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PRE ANAESTHETIC EVALUATION

DEFINITION

“ The process of clinical assessment that precedes the delivery of anaesthesia care for surgery and for non surgical procedure”

ASA task force on pre anaesthetic evaluation, 2002.

OBJECTIVESOBJECTIVES

Evaluate the patients’ medical condition.Evaluate the patients’ medical condition. Optimize the patients’ medical condition for Optimize the patients’ medical condition for

anaesthesia and surgery.anaesthesia and surgery. Determine and minimize the risk factors associated Determine and minimize the risk factors associated

with anaesthesia.with anaesthesia. Plan anaesthesia technique and perioperative care Plan anaesthesia technique and perioperative care

for the patient.for the patient. Develop rapport with the patient.Develop rapport with the patient.

OBJECTIVES OBJECTIVES

Inform and educate the patient regarding the Inform and educate the patient regarding the nature of surgery, type of anaesthesia and peri-nature of surgery, type of anaesthesia and peri-operative care.operative care.

Obtain consent. Obtain consent.

GENERAL PRINCIPLESGENERAL PRINCIPLES

1. 1. Pre anaesthetic assesment should be performed Pre anaesthetic assesment should be performed by the anaesthesiologist who is to conduct by the anaesthesiologist who is to conduct anaesthesia.anaesthesia.

2. 2. May be conducted as an personal interview in the May be conducted as an personal interview in the ward ,operating theatre or pre-anaesthetic clinic ward ,operating theatre or pre-anaesthetic clinic using preset questionnaire.using preset questionnaire.

3. Should be performed at an appropriate time 3. Should be performed at an appropriate time before scheduled surgery. before scheduled surgery.

ASA task force on pre anaesthetic evaluation, 2002

GENERAL PRINCIPLESGENERAL PRINCIPLES

4.4. Inputs from other medical specialties maybe Inputs from other medical specialties maybe required. required.

5. In case of emergency surgery where early 5. In case of emergency surgery where early consultation is not possible the consultation is not possible the anaesthesiologist is still responsible for the pre anaesthesiologist is still responsible for the pre anaesthetic assessment.anaesthetic assessment.

ASA task force on pre anaesthetic evaluation, 2002

BENEFITS OF BENEFITS OF PREOPERATIVE EVALUATIONPREOPERATIVE EVALUATION

Detection and modification of risk factors.Detection and modification of risk factors. Planning of post-op pain management.Planning of post-op pain management. To keep patient informed about his anaesthesia To keep patient informed about his anaesthesia

plans.plans. To reduce anaesthesia related complications.To reduce anaesthesia related complications. Minimize costs of the patient.Minimize costs of the patient.

HISTORY AND PHYSICAL EXAMINATION ARE THE MOST IMPORTANT

ASSESSORS FOR DISEASE AND RISK

PREOPERATIVE ASSESMENT PREOPERATIVE ASSESMENT STEPSSTEPS

Patient particulars:Patient particulars:

1.Name 1.Name

2.Age2.Age

3.Sex3.Sex

4.Address4.Address

5.Occupation 5.Occupation

6.Date of admission6.Date of admission

7.IP number 7.IP number

COMPONENTS OF HISTORY COMPONENTS OF HISTORY TAKINGTAKING

History of presenting illnessHistory of presenting illness Past historyPast history Treatment historyTreatment history Personal historyPersonal history Family historyFamily history Menstrual historyMenstrual history Obstetric historyObstetric history

HISTORY OF PRESENTING HISTORY OF PRESENTING ILLNESSILLNESS

OnsetOnset DurationDuration ProgressionProgression Therapies related to the current problemTherapies related to the current problem

RESPIRATORY SYSTEM RESPIRATORY SYSTEM SYMPTOMSSYMPTOMS

CoughCough Expectoration Expectoration DyspneaDyspnea Fever with chillsFever with chills Sore throatSore throat Nasal congestionNasal congestion WheezeWheeze Asthma / TB / COPD / Sleep apneaAsthma / TB / COPD / Sleep apnea

CARDIOVASCULAR SYMPTOMSCARDIOVASCULAR SYMPTOMS

Chest painChest pain Shortness of breathShortness of breath FatigueFatigue OrthopneaOrthopnea PNDPND Nocturnal coughNocturnal cough Peripheral edemaPeripheral edema Past h/o syncopePast h/o syncope

PAST HISTORYPAST HISTORY

H/O Diabetes, Hypertension, IHD, TB, H/O Diabetes, Hypertension, IHD, TB, Asthma, Epilepsy, Cerebrovascular Asthma, Epilepsy, Cerebrovascular accidents.accidents.

