Preoperative Assessment of Patients for Anesthesia: Guidelines and Protocols

 
Assessment of patients
before anaesthesia
 
FIBMS Anaesthesia
 
Dr : Bassim mohammed
MSc anesthesia & intensive care
 
 
By:  
Dr : Miaad Adnan
 
1
st
 lecture/ 3
rd
 stage/
anesthesia technology
2022 - 2023
 
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Doctor-patient relationship
Surgical procedure
Preoperative Preparation
 Plan of Anesthetic Technique
 Perioperative risk determination.
Coexisting medical conditions
Perioperative risk determination.
Develop a management plan for perioperative anesthetic care
Reduce peri-operative morbidity and mortality
Reduce patient anxiety
Obtain informed consent
1
 
The anesthetic plan :
 
Type of anesthesia :
2
 
1 - Preoperative management
3
 
The anesthetic plan :
 
1.
History
 
2.
Physical examination
 
3.
Evaluation of coexisting disease
 
4.
Preop lab and diagnostic investigations
 
5.
Preop medication management
 
6.
Anesthetic note
 
7.
Guideline for NPO status
 
The anesthetic plan :
4
 
2 - Intraoperative management
Monitoring
Positioning
Fluid management
Special techniques
3 - Postoperative
Pain control
Intensive care
* Postoperative ventilation
* Hemodynamic monitoring
 
 1 . History :
History and physical examination 
are the most important assessors of disease and risk.
 
General history
History of   
1- Coexisting medical illnesses
                        2- Medications, 
present therapy
                        3- Allergies and drug reactions
                        4- tobacco and alcohol intake
Previous anesthetics, surgeries, deliveries
Family History
Last oral intake
5
6
                 Cardiovascular system
 
Specific enquiries must be made about:
- Angina
incidence
precipitating factors
duration
use of anti-anginal medications, e.g. glyceryl trinitrate (GTN) oral or
sublingual  )
 
- Previous myocardial infarction (MI) and subsequent symptoms
- Symptoms indicating heart failure
 
       1 . History :
7
                 Cardiovascular system
 
 
-
myocardial infarction are at a greater risk of perioperative re-infarction
-
Elective surgery postponed until at least 6 months after the event
 
-
Untreated or poorly controlled hypertension 
(diastolic consistently > 110 mmHg)
may lead to exaggerated cardiovascular responses
 
- Both hypertension and hypotension can be precipitated which increase
the risk of myocardial ischemia
 
 1 . History :
8
 
 1 . History :
                 Cardiovascular system
 
 
- Heart failure will be worsened by the depressant
effects impairing the perfusion of vital organs
- Valvular heart disease
      * prosthetic valves may be on anticoagulants
           
need to be stopped or changed prior to surgery
      * Antibiotic prophylaxis
9
 
 1 . History :
                 
Active Cardiac Conditions
 
 
        • Unstable coronary syndromes
                   - Unstable or severe angina
                   - Recent MI
        • Decompensated HF
 
        • Significant arrhythmias
 
        • Severe valvular disease
10
 
 1 . History :
Minor Cardiac Predictors
 
 
       
Advanced age (>70)
Abnormal ECG
           -LV hypertrophy
           -LBBB
           -ST-T abnormalities
           -Rhythm other than sinus
       
Uncontrolled systemic hypertension
 
LBBB. Left bundle branch block
11
 
 1 . History :
              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
13
 
 1 . History :
           
Respiratory system
 
 
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 postoperative chest infections
 
 if they are obese
 
or undergoing upper
abdominal or thoracic surgery
Chronic obstructive lung disease production of sputum (volume and
color)
Dyspnea
Asthma, including precipitating factor
Upper respiratory tract infection
   
anaesthesia and surgery should be postponed unless it is for a life-threatening condition
15
 
 1 . History :
             
Family history
 
 
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inherited conditions in the family
history of prolonged apnoea
unexplained death
malignant hyperpyrexia
Surgery postponed
16
 
 1 . History :
             SOCIAL HISTORY
 
 
Smoking
number of cigarettes
amount of tobacco
 
Alcohol
induction of liver enzymes
tolerance
Pregnancy
increased risk of regurgitation and aspiration
Elective surgery is best postponed until after
delivery.
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 2 - Physical examination :
 
