Assessment and optimization

of patient for anaesthesia

By Muhamad Zulfadhli bin
Abdullah
Nazhatulnadia binti Hashim
Lim Lee Hui

Miss A, 63 years old , Malay lady came for p

Chief
Complaint
re-anaesthetic
assessment

History of presenting complaint

5 years ago:
Swelling found at left lumbar region of abdomen:
- ping pong size at first presentation
- painless
2 years ago:
- size growing bigger in oval shape
- irreducible swelling
- painful ( on and off, dull, localised, exacerbated by c
oughing, relieved by pain killer)
One month ago:
- pain is persistently present, thus she couldnt bear
with it and sought for help

 No fever, no upper respiratory tract

infection symptoms
no chest pain, no palpitation, no
orthopnea, no postural nocturnal dyspnea
(PND)

11/22/16

Hypertension- on Perindopril 8mg OD

Amlodipine 10mg OD
Past
MedicalonHistory
Dyslipidemia:
Simvastatin 20mg ON
Food allergy: allergic to seafood which ca
uses her to have eyes itchiness
No known drug allergy

 No known
past surgical
history
Past
Surgical
History

 Diagnosis: paraumbilical hernia

Operation: laparoscopic paraumbilical her
nia repair

11/22/16

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

Cardiovascular- dual rhythms no murmur (

DRNM), Heart rate: 62 beats/min, BP: 152/8
2 mmHg
Respiratory: lung field clear
Central nervous system: grossly intact
Abdominal: swelling at left lumbar region, s
ize measured 7cm by 7cm, smooth surface
with demarcated margin in oval shape, tend
erness, soft in consistency, warm to touch, i
rreducible.

Investigation

Full blood count

Renal profile
Coagulation profile
12-lead ECG
Chest X-Ray

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

AIMS OF PRE-OPERATIVE ASSESSMENT

Thorough pre-operative assessment has been proven t
o improve outcome and reduce post-operative length of st
ay. Every patient must be assessed prior to the administra
tion of anaesthesia for several reasons:
To optimize the patient before surgery
to explain the anaesthetic technique to the patient;
to identify underlying conditions that would increase the
patients peri-operative risk;
to discuss pre-, peri- and post-operative risks with the pati
ent;
to reassure the patient;
to obtain WRITTEN informed consent (from family memb
ers)

Pre-operation assessment

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Assessment of surgical risk

11/22/16

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

A normal healthy patient

Non-smoker
No systemic disease

ASA II

A patient with mild systemic

disease with no functioning
limitation

Smoker
Obesity
Well-controlled diabetes mellitus /
hypertension

ASA III

A patient with severe systemic

disease that limits activity

Poorly controlled diabetes mellitus/

hypertension
COPD
Stable CAD

ASA IV

A patient with severe systemic disease that is a constant threat to life.

Unstable CAD
End stage renal failure
Acute respiratory failure

ASA V

A moribund patient who is not expected to survive without the surgery

Ruptured abdominal aortic aneurysm

Intracranial bleed with mass effect

ASA VI

A declared brain-dead patient

whose organs are being
removed for donation purposes
17

 To determine the status of patients cardiac con

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

Pharynx - from the base of the skull down to the i

nferior border of the cricoid cartilage (around the
Airway
C6 vertebral level)
Larynx- from the superior border of the epiglottis
to the inferior border of the cricoid cartilage
Trachea and large bronchi

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Aim of airway assessment

The airway of all patient must be assessed in order t
o try to predict those patients who may be difficult to
intubate
Respiratory events are the most common anaestheti
c related injuries, following dental damage. Three ma
in causes:
- Inadequate ventilation
- Oesophageal intubation
Prediction of the difficult airway allows time for prop
er selection of equipment, technique and personal e
xperienced in difficult airways

Components of airway exam

ination

cervical spine stability and neck movement upper cervical spine e

xtension, lower cervical spine flexion (sniffing position)
Mallampati classification
"3-2-1 rule
- thyromental distance (distance of lower mandible in midline from th
e mentum to the thyroid notch); <3 finger breadths (<6 cm) is associat
ed with difficult intubation
- mouth opening (<2 finger breadths is associated with difficult intuba
tion)
- anterior jaw subluxation (<1 finger breadth is associated with difficul
t intubation)
tongue size
dentition, dental appliances/prosthetic caps, existing chipped/loos
e teeth must inform patients of rare possibility of damage
Nostril patency

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

Hold head erect, facing to the front.

