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11/22/16
No known
past surgical
history
Past
Surgical
History
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Pre-anaesthetic assessment
NYHA 1
METs > 4
Age : 63
Sex: Female
Weight: 73.05 kg
Height : 157 cm
BMI : 29.7 kg/m2
ASA 2
Physical examination
Alert
Not cachexic
Well hydrated
Airway assessment :
1)mouth opening > 2 fingers
2)thyromental distance > 3 fingers
3) neck movement full
4) Mallampati 1
No dentures/loose teeth
Trachea centrally located
Normal airway
Investigation
M
Continue anti-hypertensive drug with super
vision,
except witholding
Perindopril in the
Anesthetic
Team Plan
morning of the surgery
GSH (group screening and hold) on admissi
on
Aspiration prophylaxis
Pre-operation assessment
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AMERICAN SOCIETY OF A
NESTHESIOLOGY (ASA) C
LASSIFICATION
Common classification of physical status at the time of
surgery.
Helps in predicting perioperative risks
Classified based on comorbid conditions that are threat
ening to life or that limit activity.
ASA
CLASSIFICATION
DEFINITION
EXAMPLES
ASA I
Non-smoker
No systemic disease
ASA II
Smoker
Obesity
Well-controlled diabetes mellitus /
hypertension
ASA III
ASA IV
Unstable CAD
End stage renal failure
Acute respiratory failure
ASA V
ASA VI
NEW
YORK HEART ASSOCIATIO
ditions.
N
(NYHA)
CLASSIFICATION
To
prevent any
occurrence of perioperative adv
erse cardiac event in the non cardiac surgical p
atient.
CLASS
I
II
III
IV
PATIENT SYMPTOMS
No limitation of physical activity.
Ordinary physical activity does not
cause symptoms of heart failure
Slight limitation of physical activity
Comfortable at rest.
Ordinary physical activity results in
symptoms of heart failure.
Marked limitation of physical activity.
Comfortable at rest.
Less than ordinary activity causes
symptoms of heart failure.
Unable to carry on any physical activity
without discomfort.
Symptoms of heart failure at rest.
METABOLIC EQUIVALENTS
A unit used to estimate the amount of oxygen used by t
(METs)
he body during physical activity.
One MET is defined as oxygen consumption of a 70kg
man at rest.
One MET is equal to 3.5 ml/kg/min oxygen consumptio
n.
A reliable predictor of future cardiac events.
It is an assessment of exercise tolerance
Patients who have minor or no clinical symptoms do n
ot require further cardiac testing unless functional cap
acity is poor
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Airway Assessment
Normal airway
Mouth opening > 2 fingers
Thyromental distance > 3 fingers
Full neck movement
Mallampati score 1
No loose teeth
No dentures
Trachea central
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27
Thyromental
distance
With the head fully extended on the neck, the dis
tance between the bony point of the chin and th
e prominence of the thyroid cartilage is measure
d. A distance of less than 6cm suggests difficult i
ntubation.
This space determines how easily the laryngeal a
nd pharyngeal axis will fall in when the a-o joint i
s extended
If distance less than 6cm, the laryngeal axis mak
es a more acute angle with the pharyngeal axis a
and it will be difficult to achieve alignment. Less s
pace to displace the tongue.
28
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Mouth opening
Inter incisor distance with maximal mouth o
pening. Normal values >5cm, 2 fingers
Neck
movement
Mallampati Score
Class I visualization of
soft palate, fauces, uvula
and both anterior and
posterior pillars
Class II visualization of
the soft palate, fauces, and
uvula
Class III - visualization of
the soft palate, and the base
of the uvula
Class IV the soft palate is
not visible at all
31
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33
Difficult ve
ntilation
The inability of a trained
anaesthetist to maintain
the oxygen saturation >
90% using a face mask f
or ventilation and 100%
inspired oxygen, provide
d that the pre-ventilatio
n oxygen saturation leve
l was within normal rang
e
Difficult intubati
on
BONES
Beard
Obesity (BMI>25)
No Teeth
Elderly (age >55)
Smoking history (sleep a
pnea)
LEMON trial
Look- obesity, beard, de
ntal/facial abnormalities
, neck, facial/neck traum
a
Evaluate- 3-2-1 rule
Mallampati score
Obstruction- stridor, for
eign bodies
Neck mobility
Management of pre-operative c
onditions
Hypertension
-untreated or poorly controlled Hypertension may lead t
o exaggerated cardiovascular responses during anesth
esia. Increase risk of MI and cerebral ischemia.
