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Preoperative assessment Yr 4 Anaesthesia Clerkship

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Title: Preoperative assessment Yr 4 Anaesthesia Clerkship


1
Preoperative assessmentYr 4 Anaesthesia Clerkship
  • Dr Patricia Chalmers
  • 2010-2011

2
  • Objectives of preoperative assessment
  • Fasting status
  • The airway
  • Volume status
  • Systemic effects of anaesthetic agents
  • Allergies and genetic considerations
  • Risk Stratification
  • Respiratory and cardiovascular assessment
  • Patient sketches
  • Overview of history and examination

3
Preoperative Assessment
  • Objectives
  • To deliver good quality care
  • To establish doctor-patient rapport
  • To establish a clinical picture of the patient
  • To identify risk factors
  • To draw up a management plan
  • To optimise any concurrent medical conditions
  • To minimise the occurrence of critical incidents
    in the perioperative period

4
Clinical Picture
  • Full medical history and physical examination
  • Points of specific relevance to anaesthesia
  • RISK STRATIFICATION
  • General health of patient and functional capacity
  • Surgical procedure
  • Concurrent medical conditions and medication
  • History of reactions and allergies to anesthesia
    THE AIRWAY
  • Fasting Status Volume Status

5
FASTING STATUS
6
FASTING STATUS
  • 6 hrs solids
  • 4hrs liquids
  • (2hrs clear fluid /water)

7
The Full StomachMechanisms
  • Reflux
  • Delayed gastric emptying
  • Raised abdominal pressure
  • Pharyngeal and laryngeal incompetence

8
The Full StomachClinical conditions
  • GORD
  • Opioids
  • Autonomic neuropathy diabetes
  • Pregnancy
  • Intestinal obstruction
  • Trauma
  • Head Injury
  • Myopathies/ bulbar palsy

9
Preoperative measures to reduce risk of aspiration
  • Proton pump inhibitors
  • H2 blockers
  • Metoclopramide
  • 0.3M Sodium citrate 30ml
  • Nasogastric tube where applicable
  • (Induction of anaesthesia RSI)

10
THE AIRWAY
11
THE AIRWAY
  • Examination Facial swelling
  • Mouth opening
  • Dentition
  • Macroglossia
  • MALLAMPATI GRADE
  • Thyromental distance
  • Neck shape and mobility

12
Mallampati Grades
13
Mallampati Grades
14
Volume Status
15
VOLUME STATUS
  • Assess preoperative deficit
  • Clinical picture
  • Formula

16
Volume Status
  • TBW 70kg male
  • 55-60 Body weight 45l
  • Intracellular 30 L
  • Extracellular 15 L
    interstitial 12L intravascular 3L

17
Clinical Dehydration
  • Body wt loss SS
  • 5 thirst, dry mouth
  • 5-10 reduced
    peripheral perfusion,
  • reduced
    skin turgor, oliguria,
  • postural
    hypotension, tachycardia
  • reduced
    CVP, lassitude,
  • 10-15 inc RR,
    hypotension, anuria,
  • delirium,
    coma
  • gt15 Life threatening

18
Formula
  • 4mls/kg/hr for first 10 kg body weight
  • 2mls/kg/hr for the next 20kg body wt
  • 1ml/g /hr for every other kg body weight
  • Adult 2mls/kg/hr

19
Fluid replacement
  • Replace existing deficit 50 deficit in 1st hr,
  • 25
    in 2nd hr,
  • 25
    in 3rd hr
  • Maintain fluid balance 2mls/kg/hr
  • Deficit fasting/ burns/GI losses
  • Consider ongoing losses

20
Effects of anesthetic agents and drugs
  • Respiratory depression, impaired lung function ?,
    HYPOXIA
  • Depressed myocardial function ?HYPOTENSION
    arrthymias,
  • Impaired delivery of O2 to the tissues

21
Effects of anaesthetic agents on respiratory
function
  • Depression of RC
  • Diminished muscle tone
  • Reduced lung compliance(loss of elastic recoil)?
    ?TLC ?TV ?FRC and ?Closing volume
  • Atelectasis
  • ?Dead space(respiratory circuit)

22
Increased work of breathing Increased ventilation
/perfusion mismatch
23
Effects of anaesthetic agents on cardiovascular
function
  • Reduced contractility
  • Reduced stroke volume
  • Vasodilatation
  • Hypotension
  • Risk of reduced coronary perfus

perfusion
24
Effects of anesthetic agents and drugs (contd)
  • Metabolism and elimination of drugs dependent on
    hepatic and renal function
  • Muscle relaxation and paralysis
  • Stress Response
  • Adverse effect on co-morbidities

25
Perioperative Clinical Risks
  • Respiratory depression
  • Cardiac ischaemia
  • Arrthymias
  • Myocardial infarction
  • Stroke
  • Renal impairment

26
Risk Stratification
  • ASA grades
  • Surgical procedure
  • Age
  • BMI
  • Elective v Emergency

27
ASA GRADING
  • 1. Healthy Patient
  • 2.Mild systemic disease with no impact on life
  • 3.Systemic disease with limiting factors
  • 4. Systemic disease with a constant threat to
    life
  • 5. Moribund patient

28
Grading of General Surgical Procedures
  • Minor eg skin lesion
  • 2. Intermediate eg inguinal hernia arthroscopy
  • 3. Major eg hysterectomy,
  • 4. Major eg colonic resection, radical neck
    dissection,

29
Preoperative assessment
  • Is there any evidence of active disease?
  • Are there any clinical risk factors?
  • What is the patients functional capacity?
  • What maintenance medication is the patient on?
  • How can we optimise the patients clinical
    condition?

