III International Symposium“New Horizons of anesthesiology, intensive care of critical conditions and pain treatment”

СEEA COURSE, MODULE VI

PRE ANAESTHESIC EVALUATION

FOR ELECTIVE SURGERY

Ruslan Baltaga, MD, PhD, DESA

State University of Medicine and Pharmacy

“Nicolae Testemitanu”, Chisinau

Failure to prepare

is

Preparation to fail

P.P.P.P.P.

Electronic databases were searched from the year 2000 until July 2010 without language restrictions. These searches produced 15 425 abstracts

Electronic databases were searched from July 2010 (end of the literature search of the previous ESA guidelines on pre-operative evaluation) to May 2016 without language restrictions.

A total of 34 066 abtracts were screened from which 2536 were included for further analysis.

Preanaesthesic evaluation

• should allow identification of those patients for whom the peri-operative period may bring an increased risk of morbidity and mortality in addition to those risks associated with any underlying disease.

• This identification should help to design peri-operative strategies that aim to reduce additional peri-operative risks

Preanaesthesic evaluation

Preanesthesia visit should definitely include the following

• An interview with the patient or guardian to review medical, anesthesia, and medication history

• An appropriate physical examination

• Review of diagnostic data (laboratory, electrocardiogram, radiographs, consultations)

• Assignment of ASA physical status score (ASA-PS)

American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Practice advisory for

preanesthesia evaluation: A report by the American Society of Anesthesiologists Task Force on Preanesthesia

Evaluation. [Last accessed on 2007 Mar 11];Anesthesiology. 2002 96:485–96. Available

from: http://www.asahq.org

http://www.asahq.org/

Electronic databases were searched from the year 2000 until July 2010 without language restrictions. These searches produced 15 425 abstracts

Electronic databases were searched from July 2010 (end of the literature search of the previous ESA guidelines on pre-operative evaluation) to May 2016 without language restrictions.

A total of 34 066 abtracts were screened from which 2536 were included for further analysis.

Magic 6

1. Are you in treatment with another practitionar or in another hospital fors some chronic dideaseof your heart, lungs, kidneus, liver or for diabetes, thyroid or surrenal glands ?

•YES NO

2. Do you sometimes experience an oppressive feeling behind the sternum, palpitations, of swollen ankles?

YES NO

3. Do you take medicine on a regular basis except for a sleeping tablet, contraception or a non-opioid analgesic ? If so, which and which dose ?

YES NO

Magic 6 (cont.)4. Did you or anyone of your family, during general,local or regional anesthesia an unusual reaction or were there problems after the intervention

YES NO

5. Did you continue to bleed after a tooth extraction or a wound ? YES NO

.Do you easily have blue blisters after any trauma ? YES NO

Do you have spontaneous epistaxis from time to time ? YES NO

6. Are you hypersensitive or allergic to the following

• Wound dressing YES NO

• Desinfectants YES NO

• Latex YES NO

• Antibiotics or other medicine YES NO

If so, which ?

• Other substances

• Do you wish to come anyhow to the preoperative consultation because of a question or problem not mentioned hereYES NO

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Nr total de paturi în spital 170 305 170

168

225 200 160 155 181 120

240

321 225 272 110 300 80 850 650 162 530 130 500 100 796 160 600 190 115 530 175 182 108 175 335 85

Nr de pat. Prof chirurgie 30 120 45

33

50 40 35 35 40 35

55

80 55 18 25 10 390 600 43 25 60 0 511 130 210 42 17 0 40 30 18 40 65 17

Profil obstetrică 16 0 5

10

35 22 10 10 20 7

15

40 20 38 17 0 0 0 0 24 15 235 0 0 0 0 20 4 0 20 10 10 20 50 5

Nr de paturi de TI 3 15 6

6

4 6 4 6 5 4

6

6 4 8 6 33 1 24 36 4 8 3 18 4 90 10 18 3 4 6 8 62+1/pediatri

e4 4 7 6

Suprafaţa totală a secţiei T I 190 1161,14

400

385 394 300 270 248 98 120 250 40 944,1 304,8 430 276 630 190,4 3887 372 301,4 140 306,8 430 78 52 127,7 408