Then extend the head maximally.
Observing estimated angle traversed
by the occlusal surface of upper
teeth.
30

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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 The clinical situation in which a conventionally tr

ained anesthetist experienced difficulty with mask
ventilation,
difficultyAIRWAY
with tracheal intubation or b
DIFFICULT
oth.

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

More than 3 attemps

Longer than 10 minutes
Failure of optimal best a
ttempt

To asses ventilation diffi

culty

Evaluation of difficult airw

ays

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.
11/22/16
For any surgery, patients with insulin-dependen

 Patients on oral treatment for type 2 DM

should stop taking their medication 12-24
hours prior to surgery.
The release of glucocorticoids during the
stress response to surgery means that pa
tients with type 1 DM will require more in
sulin than normal and patients with type
2 DM may require insulin peri- and imme
diately post-operatively.
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Sliding scale insulin infusion

Sliding scales are continuous infusions of
glucose, insulin and potassium (GIK), the r
ates of which are guided by regular sampl
es of the patients blood glucose.
Monitor blood glucose hourly (every two
hours when stable) and adjust insulin infu
sion rate according to the following algori
thm:
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 Mix 100 U short-acting insulin in 100 mL normal saline (1 U

= 1 mL)
Start insulin infusion at 0.5 to 1 U per hour (0.5 to 1 mL per ho
ur)*
Start a separate infusion of 5 percent dextrose in water at 100 t
o 125 mL per hour
algorithm of infusion
*Glucose infusion rate can also be increased if tende
ncy toward hypoglycemia persists.
Target blood glucose range is 120 to 180 mg per dL
(6.67 to 10.0 mmol per L).

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BLOOD GLUCOSE
LEVEL(MMOL PER L)

11/22/16

Below 3.89

Turn off insulin infusion

for 30 minutes, recheck
blood glucose level. If
blood glucose level is
still below 70, give 10 g
glucose and recheck
blood glucose level
every 30 minutes until
the level is above
100mg/dl (5.56), then
restart infusion and
decrease rate by 1 U per
hour.

3.94 - 6.67

Decrease insulin infusion

rate by 1 U per hour

6.72-10.0

Continue insulin infusion

as is

10.1 - 13.89

Increase insulin infusion

rate by 2 U per hour

13.94 - 16.67

Increase insulin infusion

Reduction of Aspiration Risk

The goal of starving patients prior to surgery is to reduce the stomach

contents sufficiently to reduce risk of aspiration-induced asphyxia or p
neumonitis.
For most patients:
no solid food for 8 hours
no milky drinks for 6 hours
no breast milk for 4 hours
no clear fluids for 2 hours
Some patients require intravenous fluids if they are to be starved: Deh
ydration or hypoglycaemia can occur in children, patients who have ta
ken a bowel preparation or who are pyrexial.
Risk of thrombosis is high in patients with sickle cell disease, polycytha
emia or cyanotic heart disease.
Hepatorenal syndrome can be induced in patients with jaundice.
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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

11/22/16

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

2. Confusion and Agitation

ABCs first confusion or agitation can be caused by airw
ay obstruction, hypercapnea,hypoxemia
neurologic status (Glasgow Coma Scale, pupils), residual
paralysis from anesthetic
distended bowel/bladder
metabolic disturbance (hypoglycemia, hypercalcemia, hy
ponatremia especially post-TURP)
intracranial cause (stroke, raised intracranial pressure)
drug effect (ketamine, anticholinergics)
elderly patients are more susceptible to post-operative d
elirium

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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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