H/O any past surgeries , hospital H/O any past surgeries , hospital admissions.admissions.

H/O Anaesthesia exposure.H/O Anaesthesia exposure.

H/O Contact eg: TB , STDs.H/O Contact eg: TB , STDs.

TREATMENT HISTORYTREATMENT HISTORY

Dose of medicationDose of medication

Duration of treatmentDuration of treatment

RegularityRegularity

Side effectsSide effects

H/O any Ayurvedic / homeopathic H/O any Ayurvedic / homeopathic

treatmenttreatment

MENSTRUAL HISTORY

Onset of menarche Last menstrual date Duration of normal menstrual flow Amount of blood loss Any irregularities Menopause

OBSTETRIC HISTORYOBSTETRIC HISTORY

LMPLMP Number of childrenNumber of children H/O last child birthH/O last child birth H/O any abortions in the pastH/O any abortions in the past H/O indications for the present caesarean section H/O indications for the present caesarean section

or in the past if anyor in the past if any

PAEDIATRIC CASESPAEDIATRIC CASES

Birth historyBirth history Development historyDevelopment history Immunization historyImmunization history H/O failure to thriveH/O failure to thrive H/O congenital diseases H/O congenital diseases H/O drug intakeH/O drug intake

H/O Allergic ReactionsH/O Allergic Reactions::

• AntibioticsAntibiotics• Induction agentsInduction agents

• PropofolPropofol

• Reported allergy to anesthesiaReported allergy to anesthesia• Malignant HyperthermiaMalignant Hyperthermia

• Halogenated agentsHalogenated agents• succinylcholinesuccinylcholine

• Atypical PseudocholinesteraseAtypical Pseudocholinesterase

H/O difficulty with prior H/O difficulty with prior anaesthetic procedure:anaesthetic procedure:

• “Has anyone in your family experienced unusual or serious reactions to anesthesia?”• Malignant hyperthermia

• Previous history of difficulty under anesthesia• Difficult Intubation• Significant PONV• Review available old records

Social History/Personal History

• SmokingSmoking• AlcoholAlcohol• Recreational drug useRecreational drug use

Smoking:Smoking:

• Productive Cough, H/O haemoptysis.Productive Cough, H/O haemoptysis.• How many pack years?How many pack years?• Eliminate cigarette use for 2-4 weeks prior to Eliminate cigarette use for 2-4 weeks prior to

elective surgery to reduce complications.elective surgery to reduce complications.• If not possible at least 12-24 hrs prior to surgery.If not possible at least 12-24 hrs prior to surgery.• Assess need for further pulmonary evaluationAssess need for further pulmonary evaluation

Alcohol:Alcohol:• Self-reporting of use typically underestimates Self-reporting of use typically underestimates

actual useactual use• Acute intoxication Acute intoxication

• Lowers anesthetic requirementsLowers anesthetic requirements• Predisposes to hypothermia and hypoglycemiaPredisposes to hypothermia and hypoglycemia

• WithdrawalWithdrawal• Increase anesthetic requirementsIncrease anesthetic requirements• HypertensionHypertension• TremorsTremors• DeliriumDelirium• SeizuresSeizures

Recreational drugs:Recreational drugs:

Define types, routes, frequency, last usedDefine types, routes, frequency, last used

• Stimulant abuseStimulant abuse• PalpitationsPalpitations• True anginaTrue angina• Lowered threshold for serious arrhythmiaLowered threshold for serious arrhythmia• ConvulsionsConvulsions

Routine use of narcotics/benzodiazepinesRoutine use of narcotics/benzodiazepines

(whether prescribed or illegal) may (whether prescribed or illegal) may significantly increase the dose required to significantly increase the dose required to induce anesthesia or maintain anesthesia.induce anesthesia or maintain anesthesia.

