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principles of preoperative evaluation and preparation.pptx

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principles of preoperative evaluation and preparation.pptx

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The importance of preoperative assessment and evaluation to prepare the patient to surgical procedure is directly proportional with the degree of successful of any surgical procedure.
So, good preoperative assessment and evolution is necessary to avoid the morbidity and mortality that expected to the surgical procedures.

The importance of preoperative assessment and evaluation to prepare the patient to surgical procedure is directly proportional with the degree of successful of any surgical procedure.
So, good preoperative assessment and evolution is necessary to avoid the morbidity and mortality that expected to the surgical procedures.

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principles of preoperative evaluation and preparation.pptx

  1. 1. Principles of Preoperative evaluation and preparation Mahmood Hasan Taha H.D Anesthesia Head of Anesthesia Dep. Zakho Emergency H. April 2018
  2. 2. Reason for evaluation Anesthesia and surgery are physiologically stressful.  Invasive interventions may exacerbate or uncover underlying disease process.  most feared complications: difficulty in oxygenation, ventilation, myocardial infarction , and cerebrovascular accidents.
  3. 3.  Allows the anesthesiologist, surgeon to stratify and reduce risk for the patient.  Screen for and manage co-morbid disease.  Identify need for specialized technique.  Identify need for advanced post-op care.
  4. 4. Avoid unnecessary delays/cancellations. Motivate patients to improve pre-op. outcome.  Obtain informed consent.
  5. 5. Why is anesthesia risky? Difficulty in obtaining an airway (adequately oxygenate and ventilate). Injury during airway management. Induction: time of hemodynamic stress; hypotension, hypertension, arrhythmias, arrest. Maintenances: differing degrees of stimulation, fluid shifts, blood loss.
  6. 6. Emergence: physiologically stressful, secure airway may be lost, hypothermia. Anaphylactic reactions to medications.  positioning.  Spinal/epidural/regional carries risk ?!!
  7. 7. Evaluation Steps
  8. 8. 1. History: present illness, PMH, PS/AH, Social H., drugs., Exercise and METs. 2. Examination: Airway, CVS, Resp., Musculoskeletal, Neurological, Peripheral vasculature, BMI.
  9. 9. 3. Investigations. 4. Risk of anesthesia and suspected surgery. 5.Marking the site/side of operation. 6.Informed written consent.
  10. 10. The ASA Physical Status Classification Example Definition ASA Non-smoker Normal healthy patient 1 Smoker, BMI 30-40, pregnant, well controlled HTN/DM Mild systemic disease (no functional limitations) 2 Poorly controlled HTN/ DM Sever systemic disease (some functional limitation) 3 Recent MI, CVA, sever CHF Sever systemic disease that is a constant threat to life 4 Ruptured AAA Moribund patient who is not expected to survive without the operation 5 Brain dead pat. whose organs are being removed for donation 6 e.g. ASA 2E Emergency E
  11. 11. Airway Examination  Teeth and bite.  Mouth opening (inter-incisor distance).  Mallampati score.  Thyromental, Hyomental distances.  Length & thickness of neck.  Range of motion of head & neck.
  12. 12. Mallampati Classification (pharyngeal view)
  13. 13. Mallampati Class ?
  14. 14. Mallampati Class ?
  15. 15. Thyromental distance
  16. 16. Clinical Predictors of Increased Perioperative Cardiovascular Risk MINOR  Advanced age.  Abnormal ECG, Abnormal Rhythm.  Low functional capacity (e.g. inability to climb one flight of stairs with a bag of groceries).  History of stroke.  Uncontrolled systemic hypertension.
