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Preoperative Assessment

Preoperative Assessment. Professor Lester AH Critchley. Purpose of anaesthetist’s visit. Assessment of patient for anaesthesia Discuss the anaesthetic with patient Planning anaesthetic management Prepare patient for anaesthesia. Assessment of patient. General fitness of patient

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Preoperative Assessment

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  1. Preoperative Assessment Professor Lester AH Critchley Med 5: Anaeshesia

  2. Purpose of anaesthetist’s visit • Assessment of patient for anaesthesia • Discuss the anaesthetic with patient • Planning anaesthetic management • Prepare patient for anaesthesia Med 5: Anaeshesia

  3. Assessment of patient • General fitness of patient • Specific problems: • Medical • Technical • Anaesthetic drug • Psychological Med 5: Anaeshesia

  4. General fitness of patient • Most important: • Cardio-respiratory reserve • How & why? • Context of the surgical procedure Med 5: Anaeshesia

  5. Medical problems • Disease processes • Medical therapies Med 5: Anaeshesia

  6. Disease processes • COAD • Heart disease • Hypertension • Heart failure • Valvular heart disease • Diabetes • Others: • Liver failure • Kidney failure • Thyroid Med 5: Anaeshesia

  7. ASA classification:American Society of Anesthesiologists physical status Additional categories added since June 2005 ASA 5 A moribund patient who is not expected to survive without the operation ASA 6 A declared brain-dead patient whose organs are being removed for donor purposes Med 5: Anaeshesia

  8. A 27-year old business man admitted for removal of nasal polyps. He has allergic rhinitis and bronchial asthma, for which he takes regular beconase (steroid) and ventolin inhalers. • A 75-year old man admitted for a transurethral resection (TURP) following an episode of acute retention of urine, due to benign prostatic hypertrophy (BPH). He has severe chronic bronchitis and is limited to walking only 100 yards on the flat before he has to stop to regain his breath. He has had numerous hospital admissions for his chest. • A 35-year old secretary with past good health admitted for an emergency laparoscopic appendectomy. She has a two day history of abdominal pain. • A middle-aged insulin dependant diabetic admitted for an eye operation proceedure. The patient is known to have significant renal dysfunction with high creatinine levels and she is CAPD. • A 92-year old demented woman is admitted with a ruptured aortic aneurysm. She is hypotensive and struggling to breathe. • A 45-year old school teacher admitted for a total abdominal hysterectomy for uterine fibroids. She is a type 2 diabetic controlled by oral hypoglycaemic drugs and diet. She has been a diabetic for several years and has no major complications from her disease. Med 5: Anaeshesia

  9. Ongoing treatments Antihypertensives Anticonvulsants Routes of admission Oral vs IV Anticoagulants Warfarin Heparin Aspirin & NSAIDs (Regional blocks) Steroids Pituitary-adrenal suppression Psychiatric Antidressants MAO inhibitors Lithium Medical therapies Med 5: Anaeshesia

  10. Technical problems • *Airway (& assessment) • *IV access (&assessment – inspection) • Spinal access • Others • Cervical spine injury • Deformities • Obesity • Neonates Med 5: Anaeshesia

  11. Outline of upper airway TONGUE Posterior tongue & epiglottis obstruct view of larynx. During laryngoscopy they are displaced forward by scope blade Med 5: Anaeshesia

  12. The LEMON guide:Physical signs for predicting difficult intubation? • Look externally, • Evaluate the 3-3-2 rule, • Mallampati, • Obstruction, • Neck mobility Med 5: Anaeshesia National Emergency Airway Management Course

  13. Look externally Med 5: Anaeshesia

  14. Evaluate the 3-3-2 rule Med 5: Anaeshesia

  15. Med 5: Anaeshesia

  16. Mallampati classification Med 5: Anaeshesia

  17. Med 5: Anaeshesia

  18. Mallampati score? Med 5: Anaeshesia

  19. Med 5: Anaeshesia

  20. Anaesthetic Drugs • Allergies & Anaphyllaxis • Inherited disorders • Scoline apnoea • Malignant hyperpyrexia • Porphyria Med 5: Anaeshesia

