthetic plan with contingencies to deal with patients comorbidity associated complications and/or need to optimize patient prior to surgery.
It is also a medicolegal document.
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The process should be used to educate the patient about anesthesia and the perioperative period, answer all questions, and obtain informed consent.
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thorough history and physical exam
thorough history and physical exam
thorough history and physical exam
thorough history and physical exam
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Salient information obtained from history;
Indication for surgery
Site of surgery(has implications on positioning)
Urgency of procedure (? RSI)
Allergies
Prior surgeries and prior experience with anaesthetics(e.g. PONV, malignant hyperthermia )
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Last meal taken
Current comorbidities(acute or chronic )
Current medications(as well as supplements)
(It is also a chance to take note of pre-anaesthetic health condition allowing comparison with outcome post-op)
Risk classification –ASA Physical status classification
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ASA Physical Status 1 - A normal healthy patient ASA Physical Status 2 - A patient with mild
systemic disease ASA Physical Status 3 - A patient with severe
systemic disease ASA Physical Status 4 - A patient with severe
systemic disease that is a constant threat to life ASA Physical Status 5 - A moribund patient who
is not expected to survive without the operation ASA Physical Status 6 - A declared brain-dead
patient whose organs are being removed for donor purposes
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medical status mortality
ASA I normal healthy patient without organic, biochemical, or psychiatric disease
0.06-0.08%
ASA II mild systemic disease with no significant impact on daily activity e.g. mild diabetes, controlled hypertension, obesity .
Unlikely to have an impact
0.27-0.4%
ASA III
severe systemic disease that limits activity e.g. angina, COPD, prior myocardial infarction
Probable impact 1.8-4.3%
ASA IV
an incapacitating disease that is a constant threat to life e.g. CHF, unstable angina, renal failure ,acute MI, respiratory failure requiring mechanical ventilation
Major impact 7.8-23%
ASA V moribund patient not expected to survive 24 hours e.g. ruptured aneurysm
9.4-51%
ASA VI
brain-dead patient whose organs are being harvested
ASA Physical Status Classification System
For emergent operations, you have to add the letter ‘E’ after the classification.
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Airway
Evaluation of the airway involves determination of the thyromental distance, the ability to flex the base of the neck and extend the head, and examination of the oral cavity including dentition.
Mallampati classification.
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Mallampati
Measurements 3-3-2-1 or 1-2-3-3 Patient ‘s fingers
Movement of the Neck
Malformations of the Skull
Teeth
Obstruction
Pathology
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Class I = visualize the soft palate, fauces, uvula, anterior
and posterior pillars.
Class II = visualize the soft palate, fauces and uvula.
Class III = visualize the soft palate and the base
of the uvula.
Class IV = soft palate is not visible at all.
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3 Fingers Mouth Opening
3 Fingers Hypomental Distance. (3 Fingers between the tip
of the jaw and the beginning of the neck (under the chin)
2 Fingers between the thyroid notch and the floor of the
mandible (top of the neck)
1 Finger Lower Jaw Anterior sublaxation
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Skull (Hydro and Microcephalus)
Teeth ( protruded, & loose teeth. Macro and Micro mandibles)
Obstruction (obesity, short Bull Neck & swellings around the head
and neck)
Pathology (Craniofacial abnormalities & Syndromes e.g. Treacher
Collins, Goldenhar's, Pierre Robin syndromes)
.
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Pierre Robin( hypertelorism; and external and middle ear deformities)
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A screening evaluation should include questions regarding the history of tobacco use, shortness of breath, cough, wheezing, stridor, and snoring or sleep apnea.
The patient should also be questioned regarding the presence or recent history of an upper respiratory tract infection.
Auscultation should be used to detect decreased breath sounds, wheezing, stridor, or rales.
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When screening a patient for cardiovascular disease prior to surgery, the anesthesiologist is most interested in recognizing signs and symptoms of uncontrolled hypertension and unstable cardiac disease such as ; myocardial ischemia, congestive heart failure, valvular heart disease, and significant cardiac dysrhythmias
Exercise tolerance is one of the most important determinants of perioperative risk and the need for further testing and invasive monitoring.
Inability to walk 4 blocks (1 block is100-200 meters) or climb 2 flights of stairs is defined as poor exercise tolerance.(this doubles your risk of adverse cardiovascular outcomes)
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A screening of the neurological system in the apparently healthy patient can mostly be accomplished through simple observation.
The patient's ability to answer health history questions practically ensures a normal mental status.
Questions can be directed to exclude the presence of ; Increased intracranial pressure,
Cerebrovascular disease,
Seizure history,
Preexisting neuromuscular disease,
Nerve injuries,
Spinal cord Injury;
Disorders of NM junction e.g myasthenia gravis, muscular dystrophies
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Each patient should be screened for endocrine diseases that may affect the perioperative course:
diabetes,
thyroid disease,
parathyroid disease,
endocrine-secreting tumors, and
adrenal cortical suppression.
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significant blood loss;
respiratory compromise;
positioning
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Reasonable testing
positive finding in history and physical exam.
need for baseline value in anticipation of significant
change due to surgery and medical intervention
patient's inclusion in population at higher risk
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• Anesthetic indications: -Anxiolysis, sedation and amnesia. e.g. benzodiazepine(diazepam ,lorazepam) -Analgesia e.g narcotics-Drying of airway secretions e.g atropine,glycopyrrolate,scopolamine-Reduction of anesthetic requirements ,Facilitation of smooth induction -Patients at risk for GE reflux :ranitidine ,metoclopramide , sodium citrate
• Surgical indications: -Antibiotic prophylaxis for infective endocarditis. -Prophylaxis against DVT for high risk patients : low-dose heparin or aspirinintermittent calf compression, or warfarin.
• Co-existing Disease indications: Some medications should be continued on the day of surgery e,g B blockers, thyroxine. Others are stopped e.g oral hypoglycemics and antidepressants .Steroids within the last six months may require supplemental steroids
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INGESTED MATERIAL
MINIMUM FASTING PERIOD,
APPLIED TO ALL AGES (hr)
Clear liquids 2
Breast milk 4
Infant formula 6
Nonhuman milk 6
Light meal (toast and clear liquids) 6
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