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Role of anesthesiologist in pre-opertive period
Dr.ahmed turkistaniDepartment of anesthesia
Professor& chairmanKing saud university
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- To understand the perioperative period term.
- To understand the objectives of preoprative visit.
- To identify the risk factors in anesthesia.- To identify the lab tests needed before
surgery.
Objectives:
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Stages of the Peri-Operative Period
Pre-Operative
From time of decision to have
surgery until admitted into the
OR theatre.
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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)
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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)
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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
Preoperative visit.
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Benefits from surgery ←→ Risk of complications
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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.
Preoperative Evaluation:
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Age Obesity Smoking General health status Chronic obstructive pulmonary disease
(COPD) Asthma
Patient related risk factors(pulmonary)
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Smoking Important risk factor Smoking history of 40 pack years or more
→↑risk of pulmonary complications stopped smoking < 2 months : stopped for
> 2 months 4:1(57% : 14.5%) quit smoking > 6 months : never smoked
= 1:1 (11.9% : 11%)
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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
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Active Cardiac Conditions Unstable coronary syndromes
◦ Unstable or severe angina◦ Recent MI
Decompensated HF Significant arrhythmias Severe valvular disease
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Minor Cardiac Predictors Advanced age (>70) Abnormal ECG
◦ LV hypertrophy◦ LBBB◦ ST-T abnormalities◦ Rhythm other than sinus
Uncontrolled systemic hypertension
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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
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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.
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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.
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Step #1:Is the surgery emergent?
Is the surgery emergent? Operating room*yes
(Next Step)
no
Consider beta-blockade, pain controland other peri-operative management
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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
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Step 2
Unstable coronary syndromes
Decompensated heart failure
Significant arrhythmias
Severe valvular disease
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Step #2: Active Cardiac Conditions
Active Cardiac conditionsyes Evaluate and treat per
current guidelines
Consider Operating Room
no
(Next Step)
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Step 3: Surgery Low Risk?
Low risk surgery includes:1. Endoscopic procedures2. Superficial procedures3. Cataract surgery4. Breast surgery5. Ambulatory surgery
Cardiac risk <1% Testing does not change management
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Step #3: Surgery Low Risk?
Low risk surgery
No
Operating roomyes
(Next Step)
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Airway Evaluation
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
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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)
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Airway Evaluation Oropharyngeal visualization Mallampati Score Sitting position, protrude tongue, don’t say
“AHH”
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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.
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Preoperative Testing5
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.
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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
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Preoperative Testing Disease-based indications
◦ Cerebrovascular disease Creatinine, glucose, ECG
◦ Diabetes Creatinine, electrolytes, glucose, ECG
◦ Hepatic disease CBC, creatinine, lytes, LFTs, PT
◦ Malignancy CBC, CXR
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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.
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Preoperative Testing Disease-based
◦ Sleep apnea CBC, ECG
◦ Smoking >40 pack year CBC, ECG, CXR
◦ Systemic Lupus Cr, ECG, CXR
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Preoperative Testing Therapy-based indications
◦ Radiation therapy CBC, ECG, CXR
◦ Warfarin PT
◦ Digoxin Lytes, ECG, Dig level
◦ Diuretics Cr, lytes, ECG
◦ Steroids Glucose, ECG