PRE ANAESTHETIC CHECKUP-1.pptx

Anesthesia preanaesth check up important considerations

1. PRE ANAESTHETIC CHECKUP Dr Radhika Raj M R Guide: Dr Nidhi

2. Pre Anaesthetic Evaluation Defnition The process of clinical assessment that precedes the delivery of anesthesia care fo r surgery and for non-surgical procedures. Preoperative evaluation is an integral component of the anesthesiologists’ role as perioperative physicians who are involved in integrated medical care before, during, and after surgery

3. Goals and Benefits of PAC To e nsure that the patient can safely tolerate anesthesia for the planned sur gery. Mitigate perioperative risks Better document comorbid illness Reduce the patient’s (and family’s) anxiety through education Optimize preexisting medical conditions Order specialized investigations Initiate interventions intended to decrease risk To discuss aspects of perioperative care (e.g.anticipated risks, fasting guidelines), To arrange appropriate levels of postoperative care To predict the difficulty during intubation To obtain informed consent

4. Clinical examination Medical History Physical examination Medical history Planned surgery and its indication Current known medical problems and past medical issues Diseases or symptoms their associated severity, stability, associated activity limitations, exacerbations (current or recent), prior treatments, and planned interventions Previous surgeries, anesthesia types, and anesthesia-related complications Prescription and over-the-counter medications should be documented, along with their dosages and schedules

5. any allergies to medications and other substances Addictions- tobacco,alcohol,drugs consumption smoking history Pack year :No. cigarettes smoked per day x years smoked /20 20 pack years is considered as a significant factor for developing COPD Family history: personal or family history of pseudocholinesterase deficiency and malignant hyperthermia (including a suggestive history such as hyperthermia or rigidity during anesthesia) must be clearly documented to facilitate appropriate planning before the day of surgery. Information from previous anesthetic records may clarify an uncertain history Menstrual history: LMP

6. ASSESSMENT OF FUNCTIONAL CAPACITY A ssessment of the patient’s cardiopulmonary fitness or functional capacity is an integral component of the preoperative clinical examination Functional capacity is typically quantified in using the metabolic equivalent of task (MET) One metabolic equivalent of task (MET) is the amount of oxygen consumed while sitting at rest, and is equivalent to an oxygen consumption of 3.5 mL/min/kg body weight. Value :- 1 – 12 (Light – Moderate – Vigorous)

7. Dukes activity status index 1-4 METS ( eating,dressing ,walking around the house,dish washing) 5-9METS ( Climb a flight of stairs ,walk one or 2 blocks on level ground,run a short distance,moderate activites like golf,dancing ) >10 METS ( sternous sports (swimming ,bicycle,tennis),heavy professional domestic work

8. PHYSICAL EXAMINATION GPE – Weight,Height, BMI Higher mental function Built Nutritional Status Nails :Cyanosis, Clubbing Conjunctiva Sclera ( Jaundice) Back & Spine Edema Gait Vital Signs – BP Pulse RR Temperature

9. Airway examination Pt is asked about:- Artificial Dentures If yes it must be either removed / protected during the course of anesthesia Teeth ( Loose, Cracked, Chipped, Capped) Mouth opening Jaw Joint ( if it clicks, pops or hurts) Maybe TM joint syndrome accompanied by chronic pain / repeated dislocation of jaw. Snoring (Predictor of difficult intubation) Day time sleep (Somnolence) ( Sleep Apnea)

10. MALLAMPATI CLASSIFICATION Class I: soft palate, tonsillar fauces , tonsillar pillars, and tip of uvula visualized Class II: soft palate, tonsillar fauces , and uvula visualized Class III: soft palate and base of uvula visualized Class IV: only hard palate visualized Class III and IV→ Difficult to Intubate

11. DIFFICULT MASK VENTILATION Predictors A ge more than 55 years, BMI more than 26 kg/m2 A bsence of teeth P resence of a beard H istory of snoring Others increased neck circumference face and neck deformities (i.e., prior surgery, prior radiation, prior trauma, congenital abnormalities) Rheumatoid arthritis-cervical spine is often affected-atlanto axial instability Trisomy 21 (Down syndrome)-microstomia,macroglossia, atlanto axial instability and sublaxation scleroderma -autoimmune condition causing fibrosis of skin-contractures may be seen,microstomia,mandibular bone resorption -difficult intubation and difficul vascular assess cervical spine disease, or previous cervical spine surgery

12. UPPER LIP BITE TEST ULBT is considered to be highly accurate in predicting difficult mask ventilation as it assesses both buck teeth & mandibular subluxation simultaneously. * It is performed according to following criteria: Class 1 lower incisors can bite the upper lip above the vermilion line. Class 2  lower incisors can bite the upper lip below the vermilion line. Class 3 lower incisors cannot bite the upper lip.