Routine use of recreational drugs will impact Routine use of recreational drugs will impact post-op pain requirements.post-op pain requirements.

EXERCISE TOLERANCEEXERCISE TOLERANCE

1 MET 1 MET Can you take care of yourself?Can you take care of yourself?

Eat or use the toilet?Eat or use the toilet? Walk a block or two on level ground at 2-3 mph Walk a block or two on level ground at 2-3 mph Do light work around the house like Do light work around the house like dusting or washing dishes?dusting or washing dishes?

4 MET 4 MET Climb a flight of stairs or walk up a hill?Climb a flight of stairs or walk up a hill?

Walk on a level ground at 4mph?Walk on a level ground at 4mph? Run a short distance?Run a short distance? Do heavy work around the house like scrubbing Do heavy work around the house like scrubbing floors or lifting heavy furnitures?floors or lifting heavy furnitures?

EXERCISE TOLERANCEEXERCISE TOLERANCE

10 MET 10 MET Participate in strenuous activities and sports Participate in strenuous activities and sports

like swimming, tennis, football, basketball.like swimming, tennis, football, basketball.

Poor “Exercise Tolerance” (could not walk four blocks/climb Poor “Exercise Tolerance” (could not walk four blocks/climb two flight of stairs)independently predicted a complication two flight of stairs)independently predicted a complication with an odds ratio of 1.94.with an odds ratio of 1.94.

GENERAL PHYSICAL GENERAL PHYSICAL EXAMINATIONEXAMINATION

Level of consciousnessLevel of consciousness Build and nourishment and assessment of BMIBuild and nourishment and assessment of BMI Height and weight of the patient.Height and weight of the patient. Pallor, icterus, cyanosis, clubbing, palpable Pallor, icterus, cyanosis, clubbing, palpable

lymph node.lymph node. Baseline Vital Signs:Baseline Vital Signs:

• Blood pressure Blood pressure • Resting pulse Resting pulse • RespirationRespiration• JVPJVP

Venous access sites.Venous access sites.

Physical Exam:

• Specific to Regional Anesthesia• Detailed assessment of extremity• Detailed assessment of back

• Deformities• Infection• History of injury• Previous back surgery• Chronic pain issues

AIRWAY ASSESSMENT

• NARES• MOUTH OPENING / CAVITY• TEETH- PROTRUDING, LOOSE, DENTURES• PALATE• PROGNATHISM• T-M JOINT MOVEMENTS• NECK MOVEMENTS• VOICE- STRIDOR, RECENT CHANGE,

HOARSENESS

ASSESSMENT IN REGARD TO MASK VENTILATION

BONESBONES

B - BeardB - BeardO - Obesity O - Obesity

BMI > 26 BMI > 26 WT > 110 WT > 110

KgKgN - No teethN - No teethE -Elderly (age>55 E -Elderly (age>55

yrs)yrs)S - Snoring S - Snoring

historyhistory

Neck Movement Range Assessment – Direct assessment

Neck flexion on chest by 25 - 30° & extension of atlanto – occipital joint by 85° makes laryngoscopy easy

Patient should be able to touch manubrium sternum with his chin – Flexion

Patient should be able to see the ceiling without raising his eyeball - Extension

MEASUREMENT OF ATLANTO-OCCIPITAL MEASUREMENT OF ATLANTO-OCCIPITAL ANGLEANGLE

(BELLHOUSE AND DORE)(BELLHOUSE AND DORE)

GRADE IGRADE I - >35°- >35°

GRADE IIGRADE II - 22° - 34°- 22° - 34°

GRADE IIIGRADE III - 12°- 21°- 12°- 21°

GRADE IV- < 12°GRADE IV- < 12°

(NORMAL ANGLE (NORMAL ANGLE OF EXTENSION IS OF EXTENSION IS 35° OR MORE)35° OR MORE)

Neck movement range assessment – In direct assessment

“Prayer sign”

“Palm print sign”

MALLAMPATI CLASSIFICATIONMALLAMPATI CLASSIFICATION(SAMSOON AND YOUNG MODIFICATION)(SAMSOON AND YOUNG MODIFICATION)