General History
 
Physical examination
 
Evaluation of coexisting disease
 
Preop lab and diagnostic investigations
 
Preop medication management
 
18
 
 2 - Physical examination :
 
* Vital signs, (CNS, 
heart, lung,)
* Airway,
* If regional anaesthesia is proposed
- Assessment of the site of block
- Back
19
 
2 - Physical examination :
20
vital signs
 
Blood pressure
Resting pulse
      - rate, rhythm
Respiration
      - rate, depth, and pattern at rest
Body temperature
Pain score
 
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Predictors of difficult intubation
Mallampati classification
 ULBT (upper lip bite test)
Inter-incisors gap (
IID)
Thyromental distance (
TMD)
Forward movement of mandible
Document loose or chipped teeth
Tracheal deviation
 Movement of the Neck
 
 
 
Mallampati test
 
 
 
 
 
 
 
 
Class I = visualize the soft palate, uvula, anterior and posterior pillars.
Class II = visualize the soft palate and uvula.
Class III = visualize the soft palate and the base of the uvula.
Class IV = soft palate is not visible at all.
 
 
 
Interincisor distance (IID)
 
Less than or equal to
4.5 cm is considered
a potentially difficult
intubation.
 Generally greater than
2.5 to 3 fingerbreadths
(depending on observers fingers)
 
Sterno-mental Distance (SMD)
 
Extended head and neck, mouth closed, distance  <12.5cm is a difficult
intubation
 
 
 
Neck movement
 
CRANIOFACIAL DEFORMITIES
Temporomandibular joint
protrusion of mandible
 
 
 
 
 
 
 
 
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CBC
 anticipated significant blood loss, suspected hematological disorder
(eg.anemia, thalassemia, SCD), or recent chemotherapy.
Complete blood count:-
 Red blood cells(RBC), which carry oxygen
  White blood cells(WBC), which fight infection
 Hemoglobin(Hb), the oxygen-carrying protein in red blood cells
 Hematocrit (HCT), the proportion of red blood cells to the fluid
component, or plasma, in blood
 Platelets (PLT), which help with blood clotting
 
Blood test
 
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indication:
 any deranged coagulation, such as:
 iatrogenic causes (e.g. warfarin),
inherited coagulopathies (e.g haemophilia
A/B)
liver impairment.
Surgery with expected blood loss
.
9.5-13.5 seconds
0.7-1.2
25 – 35 seconds
 
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To assess the
 
baseline renal function
, which help inform any potential IV fluid management
intra- and post-operatively
 
COMMON ELECTROLYTES INCLUDE:
 Chloride (CL) :   
95-105
 mmol/L
Sodium Na:  
135-145
 mmol/L
Potassium (K) :  
3.5-5 
mmol/L
Total calcium:  
8.5-10.2
 mg/dL
Magnesium:  
1.5-2
 mEq/L
Glucose:    
65-110
 mg/dL
 
 
Creatinine
:    0.8-1.3 
mg/dL
Urea:  
7-30  
mg/dL
Uric acid:  
3.5-7.2 
 mg/dL
Inorganic phosphorous:  
2.8-4.5  mg/d
L
 Ionized calcium:  
4.8-5.5
 mg/dL
 
Investigations
 
 
ECG 
age >50 yrs ,history of cardiac disease, hypertension, peripheral vascular
disease.
It can indicate any underlying cardiac pathology and provide a baseline if there
are post-operative signs of cardiac ischaemia.
 
An echocardiogram (ECHO) 
may be considered if the person has:
 (1) a heart murmur
(2) cardiac symptom(s)
 (3) signs or symptoms of heart failure.
 
Chest X-rays 
prior cardiothoracic procedures ,COPD, asthma, recently resolved
respiratory tract infection , a change in respiratory symptoms in the past six
months, stable cardiac disease, smoking, and extremes of age.
 
 
 
 
 
Pulmonary function tests (PFTs) are a group of tests that measure how well your lungs work. This includes how
well you’re able to breathe and how effective your lungs are able to bring oxygen to the rest of your body
 
(VC).
 
Functional residual capacity (FRC).  2300ml
 
Total lung capacity TLC 5800 ml.
 
 VT.
 
 ERV
 
  IRV.
 
  VC.
 
