Protocol of Perioperative care NICE.pptx

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1. Preoperative assessment and anaesthetic planning 90% false-positive rateThyromental distanceExtend neck. Measure from tip of thyroid cartilage to tip of mandibleNormal > 7 cm<6 cmPositive predictive value 75%When combined with Mallampati: sensitivity 81%, specificity 97%Sternomental distanceExtend neck. Close mouth. Upper border of manubrium to tip of mandible<12.5 cmPositive predictive value 82%Mouth opening (inter-incisor gap)Distance between incisors (or gums) with mouth maximally open<3 cm (<2.5 cm LMA insertion difficult and <2 cm impossible)Jaw protrusionClass A: lower incisors anterior to upperClass B: lower incisors level with upperClass C: lower incisors cannot meet upperClass B and CDentitionBuck teeth, poor dentition with loose teeth and anterior gapsNeck movementsFinger on chin and occipital protuberance. Extend head maximally. Normal if finger on chin higherLevel fingers, moderate restrictionOccipital finger higher = severe limitationWilson’s Score(Complicated therefore less practical) WeightHead and neck movementJaw movementReceding mandibleBuck teeth≥ 2(each factor scored 0, 1 or 2)Positive predictive value 75%Sensitivity 88% *  Sensitivity = probability of identification of true positives, i.e. detects a difficult case that is difficult. When low, lots of false negatives occur meaning you fail to predict difficult cases. Specificity = probability of identification of true negatives, i.e. detects a normal case that is normal. When low, lots of false positives occur. Positive predictive value = the probability of a positive result being a true positive, i.e. it is the % of patients found to be difficult out of all those predicted to be difficult.

2. Preoperative investigations (NICE guidelines) In 2016 NICE updated their 2003 guidance regarding the use of routine preoperative investigations [ 3 ] . The guidance is based on the best available evidence, which in this case is all level IV (expert opinion from the consensus development process and clinical experience). This makes the recommendations grade D. The guidance tailors the recommended investigations according to: Patient’s ASA grade Co-morbidity Cardiovascular (including diabetes) Respiratory Renal Obesity The grade of complexity of the surgery (see  Table 23.2  below). Table 23.2 Surgical complexity The tests are summerised in the form of colour-coded table using a traffic light system: red = not recommended; yellow = consider; green = recommended. Surgical complexity Examples Minor (grade 1) I&D abscess Intermediate (grade 2) Inguinal hernia, tonsillectomy, arthroscopy Major (grade 3 or 4) TAH, TURP, Joint replacement, bowel resection