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Questions and Answers
Which of the following is a potential consequence of prolonged fasting before surgery?
What should be assessed regarding asthma patients for perioperative management?
What is recommended for smokers prior to surgery to decrease complications?
What significant cardiac issue should be measured at the end of an examination?
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What should be done with patients showing symptoms of a lower respiratory tract infection on the day of surgery?
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What symptom may persist for 3-4 weeks following a viral upper respiratory tract infection?
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Which of the following is NOT associated with smoking's effects on the respiratory system?
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Which of the following could be a sign of a serious cardiovascular problem?
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What feature does a high Mallampati score indicate in relation to intubation?
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Which distance measurement should be greater than 12.5 cm to reduce the risk of difficult intubation?
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In assessing airway anatomy, which of the following factors is most closely associated with obesity?
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Which condition would a modified Mallampati score of class IV suggest?
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What does a thyromental distance (TMD) of less than 7 cm indicate?
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Which of the following factors does NOT typically affect the ease of intubation?
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What is the primary focus of an airway assessment during anesthesia?
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Which of the following is NOT a predictor of difficult intubation?
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What is the primary goal of preoperative assessment?
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Which ASA classification corresponds to a patient with severe systemic disease that poses a constant threat to life?
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Which of the following is NOT a component of a minimum preoperative visit according to the ASA?
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Which of the following describes premedication?
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Why is it important to assess family anesthesia history during preoperative assessment?
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What is the meaning of ASA6 in the ASA physical classification system?
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What is a potential outcome of effectively reducing patient anxiety during preoperative assessment?
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What should a doctor prioritize when formulating the anesthesia plan?
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Study Notes
Preoperative Assessment
- Preoperative assessment helps identify co-morbidities that might result in complications during surgery and recovery.
- Typically conducted 2-4 weeks before elective procedures.
- Premedication is used to prepare the patient for anesthesia and optimize conditions for surgery.
Goals of Preoperative Assessment
- Build a strong doctor-patient relationship
- Plan the anesthesia technique
- Screen for and manage co-morbidities
- Assess and minimize risks associated with anesthesia
- Identify the need for specialized techniques
- Identify the need for advanced post-operative care
- Prepare the patient preoperatively
- Determine perioperative risk
- Reduce patient anxiety
- Obtain informed consent
Minimum Preoperative Visit Components (ASA)
- Medical, anesthesia, and medication history
- Appropriate physical examination
- Review of diagnostic data (ECG, labs, x-rays)
- Assessment of ASA physical status
- Formulation and discussion of an anesthesia plan
### ASA Physical Classification
- ASA1: Normal healthy patient
- ASA2: Mild systemic disease - no impact on daily life
- ASA3: Severe systemic disease - significant impact on daily life
- ASA4: Severe systemic disease that is a constant threat to life
- ASA5: Moribund, not expected to survive without the operation
- ASA6: Declared brain-dead patient - organ donor
- E: Emergency surgery
History
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Medical problems (current & past)
- Diabetes Mellitus (DM), Hypertension (HTN), Chronic Obstructive Pulmonary Disease (COPD), Coronary Artery Disease (CAD), thyroid disorder
- Previous surgeries; date
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Family anesthesia history
- Problems with anesthesia in family
- Type of anesthesia
- (Pseudocholinesterase deficiency and malignant hyperpyrexia)
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Previous anesthesia & related problems
- Allergy to drugs
- Postoperative nausea and vomiting (PONV)
- Anesthesia awareness
- Difficult intubation
- Delayed emergence
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Allergies and drug intolerances
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Medications, alcohol, and tobacco
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Review of systems (include snoring and fatigue)
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Exercise tolerance and physical activity level
Physical Examination
- Airway
- Heart and lungs
- Vital signs including O2 saturation
- Blood pressure
- Resting pulse, rate, rhythm
- Respiration, rate, depth, and pattern at rest
- Body temperature
- Height and weight (BMI)
- Other specific examinations depending on the individual patient and procedure
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
Modified Mallampati Score
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Used to predict the ease of endotracheal intubation.
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Assessed by asking the patient, in a sitting posture, to open his or her mouth and to protrude the tongue as much as possible.
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Class I: Soft palate, uvula, fauces, pillars visible
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Class II: Soft palate, major part of uvula, fauces visible
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Class III: Soft palate, base of uvula visible
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Class IV: Only hard palate visible
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A high Mallampati score (class 3 or 4) is associated with more difficult intubation as well as a higher incidence of sleep apnea.
Thyromental Distance (TMD)
- Distance from the thyroid cartilage to the mental prominence when the neck is extended fully.
- Should be 7 cm
Sternomental Distance (SMD)
- Distance from the upper border of the manubrium sterni to the tip of the chin, with the mouth closed and the head fully extended.
- Should be >12.5cm
Laryngoscopy: Cormack and Lehane
- Also look for:
- Body: obese? If female: large pendulous breast?
- Neck anatomy: short? thick? webbed?
- Mouth: limitations (opening)? Teeth?(number & health) Enlarged tongue?(hypothyroidism, acromegaly & obesity)
- Mandible (+TMJ): micrognathia, receding mandible (ask patient to sublux their lower incisor beyond upper incisor)
- Maxilla: protruding?(buck teeth)
- Face: beard? Facial trauma?
- Nose: nasal passage patency,
- Head size: Children (ex. hydrocephalus or rickets) | Adults (ex. acromegaly)
Cardiovascular System:
- Dysrhythmias
- Atrial fibrillation
- Heart failure
- Heart murmur
- Valvular heart disease
- Blood pressure is best measured at the end of the examination
Respiratory System
- Cyanosis
- Pattern of ventilation
- Respiratory rate (RR)
- Dyspnoea
- Wheeziness
- Signs of collapse
- Consolidation and effusion
Pulmonary Disease
- Smoking
- Increased carboxyhemoglobin levels
- Decreased ciliary function
- Increased sputum production
- Nicotine adverse effects on the cardiovascular system
- Preoperative advices:
- 2 days of cessation can decrease nicotine effect, improve mucus clearance, and decrease carboxyhemoglobin levels
- 4-8 weeks of cessation are believed to be needed for postoperative complication reduction
Asthma
- Obtain information about irritating factors, severity, and current disease status
- Frequent use of bronchodilators, recurrent hospitalization, and requirements for systemic steroids are all indicators of severe disease.
- Those who received more than a (burst and taper) of steroids in the previous 6 months should be considered for stress dose perioperatively.
Respiratory Tract Infection
- Patients presenting on the day of surgery with symptoms and signs of a lower respiratory tract infection should be treated appropriately and postponed to such time that they are symptom-free.
- Viral upper respiratory tract infection can cause bronchial reactivity which may persist for 3-4 weeks.
- Unless surgery is urgent, such patients should be postponed for 4 weeks to minimize the risk of postoperative respiratory infection
Prolonged Fasting
- Prolonged fasting should be avoided as this is associated with dehydration, increased postoperative nausea and vomiting, electrolyte imbalance, and patient distress.
- Optimal fasting hours decrease volume and acidity of stomach contents and reduce aspiration and regurgitation risk.
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