Pre Anaesthetic ClinicPre Anaesthetic Clinic

Dr. P.Sivaraj MD DAAssistant professorDept of Anaesthesiology, GVMCGovt Villupuram Medical College and Hospital.

IntroductionIntroduction

Definition Definition

The process of clinical assessment that

precedes the delivery of anaesthesia care

Goal Goal AnxietyPlan in intervention and optimiz Facilitate early normalcy Improve out comeEfficient and cost effective CareConsentOption in Pain Control Determine appropriate testDiscuss risk Practice advisory for preanesthesia evaluation: a report by the

American Society of Anesthesiologists Task Force on Preanesthesia Evaluation.American Society of Anesthesiologists Task Force on Preanesthesia Evaluation Anesthesiology. 2002 Feb; 96(2):485-96.

 Roizen MF, Foss JF, Fischer SP. Preoperative evaluation. In: Miller RD, editor. Anesthesia. 5th ed. Vol. 1. New York: Churchill-Livingstone; 2000. pp. 824–83.

Cancellation in elective orthopaedic surgery. Koppada B, Pena M, Joshi A Health Trends. 1991; 23(3):114-5 .

Uses Uses Educate the patientsOrganize the resourcesInformed consentFormulate plans for intra operative carePerioperative pain managementPost operative recovery

I. Problem Identification

II. Risk Assessment

III. Preoperative Preparation

IV. Plan of Anesthetic Technique

The purpose of the preoperative visit:The purpose of the preoperative visit:

I. Problem IdentificationI. Problem Identification

● Case History

●Physical examination

●Laboratory investigation

I. Problem IdentificationI. Problem Identification

1. h/o present illness• Cardiovascular : hypertension ; ischemic , valvular or congenital heart

disease; CHF or cardiomyopathy, , arrhythmias

• Respiratory : smoking; COPD; restrictive lung disease; altered control of breathing (obstructive sleep apnea, CNS disorders, etc.)

• Neuromuscular : raised ICP ; TIA's or CVA's; seizures; spinal cord Injury; disorders of NM junction e.g myasthenia gravis, muscular dystrophies ,MH

• Endocrlne : DM; thyroid disease; pheochromocytoma; steroid therapy

• GI - Hepatic : hepatic disease; gastresophageal reflux

• Renal : renal failure

I. Problem IdentificationI. Problem Identification

• Hematologic : anemias; coagulopathies

• Elderly , Children, Pregnancy

2 h/o past illness Chronic diseases Jaundice • Medications and Allergies• Prior Anesthetics• Alcohol, drugs, smoking, activities and exercise tolerance

3. Family history

Physical Examination:Physical Examination:General & Local examination

Evaluation of :

• Upper airway

• Respiratory system

• Cardiovascular system

• Vital signs

Preoperative Laboratory Testing:Preoperative Laboratory Testing:

only if indicated from the preoperative history and physical only if indicated from the preoperative history and physical examination.examination."Routine or standing" pre operative tests should be discouraged"Routine or standing" pre operative tests should be discouraged

-CBC anticipated significant blood loss, suspected hematological disorder (eg.anemia, thalassemia, SCD), or recent chemotherapy.

-Electrolytes diuretics, chemotherapy, renal or adrenal disorders

Investigations Investigations -ECG age >50 yrs ,history of cardiac disease, hypertension, peripheral vascular disease, DM, renal, thyroid or metabolic disease.

-Chest X-rays prior cardiothoracic procedures ,COPD, asthma, a change in respiratory symptoms in the past six months.

-Urine analysis DM, renal disease or recent UTI.

-Echocardiography

-Indirect laryngoscopy

-Pulmonary function tests

Should routine pre-operative testing be abandoned?

Klein AA, Arrowsmith JE Anaesthesia. 2010 Oct; 65(10):974-6.

The preoperative evaluation: use the history and physical rather than routine testing.

Michota FA, Frost SD Cleve Clin J Med. 2004 Jan; 71(1):63-70.

ASA Physical Status Classification System

For emergent operations, you have to add the letter ‘E’ after the classification.

Patient assessment Patient assessment ASA physical status

Cardiac risk1. Goldman multifactorial cardiac risk index

2. Detsky’s multifactorial index

3. Revised Cardiac Risk Index

II. Risk AssessmentII. Risk Assessment

Components for evaluating perioperative risk:

• Patient's medical condition preoperatively• Type or extent of the surgical procedure• Risk from the anesthetic

““Most of the work, however, addresses the operative riskMost of the work, however, addresses the operative risk

according to the patient's preoperative medical status”according to the patient's preoperative medical status”

Types of surgical proceduresTypes of surgical proceduresClass A

Class B

Class CPhysiology, morbidity, blood, invasive

monitor, post op icu

III. Preoperative PreparationIII. Preoperative Preparation

Anesthetic indications:

Anxiolysis, sedation and amnesia. e.g. benzodiazepine(diazepam ,lorazepam)

Analgesia e.g. narcotics

Drying of airway secretions e.g. atropine, glycopyrrolate

Reduction of anesthetic requirements ,

Facilitation of smooth induction

Patients at risk for GE reflux : ranitidine ,metoclopramide , sodium citrate

Preoperative preparationsPreoperative preparationsSurgical indications:

- Antibiotic prophylaxis for infective endocarditis.

