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preanasthetic evaluation

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preanasthetic evaluation

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preanasthetic evaluation

  1. 1. DR.CHARULATHA.R Preanaesthetic evaluation
  2. 2.  anaesthesiologist = perioperative physician  Use our unique knowledge and experience to manage medical complexities related to surgery  3 % of perioperative adverse events were related to inadequate preoperative assessment
  3. 3. goals  1.patients can safely tolerate anaesthesia for planned surgical procedure  2.to mitigate risks associated with overall perioperative period
  4. 4. How do we achieve it?  Document comorbid illness  Perform focussed clinical examination  Optimize preexisting medical conditions  Make selective referrals to specialists  Order preoperative investigations  Initiate interventions to reduce perioperative risk  Discuss aspects of perioperative care
  5. 5. Anaesthesiologist lead PAC  More selective ordering of laboratory tests  Reduced healthcare costs  Reduced patient anxiety  Improved acceptance of regional anaesthesia  Fewer case cancellations on day of surgery  Shorter duration of hospitalization  Lower hospital costs
  6. 6. Medical consultation?  Management of unstable medical conditions before elective surgery  Preop optimization of poorly controlled medical diseases  Clinically relevant preop diagnostic workup  Uncommon medical disorder
  7. 7. Detecting disease  All that is required is clinical examination  History taking -56%  Physical examination -73%  ECGs and chest Xrays -3%  Stress tests -6 %  Respiratory ,urinary,neurolgic-history
  8. 8. Components of medical history  Ask the right question  Indication for surgery and planned procedure  Development of surgical condition and prior related therapies  Current and past medical problems,pervious surgical procedures,types of anaesthesia ,any anaesthesia related complications  allergies
  9. 9. Personal history  Tobacco, alcohol ,illicit drug use  Quantitative documentation of tobacco exposure  Pseudocholinesterase deficiency/ Malignant hyperthermia  Snoring and excessive daytime sleepiness  Last menstrual period  GE reflux  Excessive bleeding problems
  10. 10. Comorbid conditions  Severity,stability,exarcerbations  Prior treatments,planned interventions  Degree of control  Activity limiting nature of problems  Medications and schedules  Recent corticosteroid use
  11. 11. METs  Assessment of functional capacity  Metabolic equivalents of the task  Measure of volume consumed during an activity  Poor exercise capacity may be the cause or result of cardiopulmonary disease  Inability to perform average levels of exercise increases risk of perioperative complications
  12. 12. Physical examination  Vital signs  BMI  Airway examiation  Evaluation of heart,lungs ,spine  Direct observation of exercise tolerance  Basic neurologic examination  Carotid bruit
  13. 13. Components of airway examination  Length of upper incisors  Visibility of uvula  Compliance of mandibular space  Thyromental distance  Length and circumference of neck  Range of motion of head and neck  Relationship of upper incisors to lower incisors
  14. 14. Cardiovascular diseaase  Hypertension  Ischemic heart disease  Coronary stents  Heart failure  Murmurs and valvular abnormalities  Rhythm disturbances in preoperative ECG  Peripheral arterial disease
  15. 15. hypertension  Identify cause,other cardiovascular risk factors,end organ damage  BP measurement in both arms  Investigations?  Elective surgery delayed when systolic> 200 mm Hg or diastolic >115 mm Hg  BP less than 180/110 mm Hg  Future appropriate postop management of inadequately treated hypertension  ACE inhibitors and ARBs
  16. 16. Ischemic heart disease  Step 1-emergency surgery  Step2- active cardiac conditions  Step 3 –low risk surgery  Step 4- functional capacity  Step 5- clinical predictors
  17. 17. Revised cardiac risk index  High risk surgery  Ischemic heart disease  History of congestive heart failure  History of cerebrovascular disease  Diabetes mellitus requiring insulin  Creatinine >2.0 mg/dL
  18. 18.  Preoperative anaemia is associated with increased perioperative cardiac events  Increasing blood transfusion rates does not decrease perioperative cardiac risk  Anaemia decreases effects of beta blocker therapy  Increased harm when the patient is bleeding