MALAMPATI CLASS Class 1 – Faucial pillars, soft palate, uvula

could be visualized Class 2 – Uvula, fauces and soft palate

could be visualized but tonsillar pillars was masked by base of the tongue

Class 3 - Only soft palate and hard palate could be visualized

Mallampati S Rao etal., A clinical sign to predict difficult tracheal intubation: a prospective study CAN ANAESTH SOC J 1985 / 32:4/ pp429 - 34

MALAMPATI CLASSIFICATION

Modified by Samsoon & Young Class 4 – Only hard palate seen Test has to be repeated twice – to avoid

errors

Grade I & II are associated with easy intubation while grade III & IV are associated with difficlut intubation.

FAILURE OF MALAMPATTI CLASSIFICATION

Failure to include evaluation of two important factors affecting visualization of glottis

1. Neck mobility

2. Size of mandibular space

3. Does not tell us about the space anterior to larynx

TESTS FOR MANDIBULAR TESTS FOR MANDIBULAR DISTANCEDISTANCE

• THYROMENTAL DISTANCE (PATIL THYROMENTAL DISTANCE (PATIL TEST)TEST)

• STERNOMENTAL DISTANCE ( SAVVA STERNOMENTAL DISTANCE ( SAVVA TEST)TEST)

• MANDIBULOHYOID DISTANCEMANDIBULOHYOID DISTANCE

THYROMENTAL DISTANCETHYROMENTAL DISTANCEDistance of mentum to thyroid notch. Distance of mentum to thyroid notch. Patient’s neck fully extended.Patient’s neck fully extended.Helps to determine how readily laryngeal axis will Helps to determine how readily laryngeal axis will

fall in line with pharyngeal axis with patient's fall in line with pharyngeal axis with patient's neck fully extendedneck fully extended

Difficult < 3 Fingers 0R < 6 CMDifficult < 3 Fingers 0R < 6 CMLess difficult 6-6.5 CMLess difficult 6-6.5 CMNormal > 6.5 CMNormal > 6.5 CM

STERNOMENTAL DISTANCESTERNOMENTAL DISTANCE

Distance from upper border of manubrium Distance from upper border of manubrium to tip of mandible with neck fully extended to tip of mandible with neck fully extended and mouth closedand mouth closed

<12.5cm is significant<12.5cm is significant

MANDIBULO HYOID DISTANCEMANDIBULO HYOID DISTANCE

Distance between mentum and hyoid bone.Distance between mentum and hyoid bone.

Grade I : Grade I : >> 6cm 6cm Grade II: 4 – 6cmGrade II: 4 – 6cm Grade III : Grade III : < 4cm – Impossible < 4cm – Impossible

laryngoscopy & Intubationlaryngoscopy & Intubation

INTER INCISSOR GAPINTER INCISSOR GAP

4.6 cm or more – normal-easy insertion of 4.6 cm or more – normal-easy insertion of laryngoscope blade.laryngoscope blade.

<3 cm –difficulty in intubation.<3 cm –difficulty in intubation.

<2.5 cm- LMA insertion difficult.<2.5 cm- LMA insertion difficult.

Predictive Performance of Three Multivariate Difficult Tracheal Intubation Models: A Double-Blind,Case-Controlled Study

Mohamed Naguib, MB, BCh, MSc, FFARCSI, MD*, Franklin L. Scamman, MD‡, Cormac O’Sullivan, CRNA‡, John Aker, CRNA§, Alan F. Ross, MD‡,

Steven Kosmach, MSN, RN*, and Joe E. Ensor, PhD†

WILSON SCORING SYSTEM00 11 22

WEIGHTWEIGHT < 90 Kg< 90 Kg 90-110 Kg90-110 Kg > 110 Kg> 110 Kg

HEAD & NECK HEAD & NECK MOVEMENTMOVEMENT

>90>90 9090++1010 < 90< 90

JAW MOVT JAW MOVT INTERDENTALINTERDENTAL

> 5 Cm> 5 Cm 55 < 5 Cm< 5 Cm

MANDIBULAR MANDIBULAR RECESSIONRECESSION

MILDMILD MODERATEMODERATE SEVERESEVERE

PROTRUDING PROTRUDING INCISORSINCISORS

MILDMILD MODERATEMODERATE SEVERESEVERE

• RISK SCORE BETWEEN 0-10.RISK SCORE BETWEEN 0-10.• Score <5 is associated with easy laryngoscopy, 6-7 Score <5 is associated with easy laryngoscopy, 6-7 moderate difficulty and >8 have severe difficulty.moderate difficulty and >8 have severe difficulty.

