Preop evaluation workshop (2)
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Transcript of Preop evaluation workshop (2)
Preoperative evaluation
workshop
Ahmad abou leila
PGYIV Ahmad Abou Leila-AUBMC
Patient disease Anesthesia surgery
Satisfied
Readmitted
Minor morbidity
Major morbidity
Death
Ahmad Abou Leila-AUBMC
Anesthesiologist role
Preoperative evaluation
Uncover the patient
risk factors
Preoperative treatment
And optimization
consultations
Further testing
Anesthesia plan
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Steps for preop evaluation
Asses patient risk Asses surgical risk
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Patient risk
• History
• Physical exam
• Lab and radiology testing
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Preop evaluation steps
Acute history
Chronic history
Physical exam
Labs and
radiology
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Acute history
• History of present illness
• Exercise tolerance
– Surgery is major stress
– Good exercise tolerance
– Hewill tolerate surgical stress.
• Fasting hours
• Presence of concurrent symptoms
– Jaundice,wheezes,GERD,toxic symptoms
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Chronic history
• Chronic medical problems
• Medications and allergies
• social history
– smoking (packet per year, cessation,risk factor)
– Alcohol(opiods tolerance,alcoholic cardiomyopathy)
• History of prior operations (difficult airway,malignant hyperthermia,PONV
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Physical exam
• Air way
• Cardiac
• Lungs
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As a routine in order to
complete our preop
evaluation we send the
patient to lab or radiology
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Labs or radiology
Only when indicated
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Tutorial on preop evaluation
Ahmad abouleila
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Acute History
Assessment of present illness
Physiologic disturbances
What is the surgery?
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What is the Surgery
Elective or emergent(LIFE SAVING)
Elective one can wait and optimized
Life saving no anesthesia clearance
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The pathologic impact
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Acute history
Assess exercise tolerance
Assessment of Cardiac and
pulmonary reserve
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Good exercise Tolerance mean
that the heart will not fail upon
the surgical stress
Opposite is true
excellent exercise tolerance in
patients with stable angina means
that myocardium can be stressed
without failing Ahmad Abou Leila-AUBMC
Able to climb the 4th floor
without dyspnea,chest pain
Good exercise tolerance
Take care in patient who suffer
from back pain,poor exercise
tolerance not due to limited
cardiopulmonary reserve
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HIGH RISK
Low RISK
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Acute history
NPO status
Risk of Aspiration
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What is the minimum fasting hours
for
6 hours
6 hours
4 hours
2 hours
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Normal medication allowed with
sips of water
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Any fluid u can read print thought it
is clear fluid
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Acute history
Presence of concurrent symptoms
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In preop evaluation of patient with history of
mild intermittent asthma u find chest
wheezes
Would u cancel the case
Yes if the condition not optimized
If patient has severe persistent asthma
With optimal treatment
Still wheezing
Stable and proceed
With good preparation and minimal instrumentation Ahmad Abou Leila-AUBMC
If patient has symptomatic hyperthyroidism
and scheduled for elective surgery
What should u do
Cancel the case and refer to endocrinologist
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Thyroid storm
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1 year old baby with runny nose, shall we
cancel surgery
no
If discharge clear ,no fever,no wheezes ,normal cxr
Don’t cancel
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Chronic history
Past medical history
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Past medical history
CVS diseases
CAD,HTN,HF,arrythmias
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Cardiovascular events are the leading cause
of morbidity and mortality peri-operatively
MI accounts for up to 40% of
perioperative fatalities.
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A 65-year-old postmenopausal female with a medical
history of coronary artery disease (CAD), hypertension,
atrial fibrillation, and dyslipidemia presents to the
emergency department (ED) complaining of an acute onset
of leg pain. Further testing and evaluation reveals that she
has an acute arterial emboli and needs immediate
embolectomy. Her heart rate is 85 bpm. As the medical
consultant, what is the MOST APPROPRIATE next step?
A. Complete a full preoperative evaluation, including a stress test, because she
will need a vascular procedure.
B. Ask the patient about her physical activity so you can calculate her metabolic
equivalents (METs) because she will have an intermediate-risk surgery.
C. Evaluate her postoperatively for signs and symptoms of a myocardial
infarction (MI).
