Podcast
Questions and Answers
Which of the following anatomical abnormalities is NOT associated with pre-eclampsia?
Which of the following anatomical abnormalities is NOT associated with pre-eclampsia?
Which of the following is a predictor of difficult intubation?
Which of the following is a predictor of difficult intubation?
What is an appropriate assessment method for evaluating potential difficult intubation?
What is an appropriate assessment method for evaluating potential difficult intubation?
Which condition would NOT contribute to a history of difficult intubation?
Which condition would NOT contribute to a history of difficult intubation?
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Which neck measurement is considered an indicator of potential intubation difficulty?
Which neck measurement is considered an indicator of potential intubation difficulty?
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What is the mortality percentage for a patient classified as IV based on the scoring system?
What is the mortality percentage for a patient classified as IV based on the scoring system?
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Which scoring point indicates a class II risk with 0.9% complications?
Which scoring point indicates a class II risk with 0.9% complications?
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Which condition is NOT assigned 1 point in the cardiac risk scoring system?
Which condition is NOT assigned 1 point in the cardiac risk scoring system?
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What MET level indicates that patients may experience increased cardiac and long-term risks?
What MET level indicates that patients may experience increased cardiac and long-term risks?
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Which of the following complications are predicted by the scoring system?
Which of the following complications are predicted by the scoring system?
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Which scoring class is associated with a complication rate of greater than 11%?
Which scoring class is associated with a complication rate of greater than 11%?
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What is one condition indicated by a serum creatinine level greater than 2.0 mg/dl in the risk scoring system?
What is one condition indicated by a serum creatinine level greater than 2.0 mg/dl in the risk scoring system?
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In the surgical risk assessment, what should be done for a patient classified as having intermediate cardiac risk?
In the surgical risk assessment, what should be done for a patient classified as having intermediate cardiac risk?
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What percentage of patients undergoing major non-cardiothoracic surgery develop postoperative pulmonary complications?
What percentage of patients undergoing major non-cardiothoracic surgery develop postoperative pulmonary complications?
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Which of the following is NOT a postoperative pulmonary complication?
Which of the following is NOT a postoperative pulmonary complication?
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What is the relationship between spirometry and history/physical examination in predicting lung impairment?
What is the relationship between spirometry and history/physical examination in predicting lung impairment?
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Which factor contributes significantly to patient morbidity and mortality after surgery?
Which factor contributes significantly to patient morbidity and mortality after surgery?
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In high-risk patients, what percentage might develop postoperative pulmonary complications?
In high-risk patients, what percentage might develop postoperative pulmonary complications?
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Which complication is MOST commonly related to deaths occurring within a week of surgery?
Which complication is MOST commonly related to deaths occurring within a week of surgery?
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What is a major reason for using spirometry in patients?
What is a major reason for using spirometry in patients?
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Which of these is associated with prolonged mechanical ventilation as a postoperative pulmonary complication?
Which of these is associated with prolonged mechanical ventilation as a postoperative pulmonary complication?
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What is the mortality rate for patients with moderate to severe systemic disease and some functional limitations?
What is the mortality rate for patients with moderate to severe systemic disease and some functional limitations?
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Which condition corresponds to a mortality rate of approximately 4.30%?
Which condition corresponds to a mortality rate of approximately 4.30%?
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What is a possible finding in the physical examination that contributes 11 points in the Revised Cardiac Risk Index?
What is a possible finding in the physical examination that contributes 11 points in the Revised Cardiac Risk Index?
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What is characterized as a moribund patient with an expected survival of less than 24 hours without surgery?
What is characterized as a moribund patient with an expected survival of less than 24 hours without surgery?
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Which of the following conditions carries the highest mortality rate according to the classification provided?
Which of the following conditions carries the highest mortality rate according to the classification provided?
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A patient with which of the following conditions is classified as having mild systemic disease?
A patient with which of the following conditions is classified as having mild systemic disease?
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What would a history of MI within the last 6 months contribute to the risk index?
What would a history of MI within the last 6 months contribute to the risk index?
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What is the mortality rate for patients classified as Class IV with inability to carry on any physical activity without discomfort?
What is the mortality rate for patients classified as Class IV with inability to carry on any physical activity without discomfort?
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What is the primary focus of the guidelines by the American Society of Regional Anesthesia and Pain Medicine?
What is the primary focus of the guidelines by the American Society of Regional Anesthesia and Pain Medicine?
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Which therapy is suggested to be continued in patients at risk of myocardial infarction during the perioperative period?
Which therapy is suggested to be continued in patients at risk of myocardial infarction during the perioperative period?
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What is a key consideration in the management of patients receiving warfarin during the perioperative period?
What is a key consideration in the management of patients receiving warfarin during the perioperative period?
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In what year was the article on perioperative antiplatelet therapy published?
