Professional Documents
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Moderator
INTRODUCTION
Anesthesia and surgery are physiologically
stressful, invasive interventions which may
exacerbate or uncover underlying disease
processes.
Aim
Problem Identification
Risk Assessment
Preoperative Preparation
Plan Anesthetic Technique
Problem identification
Identify unrecognized co-morbid disease and
risk factors for medical complications of
surgery
Optimize preoperative medical condition
Understand, recognize, and treat potential
complications.
History
Reason the patient is having surgery /
procedure.
How the condition developed and related
therapies
Concurrent past/present medical problems
Previous surgeries
History of past anaesthesia and related
complications
Physical examination
General examination
Local examination
Airway assessment
Systemic examination
Laboratory tests
Other tests
Airway assessment
Condition of teeth
Incisors
Tongue size
Facial hair
Thyromental distance
Length of neck
Neck circumference
Range of motion of head and neck
Protrusion of mandible
Patient maximally protrudes mandible, with
assessment of the relative position of lower teeth
to upper teeth.
Inability to protrude lower incisors beyond the
upper incisors is associated with difficult
intubation(B ,C).
CLASS A- Lower incisors protruded anterior.
CLASS B- Teeth level (edge to edge).
CLASS C- Lower incisors can not even be
brought at level.
Mallampatti grading
GRADE 1 INCLUDES
VISUALIZATION OF ENTIRE
GLOTTIC APERTURE;
GRADE 2 INCLUDES
VISUALIZATION OF ONLY POST
ASPECTS OF
GLOTTIC
APERTURE;
GRADE 3 IS VISUALIZATION OF TIP
OF EPIGLOTTIS;
GRADE 4 IS VISUALIZATION OF NO
MORE THAN SOFT PALATE
RISK ASSESSMENT
HTN
Defined as two or more B.P. readings>140/90
mm
Cause
Other risk factors
End organ damage
Therapy
Co arctation of aorta
Hyperthyroidism
Pheochromocytoma
Steroid usage
Illicit drugs
Investigations
ECG
BUN
Electrolytes
Stress testing
2 D ECHO
Therapy
Beta blockers
Calcium channel blockers
Diuretics electrolytes?
IHD
MAJOR
Unstable coronary syndromes
Acute (<7d) or recent MI (<1mth) with evidence of
ischemic risk
Unstable or severe angina
Decompensated heart failure
Significant arrhythmias
High-grade AV block
Symptomatic ventricular arrhythmia
SVT with uncontrolled rate
Severe valvular disease
INTERMEDIATE
Mild angina pectoris
Previous myocardial infarction (>1mth) by
history of pathological Q waves
Compensated or prior heart failure
Diabetes mellitus (particularly insulin
dependent)
Renal insufficiency (creatinine >2.0)
MINOR
Advanced age
Abnormal ECG (LVH, LBBB, ST-T abnormalities)
Rhythm other than sinus (e.g. a fib)
Low functional capacity (e.g. inability to climb
one flight of stairs with a bag of groceries)
History of stroke
Uncontrolled systemic hypertension
Functional Capacity
Metabolic equivalents
Surgery-specific risk
High (Reported risk >5%)
Emergent major operations, particularly in
elderly
Aortic and other major vascular surgery
Surgical procedures associated with large fluid
shifts and/or blood loss
5 step approach
1. urgency
2. active cardiac condition?
3. surgical risk/ severity
4. functional capacity
5. for poor / intermediate functional capacity
Applying Classification of
Recommendations and Level of
Evidence (LOE)
Applying Classification of
Recommendations and Level of
Evidence
Pre op ecg?
Class I & II
0-1 clinical risk factor & vasc surgery (LOE: B)
1 risk factor & intermediate risk surgery (LOE:
B)
Class III
Not indicated in asymptomatic persons & low
risk procedure (LOE: B)
Class I
Stable angina & left main stenosis
Stable angina & 3 vessel disease
Stable angina & 2 vessel disease (prox LAD
stenosis) & either EF < 50% or ischemia on
stress test
High risk unstable angina or NSTEMI
Acute STEMI
PCI: angioplasty
Delay surgery for > 14 days to allow healing of
vessel injury
Should continue aspirin perioperatively
thank you