Predictive Performance of Three Multivariate DifficultTracheal Intubation Models: A Double-Blind,

Case-Controlled Study, Anaesth Analg 2006;102:818-24

Dr. Binnions LEMON Law: An easy way to remember multiple tests…

Look externally. Evaluate the 3-3-2 rule. Mallampati. Obstruction Neck mobility.

Physical Exam:Physical Exam: (contd)(contd)

RESPIRATORY SYSTEMRESPIRATORY SYSTEM

• Deviation of tracheaDeviation of trachea• LungsLungs

• WheezesWheezes• CrepitationsCrepitations• Correlate what you hear with observation of how Correlate what you hear with observation of how

patient is breathing…. easy v/s laboredpatient is breathing…. easy v/s labored• Use of accessory musclesUse of accessory muscles• Breathing pattern.Breathing pattern.• Chest deformities.Chest deformities.

Physical Exam:Physical Exam: (contd) (contd)

CARDIOVASCULAR SYSTEMCARDIOVASCULAR SYSTEM

• HeartHeart• MurmurMurmur• Pericardial rubPericardial rub


• AbdomenAbdomen• DistentionDistention• AscitesAscites• Predisposition to regurgitationPredisposition to regurgitation• Compromise ventilationCompromise ventilation


• ExtremitiesExtremities• ClubbingClubbing• CyanosisCyanosis• Cutaneous infectionCutaneous infection

• No IV cannulationNo IV cannulation• No regional nerve blockNo regional nerve block


• CNSCNS• Document neurological statusDocument neurological status• Cranial nerve functionCranial nerve function• CognitionCognition• Peripheral sensorimotor functionPeripheral sensorimotor function

ASA Physical Status ClassificationASA Physical Status Classification

• ASA I – a normal healthy patientASA I – a normal healthy patient

• ASA II – a patient with mild systemic disease (mild diabetes, controlled ASA II – a patient with mild systemic disease (mild diabetes, controlled HTN, obesity).HTN, obesity).

• ASA III – a patient with severe systemic disease that limits activity (COPD, ASA III – a patient with severe systemic disease that limits activity (COPD, angina, prior MI).angina, prior MI).

• ASA IV – a patient with an incapacitating disease that is a constant threat ASA IV – a patient with an incapacitating disease that is a constant threat to life (CHF, renal failure).to life (CHF, renal failure).

• ASA V – a moribund patient not expected to survive 24 hours (ruptured ASA V – a moribund patient not expected to survive 24 hours (ruptured AAA).AAA).

• ASA VI – brain dead patient whose organs are being harvested.ASA VI – brain dead patient whose organs are being harvested.

• ““E” – for emergent operations add the letter E after the classification.E” – for emergent operations add the letter E after the classification.

NYHA CLASS SYMPTOMS

CLASS I No limitation of physical activity, ordinary activity does not cause fatigue ,palpitation or syncope.

CLASS II Slight limitation of physical activity, ordinary activity results in fatigue, palpitation and syncope.

CLASS III Marked limitation of physical activity, less than ordinary activity results in fatigue, palpitation and syncope. Comfortable at rest.

CLASS IV Inability to perform any physical activity.