  17. 17. Functional Capacity and Metabolic Equivalent:  1 MET: Can you take care of yourself? Eat, dress, use the toilet? Walk a block or two on level ground.  4 METs : Do light work around the house like dusting or washing the dishes? Climb a flight of stairs.  >10 METs : Participate in sports like swimming , tennis, football , basketball..?
  18. 18. Perioperative cardiac and long-term risks are elevated in patients unable to obtain 4-MET Demand .
  19. 19.  INTERMEDIATE  Mild angina pectoris.  Previous MI (>1month).  Compensated heart failure.  Diabetes mellitus (particularly insulin type).  Renal insufficiency (creatinine >2.0).
  20. 20. MAJOR  Acute (<7day) or recent MI (<1month) with evidence of ischemic risk.  Unstable or severe angina.  Decompensated heart failure.  Significant arrhythmias.
  21. 21.  High-grade AV block.  Symptomatic ventricular arrhythmia.  SVT uncontrolled rate.  Severe valvular disease.
  22. 22. Surgery-specific risk .
  23. 23. Low risk (<1%): Endoscopic procedures. Superficial procedures. Cataract surgery. Breast surgery.
  24. 24. Intermediate risk (<5%):  Carotid.  Head and neck surgery.  Intraperitoneal and intrathoracic procedures.  Orthopedic surgery.  Prostate surgery.
  25. 25. High risk (>5%):  Emergent major operations, particularly in elderly.  Aortic and other major vascular surgery.  Surgical procedures associated with large fluid shifts and/or blood loss.
  26. 26. Evaluating Respiratory Disease Risk Factors for Pulmonary Complications:  Urea > 40 mg/dL.  Age > 70.  COPD.  Neck, thoracic, upper abdominal, aortic or neurological surgery.
  27. 27.  Prolonged procedures (> 2 hours).  Emergency surgery.  Hypoalbuminaemia (< 30 g/L).  Exercise tolerance < 1 flight of stairs, <100 yards (<91M).  BMI > 30.
  28. 28. URTI & anesthesia  Mild symptoms → can usually proceed.  Severe symptoms or underlying disease → postpone.  Risk of increased bronchial reactivity and LRTI → postpone.  Spinal ?! Epidural ?!
  29. 29. Diabetes Mellitus  FBS > 126mg/dl, HbA₁c ≥6.5%.  Should be well controlled prior to elective surgery. ( 150 – 180mg/dl ?).  Surgical stress promotes hyperglycemia in the diabetic patient.  Perioperative morbidity - end-organ damage.
  30. 30.  ⅓ -½ of patients with type2 DM may unaware of their condition till time of surgery.  Preoperative CXR in DM in more likely to uncover cardiac enlargement , pulmonary vascular congestion, pleural effusion, although it is not routinely indicated.
  31. 31.  ECG: Silent ischemia.  DM with HTN → 50% autonomic neuropathy.  DM > 10 years → CAD.
  32. 32. Problems of DM with Anesthesia  Autonomic neuropathy.  Delayed gastric emptying.  Renal impairment.  limited mobility of joints.
  33. 33. Smoking and Anesthesia
  34. 34.  Nicotine half-life: 1-2 hrs.  Carbon monoxide (CO) half-life: 4hrs.  Bronchociliary function improves within 2-3days of cessation.
  35. 35.  Sputum volume decreases to normal levels within 2 weeks.  Smoker with irritable air way, wheezy chest ? Mask A ?, LMA ?, ETT ? Smoking immediately before surgery…?!!
  36. 36. Hookah (Water pipe Tobacco Smoking)
  37. 37.  Other names: narghile, arghile, shesha.  No indication that water pipe tobacco smoking (WTS) is less risky than cigarette smoking.  Word wide icreasing among adolescents and young adults, (30-40% of high school and college students).
  38. 38. WTS Vs Cigarette  Studies shows that measurement of total puff volume; WTS: 50 -80 L of smoke, in contrast cigarette smokers inhale about 0.5 – 0.8 L/single cigarette, i.e. the ratio is 60 -160 cigarette.  1.2 times of nicotine, 8 times of CO, 3 times of nitric oxides, 4-15 times acrolien, 6-31 times the formaldehyde, 3- 245 times the polycyclic aromatic hydrocarbones (PAHs).