In what year was the article on perioperative antiplatelet therapy published?
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Which of the following groups authored the evidence-based guidelines for regional anesthesia?
Which of the following groups authored the evidence-based guidelines for regional anesthesia?
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What is the main rationale for continuing antiplatelet therapy perioperatively?
What is the main rationale for continuing antiplatelet therapy perioperatively?
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Which of the following is NOT typically a part of the perioperative management for patients on antiplatelet therapy?
Which of the following is NOT typically a part of the perioperative management for patients on antiplatelet therapy?
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What is the significance of the DOI provided in the article reference?
What is the significance of the DOI provided in the article reference?
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What is the recommended time for complete gastric clearance after ingestion?
What is the recommended time for complete gastric clearance after ingestion?
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Which drugs are advised to be avoided in extreme age patients and patients with severe health conditions?
Which drugs are advised to be avoided in extreme age patients and patients with severe health conditions?
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What should be included in the pre-anesthetic assessment?
What should be included in the pre-anesthetic assessment?
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During emergencies, how should consent for anesthesia be managed?
During emergencies, how should consent for anesthesia be managed?
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Which of the following is NOT one of the aims during the intraoperative phase?
Which of the following is NOT one of the aims during the intraoperative phase?
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What does the acronym ABCD stand for in the postoperative phase?
What does the acronym ABCD stand for in the postoperative phase?
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What should be documented in the patient’s anesthetic record?
What should be documented in the patient’s anesthetic record?
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Which of the following is NOT a consideration during preoperative visits?
Which of the following is NOT a consideration during preoperative visits?
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Study Notes
Preoperative Assessment
- Reduce patient surgical and anesthetic perioperative morbidity or mortality, returning them to desired function as quickly as possible
- History and physical examination crucial, focusing on cardiac and pulmonary risk factors, and functional capacity
- Laboratory investigations only when indicated by patient's medical status, drug therapy, or procedure. Routine testing is not beneficial
- Comorbid patients should be optimized for the procedure
- Consultations with appropriate medical specialists necessary to improve patient health
- Pre-anesthetic assessment performed by anaesthesiologist, but if not possible, a mechanism for conveying findings is necessary
- Assessment performed at an appropriate time before scheduled surgery
- Day care patients also require appropriate pre-anesthetic timing
- Preoperative admission indicated for patients requiring further evaluation or intervention before a major surgery
- Admission not necessary just for pre-operative investigations, which can be performed as an outpatient
- Assessment delivered via personal interview in the ward, operating theatre (induction room) or a pre-anaesthetic clinic. Alternatively, using pre-set questionnaires with trained nursing or paramedical staff under an anaesthetist's supervision.
- Input from other medical specialties might be needed but only the anaesthesiologist can determine patient fitness for anesthesia
- In emergency surgery, anaesthesiologist still responsible for assessment, even if consultation isn't possible. If delaying surgery is problematic due to increased anesthetic risk, documentation required
- History must include past and current medical history, past surgical history, family history of anaesthetic complications, social history, allergy history, current drug therapy, previous anesthetic complications
History Considerations for Children
- Birth history, focusing on prematurity and perinatal complications
- Congenital chromosomal or anatomic malformations
- Recent infections, especially respiratory tract infections
History Considerations in General
- Complete review of systems for undiagnosed or inadequately controlled chronic disease
- Cardiovascular and respiratory systems most critical in determining anesthetic fitness
Physical Examination
- General assessment (weight, height, temperature, vital signs)
- Airway assessment
- Systemic examination
- Site of regional block (spine, deformities)
Airway Assessment
- Airway maintenance fundamental to safe anesthetic practice
- Identifying patients with potential airway management issues during the pre-operative assessment is vital
Patients with Potential Difficult Airway
- Obesity
- Pregnancy (especially pre-eclampsia)
- Anatomical abnormalities (micrognathia/macrognathia, macroglossia, congenital syndromes like Pierre-Robin or Treacher-Collins, burn contractures involving head and neck)