D. Ask for surgery to be delayed for 2 days until a ß blocker lowers her heart
rate to between 55 and 65 bpm slowly.
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Patient with uncomplicated MI,his
surgery must be postponed at least
6 weeks
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A 54-year-old male gun shot survivor is evaluated prior to surgery for a
herniated lumbar disc. He has had increasing lower back pain for the
past year that is poorly controlled with pain medications. He also had a
non-ST-segment elevation MI and underwent cardiac catheterization
with coronary artery stent placement 2 weeks ago with a subsequent
stress test that did not show any residual ischemia. His ECG shows a
normal sinus rhythm. Which statement is MOST CORRECT?
A. This patient is at low risk for cardiac complications because his
stress test was negative.
B. Because the patient had a negative stress test, he no longer has
any red flag/active cardiac conditions.
C. Depending on the type of stent placed, elective surgery may be
contraindicated for up to 1 year.
D. If a bare-metal stent (BMS) was placed, the patient can safely
proceed to surgery in 1 week.
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Ahmad Abou Leila-AUBMC
Balloon angioplasty…………2-4weeks
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Mayo Clinic Data: Bare Metal
Stents
• major adverse cardiac events (MACE)
after non-cardiac surgery (NCS)
decreased with increased time post-
BMS placement • 10.5% (< 30d)
• 3.8% (31-90d)
• 2.8% (> 90d)
• and that bleeding complications were not associated with
antiplatelet therapy within a week of surgery
[Nuttal et. al. Anesthesiology 109: 588, 2008]
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Mayo Clinic Data: Drug Eluting
Stents
• MACE after NCS was independent of time
post-placement
• 6.4% (0-90d)
• 5.7% (91-180d)
• 5.9% (181-365d)
• 3.3% (>356d) Rabbitts et. al. Anesthesiology 109: 596, 2008].
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You are evaluating a patient who is scheduled for cataract surgery. She is 78-years-old and has a complicated medical history, including diabetes mellitus, hypertension, chronic kidney disease, dyslipidemia, CAD with a 3-vessel coronary artery bypass graft (CABG) 2 years ago, and a 110 pack/year smoking habit that ended after her CABG. After you take her history and examine her, you determine she does not have any red flag issues. Which of the statements concerning the rest of the preoperative evaluation is MOST ACCURATE?
Because this patient has a strong history of CAD, she will need noninvasive cardiac
stress testing before her surgery.
Because this patient had a CABG in the last 2 years, an evaluation of her MET capacity
is unnecessary.
Because the planned surgery is a high-risk procedure, the patient needs noninvasive
cardiac stress testing before surgery.
Because the planned surgery is a low-risk surgery, no further evaluation is needed.
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Which one of the following surgical procedures is associated with the highest risk for perioperative myocardial ischemia
Femoropopliteal bypass
Pulmonary lobectomy
Hip arthroplasty
Transurethral resection of the prostate
Mastectomy
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Ahmad Abou Leila-AUBMC
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• Low risk Surgery
• cardiac risk < 1%
– Endoscopic procedures
– Superficial procedures
– Cataract surgery
– Breast surgery
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• Intermediate Risk
• cardiac risk < 5%
– Carotid endarterectomy
– Head and neck surgery
– Intraperitoneal and
Intrathoracic
– Orthopedic surgery
– Prostate surgery Ahmad Abou Leila-AUBMC
• High risk
• reported risk of adverse cardiac event >5%
– Emergency surgery
– Aortic procedures
– Peripheral vascular surgery
– Prolonged surgical procedures associated with large volume shifts or high EBL
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Patients with DBP between 110 and 130 mmHg were randomly
allocated to admission for BP control, followed by surgery,
versus 10 mg intranasal nifedipine and immediate surgery
no statistically significant differences in postoperative complications
(no neurologic or cardiovascular complications in either group).