  39. 39.  Should be carefully assessed preoperatively with additional precautions and should be treated in the same manner as a cigarette smoker.  A high carboxyhemoglobin levels (15 – 28%) suggest that patients require special attention. NR: non smokers: up to 3%, smokers 2-5%, heavy smokers 5-10%.
  40. 40.  New generation oximeters are highly advisable.  Blood sample on the day of the surgery for measurement of carboxyhemoglobin... ?
  41. 41. Preoperative Medication Management  What to stop ?  What to keep ?  What to add ?
  42. 42. Hold on day of surgery  Diuretics: unless thiazide for hypertension unless severe heart failure.  Insulin & OHA ?!  ACEI’s or ARB’s (individual choice). depends on procedure / risk of hypotension
  43. 43. e.g. Time NSAIDs Stop 48 hours pre-op Warfarin (bridging to enoxaparin). Stop 4 days pre-op Clopidogrel Stop 7 days pre-op Stop 6 weeks prior to surgery. Oral Contraceptive Pills Aspirin 75 mg usually continued.
  44. 44. Premedication  Alleviate anxiety/sedation/amnesia Reduce risk of reflux.  Manage pain.  Control perioperative risk. Dry secretions.
  45. 45. Preoperative Fasting Guidelines
  46. 46. Minimum Fasting period Ingested Material 2 hours Clear liquids: water, fruit juices without pulp, carbonated beverages, tea and black coffee (clear liquids should not include alcohol) 4 hours Breast Milk 6 hours Infant formula 6 hours Non-human milk 6 hours Light meal (typically consists of toast and clear liquids) 8 hours Full, heavy, fatty meal
  47. 47. Preoperative laboratory tests  No evidence supports the routine use of laboratory tests.  Selected tests should based on patient's preoperative history, physical examination and proposed surgical procedures.
  48. 48. Unless there has been intervening changes in patient's status: • within 6 months of the procedure ECG & Chest X- Ray within one month are accepted in the stable conditions Chemistries and hemoglobin/ HTC not more than 1 week Coagulation studies 4 month intervals Virology screen
  49. 49. Anticoagulant and antiplatelet (ASRA recommendations)
  50. 50. Antiplatelet Aspirin and NSAID Either medication alone does not increase risk.  Normal bleeding time does not indicate normal homeostasis and vise versa.  Check for history of bruising, excessive bleeding, female, old age.
  51. 51. Anticoagulant Oral anticoagulant: Warfarin Monitoring: PT and INR. Must be stopped ideally 4-5 days (normal PT &INR), this should be discussed with the physician.
  52. 52. Parenteral anticoagulant Heparin:  Monitoring: aPTT.  To be stopped 4-6 hr. LMW Heparin:  Half-life: 3-4 times more than Heparin.  prophylactic dose: wait 10 - 12 hr.  Therapeutic dose: delay 24 hr.
  53. 53. Anesthesia and Herbal Therapy Garlic  Reduces blood pressure , thrombus formation, and serum lipid and cholesterol levels.  Inhibits in vivo platelet aggregation is dose- dependent.  Time to normal hemostasis after discontinuation : 7 days.
  54. 54. Ginkgo  Cognitive disorders, peripheral vascular disease, vertigo, tinnitus, and altitude sickness.  Inhibits platelet activating factor.  Time to normal hemostasis after discontinuation :36 hrs.
  55. 55. Ginseng  Protects against effects of stress.  May inhibit the coagulation cascade.  Time to normal hemostasis after discontinuation – 24 hrs. These represent no added risk for spinal hematoma
  56. 56. Summery  Preoperative evaluation is mandatory.  The anesthetist is uniquely qualified to evaluate the risk and he is responsible for deciding fitness for anesthesia.  The risk is cumulative of: medical + surgical.
  57. 57.  Preoperative investigation should be requested according to its indications, routine (blanket )preoperative investigations waste resources & time.  Mendelson’s syndrome may be fatal, there for fasting time should be taken seriously.

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