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PREOPERATIVE EVALUATION

AND PREPARATION

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Anesthesiology

Cutting Medical
specialties specialties

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The purpose of preoperative evaluation is not to give
medical clearance, but rather to perform an evaluation
of the patients current medical status; make
recommendations concerning the evaluation,
management, and risk of cardiac problems over the
entire perioperative period; and provide a clinical risk
profile that the patient, primary physician,
anesthesiologist, and surgeon can use in making
treatment decisions

Kim A. Eagle, FACC, Chair, ACC/AHA Task Force on Practice Guidelines


for Perioperative Cardiovascular Evaluation for Noncardiac Surgery

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Preoperative anesthetic
evaluation
1. Identification of disease
2. Assessment of the severity of the underlying
disesase
3. Medical optimization or treatment of
identified disease
4. Assessment of preoperative anesthetic risk
5. Plan of anesthetic management

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What are You Really Being
Asked to Do?

Assess risks of anesthesia


Assess the risks of the procedure
Manage complicated medical problems
Predict the future

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Pre-anaesthetic evaluation

medical history, current medications.


History previous anaesthetics.

age, weight, teeth condition.


Examination. Airway assessment, neck flexibility and
head extension

Investigations. Relevant to age and medical conditions.

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Pre-anaesthetic evaluation

The plan

If airway management
best combination and is deemed difficult,
drugs and dosages and then alternative
the degree of how fasting time placement methods
much monitoring is such as fiberoptic
required . intubation may be
used.

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Preoperative Evaluation

Anesthetic drugs and techniques have profound effects


on human physiology. Hence, a focused review of all
major organ systems should be completed prior to
surgery.

Goals of the preoperative evaluation is to ensure that the


patient is in the best (or optimal) condition.

Patients with unstable symptoms should be postponed


for optimization prior to elective surgery.

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1.Review of patient data
Medical record
Interview history
History of underlying disease,
medication,
functional capacitance,
previous anesthetic history,
family history,
smoking and alcoholic use,
review of system,
psychological support
Airway evaluation
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2. Physical examination
Vital signs
General appearance
HEENT
Respiratory system
CVS system
Abdomen
Extremities and spine
Neurologic system

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Airway evaluation
History of difficult intubation
Head and neck examination for airway
evaluation
Face
Oral cavity : mouth opening
mandibular space
tongue
teeth
Mallampati classification
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Predictors of difficult intubation ( 4 M )
M allampati

M easurements 3-3-2-1 or 1-2-3-3 Patient s


fingers
M ovement of the Neck

M alformations of the Skul


Teeth
Obstruction
Pathology
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MALLAMPATI
Class I = visualize the soft palate, fauces, uvula,
anterior and posterior pillars.

Class II = visualize the soft palate, fauces and


uvula.

Class III = visualize the soft palate and the base


of the uvula.

Class IV = soft palate is not visible at all.

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Measurements 3-3-2-1
3 Fingers Mouth Opening

3 Fingers Hypomental Distance. (3 Fingers


between the tip of the jaw and the
beginning of the neck (under the chin)

2 Fingers between the thyroid notch and the


floor of the mandible (top of the neck)

1 Finger Lower Jaw Anterior subluxation

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Malformation of the skull
Skull (Hydro and Microcephalus)

Teeth (Buck, protruded, & loose teeth. Macro and


Micro mandibles)

Obstruction (obesity, short Bull Neck & swellings


around the head and neck)

Pathology (Craniofacial abnormalities & Syndromes


e.g. Treacher Collins, Goldenhar's, Pierre Robin
syndromes)
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Pierre Robin
( hypertelorism; and external
and middle ear deformities)

Treacher Collins
(mandibulofacial
dysostosis)

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Goldenhar's
(oculoauriculovertebral dysplasia)

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ASA Physical Status Classification System

medical status mortality


ASA I normal healthy patient without organic, biochemical, 0.06-0.08%
or psychiatric disease
ASA II mild systemic disease with no significant impact on Unlikely to have
daily activity e.g. mild diabetes, controlled an impact
hypertension, obesity . 0.27-0.4%
ASA III severe systemic disease that limits activity e.g. angina, Probable impact
COPD, prior myocardial infarction 1.8-4.3%
ASA IV an incapacitating disease that is a constant threat to Major impact
life e.g. CHF, unstable angina, renal failure ,acute MI, 7.8-23%
respiratory failure requiring mechanical ventilation
ASA V moribund patient not expected to survive 24 hours e.g. 9.4-51%
ruptured aneurysm
ASA VI brain-dead patient whose organs are being harvested

For emergent operations, you have to add the letter E after the classification.
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Fasting Recommendations

MINIMUM FASTING PERIOD,


INGESTED MATERIAL APPLIED TO ALL AGES (hr)
Clear liquids 2

Breast milk 4

Infant formula 6

Nonhuman milk 6

Light meal (toast and clear liquids) 6

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Plan of Anesthetic Technique
1. Is the patient's condition optimal?

2. Are there any problems which require consultation or


special tests? Please assess and advise

3. Is there an alternative procedure which may be more


appropriate?

4. What are the plans for postoperative management of the


patient?

5. What premedication if any is appropriate?

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