role of anesthesiologist in pre-opertive period

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

Q & A