However, the average hospitalization time was significantly longer (12
vs. 6 days, p = 0.003)
Weksler et. al. Randomized, Prospective Study (n = 989)
Howell: Metaanalysis and Retrospective/Cohort Studies
No significant relationship between admission blood
pressure and outcome
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Resting ECG
• Class I (definite indication) – Recent ischemic symptoms
– Major / intermediate clinical predictors and high or intermediate risk procedure
• Class II (probably warranted) – Asymptomatic diabetics
– History of cardiac revascularization
– Asymptomatic man > 45 yo or woman > 55 yo
– Prior hospitalization for cardiac causes
• Class III (not indicated) – Asymptomatic patient; low risk procedure
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Relative Risk of Cardiovascular Death
(EKG Findings):
Atrial fibrillation 4.0
Left or right bundle branch block 2.0
Left ventricular hypertrophy 1.8
Premature ventricular complexes 2.3
Pacemaker rhythm 4.4
Q-wave 2.4
STD 2.1
Any abnormal EKG 4.5
Multivariate logistic regression was applied to evaluate the relation between ECG abnormalities and cardiovascular death
Patients with abnormal ECG findings had a greater incidence of cardiovascular death than those with normal ECG results (1.8% vs 0.3%; adjusted OR 4.5, CI 3.3 to 6.0).
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Relative Risk of Cardiovascular Death
(EKG Findings):
Atrial fibrillation 4.0
Left or right bundle branch block 2.0
Left ventricular hypertrophy 1.8
Premature ventricular complexes 2.3
Pacemaker rhythm 4.4
Q-wave 2.4
STD 2.1
Any abnormal EKG 4.5
Relative Risk of Cardiovascular Death
(EKG Findings):
Atrial fibrillation 4.0
Left or right bundle branch block 2.0
Left ventricular hypertrophy 1.8
Premature ventricular complexes 2.3
Pacemaker rhythm 4.4
Q-wave 2.4
STD 2.1
Any abnormal EKG 4.5
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Preoperative
ECHOCARDIOGRAM • Resting Left Ventricular Function: has not
been shown to be a consistent predictor of
perioperative ischemic events
[ACC/AHA Guidelines}
Patients with poor functional status should
undergo noninvasive testing unless low-risk
surgery is planned
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NO cardiac evaluation
EMEREGENCY
CABG < 5 years(no new syptoms)
Favorable Cardiac workup
< 2years (no new syptoms)
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Chest conditions
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5-10% of all surgical patients (and 940% of
those undergoing abdominal surgery) will
experience post-operative pulmonary
complications
Obese patients do have a higher incidence of pulmonary
thrombotic complications [Gutt Am J Surg 189: 14, 2005]
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POST OPERATIVE Respiratory Failure
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Predictor Points
Surgery
AAA 27
Thoracic Surgery 21
NSGY, upper abdominal, or peripheral
vascular 14
Neck 11
Emergency 11
Albumin < 30 g/dL 9
BUN > 30 mg/dL 8
Partially or fully dependent 7
COPD 6
Age >= 70 6
Age 60-69 6Risk
<=10 0.5%
11-9 2.2%
20-27 5.0%
28-40 11.6%
>40 30.5%
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Preventive measures
• Lung expansion maneuvers (deep-
breathing exercises and incentive
spirometry
• Pain control(epidural analgesia)
• Preoperative education
• intermittent positive pressure breathing
and CPAP, while effective, are not
recommended due to their high cost
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Which of the following would be the most appropriate test
for preoperative evaluation?
Ahmad Abou Leila-AUBMC
PFTS and CXR ordered only
in
1.Patient symptomatic
2.Unexplained dyspnea
3.Intrathoracic procedure such as lung
volume reduction
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Past medical history Diabetes mellitus
CVS risk factor
Intraop hypoglycemia
Gastroparesis
Wound infection
Difficult airway
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Prayer sign in DM
Difficult airway
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Past medical history
Renal failure
Drug metabolism disturbance
Electrolyte imbalance
Anemia
Uraemic gastroparesis
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Chronic history
Medication and allergies
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Ahmad Abou Leila-AUBMC
A 70-year-old man with a history of coronary artery disease,
hyperlipidemia, and hypertension is admitted with community-
acquired pneumonia. On his second hospital day he has a
seizure. A computed tomography scan reveals a 5-cm mass with
evidence of midline shift. He is taking clopidogrel and aspirin
after having a recent coronary artery stent placed 4 weeks ago.
The neurosurgeon says your patient will need to go to the
operating room in the next 7 days. What would be the optimal
management of this patient’s antiplatelet medications?
