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Speaker:Hesham Alkharabsheh MD
Assistant Consultant Cardiac Anesthesia
KFSH&RC
PRE-ANESTHESIA ASSESSMENT
Aim and objectives:
o Reduce the incidence of cancellation.
o To include only medically fit patients.
o Reduce patients and family's anxiety.
o Early pre-operative assessment..
Components of the
Pre- Anesthetic Evaluation
Personal Interview:In PAC (pre-anesthesia clinic) or in the floor
Review of systems
Class III:
Soft palate, base of uvula
Class IV:
Hard palate only
ASA Classification
ASA I:
normal healthy patient without organic, biochemical, or psychiatric disease
ASA II:
mild systemic disease with no significant impact on daily activity e.g. mild diabetes, controlled
hypertension, obesity .
ASA III:
Severe systemic disease that limits activity e.g. angina, COPD, prior myocardial infarction
ASA IV:
an incapacitating disease that is a constant threat to life e.g. CHF, unstable angina, renal
failure ,acute MI, respiratory failure requiring mechanical ventilation
ASA V:
moribund patient not expected to survive 24 hours e.g. ruptured aneurysm
ASA VI:
brain-dead patient whose organs are being harvested
NPO Guidelines
Healthy Adults (No risk factors)
No solid foods for a minimum of 6 hours
Clear liquids up to 2 hours prior to elective case
Oral medications up to 1-2 hours with sip of water
Pediatric patients
Clear liquids up to 2 hours preOp
Breast milk up to 4 hours preOp
Solid foods, nonhuman milk, formula up to 6 hours preOp
Aspiration
Who has a higher risk ?
Gastrointestinal Obstruction
GERD
Diabetes mellitus
Recent solid-food intake
Abdominal distention
Pregnancy
Depressed consciousness
Recent opioid administration
Upper GI or naso-oropharyngeal bleeding, with or without
trauma
Emergency surgery
Systems Approach
Airway
Examination as previously described
Pulmonary
History – Tobacco use, asthma, SOB/DOE, sleep apnea, wheezing,
cough, etc.
Physical exam –
Lung sounds, chest excursion, use of accessory muscles, cyanosis,
clubbing, etc.
Cardiovascular
HTN, CAD, MI, angina, CHF, dysrhythmias, valvular dx, heart sounds,
carotid bruits, peripheral pulses
Neurologic
Mental status, h/o seizures, neuromuscular disease, nerve injury
Endocrine
Diabetes mellitus, thyroid disease, adrenal cortical suppression, etc.
The Patient with
Pulmonary Disease
Site and Type of Surgery
Thoracic and upper abdominal procedures are associated with increased pulmonary
complications
Interview
Exercise tolerance, chronic cough, smoking history
What are their current treatment modalities?
Physical Exam
Lungs sounds – wheezing, rhonchi, decreased breath sounds
Pulmonary Disease
Poor lung function: the patient cannot cope with GA.
The need for ICU, HDU.
Sleep Apnea – CPAP mask.
Operation under L.A.? Regional
Cardiac Evaluation
Clinical predictors
Functional capacity
Surgical risk
Non-invasive testing
Invasive testing
Clinical Predictors of Increased
Perioperative Cardiovascular Risk
(Myocardial Infarction, Congestive Heart Failure, Death)
Minor
Advanced age
Abnormal EKG(LVH, LBBB, ST-T abnormalities)
Rhythm other than sinus (eg, atrial fibrillation)
Low functional capacity (eg, unstable to climb one flight of stairs with a
bag of groceries)
History of stroke
Uncontrolled systemic hypertension
Intermediate
Mild angina pectoris
Prior myocardial infarction by history or pathological waves
Compensated or prior CHF
Diabetes mellitus
Clinical Predictors of Increased
Perioperative Cardiovascular Risk
(Myocardial Infarction, Congestive Heart Failure, Death)
Major
4 METs
o Can you climb a flight of stairs or walk up a hill?
o Can you run a short distance?
o Can you do heavy housework, such as scrubbing floors or lifting or moving heavy furniture?
o Do you participate in moderate recreational activities, such as golf, bowling, dancing, doubles tennis, or
throwing a baseball or football?
>10 METs
o Do you participate in strenuous sports, such as swimming, singles tennis, football, basketball, or skiing?
Surgical Risk
Low surgical risk:
o Endoscopy
o Bronchoscopy
o Cystoscopy
o Dermatologic procedures
o Breast biopsy
o Opthalmologic procedures
Intermediate surgical risk:
o Orthopedic surgery
o Urologic surgery
o Uncomplicated abdominal surgery
o Uncomplicated head and neck
High surgical risk:
o Emergency surgery
o Cardiac procedures
o Aortic or vascular surgery
o Anticipated prolonged surgery
o Large fluid shifts or blood loss
o Ex: Whipple, spinal surgery
Other Diseases of Concern
Diabetic Mellitus
o Increased risk of CAD, perioperative MI, hypertension, and CHF
o Consider beta-blockade in diabetics with CAD to help limit myocardial
ischemia
o Hypo or Hyperglycemia
Renal Disease
o Altered drug metabolism
o Fluid management
Liver Disease
o Coagulation abnormalities
o Altered protein binding and volume of distribution
Obesity
Weight, Height and BMI should be calculated.
ECG: age >50 yrs ,history of cardiac disease, hypertension, peripheral vascular disease,
DM, renal, thyroid or metabolic disease.
Surgical indications:
o -Antibiotic prophylaxis for infective endocarditis.
o -Prophylaxis against DVT for high risk patients : low-dose heparin or aspirin
o intermittent calf compression, or warfarin.
THANK YOU