13. RULE OF 123 …. Temporomandibular jt: ability to insuniate 1- finger in front of tragus with mouth open. Mouth opening inter-incisor gap should be at least 2-finger breadth. Thyromental distance should be at least 3-finger breadth. Hyomental distance 2 finger breadth of adult

14. PATIL TEST – Measures distance between thyroid notch & mental symphysis ( thyromental gap) > 6.5 cm – Normal 6.0-6.5 cm – Intubation & Laryngoscopy possible but difficult < 6.0 cm – Very difficult Laryngoscopy and intubation HYOMENTAL DISTANCE – Grade 1 : > 6 cm Grade 2 : 4-6 cm Grade 3 : < 4 cm ( very difficult laryngoscopy )

15. PRAYER SIGN: To evaluate the prayer sign, patients are asked to approximate the palmar surfaces of their hands. If the palmar surfaces of phalangeal joints touch completely, the prayer sign is negative. If the palmar surfaces of the phalangeal joints could not be approximated despite maximal effort, the prayer sign is positive.

16. PALM PRINT TEST: The palm and fingers of the dominant hand of the patient is painted with black writing ink using a brush. The patient then presses the hand firmly against a white sheet of paper on a hard surface. Scoring is done as: * Grade 0 - All phalangeal areas are as visible. * Grade 1 - Deficiency in the inter- phalangeal areas of 4th and/or 5 th digit. * Grade2 - Deficiency in the inter- phalangeal areas of 2nd to 5th digit. * Grade 3 - Only the tips of digits seen.

17. Respiratory System History of cough H/o of TB, Asthma, Pneumonia H/o of Smoking I nspection cyanosis clubbing, accessory muscle use respiratory effort Auscultation wheezing decreased breath sounds abnormal breath sounds

18. Risk Factors for Postoperative Pulmonary Complications

19. Cardiovascular system We need to check that the pt is having any the following conditions or not : CHF HT N IHD Cardiomyopathy Valvular / Subvalvular ds Arrhythmias Atherosclerosis To assess CVS: the pt is asked about -- Shortness of breath(at rest,sleep ) -- chest pain, chest tightness -- Pedal edema -- Previous Heart / Lung surgery -- medication

20. Revised Cardiac Risk Index High-risk surgery ( intraperitoneal , intrathoracic , or 1 suprainguinal vascular procedures)   Ischemic heart disease (by any diagnostic criteria) 1 History of congestive heart failure 1 History of cerebrovascular disease 1 Diabetes mellitus requiring insulin 1 Creatinine >2.0 mg/ dL 1 Components Points Assigned Revised Cardiac Risk Index Score Risk of Major CardiacEvents 0 0.4% 1 1.0% 2 2.4% ≥3 5.4%

21. Hypertension Blood pressure > 140/90 mmHg Measurement should be >2 times on different occasion Should be taken in both arms T he goals of preoperative evaluation are to identify any secondary causes of hypertension, presence of other cardiovascular risk factors (e.g., smoking, diabetes mellitus), and evidence of end-organ damage. The physical examination should focus on vital signs, thyroid gland, peripheral pulses, and cardiovascular system (including bruits and signs of intravascular volume overload). Cancellation/ postpone case if BP > 180/110 mmHg Stop ACE inhibitor and ARBs and continue beta blocker and clonidine

22. NYHA CLASSIFICATION NYHA class I: no limitation of physical activity; ordinary activity not a cause of fatigue, palpitations, or syncope NYHA class II: slight limitation of physical activity; ordinary activity resulting in fatigue, palpitations, or syncope NYHA class III: marked limitation of physical activity; less than ordinary activity resulting in fatigue, palpita_x0002_tions, or syncope; comfort at rest NYHA class IV: inability to do any physical activity without discomfort; symptoms at res t

23. Renal system The preoperative evaluation of patients with CKD should emphasize the cardiovascular system, cerebrovascular system, intravascular volume status, and electrolyte status. The early stages of CKD typically cause no symptoms. The anesthesiologist should inquire about the cardiovascular systems (i.e., chest pain, orthopnea, paroxysmal nocturnal dyspnea), urine output, associated comorbidities, medications, dialysis schedules, and any hemodialysis catheter problems (e.g., infection, thrombosis).