 RV
 
2 - Physical examination :
                  Cardiovascular system
 
Dysrhythmias
 
Atrial fibrillation
 
Heart failure
Heart murmur
Valvular heart disease
Blood pressure is best measured at the end of the examination
25
 
2 - Physical examination :
                 Respiratory system
 
cyanosis
pattern of ventilation
respiratory rate RR
Dyspnoea
Wheeziness
signs of collapse
consolidation and effusion
26
 
2 - Physical examination :
             Nervous system
 
Chronic disease of the peripheral and central nervous systems
evidence of motor or sensory impairment recorded
dystrophic myotonica
27
 
restriction of movement and deformities
reduced muscle mass
peripheral neuropathies
pulmonary involvement
Particular attention to the patient's cervical spine and temporomandibular joints
               Musculoskeletal
 
3-Evaluation of coexisting disease
:
 
Hypertension, Ischemic heart disease, Heart failure, Valvular heart
disease, Patients with rhythm disturbances, Patient with coronary
stents, Patients with pacemakers and ICD devices, Patients with
peripheral arterial disease
29
         Cardiovascular disorders :
 
Upper respiratory tract infection, Asthma and COPD, Chronic
smokers, Restrictive lung diseases,Obstructive sleep apnoea(OSA),
Patients scheduled for lung resection
        Pulmonary disorder
 
3-Evaluation of coexisting disease
:
 
Diabetes Mellitus, Thyroid disorders, Hypothalamic- pituitary-
adrenal disorders, Pheochromocytoma
31
         Endocrine system
 
Diabetes : control blood sugar
CVS - HT, myocardial ischemia
CNS - 
stroke, weakness, autonomic neuropathy peripheral
neuropathy
GI – gastro paresis
Stiff joint : cervical spine, TM joint
        Diabetes Mellitus
 
3-Evaluation of coexisting disease
:
 
Liver disease
Gastroesophageal reflux symptom increase
     risk of pulmonary aspiration
33
         GIT system
 
Surgical stress, anaesthetic agents tend to decrease GFR
* Renal impairment  - CKD
                           -  AKI
* Contrast induced nephropathy
* The emphases of the preoperative evaluation of patients with renal insufficiency are on
the cardiovascular system, cerebrovascular system, fluid volume, and electrolyte status
         renal system
 
7- NPO :
39
39
 
thank
 
you
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Efficient preoperative assessment is crucial to ensure patient safety and optimal outcomes during anesthesia administration. This process involves thorough history taking, physical examination, evaluation of medical conditions, and planning for anesthesia techniques. The assessment helps in identifying risks, developing management plans, and reducing perioperative complications. The anesthetic plan includes preoperative, intraoperative, and postoperative management strategies to ensure patient comfort and safety throughout the anesthesia process.


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  1. Assessment of patients before anaesthesia By: Dr : Miaad Adnan FIBMS Anaesthesia Dr : Bassim mohammed MSc anesthesia & intensive care 1st lecture/ 3rd stage/ anesthesia technology 2022 - 2023

  2. 1 Purpose of preoperative evaluation ? Doctor-patient relationship Surgical procedure Preoperative Preparation Plan of Anesthetic Technique Perioperative risk determination. Coexisting medical conditions Perioperative risk determination. Develop a management plan for perioperative anesthetic care Reduce peri-operative morbidity and mortality Reduce patient anxiety Obtain informed consent

  3. 2 The anesthetic plan : Type of anesthesia : Neuroaxial or regional or local anesthesia Technique General Sedation Supplemental oxygen Airway management Induction Drugs Drugs Maintenance Muscle relaxation

  4. 3 The anesthetic plan : 1 - Preoperative management 1. History 2. Physical examination 3. Evaluation of coexisting disease 4. Preop lab and diagnostic investigations 5. Preop medication management 6. Anesthetic note 7. Guideline for NPO status

  5. 4 The anesthetic plan : 2 - Intraoperative management Monitoring Positioning Fluid management Special techniques 3 - Postoperative Pain control Intensive care * Postoperative ventilation * Hemodynamic monitoring

  6. 5 1 . History : History and physical examination are the most important assessors of disease and risk. General history History of 1- Coexisting medical illnesses 2- Medications, present therapy 3- Allergies and drug reactions 4- tobacco and alcohol intake Previous anesthetics, surgeries, deliveries Family History Last oral intake