RISK FACTORS FOR RISK FACTORS FOR PULMONARY COMPLICATIONSPULMONARY COMPLICATIONS

History of cigarette use (current or >40 pack-year)History of cigarette use (current or >40 pack-year) ASA-PS score >2ASA-PS score >2 Age > 70 yrsAge > 70 yrs COPDCOPD Neck, thoracic, upper abdominal, aortic or neurologic Neck, thoracic, upper abdominal, aortic or neurologic

surgeriessurgeries Anticipated prolong procedure>2 hrsAnticipated prolong procedure>2 hrs Albumin <3gm/dLAlbumin <3gm/dL BMI>30BMI>30 Exercise capacity <2 blocksExercise capacity <2 blocks

Preoperative labs:Preoperative labs:

• Hematocrit and HemoglobinHematocrit and Hemoglobin• Pre-surgical “Standard of Care”Pre-surgical “Standard of Care”• Hcts of 25-30% tolerated in healthy pt.Hcts of 25-30% tolerated in healthy pt.• Low Hemoglobin may result in ischemia Low Hemoglobin may result in ischemia

in patient with history of CADin patient with history of CAD• Evaluate each patient individually for the Evaluate each patient individually for the

etiology and duration of their anemiaetiology and duration of their anemia

Will the surgery involve significant blood loss?

Obtain Hb or haematocrit if neither was obtained in past 2 month or if patient has donated blood in past 2 months

Does the patient have any of the following? Anaemia, leukemia,cancer or abnormal bleeding or renal disease?Does the patient smoke >half pack of ciggarettes a day?Does the patient takes anticoagulants?

Surgery may be proceeded without haemoglobin or haematocrit.

Is the patient <6 mnths or >40 years or a female.

NO

NO

NO

YES

RBS/FBS/PPBSRBS/FBS/PPBS

H/O Diabetes H/O Diabetes H/O NocturiaH/O Nocturia H/O use of steroids (eg : in asthmatics H/O use of steroids (eg : in asthmatics

or COPD patients)or COPD patients) > 35yrs age> 35yrs age Obese (BMI> 33)Obese (BMI> 33)

Does the patient has CVS symptoms?Symptoms suggestive of renal pathology? H/O UTI History or present complain of haematuriaDiabetes MellitusLiver diseaseMorbid obesityAge >65 yers old

Obtain routine urine analysis,serum urea and creatinine.

Does the patient take steroid,diuretics ? OR

Has there been recent change in patient diet to high protein containing diet?

Surgery can be proceeded without urea,creatinine or routine urine examination.

YES

YES

NO

NO

SERUM ELECTROLYTESSERUM ELECTROLYTES

Diabetes Diabetes Dialysis Dialysis DiureticsDiuretics Dehydration Dehydration High risk surgeriesHigh risk surgeries

LIVER FUNCTION TESTLIVER FUNCTION TEST

AlcoholicsAlcoholics H/O jaundiceH/O jaundice H/O gall stones H/O gall stones H/O bleeding tendenciesH/O bleeding tendencies H/O intake of oral anti-coagulants H/O intake of oral anti-coagulants H/O malignancyH/O malignancy

ECG

INDICATED IN :INDICATED IN : All patients >50yrs (M) > 55yrs ( F )All patients >50yrs (M) > 55yrs ( F ) H/o CVS disorders or symptoms & H/o CVS disorders or symptoms &

signssigns Diabetes .Diabetes . Smokers .Smokers . H/o vascular surgeries.H/o vascular surgeries. H/O GERD.H/O GERD.

CHEST X-RAYDoes the patient has one of the following condition?1.Cardiovascular disease?2.Pulmonary symptoms or known pulmonary disease( eg: TB,Asthma,COPD)3.Diagnosed to suffer from Malignancy or has been treated for the same

Obtain Chest X-ray if none has been obtained since past 2 months or there has been recent change in symptoms.

1.Does the patient has signs and symptoms of on going chest infections( eg: cough, productive sputum,recent change in sputum colour)

2.Change in Cardiovascular symptoms

3.Travel or exposure to high risk areas of tuberculosis or other chest disease or history of contanct with individuals suffering from the same.

4.H/O trauma to the chest or in case of RTA. 5.History or symptoms of rhematoid arthritis,thyroid goitre or physical evedence of deviation of traches

YES

NO

YES

COAGULATION TESTING

Includes bleeding time, clotting time,

APTT,INR and P-Time. Family H/O coagulopathies. H/O anticoagulant use. H/O hepatic disorder.