30
Patient sketch 1
  • 53 year old female for ligation of varicose veins
  • She has a history of asthma and neglects her
    medication
  • o/e anxious
  • RR 24/min
  • widespread rhonchi
  • PEF 65
  • Other systems unremarkable

31
Patient sketch 2
  • 64 yr old male with intestinal obstruction for a
    laparatomy
  • History of COPD previous heavy smoker
  • Gets breathless walking uphill or fast on level
    ground
  • Coughing purulent sputum
  • FEV1 75
  • On combined therapy with beta 2 agonist and
    anticholinergic

32
Preoperative measures to improve lung function
  • Stop smoking
  • Chest physio
  • Bronchodilators
  • Antibiotics
  • Steroids

33
Patient sketch 3
  • 55yr old female for hysterectomy
  • Diabetic on twice daily insulin
  • BP 140/90
  • What investigations and management

34
Patient sketch 4
22 kg child for removal of plaster cast Fasting
from midnight In theatre at 10.00am What is her
fluid deficit?
35
Patient Sketch 5
84 yr old female with a fractured neck of
femur Tripped in bathroom lives alone and lay
there for 20 hours She is thin stature, lives
on tea, toast and cake History of CCF On
diuretics ? Considerations and management
36
Patient Sketch 6 40 yr old male for elective
cholecystectomy Heavy smoker HR 80/min BP
200/115 Hb 14.0 gm/dl Urea 8 mmols/l Creatinine
140mmols/l
37
Patient sketch 7
40 yr old male for cholecystectomy HR 80/min
reg BP 150/95 Hb 12.8 gm/dl Urea 5.8
mmols/l Creatinine 115 µmols/l Na 130mmols/l K
4.5mmols/l
38
Patient sketch 8
  • 44 year old female for mastectomy and
    reconstruction
  • 5 year history of angina, becoming more frequent
    and increasing in severity over past 6 months
  • Both parents died from myocardial infarction
  • Coronary angiogram 2yrs ago no vessel disease
  • Ca antagonists,glyceryl trinitrate, isosorbide
    dinitrate, verapamil,
  • Risk Factors Investigations Management

39
Perioperative Cardiac Risk in relation to
noncardiac surgery
  • Hi gt5 Vascular Aortic and peripheral vascular
    surgery
  • Intermediate 1-5 intraperitoneal,
    intrathoracic, carotid endarterectomy, head and
    neck , orthopaedic, prostrate,
  • Lo risk lt1 endoscopic, superficial, cataract,
    breast, day stay procedures

ACC/AHA 2007 guidelines
40
Preoperative measures to improve cardiovascular
status
  • Continue maintenance meds
  • Control heart failure
  • Stabilise arrthymias
  • Stabilise uncontrolled hypertension
  • Lo dose short acting beta-blockers for IHD if Hi
    or intermediate risk
  • Statins considered
  • Prophylactic antibiotics for valvular
    disease/prosthesis

41
Systematic enquiry
  • RS
  • CVS
  • GIT HH GORD PUD
  • Renal system
  • Hepatic system
  • Endocrine diabetes thyroid
  • Bone joint and ct disorders RA
  • Haemotological anaemia coagulopathy DVT
  • Neurological and muscular epilepsy

42
Systematic Enquiry (contd)
  • Medications Diuretics, Steroids, Diabetes,
    Epilepsy, Anticoagulants etc
  • Allergies
  • Social history Smoking, Alcohol
  • Previous Anaesthetic history PONV
  • FH genetic disorder SUX apnoea MH
  • Fasting status 6hrs (2hrs clear fluids)

43
Investigations
Age ASA Surgery Spec cons
FBC Elderly 2-5 2-4 Pallor hge
UEs Elderly 3-5 3-4 Dehydration
GH/ X-match 3-4 Poly-trauma
ECG Mgt40, Fgt50 CVS 2 RS 3 2
CXR CVS 2 RS 3 Pneumonia
44
INVESTIGATIONS
  • FBC
  • UES
  • Where indicated
  • Group Hold/X-match
  • ECG
  • CXR
  • Glucose
  • Coag screen (spinal, epidural)
  • BGA
  • Cardiac ultrasound
  • RFTs

45
Key Points (1)
  • History Full systemic history
  • Medications for maintenance
  • Allergies
  • Add previous anaesthetic history PONV
  • FH Sux apnoea, MALIGNANT HYPERTHERMIA
  • FASTING status
  • Anaesthetic Risk Stratification

46
Key Points (2)
  • Examination Full systemic examination
  • Add THE AIRWAY
  • Consider Volume status GH/X-match
  • Obtain Consent
  • Discuss pain management ---reassure
  • Continue maintenance meds
  • Draw up Anaesthetic Plan
  • Bear in mind effects of anaesthesia on patient
    and effects of co-morbidities on the anaesthetic
    technique

47
Recommended ReadingNeville Robinson, George
HallHow to Survive in AnaesthesiaBMJ Books
2nd Ed 2002
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