  21. Allergies & Anaphyllaxis • Althesin story • Older muscle relaxants, i.e. Alcuronium • Lignocaine & the airway • Newer & cleaner drugs today Med 5: Anaeshesia

  22. Inherited disorders • Succinylcholine apnoea • Plasma cholinesterase enzyme • Prolonged paralysis • Malignant hyperpyrexia • Defect of calcium in the muscle cells • Triggers – halothane / succinylcholine • Rigidity, high CO2, fever, death • Porphyria • Variety of syndomes including paralysis • Trigger – barbituates Med 5: Anaeshesia

  23. Psychological problems • Children • Dementia • Mentally retarded • Downs / Cerebral palsy / Syndromes (FLKs) • Anxiety • VIP-patients Med 5: Anaeshesia

  24. Planning anaesthetic management • Surgical procedure • Different operations different requirements • Patient factors • Anaesthetic preferences Med 5: Anaeshesia

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  30. Preparation of patient • Medically • Mentally • Prevent aspiration • Organize theatre Med 5: Anaeshesia

  31. Medical preparation • Done mainly on the surgical ward • Covered in second lecture Med 5: Anaeshesia

  32. Mental preparation • Explain - procedures • Discuss – choices of technique • Counsel - fears • Consent • Research Med 5: Anaeshesia

  33. Explain“What is going happen to the me!” • Before • GA vs. Regional technique • Monitoring lines sited • Fibre optic intubation • After • Intensive care • Pain management (APS) Med 5: Anaeshesia

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  39. Discuss • Type of anaesthetic • General • Spinal / Epidural • Regional block • Type of pain relief • i.m. morphine • PCA • Regional infusion Med 5: Anaeshesia

  40. Counsel - Fears • Death (relative died under anaesthesia) • Memory loss • Awareness • Neurological deficit (Epidural) Med 5: Anaeshesia

  41. Neurological complications • Chesterfield Royal Hospital in 1947 • Albert Woolley (aged 56-years) and Cecil Roe (aged 45-years) were healthy, middle-aged men who became paraplegic after spinal anaesthesia for minor surgery. • The spinal anaesthetic was given by the same anaesthetist, using the same drug (cinchocaine) on the same day. The outcome for the patients and their families was devastating. • At the trail 6-years later the judge accepted the suggestion that phenol, in which the ampoules of local anaesthetic had been kept, had contaminated the local anaesthetic solution via a crack. Med 5: Anaeshesia

  42. Consent – Anaesthetic • Dental damage • Neurological damage • Brain injury / death • Minor complications: • Pain / nausea / malaise / headache / sore throat / muscle pains Med 5: Anaeshesia

  43. Research • New drugs • New procedures • New devices /monitors • Need consent Med 5: Anaeshesia

  44. Prevent Aspiration • Why is aspiration a problem? • Preoperative fasting regimens • Antacid prophyllaxis • Rapid sequence induction • Cricoid pressure Med 5: Anaeshesia

  45. Downward pressure is applied to the cricoid which is transferred to the oesophagus Oesophagus is closed off Med 5: Anaeshesia

  46. Demonstration of Cricoid Pressure on a model Med 5: Anaeshesia

  47. Rapid sequence induction • Protection against aspiration: • Insufficient preop fasting • Gastric stasis • Hiatus hernia / reflux • Pregnancy Med 5: Anaeshesia

  48. Type Few episodes Prolonged Cause Surgery Medical condition - ↑ICP, Drug induced – morphine Treatment Cause Anti-emetic agent Maxalon 10mg Nausea & vomiting Med 5: Anaeshesia

  49. Organization of Case • Services • ICU bed • Pain service • Equipment • Fibreoptic bronchoscope • Blood warmers / cell saver • Room temperature • Help • i.e. Difficult paediatric case Med 5: Anaeshesia

  50. Role of the Medical Officer • Prepare patient medically for anaesthesia • Arrange things for operation • X-match blood & order blood products • Consent form • Look after patient afterwards Med 5: Anaeshesia

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