- Prophylaxis against DVT for high risk patients : low-dose heparin or aspirin, intermittent calf compression, or warfarin

Preoperative preparationsPreoperative preparationsCo-existing Disease indications:

• Some medications should be continued on the day of surgery e,g Beta -blockers, thyroxine, anti hypertensive, nitrates ,antiepileptic, bronchodilators

• Others are stopped e.g oral hypoglycemics, Tricyclic ani depressant inhibitors and MAO inhibitors

• Steroids within the last six months may require supplemental steroids

INGESTED MATERIALMINIMUM FASTING PERIOD, APPLIED TO ALL AGES (hr)

Clear liquids 2

Breast milk 4

Infant formula 6

Nonhuman milk 6

Light meal (toast) 6

Fasting Recommendations Fasting Recommendations

IV. Plan of Anesthetic TechniqueIV. Plan of Anesthetic Technique

1. Is the patient's condition optimal?

2. Are there any problems which require consultation or special tests? “Please assess and advise “

3. Is there an alternative procedure which may be more appropriate?

4. What are the plans for postoperative management of the patient?

5. What premedication if any is appropriate?

Finally, we plan our anesthetic technique :

1.Local

2. Regional anesthesia

2. General anesthesia

3. Combination

Cancelling casesCancelling cases

Control temptation of taking up every cases

Inadequate preparation

Communication

“The surgeon should not demand or insist on a

particular technique or the capability of the

anaesthesiologist to manage the particular

technique” – John Alfred Lee

BENEFITS OF AN EFFECTIVE FUNCTIONING PREANAESTHETIC CLINIC

Early anesthesia evaluation of the ambulatory surgical patient: does it really help?

Twersky RS, Lebovits AH, Lewis M, Frank D J Clin Anesth. 1992 May-Jun; 4(3):204-7.

Recommendations Recommendations  ASA Task Force has recommended that

preanaesthesia evaluations should be performed prior to the day of surgery for patients with high severity of disease and/or undergoing procedures of high surgical invasiveness

Practice advisory for preanesthesia evaluation: a report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation.American Society of Anesthesiologists Task Force on Preanesthesia Evaluation Anesthesiology. 2002 Feb; 96(2):485-96.

Reduction in excessive Reduction in excessive preoperative testingpreoperative testing

60–75% of preoperative tests ordered are medically unnecessary.

Kaplan EB, Sheiner LB, Boeckmann AJ, Roizen MF, Beal SL, Cohen SN, Nicoll CD JAMA. 1985 Jun 28; 253(24):3576-81.

•Existing literature suggests that 30-60% of abnormalities discovered on routine preoperative tests are ignored.

Roizen MF. More preoperative assessment by physicians and less by laboratory tests. N Engl J Med 2000;342:204-205.

•Given this fact, routine preoperative testing without documentation of abnormalities actually may lead to more medico-legal risk.

•In general, it is safe to use test results that were performed and were normal within the previous four months, given that no change has occurred in the patient's clinical status.

•One study reported that only 0.4% of such tests repeated at the time of surgery were abnormal and could have been predicted by the patient's history.

Smetana GW, Macpherson DS. The case against routine preoperative laboratory testing. Med Clin North Am 2003;87:7-40.

REDUCTION IN REDUCTION IN SUBSPECIALTY CONSULTSSUBSPECIALTY CONSULTS

The effect of alterations in a preoperative assessment clinic on reducing the number and improving the yield of cardiology consultations.

Tsen LC, Segal S, Pothier M, Hartley LH, Bader AM Anesth Analg. 2002 Dec; 95(6):1563-8,

Enhanced operative room Enhanced operative room functioningfunctioning

Value of preoperative clinic visits in identifying issues with potential impact on operating room efficiency.

Correll DJ, Bader AM, Hull MW, Hsu C, Tsen LC, Hepner DLAnesthesiology. 2006 Dec; 105(6):1254-9;

References References Development and effectiveness of an

anesthesia preoperative evaluation clinic in a teaching hospital.

Fischer SP Anesthesiology. 1996 Jul;

85(1):196-206.

References References Economic benefits attributed to opening

a preoperative evaluation clinic for outpatients.

Pollard JB, Zboray AL, Mazze RI Anesth

Analg. 1996 Aug; 83(2):407-10.

References References Telemedicine versus face to face patient

care: effects on professional practice and health care outcomes.

Currell R, Urquhart C, Wainwright P, Lewis R Cochrane Database Syst Rev. 2000; (2):CD002098.

Assessing telemedicine: a systematic review of the literature.

Roine R, Ohinmaa A, Hailey D CMAJ. 2001 Sep 18; 165(6):765-71.

References References Cost-effective preoperative evaluation

and testing. Fischer SP Chest. 1999 May; 115(5

Suppl):96S-100S.

Preoperative testing: moving from individual testing to risk management. Pasternak LR Anesth Analg. 2009 Feb; 108(2):393-4.

References References

More preoperative assessment by physicians and less by laboratory tests

Roizen MF N Engl J Med. 2000 Jan 20;

342(3):204-5.