Supraf ocupată de paturi în TI 110 300

320

110 36,28 86 114 140 52 60 10 165 40 379,3 438 63,3 138 80 48,7 2495 152 88,2 50 75,8 60 24 32,6 75

Paturi de terapie intensivă dotate cu ventilator de

pacient1 2 2 0 2 2 2 3 2 2 2 6 15 3 24 33 1 2 7 90 3 18 3 4 1 2 2 3 2 4 6

Există salon de trezidre? 0 0

1

0 0 0 11,1 0 1 0

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0 1 0 0 1 0 0 1 0 0 0 1 0 0 0 0 1 0 0 0 0 1 1 0 0 1

Nr de pat în salo0l de trezire 0 0

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0 0 0 1 0 2 0

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0 0 0 2 0 0 0 0 0 2 0 0 0 0 4 0 0 0 Reanimare 4 1 0 0 2

Ex serviciu de durere acută? 0 0

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Ex clinică de durere cronică? 0 0

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Ex policlinică

anesteziologică?0 0

00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

PATIENT INFORMATION

• 2011 2018

HOW MUCH?SHOULD BE A PATIENT INFORMED ABOUT ANESTHESIA?

INN NSPCEM

Tipul anesteziei GA(43) GA(18) LRA(16)Question/Answer Yes(%) Yes(%) Yes(%)1. Do you think youțve signed informed consent for

anaesthesia100 100 81,25

2. Do you know what contains? 100 77,78 81,25

3. Has doctor explained you the procedure of anaesthesia ? 100 94,44 93,75

4Has doctor answered all your questions? 100 94,44 100

5. Do you think you have all information about risks? 97,67 88,89 81,25

6. Would you need more information about anaesthesia

complications?6,98 38,89 25

Baltaga R., Oleineac E., Vaculin N. Cât de mult ar trebui să fie informat un pacient despre riscurile de anestezie. Arta Medical 2013

Which of the following information about anesthesia complication you want to know /tell before anesthesia?

RISCSpatients

INN-GA/yes(%)

patients

NSPCEM-GA/yes(%)

Doctors

NSPCEM

Pain 88,37 94,44 100

Nausea / vomiting 90,70 94,44 75

Tooth trauma 81,40 50,00 75

Sore throat/Trauma 46,51 72,2 95

Anaphylactic shock 48,84 50,00 80

Cardiovascular collapse 25,58 61,11 70

Respiratory depression 60,47 66,67 80

Aspirational

pneumonia

20,93 44,44 85

Hypothermia 13,95 66,67 50

Hypoxic brain injury 34,88 38,89 40

What complications would you prefere to be informed before anaesthesia?(cont)

RISKSINN-GA/ yes(%)

patients

NSPCEM-GA/yes(%)

patients

Doctors

Nerves injury 11,63 44,44 75

Awarness 48,84 66,67 70

Air embolus, thrombus 13,95 44,44 70

Back pain 20,93 83,33 70

Headaches 30,23 83,33 80

Malignant hyperthermia 2,33 72,22 60

Iatrogenic pneumothorax 6,98 38,89 65

Lethal complication 76,74 44,44 70

Do you want your family to be

informed about possible

complications of anesthesia?

58,14 55,56 95

20182011

Cardiovascular disease

• Perioperative cardiac complications can occur in patients with documented or asymptomatic ischaemic heart disease, ventricular dysfunction and valvular heart disease. It has been estimated that in non-cardiac surgery, major perioperative cardiac events may occur in up to 4% of cardiac patients and 1.4% of an unselected patient population

Devereaux PJ, Goldman L, Cook DJ, et al. Perioperative cardiac events in patients undergoing noncardiac surgery: a review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk. CMAJ 2005; 173:627–634.