PULMONARY FUNCTION TESTS

Indications

- COPD

- Shortness of breath

- Orthopnea

- Smokers

- Lung surgeries

OTHER LAB INVESTIGATIONS

Serological tests

- HIV

- HBsAg

- VDRL Total count , Differential count , ESR Platelet count. Arterial blood gas analysis.

Informed Consent:Informed Consent:• The anesthetic plan, alternatives, and potential The anesthetic plan, alternatives, and potential

complications must be discussed in terms and complications must be discussed in terms and in a language that is understandable to the in a language that is understandable to the patient.patient.

• Aspects of care pre-operatively and post-Aspects of care pre-operatively and post-operatively:operatively:• IntubationIntubation• Post op ventilation/ICUPost op ventilation/ICU• Invasive monitoringInvasive monitoring• Regional anesthesia techniquesRegional anesthesia techniques• Potential for blood product usePotential for blood product use

Informed Consent: Informed Consent:

• Alternative planAlternative plan• Necessary if planned procedure fails or Necessary if planned procedure fails or

there is a change in clinical circumstance.there is a change in clinical circumstance.

• Associated RisksAssociated Risks• Discuss in a manner that a reasonable Discuss in a manner that a reasonable

person would find helpful in making a person would find helpful in making a decision.decision.

• Complications that occur with high Complications that occur with high frequency.frequency.

Informed Consent – Extenuating Informed Consent – Extenuating CircumstancesCircumstances

• Anesthesia procedures may proceed Anesthesia procedures may proceed without consent in emergency without consent in emergency situations.situations.

NPO status: Pre-op Fasting Guidelines NPO status: Pre-op Fasting Guidelines

“ Prescribed period of time before a procedure when a patient is not allowed the oral intake of liquids and solids”

Practice Guidelines, Anesthesiology 2011;114:495-511Practice Guidelines, Anesthesiology 2011;114:495-511

NPO status: Preop Fasting GuidelinesNPO status: Preop Fasting Guidelines

• Recommendations – for all age groupsRecommendations – for all age groupsIngested MaterialIngested Material Fasting Period(hrs)Fasting Period(hrs)

Clear liquidsClear liquids 2 hrs2 hrsBreast milkBreast milk 4 hrs4 hrsInfant formulaInfant formula 6 hrs6 hrsNon-human milkNon-human milk 6 hrs6 hrsLight solid foodsLight solid foods 6 hrs6 hrs


NPO guidelines:NPO guidelines:

• Clear liquids include; water, sugar water, apple juice, Clear liquids include; water, sugar water, apple juice, non-carbonated soda, pulp-free juices, clear tea, non-carbonated soda, pulp-free juices, clear tea, black coffee.black coffee.

• Medications can be taken PO with up to 150ml of Medications can be taken PO with up to 150ml of water in the hour preceding anesthesia induction.water in the hour preceding anesthesia induction.

• Recommendations apply to healthy patients, elective Recommendations apply to healthy patients, elective surgery. Following the recommendations does not surgery. Following the recommendations does not guarantee that gastric emptying has occurred.guarantee that gastric emptying has occurred.


A little pre-planning goes a A little pre-planning goes a long waylong way

THANK YOUTHANK YOU

REFERENCES Miller’s Anaesthesia 7th edition Harrison’s Principles of Internal Medicine 17th edition. Clinical Anesthesia- Barash Practice Advisory for Preanesthesia Evaluation

A Report by the American Society of Anesthesiologists Task Force on preanesthesia evaluation

Anesthesiology 2002 96:485-96 Practice Guidelines for Preoperative Fasting and the Use

of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures

An Updated Report by the American Society of Anesthesiologists

Committee on Standards and Practice Parameters

: Anesthesiology Vol 114- No 3 Mar 2011

Predictive Performance of Three Multivariate Difficult

Tracheal Intubation Models: A Double-Blind,Case-Controlled Study Mohamed Naguib, MB, BCh, MSc, FFARCSI, MD*, Franklin L. Scamman, MD‡,

Cormac O’Sullivan, CRNA‡, John Aker, CRNA§, Alan F. Ross, MD‡,Steven Kosmach, MSN, RN*, and Joe E. Ensor, PhD†

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