Pre-Anesthesia Patient Assessment
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Bradford Towne, DMD Office Anesthesia Pre anesthesia patient assessment 1 Patient Assessment ANESTHESIA 2 Pre-Anesthesia Patient Assessment Delivery of a safe anesthetic experience to a patient is principled on four fundamental components Patient selection Team training Facility properly equipped Emergency preparedness Course Description 3 3 Pre-Anesthesia Patient Assessment.key - January 21, 2021
Transcript of Pre-Anesthesia Patient Assessment
Pre-Anesthesia Patient Assessment.key1
Pre-Anesthesia Patient Assessment
Delivery of a safe anesthetic experience to a patient is principled on four fundamental components
Patient selection Team training Facility properly equipped Emergency preparedness
Course Description
Pre-Anesthesia Patient Assessment
Identify the key elements of pre anesthesia physical evaluation Understand the concept of risk stratification Identify indicators of potential serious anesthesia morbidity Be able to assign a risk score to the patient
Course Objectives
Patient Assessment Goal of pre anesthesia assessment:
Stratify the risk of anesthesia and/or surgical complications Is the patient a suitable candidate for office based anesthesia?
5
5
Goal of pre anesthesia assessment(cont.)
Select appropriate setting for delivery and level of anesthesia Office or higher level facility? Level of anesthesia to be delivered?
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6
Components of Patient Assessment
Medical History
Components of Patient Assessment
Medical problem list usually patient has completed a form review with patient, clarifying answers confirm negative answers
Anesthesia history
List of medications important to confirm meds against problem list
Past medications Bone preserving meds
Bisphosphonates Denosumab(prolia) Steroids
9
9
Pre-Anesthesia Patient Assessment.key - January 21, 2021
Components of Patient Assessment This is a targeted and focused review of organ systems
cardiac- MI, HA, arythmias
pulmonary- COPD, pneumonia, asthma
liver hepatitis, cirrhosis
kidney- dialysis, ESRD
Weight/height Heart/Lung exam
Preoperative Evaluation Physical Examination
Airway evaluation Mallampati Classification:
patient sits upright head in neutral position open mouth as wide as possible protrudes tongue
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12
Preoperative Evaluation Physical Examination
Pharyngeal evaluation Malampati Classification Uvula completely visible Partially visible uvula Soft palate visible but not uvula Hard palate visible only
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Patient Assessment Anesthesia Risk Stratification
The formula is BMI = kg/m2 where kg is a person's weight in kilograms and m2 is their height in metres squared. A BMI of 25.0 or more is overweight, while the healthy range is 18.5 to 24.9.
(kg)
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16
medical history previous anesthesia experience medication list physical assessment
Stratification of patient ability to undergo anesthesia for a procedure based on
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18
Patient Assessment Anesthesia Risk Stratification
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RiskCalculator/PatientInfo.jsp
Stratification of patient ability to undergo anesthesia for a procedure based on
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20
Patient Assessment Patient Risk Stratification
Patient risk stratification categories 1 =“Very Low Risk” = no medical problems 2=“Low Risk”=
Hypertension Hyperlipidemia Asthma Other chronic, stable medical condition without significant functional impairment
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21
Patient Assessment Patient Risk Stratification
Patient risk stratification categories 3= ”Intermediate Risk”
Age 70 or older Non-insulin dependent diabetes History of treated, stable CAD Morbid obesity (BMI > 30) Anemia (hemoglobin < 10) Mild renal insufficiency
22
22
Patient Assessment Procedure Risk Stratification
complexity of procedure anticipated length of procedure degree that a procedure will have an impact on patient physiologically or hemodynamically
Stratification of procedure risk
Patient Assessment Procedure Risk Stratification
Procedure Risk Categories How does this correlate to office based Oral & Maxillofacial Surgical procedures?
1=“Very low Risk” Dental procedures (what did the authors consider to be dental procedures?) Eye surgery
2= “Low Risk” ENT procedures w/o flap or neck dissection Hernia repair
24
24
Patient Assessment Anesthesia Risk Stratification
Procedure Risk Categories How does this correlate to office based Oral & Maxillofacial Surgical procedures?
