Lecture Title: Role of anesthesiologist in pre-operative period

1. Lecture Title: Role of anesthesiologist in pre-operative period Lecturer name: Prof. Ahmed Abdulmoemn Lecture Date:

2. Lecture Objectives.. Students at the end of the lecture will be able to: • learn pre-anesthetic patient evaluation and risk stratification. • Obtain a full history and physical examination including allergies, current medications, past anesthetic history, family anesthetic history • The medical student will understand how patient co-morbidities can affect the anesthetic plan. • The medical student will be able to understand potential anesthetic options for a given surgical procedure. • The medical student will be able to plan an anesthetic for a basic surgical procedure. • The student will understand risk stratification of a patient undergoing anesthesia.

4. Stages of the Peri-Operative Period Pre-Operative • From time of decision to have surgery until admitted into the OR theatre.

5. Stages of the Peri-Operative Period Intra-Operative • Time from entering the OR theatre to entering the Recovering Room or Post Anesthetic Care Unit (PACU)

6. Stages of the Peri-Operative Period Post-Operative • Time from leaving the RR or PACU until time of follow-up evaluation (often as out-patient)

7. Preoperative visit. • To educate about anesthesia , perioperative care and pain management to reduce anxiety. • To obtain patient's medical history and physical examination . • To determine which lab test or further medical consultation are needed . • To choose care plan guided by patient's choice and risk factors

8. Benefits from surgery ←→ Risk of complications

9. Preoperative Evaluation: • A thorough history and physical exam. • Complete review of systems. • Organ specific issues. • Functional Status. • Habits (smoking, alcohol, drugs). • Medications (herbals) and allergies. • Anesthesia history. • Pre-op labs: one size does not fit all.

10. Patient related risk factors(pulmonary) • Age • Obesity • Smoking • General health status • Chronic obstructive pulmonary disease (COPD) • Asthma

11. Smoking • Important risk factor • Smoking history of 40 pack years or more →↑risk of pulmonary complications • stopped smoking < 2 months : stopped for > 2 months4:1(57% : 14.5%) • quit smoking > 6 months : never smoked = 1:1 (11.9% : 11%)

13. Risk Stratification • Revised Cardiac Risk Index • High risk surgery (vascular, thoracic) • Ischemic heart disease • Congestive heart failure • Cerebrovascular disease • Insulin therapy for diabetes • Creatinine >2.0mg/dL

14. Active Cardiac Conditions • Unstable coronary syndromes • Unstable or severe angina • Recent MI • Decompensated HF • Significant arrhythmias • Severe valvular disease

15. Minor Cardiac Predictors • Advanced age (>70) • Abnormal ECG • LV hypertrophy • LBBB • ST-T abnormalities • Rhythm other than sinus • Uncontrolled systemic hypertension

17. 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

18. Risk Stratification • ASA physical status • ASA 1 – Healthy patient without organic biochemical or psychiatric disease. • ASA 2- A Patient with mild systemic disease. No significant impact on daily activity. Unlikely impact on anesthesia and surgery. • ASA 3- Significant or severe systemic disease that limits normal activity. Significant impact on daily activity. Likely impact on anesthesia and surgery.

19. Risk Stratification • ASA 4- Severe disease that is a constant threat to life or requires intensive therapy. Serious limitation of daily activity. • ASA 5- Moribund patient who is equally likely to die in the next 24 hours with or without surgery. • ASA 6- Brain-dead organ donor • “E” – added to the classifications indicates emergency surgery.

20. Step #1:Is the surgery emergent? yes Is the surgery emergent? Operating room* no (Next Step) Consider beta-blockade, pain control and other peri-operative management

21. Step 2: Determine Presence of Active Cardiac Conditions • If none are present, proceed with surgery • Presence of one of these delays surgery for evaluation • Many patients need a cardiac cath

22. Step 2 • Unstable coronary syndromes • Decompensated heart failure • Significant arrhythmias • Severe valvular disease

23. Step #2: Active Cardiac Conditions Evaluate and treat per current guidelines yes Active Cardiac conditions no Consider Operating Room (Next Step)

24. Step 3: Surgery Low Risk? • Low risk surgery includes: • Endoscopic procedures • Superficial procedures • Cataract surgery • Breast surgery • Ambulatory surgery • Cardiac risk <1% • Testing does not change management

25. Step #3: Surgery Low Risk? yes Operating room Low risk surgery No (Next Step)

27. Airway Evaluation • Take very seriously history of prior difficulty • Head and neck movement (extension) • Alignment of oral, pharyngeal, laryngeal axes • Cervical spine arthritis or trauma, burn, radiation, tumor, infection, scleroderma, short and thick neck

28. Airway Evaluation • Jaw Movement • Both inter-incisor gap and anterior subluxation • <3.5cm inter-incisor gap concerning • Inability to sublux lower incisors beyond upper incisors • Receding mandible • Protruding Maxillary Incisors (buck teeth)

29. Airway Evaluation • Oropharyngeal visualization • Mallampati Score • Sitting position, protrude tongue, don’t say “AHH”

30. Preoperative Testing • Routine preoperative testing should not be ordered. • Preoperative testing should be performed on a selective basis for purposes of guiding or optimizing perioperative management.

31. Preoperative Testing5 • Procedure based. • Low risk • Baseline creatinine if procedure involves contrast dye. • Intermediate risk • Base line creatinine if contrast dye or >55yr of age. • High risk • CBC, lytes & S, creatinine as above. • PFTs for lung reduction surgery.

32. Preoperative Testing • Disease-based indications • Alcohol abuse • CBC, ECG, lytes, LFTs, PT • Anemia • CBC • Bleeding disorder • CBC, LFTs, PT, PTT • Cardiovascular • CBC, creatinine, CXR, ECG, lytes

33. Preoperative Testing • Disease-based indications • Cerebrovascular disease • Creatinine, glucose, ECG • Diabetes • Creatinine, electrolytes, glucose, ECG • Hepatic disease • CBC, creatinine, lytes, LFTs, PT • Malignancy • CBC, CXR

34. Preoperative Testing • Disease-based indications • Pregnancy (controversial) • Serum B-hCG- 7 days, Upreg 3 days • Pulmonary disease • CBC, ECG, CXR • Renal disease • CBC, Cr, lytes, ECG • RA • CBC, ECG, CXR, C-spine (atlantoaxial subluxation) • AP C-spine, AP odontoid view and lateral flexion and extention.

35. Preoperative Testing • Disease-based • Sleep apnea • CBC, ECG • Smoking >40 pack year • CBC, ECG, CXR • Systemic Lupus • Cr, ECG, CXR

36. Preoperative Testing • Therapy-based indications • Radiation therapy • CBC, ECG, CXR • Warfarin • PT • Digoxin • Lytes, ECG, Dig level • Diuretics • Cr, lytes, ECG • Steroids • Glucose, ECG

37. Q & A

38. Reference book and the relevant page numbers..

39. Thank You  Dr.