  19. 19. ECG Patients with symptoms /suggestive of ischemia For intermediate to high risk surgical procedures Not needed in superficial procedures or simply because of advanced age Q waves,RBBB,LBBB - important
  20. 20.  Statins and beta blockers continued  Beta blockers should be started several days before the procedure  Caution in patients with cerebrovascular disease  Aspirin is continued where the risk of cardiac events exceeds risk of major bleeding
  21. 21. Neurologic disease  Cerebrovascular disease- recent stroke orTIA is a very strong predictor of subsequent perioperative stroke  Asymtomatic bruit- carotid doppler studies  Seizure disorder- CBC and electrolytes  Parkinson disease  Neuromuscular junction disorders
  22. 22. Preoperative tests  Should be based on  1.patient ‘s medical history  2.proposed surgical procedure  3.potential for intraoperative blood loss  Selective testing enhances the standing of speciality in perioperative medicine
  23. 23. CBC  History of increased bleeding  Hematologic disorders  Renal disease  Recent chemo or radiation  Corticosteroid or anticoagulant therapy  Poor nutritional status  Trauma  Anticipated high blood loss
  24. 24. Renal function testing  Diabetes and hypertension  Cardiac disease  Fluid overload  Renal transplantation  Recent chemotherapy  Potential dehydration  Hematuria,oliguria,anuria
  25. 25. Liver function tests  History of hepatitis  Jaundice  Cirrhosis  Hepatotoxic drug exposure  Bleeding disorders  Tumor involvement of liver
  26. 26. Coagulation testing  Known bleeding disorders  Previous excessive intraoperative bleeding  Hepatic disease  Poor nutritional status  Anticoagulants  Routine testing not needed unless coagulapathy is suspected or known
  27. 27. Chest radiograph  No evidence indicates that routine preoperative chest radiographs provide prognostically important information for assessing patients perioperative risk  Rales or rhonchi  Advanced copd/suspected pulmonary edema  Pulmonary/mediastinal masses  Aortic aneursym
  28. 28. Preoperative risk assessment  Improves patient’s understanding  Helps clinical decision making  Improves perioperative outcomes  ASA PS classification  John Hopkins Surgery Risk Classification System
  29. 29. ASA PS  1- a normal healthy patient  2- a patient with mild systemic disease  3- a patient with severe systemic disease  4- a patient with severe systemic disease that is a constant threat to life  5- a moribund patient who is not expected to survive without operation  6-declared brain dead donor
  30. 30. Role of specialized testing Resting echocardiography- Valves Pulmonary hypertension Fixed wall motion abnormalities Ventricular function Dyspnea of unknown origin Recent altered clinical status in a known heart failure patient
  31. 31. CPET  Non invasive global assessment of exercise capacity  Involves a patient exercising on a treadmill or bicycle for 8 to 12 minutes  Continuous measurement of respiratory gas exchange  Poor exercise capacity associated with increased postoperative mortality/morbidity
  32. 32. PFT  Help differentiate between pulmonary and cardiac cause of dyspnea  Assess perioperative risk in lung resection surgery  Prognostic value limited
  33. 33. Medication management -stop  Clopidogrel-7 days before surgery  Ticlopidine -14 days  Insulin- short acting –discontinue  Type 1 diabetes- 1/3 rd of long acting morning dose  Type 2- upto ½ of long acting or combination  OHAs  Diuretics –except thiazides
  34. 34. stop  Warfarin- 4 days before surgery except for patients having cataract surgery withot bulbar block  NSAIDS – 48 hrs before surgery  Sildenafil-24 hrs before surgery  ACEI and ARBs
  35. 35. continue  Antihypertensive medications  Cardiac drugs  Antidepressants,anxiolytics  Thyroid  Anticonvulsant  Asthma  Steroids  Statins  MAO inhibitors
  36. 36. Preoperative fasting status  Clear fluids -2 hrs  Breast milk -4 hrs  Formula milk -6 hrs  Light meal -6 hrs  Fried fatty meal -8 hrs
  37. 37. Postoperative pain management  Visual analog score  McGill pain questionnaire  Uses  1.patient’s concern  2.preoperative instructions  3.improves patient acceptance of regional anaesthesia  4.patients with chronic pain syndromes

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