2011 2018

ACTIVE CARDIAC CONDITIONS THAT NECESSITATE FURTHER EVALUATION AND TREATMENT BEFORE NON-CARDIAC SURGERY ARE AS FOLLOWS:

• Unstable coronary syndromes• Unstable or severe angina• Recent myocardial infarction (MI) (within 30 days)

• Decompensated heart failure

• Significant arrhythmias• High-grade atrioventricular block• Symptomatic ventricular arrhythmias• Supraventricular arrhythmias with uncontrolled ventricular rate (>100 beats min−1 at rest)• Symptomatic bradycardia• Newly recognised ventricular tachycardia

• Severe valvular disease• Severe aortic stenosis (mean pressure gradient > 40 mmHg, area

Clinical risk factors are as follows:

• History of ischaemic myocardial disease

• Current stable or history of heart failure

• History of cerebrovascular disease

• Diabetes (insulin dependent)

• Renal failure (serum creatinine, SCr > 2 mg dl−1)

Recommendations 2011• If active cardiac disease is

suspected in a patient scheduled for surgery, the patient should be referred to a cardiologist for assessment and possible treatment (grade of recommendation: D).

• In patients currently taking β-blocking or statin therapy, this treatment should be continued perioperatively(grade of recommendation: A).

•The central leading role of the anaesthesiologist

in pre-operative assessment is acknowledged.

•Anaesthesiologists have a leading role in identifying

patients who require pre-operative evaluation by a team

of integrated multidisciplinary specialists, including

anaesthesiologists, cardiologists and surgeons, and when

appropriate, an extended team (internists, pulmonologists

or geriatricians).

Established risk factors

▪ age

▪ chronic obstructive lung disease

▪ congestive heart failure

▪ functional dependence

▪ a higher ASA classification

▪ prolonged duration of surgery

• type of surgery,

• weight loss,

• cerebral vascular

disease,

• long-term steroid use • alcohol use

Additional risk factors

Respiratory disease, smoking and

obstructive sleep apnoea syndrome

Preop diagnostic spirometry is not reccommended 1C (upgrade)

•Chest X ray is not reccommended routinely (1C)

•Patients with OSAS should be carefully evaluated for potenatial

difficult airway. (1B) upgrade

•Questionaire STOP- BANG is the most sensitive, specific and best

validated score (1B) upgrade

•CPAP used perioperatively redduces hypoxic events (2B)

•Inspiratory muscle training reduces postop atelectasys, pneumonia

and length of stay (2A) upgrade

•Pre – op incentive spirometry does not seem to help anymore

preventing Postop pulmonary complications

•Correction of malnutrition is suggested (2C) upgrade

•Smoking cessation at least 4 weeks pre opreduces postoperative

complications (2A)

Renal disease. Updated recommendations.

•Calculated GFR instead of creatinine for evaluation and

prediction.

•Take into consideration risk factors and take caution when

administering nephrotoxic medication

•Test results BUN/Cr ratio, Hb to take into consideration for

assessing risk

•Statin therapy is of no benefit. In preservation of renal function

Diabetes

20112018

•Management of diebetic patients should be

simmilar to patients known with cardiovascular

disease (upgrade to 2A).

•Blood sugar not measured rutinely in healthy

subjects except for major ortho and vascular

surgery (2A upgrade)

• HbA1 C for patients with known diabetes and

major orthopaedic and vascular 2A

•Careful airway assessement (upgrade 2C)

Obesity

• We suggest that pre-operative assessment of the

• obese includes at least the STOP-BANG questionnaire,

• clinical evaluation, ECG, oximetry and/or

• polysomnography.103,202,209,255–262 (2B)

• (2) We suggest laboratory tests to detect pathological

• glucose/HbA1c concentrations and anaemia in the

• obese.218,220,223 (2C)

• (3) We suggest that neck circumferences at least 43 cm as

• well as a high Mallampati score are predictors for a

• difficult intubation in the obese.209 (2C)

• (4) We suggest that the use of CPAP/PSV/BiPAP perioperatively

• might reduce hypoxic events in the

• obese.255,264 (2C)

STOP - BANG

Coagulation disorders

2011

Coagulation disorders•Bleeding history, physical examination is the best way to

identiphy patients with impaired haemostasis (1B)