3= “Intermediate Risk” Intracranial/spine surgery Cardiac catheterization chest/abdominal surgery
25
25
26
26
ASA Classification
28
28
Anesthesia Selection Facility
Office, SDS, Hospital Based on: ASA Class Risk Score Anticipated surgery length/ complexity Malampati Class Neck ROM Patient desires
Office Anesthesia selection Based on: ASA Class Risk Score Anticipated surgery length Malampati Class Neck ROM Patient desires
30
Anesthesia Selection Anesthesia options:
Anesthesia Selection
Benefits doesn’t require NPO status emergence is rapid with little to no residual effects acts as an anxiolytic acts as an analgesic
Anesthesia options: Local/N2O2 Risks
affect unpredictable need scavenging for ambient nitrous oxide exposure control sometimes can get agitation instead of sedation
32
Anesthesia Selection
Benefits more control of patient retains gag reflex acts as an anxiolytic acts as an analgesic
Anesthesia options: IV Sedation Risks
possible patient will respond to pain while operating sometimes can get agitation instead of sedation difficult to maintain an even state of sedation
33
Anesthesia Selection
Benefits best control of patient acts as an profound anxiolytic acts as an profound analgesic not dependent on LA
Anesthesia options: IV GA Risks
patient unlikely to respond to painful stimulus possible loss of gag reflex airway management difficult to maintain an even state of sedation aspiration
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CONSULTATION/PREOP EVALUATION Patient Name: _____________________ Age: ______ Date: ________________ CC/HPI: _____________________________________________________________________ Exam: _______________________________________________________________________ ______________________________________________________________________________ Radiographic Dx: ______________________________________________________________ Diagnosis: ____________________________________________________________________ Informed Consent: _____________________________________________________________ Video Watched: ________ Krames Pamphlet: _________ Prescriptions: _________________________________________________________________ Planned Operation: ____________________________________________________________
Weight(lbs): _____Height(inches): ______BMI: _______[(lbs/(inches2))*703]
Pre-op Visit Instructions/Medications (that pt will take pre-op)
Pre-op Instructions: NPO: __________ Driver: __________ Clothing: __________
E D C B A A B C D E Oral Sed IM/Ket 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
E D C B A A B C D E GA IV/Sed LA/N2O LA 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
Past Medical History
Patient Name: _____________________ Age: ______ Date: ________________ CC/HPI: _____________________________________________________________________ Exam: _______________________________________________________________________ ______________________________________________________________________________ Radiographic Dx: ______________________________________________________________ Diagnosis: ____________________________________________________________________ Informed Consent: _____________________________________________________________ Video Watched: ________ Krames Pamphlet: _________ Prescriptions: _________________________________________________________________ Planned Operation: ____________________________________________________________
Weight(lbs): _____Height(inches): ______BMI: _______[(lbs/(inches2))*703]
Pre-op Visit Instructions/Medications (that pt will take pre-op)
Pre-op Instructions: NPO: __________ Driver: __________ Clothing: __________
E D C B A A B C D E Oral Sed IM/Ket 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
E D C B A A B C D E GA IV/Sed LA/N2O LA 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
Past Medical History
37
Pre-Anesthesia Patient Assessment
Delivery of a safe anesthetic experience to a patient is principled on four fundamental components
Patient selection Team training Facility properly equipped Emergency preparedness
Course Description
Pre-Anesthesia Patient Assessment
Identify the key elements of pre anesthesia physical evaluation Understand the concept of risk stratification Identify indicators of potential serious anesthesia morbidity Be able to assign a risk score to the patient
Course Objectives
Patient Assessment Goal of pre anesthesia assessment:
Stratify the risk of anesthesia and/or surgical complications Is the patient a suitable candidate for office based anesthesia?
5
5
Goal of pre anesthesia assessment(cont.)
Select appropriate setting for delivery and level of anesthesia Office or higher level facility? Level of anesthesia to be delivered?
6
6
Components of Patient Assessment
Medical History
Components of Patient Assessment
Medical problem list usually patient has completed a form review with patient, clarifying answers confirm negative answers
Anesthesia history
List of medications important to confirm meds against problem list
Past medications Bone preserving meds
Bisphosphonates Denosumab(prolia) Steroids
9
9
Pre-Anesthesia Patient Assessment.key - January 21, 2021
Components of Patient Assessment This is a targeted and focused review of organ systems
cardiac- MI, HA, arythmias
pulmonary- COPD, pneumonia, asthma
liver hepatitis, cirrhosis
kidney- dialysis, ESRD
Weight/height Heart/Lung exam
Preoperative Evaluation Physical Examination
Airway evaluation Mallampati Classification:
patient sits upright head in neutral position open mouth as wide as possible protrudes tongue
12
12
Preoperative Evaluation Physical Examination
Pharyngeal evaluation Malampati Classification Uvula completely visible Partially visible uvula Soft palate visible but not uvula Hard palate visible only
13
13
14
14
Patient Assessment Anesthesia Risk Stratification
The formula is BMI = kg/m2 where kg is a person's weight in kilograms and m2 is their height in metres squared. A BMI of 25.0 or more is overweight, while the healthy range is 18.5 to 24.9.
