بسم الله الرحمن الرحيم

1. Role of Anesthesiologist inPeri-Operative Period essam manaaassistant professor & consultantanesthesia dept. , kkuhe_manaa@yahoo.com بسم الله الرحمن الرحيم

2. Lecture Objectives.. Students at the end of the lecture will be able to: Obtain a full history and physical examination including allergies, current medications, past anesthetic history, family anesthetic history Understand how patient co-morbidities can affect the anesthetic plan Able to plan an anesthetic for a basic surgical procedure Understand risk stratification of a patient undergoing anesthesia

3. An Anesthesiologist or Anaesthetist is a physician trained in anesthesia and perioperative medicine. They provide medical care to patients in a wide variety of (usually acute) situations. Anesthesiologists are responsible for ensuring the delivery of anesthesia safely to patients in virtually all health care settings, including all major medical and tertiary care facilities. 

4. Pre-Anesthesia Clinic KKUH

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

6. Intra-Operative • Time from entering the OR theatre to entering the Recovering Room or Post Anesthetic Care Unit (PACU)

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

8. Preoperative visit Preoperative Preparation Preoperative Evaluation Preoperative Medication

9. Preoperative Preparation • To educate about anesthesia , perioperative care and pain management to reduce anxiety • To determine which lab test or further medical consultation are needed • To choose care plan guided by patient's choice and risk factors • Benefits from surgery ← → Risk of complications

10. Preoperative Evaluation & Medication • Evaluation - A thorough history - Habits (smoking, alcohol) - Medications (herbals, Drugs) and allergies • Physical exam - Complete review of systems i.e. Functional Status (METs) • Pre-op medication

11. Functional Status Assessment Poor functional capacity is associated with increased cardiac complications in noncardiac surgery. A patient's functional capacity can be expressed in metabolic equivalents (METs). One MET equals the oxygen consumption of a 70-kg, 40-year-old man in a resting state. METs = metabolic equivalents.

13. Patient Related Risk Factors • Age • Obesity • Smoking • General health status • Chronic obstructive pulmonary disease (COPD) • Congestive heart failure

14. e.g Smoking • Smoking history of 40 pack / year 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%)

15. Risk Stratification (1) Cardiac

16. This is a multi-factorial index of cardiac risk in the non-cardiac surgical setting. It was developed for preoperative identification of patients at risk from major perioperative cardiovascular complications. The data were derived retrospectively in 1977 from 1001 patients undergoing non-cardiac surgery.  Patients with scores >25 had a 22% incidence of death, with a 56% incidence of severe cardiovascular complications. Patients with scores <26 had a 4% incidence of death, with a 17% incidence of severe cardiovascular complications. Patients with scores <6 had a 0.2% incidence of death, with a 0.7% incidence of severe cardiovascular complications. Multifactorial index of cardiac risk in noncardiac surgical procedures Goldman L, Caldera DL, Nussbaum SR N Engl J Med 1977; 297: 845-50

17. (Br J Anaesth 2004;93:393–399.) (2) ASA Physical Status ASA 1 Healthy patient without organic biochemical or psychiatric disease. ASA 2 A Patient with mild systemic disease (controlled hypertension or diabetes without systemic effects). No significant impact on daily activity. Unlikely impact on anesthesia and surgery. ASA 3 Significant or severe systemic disease that limits normal activity (controlled congestive heart failure (CHF), stable angina, old heart attack, poorly controlled hypertension, morbid obesity, chronic renal failure). Significant impact on daily activity. Likely impact on anesthesia and surgery. ASA 4 Severe disease that is a constant threat to life or requires intensive therapy (symptomatic COPD, symptomatic CHF, hepatorenal failure) . Serious limitation of daily activity. ASA 5 Moribund patient who is equally likely to die in the next 24 hours with or without surgery (multiorgan failure, sepsis syndrome). ASA 6 Brain-dead organ donor “E” Added to the classifications indicates emergency surgery. **Mortality rates of the individual classes showed considerable variation, with 0-0.3% for ASA I, 0.3-1.4% for ASA II, 1.8-4.5% for ASA III, 7.8-25.9% for ASA IV and 9.4-57.8% ASA V

19. #: Surgery Low Risk* Low risk surgery confirmed Operating room • Endoscopic procedures • Superficial procedures • Cataract surgery • Breast surgery • Ambulatory surgery *Cardiac risk <1% Testing does not change management

20. #: Active Cardiac Conditions Evaluate and treat per current guidelines (Many patients need a cardiac cath.) Active Cardiac conditions Consider Operating Room 1- Unstable coronary syndromes 2- Decompensated heart failure 3- Significant arrhythmias 4- Severe valvular disease

21. Airway Evaluation

22. Airway Evaluation (cont.) • 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

23. Airway Evaluation (cont..) • Jaw Movement Receding mandible Inability to sublux lower incisors beyond upper incisors • Protruding Maxillary Incisors (buck teeth)

24. Airway Evaluation (cont..) • Mallampati Score • Sitting position, protrude tongue, don’t say “AHH” Class 1: Full visibility of tonsils, uvula and soft palateClass 2: Visibility of hard and soft palate, upper portion of tonsils and uvulaClass 3: Soft and hard palate and base of the uvula are visibleClass 4: Only Hard Palate visible

26. Airway Evaluation (cont…) Laryngoscopy view: Cormack and Lehane Grade I: complete glottis visibleGrade II: anterior glottis not seenGrade III: epiglottis seen, but not glottisGrade IV: epiglottis not seen

27. Preoperative Lab. 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.

29. Preoperative Lab. Testing (Cont.) • Procedure based indications • Low risk • Intermediate risk • Base line creatinine • High risk • CBC, Electrolytes • PFTs for lung reduction surgery

30. Preoperative Lab. Testing (Cont..) • Disease-based indications • Anemia • CBC • Bleeding disorder • CBC, LFTs, PT, PTT • Cardiovascular • CBC, creatinine, CXR, ECG, lytes • Diabetes • Creatinine, electrolytes, glucose, ECG • Hepatic disease • CBC, creatinine, lytes, LFTs, PT • Malignancy • CBC, CXR

31. Preoperative Lab. Testing (Cont..) • Pulmonary disease • CBC, ECG, CXR • Renal disease • CBC, Cr, lytes, ECG • RA • CBC, ECG, CXR, C-spine (atlantoaxialsubluxation) • AP C-spine, AP odontoid view and lateral flexion and extention. • Sleep apnea • CBC, ECG • Smoking >40 pack year • CBC, ECG, CXR

32. Preoperative Lab. Testing (Cont…) • Therapy-based indications • Radiation therapy • CBC, ECG, CXR • Warfarin • PT • Digoxin • Lytes, ECG, Dig level • Diuretics • Cr, lytes, ECG • Steroids • Glucose, ECG

34. Q & A

35. Thank You 