24. Hepatic system Most of the patients with liver disease will be asymptomatic Some may complain F atigue, weight loss, dark urine, pale stools, pruritus, right upper quadrant pain, bloating, and jaundice Physical Examination : jaundice, bruising, ascites, pleural effusions, peripheral edema, hepatomegaly, splenomegaly, and altered mental status Past history of liver disease should be asked

25. ENDOCRINE SYSTEM Endocrine disturbances & end organ effects of - DM Thyroid/Parathyroid Pituitary Adrenals Can increase perioperative risk substantially. * Pt is asked about --waking up at night freq to urinate (DM) --increased thirst (DM) --increased perspiration than others ( Pheochromocytoma ) --Headache ( Pheochromocytoma ) --Feeling more cold/warm (hypo/hyperthyroid) --Muscle cramps/spasm in legs >3 times a year (Thyroid)

26. Diabetes Blood Sugar Normal :- Fasting :- 70-100 mg % PP :- less than 126 mg % Diagnostic Criteria :- Fasting :- > 125 mg % or Glucose tolerance test > 200 mg % (2 hr.) Random :- 200 mg % or more with symptoms ( polyurea , polydypsia , unexplained wt.loss ) usual glycemic control, history of hypoglycemic episodes, current therapy, and the severity of any end-organ complications should be documented physical examination evaluation of pulses skin breakdown joint (especially cervical spine) mobility

27. NEUROLOGICAL SYSTEM Pt is asked about -- h/o seizure / convulsion / stroke/fall/ head injury/head surgery -- pin & needle sensation in arms & legs -- Migraine

28. MUSCULOSKELETAL SYSTEM Pt is asked about -- h/o arthritis -- low back pain -- taking pain pills/pain shots in last 6 months Examination of Back & spine: -- Done to evaluate any congenital deformity/ kyphoscoliosis etc. -- to assess whether spines are fused or not.

29. HEMATOLOGICAL SYSTEM Pt is asked about -- problem with blood clotting if any after minor cuts / bruise -- H/O spontaneous bleeding -- H/O blood transfusion

30. INVESTIGATION COMPLETE BLOOD COUNT, HEMOGLOBIN, AND HEMATOCRIT Typical clinical indications include history of increased bleeding hematologic disorders CKD chronic liver disease, recent chemotherapy or radiation treatment corticosteroid therapy anticoagulant therapy poor nutritional sta tus

31. Renal function test clinical indications include diabetes mellitus hypertension cardiac disease potential dehydration (e.g., vomiting, diarrhea) anorexia bulimia fluid overload states (e.g., heart rate, ascites) known renal disease, liver disease relevant recent chemotherapy (e.g., cisplatin, carboplatin) renal transplantation

32. LIVER FUNCTION TESTING clinical indications include a history of hepatitis (viral, alcohol, drug-induced, autoimmune) jaundice cirrhosis portal hypertension biliary disease gallbladder disease hepatotoxic drug exposure tumor involvement of the liver bleeding disorders

33. COAGULATION TESTING indications for testing include a known bleeding disorder hepatic disease anticoagulant use.

34. URINALYSIS clinical indications include suspected urinary tract infection unexplained fever or chills

35. PREGNANCY TEST Practice Advisory for Preanesthesia Evaluation” suggests offering pregnancy testing to female patients of childbearing age when the result would alter the patient’s management.

36. ELECTROCARDIOGRAM clinical indications include a history of IHD hypertension diabetes mellitus heart failure chest pain palpitations abnormal valvular murmurs peripheral edema syncope dizziness dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, CVD

37. Chest XRAY clinical indications include advanced COPD bullous lung disease suspected pulmonary edema suspected pneumonia suspected mediastinal masses suspicious findings on physical examination (e.g., rales, tracheal deviation)

38. Special Consideration For Thyroid indirect laryngoscopy ENT check up for vocal cords Recent TFT Possibility of difficult intubation Pre op tracheostomy consent for possible tracheomalacia

39. American Society of Anesthesiologists Physical Status Classification

40. Recommenedation of steroids in perioperative patients

41. NBM for the surgery

42. Conclusion Pre anaesthetic evaluation is the clinical foundation for guiding perioperative patient management and it has the potential to reduce perioperative morbidity and enhance patient outcome. The fundamental purpose of preoperative evaluation is to obtain pertinent information regard_x0002_ing the patient’s medical history, formulate an assessment of the patient’s perioperative risk, and develop a plan for any requisite clinical optimization. The anesthesiologist is the perioperative medical specialist and thus is uniquely positioned to evaluate the risks associated with anesthesia or surgery, discuss these risks with the patient, and manage them perioperatively in collaboration with the surgical team, referring physician, and other medical specialists

43. Referances Millers 9th edition Airway management by Rahid Khan

44. THANK YOU...