A. Discontinue both aspirin and clopidogrel immediatelyso that the
antiplatelet effects will be minimal when your patient goes to
surgery.
B. Discontinue aspirin and clopidogrel and start your patient on
UFH.
C. Continue aspirin and clopidogrel until the day before surgery.
D. Discontinue aspirin and clopidogrel and start your patient on a
glycoprotein IIb/IIIa inhibitor until surgery.
Ahmad Abou Leila-AUBMC
A 66-year-old man with coronary artery disease had a
bare-metal stent placed in his left anterior descending
coronary artery 3 weeks ago. He has gallstones and wants
his gallbladder removed. Which of the following is the most
appropriate management plan?
A. Postpone the surgery until he has had at least 6 weeks of dual
antiplatelet therapy with aspirin and clopidogrel. Then proceed with
surgery while the patient is taking aspirin.
B. Discontinue his aspirin and clopidogrel and proceed with the
surgical procedure using LMWH as a bridging antithrombotic agent.
C. Discontinue his aspirin and clopidogrel and proceed with the
surgical procedure using eptifibatide as a bridging antithrombotic
agent.
D. Discontinue his aspirin and clopidogrel and proceed with the
surgical procedure using bivalirudin for bridging anticoagulation.
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A 70-year-old man with hypertension had a stroke 3
months ago for which he takes 81 mg aspirin daily and 5
mg amlodipine daily. He is scheduled for a dental
extraction. What is the best preoperative recommendation
to manage his aspirin therapy?
A. Do not stop aspirin before surgery.
B. Stop aspirin 1 to 3 days before surgery.
C. Stop aspirin 5 to 7 days before surgery.
D. Stop aspirin 10 to 14 days before surgery.
Ahmad Abou Leila-AUBMC
A patient scheduled for cataract surgery develops urinary
retention 3 days before his scheduled surgery and is
hospitalized. A Foley catheter is inserted and the urologist
recommends starting tamsulosin. The ophthalmologist
decides to proceed with scheduled surgery because the
patient is already in the hospital. The patient’s blood
pressure is 120/80 mm Hg. Which of the following is most
correct about management of tamsulosin in the
perioperative period?
A. Continue tamsulosin preoperatively to minimize ongoing prostatic
obstruction.
B. Continue tamsulosin preoperatively to avoid rebound hypertension (if
it is stopped).
C. Discontinue tamsulosin preoperatively to avoid floppy iris syndrome.
D. Discontinue tamsulosin preoperatively to avoid intraoperative
hypotension.
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A 60-year-old woman with hypertension and a myocardial
infarction 1 year ago is hospitalized for cholecystitis and is
scheduled for a laparoscopic cholecystectomy in 1 week.
Her medications include an aspirin, metoprolol 25 mg twice
a day, and a statin. Her blood pressure is 110/70 mm Hg
and her pulse is 64 BPM. What is the best perioperative
recommendation for her ß-blocker therapy?
A. Stop the metoprolol 2 to 3 days before surgery.
B. Stop the metoprolol on the morning of surgery.
C. Continue the metoprolol preoperatively.
D. Increase the dose of the metoprolol to 50 mg twice a day to slow
her heart rate to less than 60 BPM.
Ahmad Abou Leila-AUBMC
POISE trial: B-blockers
increase mortality
• metoprolol 100 mg 2-4 hr preop.
• Total mortality increased from 2.3 to
3.1% at 30 days.
• An important exclusion criteria in POISE
was "receiving a β-blocker or their
physician planned to start one
perioperatively“
• [Devereaux et al. Lancet 31: 371, 2008]
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Ahmad Abou Leila-AUBMC
Ahmad Abou Leila-AUBMC
Preop evaluation -medication
Oral hypoglycemic
warfarin
ACEI
Plavix
ticlopidine
Skip morning dose
7 days before
14 days before
3-4 days
1 day prior surgery
Ahmad Abou Leila-AUBMC
Ahmad Abou Leila-AUBMC
Patient A.B receiving therapeutic dose of LMWH
What is the optimal timing to stop LMWH preop?