•In addition, lab tests can be used (2C)

•Simple tests like platelets count may have pronostic value

(2A)

•Cataract surgery can be performed with continued

anticoagulant therapy with topic anaesthesia, clear incision

and skilled surgeon (2B)

•Non cardiac surgey can be performed under single

anteplatelet therapy after stent implantation (2B)

•Surgery for hip fracture in patients taking aspirin is

considered well tollerated and stopping clopidogrel for 3 days

is sufficient (2B)

•Hip fracture surgery can be performed safely without stopping

clopidogrel (1B)

•PCC for warfarin coagulopathy (FFP + Vit K) (2C)

•Elective surgical procedures can be safely performed while

on clopidogrel (2C)

2018

Anaemia and pre-operative blood conservationstrategies

THE GERIATRIC PATIENT

•Assessment of functional status is reccomended to identiphy patients at

risk (1B)

•Scoring the level of independence (1B)

•Assessement of comorbidities using age adjusted score such as

Charlson Comorbidity Index (1B)

•Periopearative medication adjustment and evaluation of medication in

sted way such as Beers criteria (1B)

•Evaluation of cognitive function based on validated tools (1B)

•Assessment of depression (1B)

•Management of risk factor for postop delirium, ESA guidelines (1B)

•Assessment of sensory impairment (1B)

•Assessment of Nutrition status (1B)

•Assessment of farilty such as Fried Score or Edmonton Frailty Scale (1B)

Alcohol and drug misuse and addiction

•Use of combination of CAGE questionaire and lab tests such as GGT and CDT

•GGT and CDT provide higher sensitivity as biomarkers

•Use of computerised self assessment questionaire

•AUDIT-C and AUDIT are not interchangeable

•Pre-op cessation may reduce postop complication rates

•No suggestion for the timing, duration and intensity of alcohol cesation

measures

•Clinical symptoms of cocaine abuse should be sought

Neuromuscular disease

Allergy

20182011

Herbal medication

Psychotropic drugs

•Patients treated with TCA should undergo cardiac

evaluation (2B)

•Discontinuation of antidepressant treatment is not

reccommended (1B)

•No evidence for dicontinuation SSRI

•Stopping irreversible MAOIs 2 weeks preop, change to

reverible MAOIs

•Continuation of antipsychotic medication in schysophrenia

•Stopping Lithium 72 h prior to surgery. Restarted if

electrolites in normal range, stable cardiovasc, and patient

eating+drinking

•Continuation of Li in minor surgery under local anaesthesia

•Stopping herbal medicine 2 weeks prior to surgery

Pre – operative bridging of anticoagulant therapy

Which pre-operative tests should be ordered?

Recommendations on which pre-operative tests should

be used for elective surgery have recently been updated

by NICE (http://www.nice.org.uk/guidance/ng45)

ASA

Surgery grades Examples

Minor •excising skin lesion•draining breast abscess

Intermediate •primary repair of inguinal hernia•excising varicose veins in the leg•tonsillectomy or adenotonsillectomy•knee arthroscopy

Major or complex •total abdominal hysterectomy•endoscopic resection of prostate•lumbar discectomy•thyroidectomy•total joint replacement•lung operations•colonic resection•radical neck dissection

Surgery grades

ASA 1 A normal healthy patient

ASA 2 A patient with mild systemic disease

ASA 3 A patient with severe systemic disease

ASA 4 A patient with severe systemic disease that is a constant threat to life

ASA grade

Test ASA 1 ASA 2 ASA 3 or ASA 4

Full blood count Not routinely Not routinely Not routinely

Haemostasis Not routinely Not routinely Not routinely

Kidney function Not routinely Not routinely Consider in people at risk of AKI

1

ECG Not routinely Not routinely Consider if no ECG results available from past 12 months

Lung function/arterial blood gas

Not routinely Not routinely Not routinely

Minor surgery

ASA grade

Test ASA 1 ASA 2 ASA 3 or ASA 4

Full blood count Not routinely Not routinely Consider for people with cardiovascular or renal disease if any symptoms not recently investigated