- Evidence of upper airway obstruction (tumors, edema, goiter, epiglottitis, maxillofacial trauma, airway burns, cervical spine problems, subluxation, rheumatoid arthritis, ankylosing spondylitis)
- History of radiotherapy (to head and neck, specifically oral cavity)
- History of difficult intubation during previous anesthetics (examining records for the cause)
- Predictors (obesity, buckteeth, large tongue, reduced jaw movement, receding chin, neck swelling, tracheal deviation, respiratory pattern)
Airway Evaluation
- Oropharyngeal visualization via Mallampati Score
- Sitting position, protruding tongue, without saying "AHH"
- Physical examination (anatomic variations, mouth opening (less than 3 finger widths), dentition)
- Neck (hyoid-mental distance, thyro-mental distance, cervical spine mobility)
- Post-tracheostomy considerations
- Assessment Methods: Mallampati Score Classification, Wilson Risk Sum Score, Cormack & Lehane Score Classification
Risk Factors for Difficult Intubation (Wilson's Risk Sum)
- Weight (<90kg, 90-110kg, >110kg)
- Head and neck movement (>90 degrees, about 90 degrees, <90 degrees)
- Jaw movement (IG ≥ 5cm, Slux > 0; IG < 5cm, Slux=0; IG < 5cm, Slux < 0)
- Receding mandible (normal, moderate, severe)
- Buck Teeth (normal, moderate, severe)
Risk Factors Related to Difficult Intubation
- Thyromental distance <6.5cm, Sternomental distance <12.5cm, Mallampati class 3 or 4. (80% likelihood)
- Cormack and Lehane Classification (Grades I-IV)
OSA (Obstructive Sleep Apnea)
- Conditions associated with OSA (obesity, thick/fat neck, micrognathia/retrognathia, large tongue, large tonsils, nasal obstruction)
- OSA severity (mild, moderate, severe, clinically or through sleep studies (polysomnography))
- Mild (obese, snoring, occasional daytime somnolence)
- Severe (morbidly obese, definite apneas/arousals, cyanotic spells, daytime somnolence)
- Moderate (between mild and severe)
Perioperative Risk
- Function of preoperative medical condition, surgical procedure invasiveness, and administered anesthetic type
- ASA classification system used (grades 1-6) for grading physical condition
NYHA Classification System
- Grading physical activity limitations used for cardiovascular disease (Classes I-IV)
Risk Stratification
- Goldman's Multifactorial Cardiac Risk Index
- Lee's Revised Cardiac Risk Index
- Variables, points and scores used to calculate risk
Investigations
- Clinical history and physical examination are the primary methods for disease screening; routine laboratory tests are not indicated for apparently healthy patients.
Recommended Pre-anesthetic Investigations
- Electrocardiogram (age >50, cardiovascular disease, DM, renal disease)
- Chest X-ray (age >60, significant respiratory or cardiovascular disease)
- Full blood count (age >60, Clinical anemia, haematological disease)
- Renal profile (age >60, renal disease, liver disease, DM)
- Coagulation profile (hematological disease, liver disease, anticoagulation, intra-thoracic/intracranial procedures)
- Random blood sugar (age >60, diabetes mellitus, liver dysfunction)
- Liver function tests (hepatobiliary disease)
- Procedures with blood loss >15%
- Blood loss > 15%
Drug History
- Obtain medication history including morning of surgery
- Monoamine oxidase inhibitors should be withdrawn 2-3 weeks before surgery
- Oral contraceptive pills should be stopped at least 6 weeks before elective surgery
- Herbal medications need to be stopped 2 weeks before anesthesia
Pulmonary Risk
- Careful history and physical examination crucial for pulmonary assessment
- Spiro-metry is not usually part of the routine assessment
- When uncertain about lung impairment, spirometry helpful
- Postoperative pulmonary complications (PPCs occur 5%-10% patients in major non-cardiac surgery and in 22% of high risk patients. Within a week of surgery, one in 4 deaths linked to PPC
Preoperative Fasting
- Pulmonary aspiration possible with gastric contents (even 30-40ml)
- Factors leading to this (inadequate anesthesia, pregnancy, obesity/difficult airway/emergency surgery).
- Full stomach and altered GI motility can impact aspiration risk
Acid Aspiration Prophylaxis
- Routine in pregnant women, and those with esophageal reflux
- Proton-pump inhibitors, H2-antagonists, and antacids useful
Premedication Considerations
- Benzodiazepines, opioids, anticholinergic drugs, and H2 blockers (avoided in extreme age patients, upper airway obstruction, severe pulmonary & heart disease & unstable patients)
Consent Considerations
- Confirmation with patient/guardian
- Details of procedure
- Procedure consent requested
Documentation Considerations
- Written summary of the assessment and any arrangements needed
Pre-operative, Intra-operative, Post-operative Assessment Summary (Pneumonic)
- Pre-Op— Introduction & role, history, examination, meds/allergies, investigations, consents, optimise patient condition, premedication, transfer
- Intra-Op—Haemodynamic stability, fluid management, normocarbia, normoglycemia, normothermia, normoxia, pain control
- Post-Op—Airway, breathing, circulation, drugs, disability, DVT prophylaxis , after
References
- Several references provided covering different aspects of preoperative assessment, guidelines, and recommendations noted.
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Description
This quiz covers essential components and best practices for preoperative assessment to minimize surgical and anesthetic risks. Key factors include patient history, physical examinations, and necessary consultations. Understanding these protocols is vital for ensuring patient safety and optimizing health before surgery.