A-12hrs
B-18hrs
Therapeutic LMWH doses should be stopped 24hrs
Prophylactic LMWH doses should be stopped 12 hrs Ahmad Abou Leila-AUBMC
Preop evaluation -allergies
Latex allergy Shall we use this tube for intubation
Yes because they are made of PVC not latex
Avoid red rubber tube
And adhesives
Ahmad Abou Leila-AUBMC
Penicillin most common medication
causing allergy
Patient allergic to penicillin are 3 x
more liable to develop allergy to
other medication
Ahmad Abou Leila-AUBMC
Allergic to pencillin ,and 2g of kefzol are sent
to the OR to be giver prior to surgeries
Preop evaluation -allergies
What is the cross allergencity between
Cephalsporins and pencillin
Shall I give or not
Ahmad Abou Leila-AUBMC
Penicillin
Cephalosporin
B-lactam ring is unstable in Cephalosporin
Skin tests have not confirmed cross reactivity
There is risk of cross allergenicity between 1st generation Cephalosporin and
penicillin Ahmad Abou Leila-AUBMC
Ahmad Abou Leila-AUBMC
Allergy to penicillin
Don’t give imipenem Ahmad Abou Leila-AUBMC
Patients who have experienced pronounced
allergic reactions with penicillins
such as anaphylaxis, angioedema, or
bronchospasm
should not
receive therapy containing a cephalosporin or
imipenem.
Aztreonam may be safely administered to patients
with a history of penicillin allergy
Ahmad Abou Leila-AUBMC
Preop evaluation -allergies
Allergic to sulfa drugs
Sulfonamides-bactrim
sulfonylureas
Which diuretic is sulfa
drug and comonly
used in the OR
Ahmad Abou Leila-AUBMC
Egg allergy
One of the components of
propofol is egg
Is it safe to use propofol in these
patients
Ahmad Abou Leila-AUBMC
Yes it is safe
Propofol made of the yellow ,whereas
allergy to egg is to white
Ahmad Abou Leila-AUBMC
Ahmad Abou Leila-AUBMC
Chronic history
Social History ,Smoking,and alcohol
Ahmad Abou Leila-AUBMC
Dec oxygen carrying capacity
Stimulates sympathetic system
Coronary narrowing
Irritable airway
Postoperative infection
Smoking
Ahmad Abou Leila-AUBMC
Preop evaluation
Patient A has stopped
smoking for few days
prior or
Patient B has stopped
smoking for 8 weeks prior
OR
How cessation of smoking
Affect the outcome of anethesia In these
2 patients
Increase in air way reactivity
Decrease in the pulmonary complication
Improve cilliary function
Decrease carboxy HB
Increase tissue oxygenation
Ahmad Abou Leila-AUBMC
Alcohol
>50 unit per week associated with
Liver enzyme induction and
anesthetic agent tolerance
Ahmad Abou Leila-AUBMC
Chronic history
Check the old anesthesia chart
Ahmad Abou Leila-AUBMC
Anesthesia Chart checking
History of difficult airway
Allergies
Complications(PONV,MH)
Ahmad Abou Leila-AUBMC
What is the absolute
contraindication for use of volatile
agents
Malignant hyperthermia
Ahmad Abou Leila-AUBMC
Preop-physical exam
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Physical examination
• heart
• Lungs
• Airway
Ahmad Abou Leila-AUBMC
Heart
congested neck veins,murmurs ,PVD
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Lungs
Wheezes,abnormal sounds,cynosis
Ahmad Abou Leila-AUBMC
Airway assessment
Lemon Score
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Lemon score
• L:Look externally (abnormal faces,facial
trauma,large beard,large tongue)
• E:Evaluate the 3-3 rule(TM distance >3fingers,interincisor distance>3fingers)
• M:Mallampati score
• O:Obstruction(OSA,Head and neck tumor)
• N:Neck mobility
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Ahmad Abou Leila-AUBMC
Ahmad Abou Leila-AUBMC
Ahmad Abou Leila-AUBMC
Ahmad Abou Leila-AUBMC
Ahmad Abou Leila-AUBMC
Ahmad Abou Leila-AUBMC