Haemostasis Not routinely Not routinely Consider in people with chronic liver disease•If people taking anticoagulants need modification of their treatment regimen, make an individualised plan in line with local guidance•If clotting status needs to be tested before surgery (depending on local guidance) use point-of-care testing

1

Kidney function Not routinely Consider in people at risk of AKI2

Yes

ECG Not routinely Consider for people with cardiovascular, renal or diabetes comorbidities

Yes

Lung function/arterial blood gas Not routinely Not routinely Consider seeking advice from a senior anaesthetist as soon as possible after assessment for people who are ASA grade 3 or 4 due to known or suspected respiratory disease

Intermediate surgery

ASA grade

Test ASA 1 ASA 2 ASA 3 or ASA 4

Full blood count Yes Yes Yes

Haemostasis Not routinely Not routinely Consider in people with chronic liver disease•If people taking anticoagulants need modification of their treatment regimen, make an individualised plan in line with local guidance•If clotting status needs to be tested before surgery (depending on local guidance) use point-of-care testing

1

Kidney function Consider in people at risk of AKI2

Yes Yes

ECG Consider for people aged over 65 if no ECG results available from past 12 months

Yes Yes

Lung function/arterial blood gas Not routinely Not routinely Consider seeking advice from a senior anaesthetist as soon as possible after assessment for people who are ASA grade 3 or 4 due to known or suspected respiratory disease

Major or complex surgery

How should the airway be evaluated?

Risk indices and biomarkers

Biomarkers

PONV

The mnemonic A2, B2, C2, D2, E2, F2, and G2.useful in emergency preanaesthesia evaluation

A 2

Affirmative history: The history of present surgical condition with the details of progression to present state. Details of past illness and treatment should be elicited.

A - Airway: Perform detailed airway examination and have a plan for airway management. Always have plan B in case plan A fails.

B2

B - Blood hemoglobin, blood loss estimation, and blood availability: Check for hemoglobin level and take measures to improve the same. Assess the requirement of blood based on expected blood loss and preoperative hemoglobin. Ensure availability of blood.

B - Breathing: Look for respiratory rate, pattern, and dyspnea.

,Kumar H., Parthasarathy, Ravishankar. A useful mnemonic for pre-anesthetic assessment. J

Anaesthesiology Clin Pharmacol. 2013 Oct-Dec; 29(4): 560–561

The mnemonic A2, B2, C2, D2, E2, F2, and G2.C2

Clinical examination: Assess pulse volume, rhythm, and blood pressure. Do detailed systemic examination. Assess effort tolerance.

C - Co-morbidities: Look for co-morbid diseases like diabetes, hypertension, asthma, and epilepsy and optimize the end organ problems.

D2

D - Drugs being used by the patient: Elicit the details of current drug therapy and allergies to plan anesthesia.

D - Details of previous anesthesia and surgeries: Elicit the details of previous anesthesia and surgeries to anticipate anesthetic difficulty.

Kumar H., Parthasarathy, Ravishankar. A useful mnemonic for pre-anesthetic assessment. J

Anaesthesiology Clin Pharmacol. 2013 Oct-Dec; 29(4): 560–561

E2 E - Evaluate investigations: Look for appropriate investigations that would guide anesthetic management.

E - End point to take up the case for surgery: End point to take up the case for surgery should be decided to avoid unnecessary postponement if further optimization is not possible.

F2 F - Fluid status: Follow fasting guidelines appropriate to the age and surgery.

F - Fasting: Advice adequate duration of fasting for that particular age to prevent aspiration.

G2 G - Give physical status: Assign a physical status classification.G - Get consent: Discuss the surgical problems and the anesthetic risk

with the patient and relatives to obtain appropriate consent.

The mnemonic A2, B2, C2, D2, E2, F2, and G2.

Kumar H., Parthasarathy, Ravishankar. A useful mnemonic for pre-anesthetic assessment. J

Anaesthesiology Clin Pharmacol. 2013 Oct-Dec; 29(4): 560–561