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Preoperative assessment

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Educate patient about anaesthesia, pain management and perioperative care ... Mortality related to anaesthesia. Approx 1:26,000 anaesthetics ... – PowerPoint PPT presentation

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Title: Preoperative assessment


1
Pre-operative assessment
  • Dr Doug Campbell
  • Division of Anesthesiology
  • February 3rd 2006

2
Goals of preoperative assessment
  • History and physical examination to determine
    relevant tests and consultations
  • Guided by patient choice and medical risk factors
    choose a plan of care
  • Informed consent
  • Educate patient about anaesthesia, pain
    management and perioperative care
  • Reduce patient care costs

3
Questions
What is the risk of proceeding versus the benefit
to the patient? Can we modify these risks
before surgery?
4
Mortality related to anaesthesia
  • Approx 126,000 anaesthetics
  • One third of deaths are preventable
  • Causes in order of frequency
  • inadequate patient preparation
  • inadequate postoperative management
  • wrong choice of anaesthetic technique
  • inadequate crisis management

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Risk and ASA classification
8
History and physical are the most important
assessors of disease and risk
9
Presenting complaint
  • Why does the patient need an operation now?
  • Is it acute/chronic illness?
  • Presenting symptoms?
  • e.g. anaemia, cachexia, pain, seizures etc
  • What are the pathophysiological consequences?
  • e.g. thyroid mass
  • Local - stridor, SVC obstruction
  • Systemic - hypo/hyperthyroidism

10
Associated medical conditions
  • Given the presenting problems are there any
    other conditions I am worried the patient could
    have?
  • Bowel ca. - liver mets with abnormal LFTs,
    abnormal coagulation, impaired drug metabolism
  • Peripheral vascular disease - IHD, carotid
    disease, HT, renal disease, COAD

11
Other medical conditions
  • Any other problems that may affect
  • perioperative morbidity and mortality?
  • cardiac disease
  • respiratory disease
  • arthritis
  • endocrine disease - diabetes, obesity etc
  • What is the patients functional capacity?

12
Functional capacity
  • 1 MET Can you dress yourself?
  • 4 MET Can you climb a flight of stairs?
  • 10 MET Can you participate in strenuous
    activities (swimming, tennis,football)

13
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14
Anaesthetic history/assessment
  • Family history
  • Previous anaesthetics
  • PONV
  • allergy
  • malignant hyperpyrexia
  • difficult airway
  • difficult IV access

15
Airway assessment
  • Best done by an anaesthetist
  • Certain features of concern
  • small mouth
  • poor dentition
  • limited neck mobility
  • scars/surgery/anatomical abnormalities
  • obesity

16
Mallampati scoring system
17
Why would this mans airway be difficult to
manage?
18
Drug history
  • Very useful, often forgotten
  • Current medications
  • ALLERGY
  • Medic alert bracelets
  • Smoking/alcohol history
  • Other drugs of abuse!

19
The more tests, the better
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27
Perioperative medications
  • Take all usual medications
  • Antihypertensives
  • Beta blockers
  • Statins
  • Think about discontinuing/replacing
  • Aspirin
  • Anticoagulants
  • Diabetic medications
  • MAOIs

28
Summary
  • History and physical most important assessors of
    disease and risk
  • ASA and functional status good predictors of risk
  • Lab tests have some usefulness
  • add little in low risk patients
  • may add false ves
  • add expense

29
Case example
  • You are an orthopaedic House Surgeon
  • Your Registrar tells you
  • There is a fractured femur in ED, get it ready
    for theatre.
  • What are you going to do?

30
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31
Case example
  • A 49 yr old Samoan woman presents for
  • elective hemicolectomy. She has a 10 yr
  • history of NIDDM . She takes glipizide
  • and metformin
  • What are you going to do?

32
Case example
  • An 81 yr old man presents for elective
  • TURP. He has atrial fibrillation, has had
  • previous TIAs and is on warfarin.
  • What are you going to do?

33
Case example
  • A 76 year old man with PVD presents for
  • femoro-popliteal bypass surgery. He has
  • an ejection systolic murmur on
  • auscultation.
  • What are you going to do?

34
Questions
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