  7. 6 1 . History : Cardiovascular system Specific enquiries must be made about: - Angina incidence precipitating factors duration use of anti-anginal medications, e.g. glyceryl trinitrate (GTN) oral or sublingual ) - Previous myocardial infarction (MI) and subsequent symptoms - Symptoms indicating heart failure

  8. 7 1 . History : Cardiovascular system - myocardial infarction are at a greater risk of perioperative re-infarction - Elective surgery postponed until at least 6 months after the event - Untreated or poorly controlled hypertension (diastolic consistently > 110 mmHg) may lead to exaggerated cardiovascular responses - Both hypertension and hypotension can be precipitated which increase the risk of myocardial ischemia

  9. 8 1 . History : Cardiovascular system - Heart failure will be worsened by the depressant effects impairing the perfusion of vital organs - Valvular heart disease * prosthetic valves may be on anticoagulants need to be stopped or changed prior to surgery * Antibiotic prophylaxis

  10. 9 1 . History : Active Cardiac Conditions Unstable coronary syndromes - Unstable or severe angina - Recent MI Decompensated HF Significant arrhythmias Severe valvular disease

  11. 10 1 . History : Minor Cardiac Predictors Advanced age (>70) Abnormal ECG -LV hypertrophy -LBBB -ST-T abnormalities -Rhythm other than sinus Uncontrolled systemic hypertension LBBB. Left bundle branch block

  12. 11 1 . History : 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

  13. 13 1 . History : Respiratory system Patients with pre-existing lung disease postoperative chest infections if they are obese or undergoing upper abdominal or thoracic surgery Chronic obstructive lung disease production of sputum (volume and color) Dyspnea Asthma, including precipitating factor Upper respiratory tract infection anaesthesia and surgery should be postponed unless it is for a life-threatening condition

  14. 15 1 . History : Family history All patients should be asked inherited conditions in the family history of prolonged apnoea unexplained death malignant hyperpyrexia Surgery postponed

  15. 16 1 . History : SOCIAL HISTORY Smoking number of cigarettes amount of tobacco Alcohol induction of liver enzymes tolerance Pregnancy increased risk of regurgitation and aspiration Elective surgery is best postponed until after delivery.

  16. American Society of Anesthesiology Risk Classification American Society of Anesthesiology Risk Classification

  17. 18 2 - Physical examination : General History Physical examination Evaluation of coexisting disease Preop lab and diagnostic investigations Preop medication management

  18. 19 2 - Physical examination : * Vital signs, (CNS, heart, lung,) * Airway, * If regional anaesthesia is proposed - Assessment of the site of block - Back

  19. 20 2 - Physical examination : vital signs Blood pressure Resting pulse - rate, rhythm Respiration - rate, depth, and pattern at rest Body temperature Pain score

  20. Airway Assessment Airway Assessment Predictors of difficult intubation Mallampati classification ULBT (upper lip bite test) Inter-incisors gap (IID) Thyromental distance (TMD) Forward movement of mandible Document loose or chipped teeth Tracheal deviation Movement of the Neck

  21. Mallampati test Class I = visualize the soft palate, uvula, anterior and posterior pillars. Class II = visualize the soft palate and uvula. Class III = visualize the soft palate and the base of the uvula. Class IV = soft palate is not visible at all.

  22. Interincisor distance (IID) Less than or equal to 4.5 cm is considered a potentially difficult intubation. Generally greater than 2.5 to 3 fingerbreadths (depending on observers fingers)

  23. Sterno-mental Distance (SMD) Extended head and neck, mouth closed, distance <12.5cm is a difficult intubation

  24. Neck movement

  25. CRANIOFACIAL DEFORMITIES Temporomandibular joint protrusion of mandible

  26. Preoperative Laboratory Testing Preoperative Laboratory Testing only if indicated from the preoperative history and physical examination. Blood test CBC anticipated significant blood loss, suspected hematological disorder (eg.anemia, thalassemia, SCD), or recent chemotherapy. Complete blood count:- Red blood cells(RBC), which carry oxygen White blood cells(WBC), which fight infection Hemoglobin(Hb), the oxygen-carrying protein in red blood cells Hematocrit (HCT), the proportion of red blood cells to the fluid component, or plasma, in blood Platelets (PLT), which help with blood clotting

  27. Clotting Screen Clotting Screen PT, INR, PTT PT, INR, PTT 9.5-13.5 seconds indication: any deranged coagulation, such as: iatrogenic causes (e.g. warfarin), inherited coagulopathies (e.g haemophilia 0.7-1.2 A/B) liver impairment. 25 35 seconds Surgery with expected blood loss.

