role of anesthesiologist in pre-opertive period
TRANSCRIPT
Role of anesthesiologist in pre-opertive period
Dr.ahmed turkistaniDepartment of anesthesia
Professor& chairmanKing saud university
- 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:
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)
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.
Benefits from surgery ←→ Risk of complications
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:
Age Obesity Smoking General health status Chronic obstructive pulmonary disease
(COPD) Asthma
Patient related risk factors(pulmonary)
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