Labs and radiology
Ahmad Abou Leila-AUBMC
Hb ,Hct
• Anemia
Ahmad Abou Leila-AUBMC
Recommended indication for preop
hct
• Any suspicion of anemia
• Patient with renal failure or malignancy
• Neonates
• Patient older than 75
• Any procedure with major blood loss
Ahmad Abou Leila-AUBMC
Blood chemistry
• No blood chemistry are warranted for healthy patient less 65y
• If type B or C surgery to be done glucose ,BUN,albumin are indicated
Renal failure patient BUN,Creatinine,electrlytes
Post dialysis
Ahmad Abou Leila-AUBMC
In the end
Class Physical Status 48 hr mortality
I NHP < 80 years old 0.07%
II Mild systemic disease 0.24%
III Severe, not incapacitating systemic
disease
1.4%
IV Incapacitating disease that is a
constant threat to life
7.5%
V Moribund pt. not expected to survive 24
hrs regardless of surgery
8.1%
E Suffix added to class Doubles risk
Ahmad Abou Leila-AUBMC
It is not the challenge to put
the patient asleep,
but
the challenge to keep the
patient safe and satisfied
AHMAD ABOU LEILA
Ahmad Abou Leila-AUBMC
Thank you all for listening
See u in next seminar
Ahmad Abou Leila-AUBMC
From preopevaluation to
anesthesia planning
Ahmad Abou Leila-AUBMC
Red rubber tube
Ahmad Abou Leila-AUBMC
PONV risk factors
• Female gender
• Non smoker
• Prior history of PONV
• Inhalation agent
• Opiods
• Neostigmine
• Gynecological ,ophthaologhy surgeries
Ahmad Abou Leila-AUBMC
My plan to Prevent PONV
• Use propofol as induction agent
• Avoid opiods
• Avoid sudden movement or change in posture during recovery
• Avoid excessive use use of muscle relaxants
• Anti emetics – Metochlopramide 10mg 10-15 min before the end of
surgery
– Zofran 4 mg at the end of surgery
– Decadron at induction
Ahmad Abou Leila-AUBMC
Patient with Parkinson
Avoid
Metochlopramide
Ahmad Abou Leila-AUBMC
Patient with Parkinson
Drug of choice
diphenhyramine
Ahmad Abou Leila-AUBMC
Intestinal obstruction
Avoid metochlopramide
Ahmad Abou Leila-AUBMC
Risk of aspiration or GERD
Metochlopramide
Ahmad Abou Leila-AUBMC
Thank u
Ahmad Abou Leila-AUBMC
18 year old male patient known to be
previously healthy ,admitted to hospital for
knee arthroscopy
Which ASA class
What type of surgery
What lab test should be obtained
ASA 1
Type A surgery
NONE
Ahmad Abou Leila-AUBMC
Narr and co-workers at the Mayo
Clinic found no harm from
omitting all laboratory testing for
ASA I patients
Ahmad Abou Leila-AUBMC
65 year old male patient admitted for lap
chole,2months ago he was admitted for
cataract surgery ,he underwent extensive
lab testing including CBCD,Chem9,EKG
Would u repeat these tests?
ASA task forces states that results from medical record within 6
months of surgery are accepted if ther is no dramatic change
in the patient medical history
Ahmad Abou Leila-AUBMC
Preop evaluation
• Patient A has mitral
stenosis
•Patient B has mitral
regurge
My plan
Avoid tachycardia My plan
Avoid bradycardia
Ahmad Abou Leila-AUBMC
patient has symptomatic hyperthyroidism
and admitted for emergent sugery
Thyroid storm
My plan
1. Invasive monitoring
2. Big gauge IV
3. Measures to control fever
4. Prepare Beta blockers
5. Firs dose of PTU administered by NGT Ahmad Abou Leila-AUBMC
Preoperative evaluation
Patient A has sickle cell
anemia Patient B has PVD
What regional anesthesia must be avoided
IV regional anesthesia Ahmad Abou Leila-AUBMC
Preop evaluation
• Patient A has mitral
stenosis
• Patient B has mitral
regurge
My plan
Avoid tachycardia My plan
Avoid bradycardia
Ahmad Abou Leila-AUBMC
Ventilator setting in COPD
• TV :LOW
• RR:LOW
• FiO2:40%
• I:E =1/3
Ahmad Abou Leila-AUBMC