(kg)
16
16
medical history previous anesthesia experience medication list physical assessment
Stratification of patient ability to undergo anesthesia for a procedure based on
18
18
Patient Assessment Anesthesia Risk Stratification
19
19
RiskCalculator/PatientInfo.jsp
Stratification of patient ability to undergo anesthesia for a procedure based on
20
20
Patient Assessment Patient Risk Stratification
Patient risk stratification categories 1 =“Very Low Risk” = no medical problems 2=“Low Risk”=
Hypertension Hyperlipidemia Asthma Other chronic, stable medical condition without significant functional impairment
21
21
Patient Assessment Patient Risk Stratification
Patient risk stratification categories 3= ”Intermediate Risk”
Age 70 or older Non-insulin dependent diabetes History of treated, stable CAD Morbid obesity (BMI > 30) Anemia (hemoglobin < 10) Mild renal insufficiency
22
22
Patient Assessment Procedure Risk Stratification
complexity of procedure anticipated length of procedure degree that a procedure will have an impact on patient physiologically or hemodynamically
Stratification of procedure risk
Patient Assessment Procedure Risk Stratification
Procedure Risk Categories How does this correlate to office based Oral & Maxillofacial Surgical procedures?
1=“Very low Risk” Dental procedures (what did the authors consider to be dental procedures?) Eye surgery
2= “Low Risk” ENT procedures w/o flap or neck dissection Hernia repair
24
24
Patient Assessment Anesthesia Risk Stratification
Procedure Risk Categories How does this correlate to office based Oral & Maxillofacial Surgical procedures?
3= “Intermediate Risk” Intracranial/spine surgery Cardiac catheterization chest/abdominal surgery
25
25
26
26
ASA Classification
28
28
Anesthesia Selection Facility
Office, SDS, Hospital Based on: ASA Class Risk Score Anticipated surgery length/ complexity Malampati Class Neck ROM Patient desires
Office Anesthesia selection Based on: ASA Class Risk Score Anticipated surgery length Malampati Class Neck ROM Patient desires
30
Anesthesia Selection Anesthesia options:
Anesthesia Selection
Benefits doesn’t require NPO status emergence is rapid with little to no residual effects acts as an anxiolytic acts as an analgesic
Anesthesia options: Local/N2O2 Risks
affect unpredictable need scavenging for ambient nitrous oxide exposure control sometimes can get agitation instead of sedation
32
Anesthesia Selection
Benefits more control of patient retains gag reflex acts as an anxiolytic acts as an analgesic
Anesthesia options: IV Sedation Risks
possible patient will respond to pain while operating sometimes can get agitation instead of sedation difficult to maintain an even state of sedation
33
Anesthesia Selection
Benefits best control of patient acts as an profound anxiolytic acts as an profound analgesic not dependent on LA
Anesthesia options: IV GA Risks
patient unlikely to respond to painful stimulus possible loss of gag reflex airway management difficult to maintain an even state of sedation aspiration
34
CONSULTATION/PREOP EVALUATION Patient Name: _____________________ Age: ______ Date: ________________ CC/HPI: _____________________________________________________________________ Exam: _______________________________________________________________________ ______________________________________________________________________________ Radiographic Dx: ______________________________________________________________ Diagnosis: ____________________________________________________________________ Informed Consent: _____________________________________________________________ Video Watched: ________ Krames Pamphlet: _________ Prescriptions: _________________________________________________________________ Planned Operation: ____________________________________________________________
Weight(lbs): _____Height(inches): ______BMI: _______[(lbs/(inches2))*703]
Pre-op Visit Instructions/Medications (that pt will take pre-op)
Pre-op Instructions: NPO: __________ Driver: __________ Clothing: __________
E D C B A A B C D E Oral Sed IM/Ket 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
E D C B A A B C D E GA IV/Sed LA/N2O LA 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
Past Medical History
Patient Name: _____________________ Age: ______ Date: ________________ CC/HPI: _____________________________________________________________________ Exam: _______________________________________________________________________ ______________________________________________________________________________ Radiographic Dx: ______________________________________________________________ Diagnosis: ____________________________________________________________________ Informed Consent: _____________________________________________________________ Video Watched: ________ Krames Pamphlet: _________ Prescriptions: _________________________________________________________________ Planned Operation: ____________________________________________________________
Weight(lbs): _____Height(inches): ______BMI: _______[(lbs/(inches2))*703]
Pre-op Visit Instructions/Medications (that pt will take pre-op)
Pre-op Instructions: NPO: __________ Driver: __________ Clothing: __________
E D C B A A B C D E Oral Sed IM/Ket 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
E D C B A A B C D E GA IV/Sed LA/N2O LA 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
Past Medical History
37
