lecture title: lecture title: role of anesthesiologist in pre-operative period lecturer name:...
TRANSCRIPT
Lecture Title: Lecture Title: Role of anesthesiologist in pre-operative period
Lecturer name: Lecturer name: Prof. Ahmed Abdulmoemn
Lecture Date:Lecture Date:
Lecture Objectives..Lecture Objectives..
Students at the end of the lecture will be able to:
1) learn pre-anesthetic patient evaluation and risk stratification. 2) Obtain a full history and physical examination including allergies, current
medications, past anesthetic history, family anesthetic history 3) The medical student will understand how patient co-morbidities can affect the
anesthetic plan. 4) The medical student will be able to understand potential anesthetic options for a
given surgical procedure. 5) The medical student will be able to plan an anesthetic for a basic surgical
procedure. 6) The student will understand risk stratification of a patient undergoing
anesthesia.
Stages of the Peri-Operative Period
Pre-Operative
• From time of decision to have surgery until admitted into the OR theatre.
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)
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)
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
Preoperative Evaluation:
• 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.
Patient related risk factors(pulmonary)
• Age • Obesity• Smoking• General health status• Chronic obstructive pulmonary disease
(COPD)• Asthma
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%)
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
Active Cardiac Conditions
• Unstable coronary syndromes– Unstable or severe angina– Recent MI
• Decompensated HF• Significant arrhythmias• Severe valvular disease
Minor Cardiac Predictors
• Advanced age (>70)• Abnormal ECG– LV hypertrophy– LBBB– ST-T abnormalities– Rhythm other than sinus
• Uncontrolled systemic hypertension
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
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.
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.
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
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
Step 2
• Unstable coronary syndromes
• Decompensated heart failure
• Significant arrhythmias
• Severe valvular disease
Step #2: Active Cardiac Conditions
Active Cardiac conditionsyes Evaluate and treat per
current guidelines
Consider Operating Room
no
(Next Step)
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
Step #3: Surgery Low Risk?
Low risk surgery
No
Operating roomyes
(Next Step)
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
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)
Airway Evaluation• Oropharyngeal visualization• Mallampati Score• Sitting position, protrude tongue, don’t say “AHH”
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.
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.
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
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
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.
Preoperative Testing
• Disease-based– Sleep apnea• CBC, ECG
– Smoking >40 pack year• CBC, ECG, CXR
– Systemic Lupus• Cr, ECG, CXR
Preoperative Testing
• Therapy-based indications– Radiation therapy
• CBC, ECG, CXR– Warfarin
• PT– Digoxin
• Lytes, ECG, Dig level– Diuretics
• Cr, lytes, ECG– Steroids
• Glucose, ECG
Q & A
Reference book and the Reference book and the relevant page numbers.relevant page numbers...
DrDr. .
TThank You hank You