Preoperative Assessment and Premedication PDF

DR. MUSTAFA SAFAA ‫ﻣﻨﺼﺔ ﺍﻷﻭﺍﺋﻞ‬ Preoperative assessment and premedication Anesthesia techniques - 3rd stage Preoperative assessment and premedication The pre-operative assessment is an opportunity to identify co-morbidities that may lead to pa...

DR. MUSTAFA SAFAA ‫ﻣﻨﺼﺔ ﺍﻷﻭﺍﺋﻞ‬ Preoperative assessment and premedication Anesthesia techniques - 3rd stage Preoperative assessment and premedication The pre-operative assessment is an opportunity to identify co-morbidities that may lead to patient complications due to anesthesia or surgical procedure, during the operative or post-operative periods. Patients scheduled for elective procedures will generally attend a pre-operative assessment 2-4 weeks before the date of their surgery. Premedication is using of medications in order to prepare the patient for anesthesia and to help provide optimal conditions for surgery. Specific needs will depend on the individual patient and procedure. Goals of preoperative assessment: 1. Surgical team-patient relationship 6. Preoperative Preparation. 2. Plan of Anesthetic Technique 7. Perioperative risk determination. 3. Screen for and manage co-morbid 8. Post-operative need for care identification disease. 9. Reduce patient anxiety. 4. To assess and minimize risks of anesthesia. 10. To obtain informed consent. 5. To identify need for specialized techniques. Minimum preoperative visit components (according to ASA) 1) Medical, anesthesia and medication history. 2) Physical examination. 3) Review of diagnostic data (ECG, labs, x-rays). 4) Assessment of ASA physical status. 5) Formulation and discussion of anesthesia plan. The ASA physical classification: American Society for ASA1: Normal healthy patient. Anesthesiologists 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 D. Medications, alcohol & tobacco. E. Review of systems (include snoring and fatigue). A. Medical problems (current & past) ex: F. Exercise tolerance and physical activity level Chronic diseases: DM, HTN, COPD, CAD, thyroid disorder … Regular medications Physical examination Previous surgeries Family anesthesia history 1. Airway. Problems with anesthesia in family 2. Vital signs.. including: Used type of anesthesia: (Pseudocholinesterase deficiency and malignant hyperpyrexia) O2 saturation Blood pressure, Resting pulse, rate, rhythm, B. Previous anesthesia & related problems. Respiration, rate, depth, and pattern at rest, Allergy to drugs Body temperature Postoperative nausea and vomiting Anesthesia awareness 3. Heart and lungs. Difficult intubation 4. Height and weight (BMI). Delayed emergence 5. Other Specific examinations depending on the individual patient and procedure. C. Allergies and drug intolerances. Airway Assessment # [Predictors of difficult intubation] 1. Mallampati test Class I: Soft palate, uvula, fauces, pillars visible. 2. ULBT (upper lip bite test) Class II: Soft palate, uvula, fauces visible. 3. Inter-incisors gap (IID) Class III: Soft palate, base of uvula visible. 4. Thyromental and Sternomental distance Class IV: Only hard palate visible. 5. Forward movement of mandible ❖ A high Mallampati score (class 3 or 4) is 6. Document loose or chipped teeth associated with more difficult intubation as well as 7. Tracheal deviation a higher incidence of sleep apnea. 8. Movement of the Neck Thyromental distance (TMD) Modified Mallampati score: Distance from the thyroid cartilage to the mental prominence when the neck is extended fully. Should be 7 cm - Used to predict the ease of endotracheal intubation - In a sitting posture Sternomental distance (SMD) - Ask the patient, to open his or her mouth Distance from the upper border of the manubrium sterni to the tip of the chin, with the mouth closed and - Protrude the tongue as much as possible. the head fully extended. Should be > 12.5 cm Laryngoscopy: Cormack - Lehane Cardiovascular system: Dysrhythmias Atrial fibrillation Heart failure Heart murmur Valvular heart disease Also Look for: Blood pressure Body: obese? If female: large pendulous breast? Respiratory system Neck anatomy: short? thick? webbed? Mouth: limitations (opening)? Teeth? (number & Cyanosis health) Enlarged tongue? (hypothyroidism, Pattern of ventilation acromegaly & obesity) Respiratory rate RR Mandible: micrognathia, receding mandible (ask patient to sublux their lower incisor beyond upper Dyspnoea incisor) Wheeziness Maxilla: protruding? (buck teeth) | Signs of collapse Face: beard? Facial trauma? | Consolidation and effusion Nose: nasal passage patency Head size: Children (ex. hydrocephalus or rickets) | Adults (ex. acromegaly) Pulmonary disease Smoking Frequents use of bronchodilators, recurrent hospitalization and requirements for systemic steroids are all indicators of severe disease. Increased carboxyhemoglobin levels. Those who received more than a (burst and taper) Decrease ciliary function. of steroids in the previous 6 months should be Increase sputum production. considered for stress dose perioperatively. Nicotine adverse effects on cardiovascular system. Preoperative advices: Respiratory Tract Infection - 2 days cessation can decreases nicotinic effect, improve mucus clearance and decrease Patients presenting on the day of surgery with carboxyhemoglobin levels symptoms and signs of a lower respiratory tract infection should be treated appropriately and - 4-8 weeks of cessation are believed to be postponed to such time that they are symptom needed for postoperative complication free. reduction Viral upper respiratory tract infection can cause bronchial reactivity which may persist for 3-4 Asthma weeks. Unless surgery is urgent, such patients should be Obtain information about irritating factors, postponed for 4 weeks to minimize the risk of severity and current disease status. postoperative respiratory infection  Optimal fasting hours decreases volume and acidity of stomach contents and reduce aspiration and regurgitation risk. Prolonged fasting should be avoided as this is associated with dehydration, increased postoperative nausea and vomiting, electrolyte imbalance and patient distress. INVESTIGATIONS Basic Investigations Other (if needed) CBC ‫التوتل‬ Echocardiography ABO and Rh ‫الفصائل‬ TFT RBS ‫الراندوم‬ HbA1c Urea and Creatinine 0‫يوريا وكرياتين‬ BT/CT, aPTT LFT Na+, K+ ‫صوديوم وبوتاسيوم‬ PFT PT/INR ‫تحليل التخثر‬ Urine test ‫ادرار‬ CXR ‫اشعة‬ ECG ‫تخطيط‬ Serology ‫صل‬C‫ضادات او ا‬C‫ا‬ Thank you