  28. Urea & Electrolytes Urea & Electrolytes (U&Es) and creatinine To assess the baseline renal function, which help inform any potential IV fluid management intra- and post-operatively COMMON ELECTROLYTES INCLUDE: Chloride (CL) : 95-105 mmol/L Sodium Na: 135-145 mmol/L Creatinine: 0.8-1.3 mg/dL Urea: 7-30 mg/dL Potassium (K) : 3.5-5 mmol/L Uric acid: 3.5-7.2 mg/dL Total calcium: 8.5-10.2 mg/dL Inorganic phosphorous: 2.8-4.5 mg/dL Magnesium: 1.5-2 mEq/L Ionized calcium: 4.8-5.5 mg/dL Glucose: 65-110 mg/dL

  29. Investigations ECG age >50 yrs ,history of cardiac disease, hypertension, peripheral vascular disease. It can indicate any underlying cardiac pathology and provide a baseline if there are post-operative signs of cardiac ischaemia. An echocardiogram (ECHO) may be considered if the person has: (1) a heart murmur (2) cardiac symptom(s) (3) signs or symptoms of heart failure. Chest X-rays prior cardiothoracic procedures ,COPD, asthma, recently resolved respiratory tract infection , a change in respiratory symptoms in the past six months, stable cardiac disease, smoking, and extremes of age.

  30. (VC). Pulmonary function tests (PFTs) are a group of tests that measure how well your lungs work. This includes how well you re able to breathe and how effective your lungs are able to bring oxygen to the rest of your body RV ERV VT. IRV. VC. Functional residual capacity (FRC). 2300ml Total lung capacity TLC 5800 ml.

  31. 25 2 - Physical examination : Cardiovascular system Dysrhythmias Atrial fibrillation Heart failure Heart murmur Valvular heart disease Blood pressure is best measured at the end of the examination

  32. 2 - Physical examination : 26 Respiratory system cyanosis pattern of ventilation respiratory rate RR Dyspnoea Wheeziness signs of collapse consolidation and effusion

  33. 2 - Physical examination : 27 Nervous system Chronic disease of the peripheral and central nervous systems evidence of motor or sensory impairment recorded dystrophic myotonica Musculoskeletal restriction of movement and deformities reduced muscle mass peripheral neuropathies pulmonary involvement Particular attention to the patient's cervical spine and temporomandibular joints

  34. 29 3-Evaluation of coexisting disease: Cardiovascular disorders : Hypertension, Ischemic heart disease, Heart failure, Valvular heart disease, Patients with rhythm disturbances, Patient with coronary stents, Patients with pacemakers and ICD devices, Patients with peripheral arterial disease Pulmonary disorder Upper respiratory tract infection, Asthma and COPD, Chronic smokers, Restrictive lung diseases,Obstructive sleep apnoea(OSA), Patients scheduled for lung resection

  35. 31 3-Evaluation of coexisting disease: Endocrine system Diabetes Mellitus, Thyroid disorders, Hypothalamic- pituitary- adrenal disorders, Pheochromocytoma Diabetes Mellitus Diabetes : control blood sugar CVS - HT, myocardial ischemia CNS - stroke, weakness, autonomic neuropathy peripheral neuropathy GI gastro paresis Stiff joint : cervical spine, TM joint

  36. 33 3-Evaluation of coexisting disease: GIT system Liver disease Gastroesophageal reflux symptom increase risk of pulmonary aspiration renal system Surgical stress, anaesthetic agents tend to decrease GFR * Renal impairment - CKD - AKI * Contrast induced nephropathy * The emphases of the preoperative evaluation of patients with renal insufficiency are on the cardiovascular system, cerebrovascular system, fluid volume, and electrolyte status

  37. 39 7- NPO :

  38. 39 you thank

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