-the severity will determine action required:
a) mild( SBP 140-159 DBP 90-99 mmHg) proceed wit
h surgery
b) moderate( SBP 160-179 DBP 100-109) close monit
oring
c) Severe ( SBP >180 DBP> 109) postpone elective sur
gery
Diabetes Mellitus
Insulin must be administered to patients with ty
pe 1 diabetes even when they have been starve
d.
Patients with diabetes, regardless of their treat
ment, must have their blood sugar monitored r
egularly prior to surgery as hypoglycaemia can l
ead to irreversible brain damage.
For major surgery a glucose,insulin,potassiu
m (GIK) infusion regime is followed such as a sl
iding scale insulin infusion.
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For any surgery, patients with insulin-dependen
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BLOOD GLUCOSE
LEVEL(MMOL PER L)
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Below 3.89
3.94 - 6.67
6.72-10.0
10.1 - 13.89
13.94 - 16.67
Psychological aspect
Patient might be anxious and insomnia b
efore operation
Midazolam , Zolpidem can be prescribed t
o help with sleep
Midazolam is also anxiolytic, help to redu
ce anxiety in patient pre-op.
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Intra-operation Monitoring
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2. Heart rate
Tachycardia or bradycardia
3. Blood pressure
Hypotension/shock or intraoperative Hypertension
4. Fluid balance (fluid given in IV)
crystalloid infusion- salt containing solution that distribute within
ECF
colloid infusion- protein or non-protein colloids- distribute within
intravascular volume
Blood products: RBCs, platelet, frozen fresh plasma (FFP)
5. Aspiration
- Maintain airway
6.Anaphylaxis
- Life-threatening because affects cardiopulmonary function
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POST OP COMPLICATIONS
1. Nausea and Vomiting
hypotension and bradycardia must be ruled out
pain and surgical manipulation also cause nausea (opiods are perhaps the m
ost potent emetics)
side effects of the medication
Risk factors
1. Previous history of anaesthetic associated nausea and vomiting
2. Young
3. Female
4. Operative procedure. (Increased incidence with eye, middle ear, and female
pelvic surgery).
5. Obese
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3. Respiratory Complications
susceptible to aspiration of gastric contents due to post
operative nausea vomitting and unreliable airway reflex
es
airway obstruction (secondary to reduced muscle tone fr
om residual anesthetic, soft tissue trauma and edema,
or pooled secretions) may lead to inadequate ventilatio
n, hypoxemia, and hypercapnia
airway obstruction can often be relieved with head tilt, ja
w elevation, and anterior displacement of the mandible.
If the obstruction is not reversible, a nasal or oral airwa
y may be used
4. Hypotension
must be identified and treated quickly to prevent inadeq
uate perfusion and ischemic damage
reduced cardiac output (hypovolemia, most common ca
use) or can be due to peripheral vasodilation (residual a
nesthetic agent)
first step in treatment is usually the administration of flu
ids inotropic agents
Hypertension
pain, hypercapnia, hypoxemia, increased intravascular fl
uid volume, and sympathomimetic drugs can cause HT
N
sodium nitroprusside or beta-blocking drugs (e.g. metop
rolol) can be used to treat HTN
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5.Pain Management
- Pain relief does not just alleviate suffering:
- Physiological benefits include:
reducing sympathetic effects of pain (tachycardia, hyper
tension, increased myocardial oxygen demand), which c
ould precipitate a myocardial infarction
earlier mobilization, reducing risk of DVT/PE;
for some operations (e.g. thoracic, upper gastrointestin
al (GI), adequate pain relief improves post-operative sur
vival by allowing the patient to cough and clear secretio
ns, reducing the risk of pneumonia, basal atelectasis, et
c.
- Effective pain control is one of the key considerations f
or safe discharge.
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