pre-operative assessment done by:- majed alturkistani
Post on 18-Jan-2016
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Pre-operative Assessment
Done by:- Majed Alturkistani
History and Physical• Indication for surgery
• surgical /anesthetic Hx: previous anesthetics/complications, previous intubations, medications, drug allergies
• PMHx
• CNS: seizures, stroke, raised intracranial pressure (ICP), spinal disease
• CVS : coronary artery disease (CAD), myocardial infarction (MI), congestive heart failure (CHF), hypertension (HTN), valvular disease, dysrhythmias, peripheral vascular disease (PVD), conditions requiring endocarditis prophylaxis, exercise tolerance, NYHA class
• Respiratory: smoking, asthma, chronic obstructive pulmonary disease (COPD), recent upper respiratory tract infection (URTI), sleep apnea
• Gl: Gastroesophageal reflux disease (GERD), liver disease
• Renal: insufficiency, dialysis.
• Hematologic: anemia, coagulopathies.
• MSK: conditions associated with difficult intubations - arthritides (e.g. rheumatoid arthritis), cervical tumours, cervical infections/abscess, trauma to cervical spine, Down syndrome, scleroderma, obesity, conditions affecting neuromuscular junction (e.g. myasthenia gravis).
• Endocrine: diabetes, thyroid, adrenal disorders
• • other: morbid obesity, pregnancy, ethanol/other drug use
• • FHx: malignant hyperthermia. atypical
Functional Capacity or (METs)
• Defined as the ratio of metabolic rate (and therefore the rate of energy consumption) during a specific physical activity to a reference metabolic rate.
• 1 MET = 3.5 mL O2 uptake/KG per min
• O2 uptake of a 40 y/o, 70 kg male sitting upright
Specific Activity Scale1. Sit upright
2. Eat, dress, use toilet, make bed
3. Walk around house, shower
4. 1 flight stairs, walk up hill, 2 block @ 2mph
5. Light house work, dust, wash dishes, golf, bowl
6. 2 flights of stairs, walk on flat @ 4mph,
7. Sex
8. Scrubbing floors, weight lifting, moving furniture
9. Broke the bed/neighbors called the cops sex
10.Shovel snow
11.Doubles tennis, swing dancing
12.Recreational Sports: Singles tennis, soccer, basketball, skiing, jogging
13.Competitive sports
Relation To Surgery
• < 4 METs Significantly Increases Risk MI, HF, Arrhythmia regardless of Surgical Risk
• Functional Capacity Complication Rate
• < 4 METs > 5%
• 4 – 10 METs 1 – 5%
• > 10 Mets < 1%
Physical Examination• Airway.
• Focus Clinical systemic examination.
• Bony land mark for regional anesthesia.
• General assessment for nutrition, hydration and Mental Status.
• Pre-existing motor or sensory deficit.
• Site for IV, Central or PA catheter.
Airway Assessment• Likely hood of difficult intubation, Ability to assume
sniffing position.
• No single test specific or sensitive
• Mallampati score
• Thyromental distance
• Mouth opening
• Tongue size
• Dentition
Mallampati Score
Investigation
Fasting Protocol • 8 hours after a meal that includes meat, fried
or fatty food.
• 6 hours after a light meal such as toast and crackers) or after ingestion of infant formula or non - human milk.
• 4 hours after ingestion of breast milk or jello.
• 2 hours after clear fluid & (water,black coffee. tea carbonated beverages,juice without pulp).
ASA Classification
Optimization by medication• Medication
• Medication to start
• Aspiration \ Na citarte, Ranitidine.
• Infective Endocarditis \ AB.
• DVT Prophylaxis \ Heparine SC.
• Adrenal Suppression \ Steroid coverage.
• Anxiety \ Benzodiazpines
• Medication to stop
• Oral Hypoglycaemic + antidepressant.
• Medication to adjust
• insulin prednison, Coumadin and Bronchodialtor.
HTN• Mild to moderate HTN —> OK
• Target sBP < 180 mmHg , dBP <110mmHG.
CAD• <3 months after MI - 37% patients may re-
infarct.
• 3-6 months after MI -15%
• >6 months after MI - risk remains constant at 5%.
Thank You
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