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Anaesthesiology
Preoperative Patient Assessment and Management
Built from Barash Clinical Anesthesia, 9th Edition
What’s inside
12 sections · 197 slides
Overview
- What the preoperative evaluation is
- Roadmap of this topic
- Who requires a preoperative evaluation
- Changing patterns of preoperative care
Approach to the healthy patient
- Purpose of the preoperative evaluation form
- Patient identification and baseline data
- Nature of the surgical illness
- Classification of urgency of surgical procedures
- Value of previous anaesthetic records
- Reported allergy to anaesthesia
- Postoperative nausea and vomiting
- Apfel simplified risk score for PONV
- Risk factors for postoperative nausea and vomiting in adults
- Predictors of postoperative vomiting in children
- Paediatric antiemetic prophylaxis
- Risk factors for paediatric postoperative nausea and vomiting
- Medication and allergy history
Screening by system
- Airway assessment: why it comes first
- Components of the airway examination
- Mallampati classification
- Modified Mallampati airway classification system
- Why a single airway test is not enough
- Multifactorial airway prediction
- Airway examination findings that suggest difficult tracheal intubation
- Pulmonary screening questions
- Cardiovascular screening priorities
- Why unstable angina is dangerous around surgery
- Cardiac devices and antithrombotic therapy
- Neurologic screening
- Endocrine screening
- Preanesthetic evaluation screen
The patient with known cardiovascular disease
- Scale of the problem
- Why cardiovascular risk is rising
- Two arms of the cardiac preoperative evaluation
- Exercise tolerance as a risk predictor
- Estimated energy requirement for various activities
- Estimated energy requirement for various activities (continued)
- Metabolic equivalents in practice
- Congestive heart failure as a risk factor
- Ventricular function and outcome
- Valvular heart disease before noncardiac surgery
- Prior myocardial infarction
- Diabetes mellitus and perioperative cardiac risk
- Hypertension before surgery
- How high is too high on the day of surgery
- Metabolic syndrome and tobacco
- ASA physical status classification
- ASA physical status classification with examples
- Revised Cardiac Risk Index
- The six Revised Cardiac Risk Index predictors
- Revised Cardiac Risk Index
- Complication rates by Revised Cardiac Risk Index score
- Cardiac risk by risk index class and procedure type
- Principles of preoperative cardiac testing
- Steps in the ACC/AHA testing algorithm
- Perioperative cardiac assessment pathway in coronary artery disease
- Preoperative 12-lead electrocardiogram
- Indications for a preoperative electrocardiogram
- Transthoracic echocardiography
- Exercise electrocardiogram stress test
- Dobutamine stress echocardiography
- Myocardial perfusion imaging
- Coronary angiography
- Preoperative coronary revascularisation
- Biomarkers in perioperative risk assessment
Special cardiovascular populations
- The elderly surgical patient
- Timing surgery after myocardial infarction
- Recommended delay after coronary intervention
- Why drug-eluting stents need longer
- Perioperative pathway for the patient with a coronary stent
- Cardiovascular implantable electronic devices
Pulmonary disease
- Postoperative respiratory complications
- How common and how serious
- Surgical site and pulmonary risk
- Mechanism of postoperative lung dysfunction
- Anaesthesia's own effect on the lungs
- Predictors of postoperative reintubation
- Effects of smoking on the perioperative lung
- Timescale of benefit from stopping smoking
- Assessing the asthmatic patient
- Steroids in the asthmatic surgical patient
- Obstructive sleep apnoea
- The obstructive sleep apnoea cycle
- STOP-Bang screening questionnaire
- STOP-Bang questionnaire to identify surgical patients at risk of sleep apnoea
- Determinants of perioperative risk in sleep apnoea
- Perioperative planning decisions in sleep apnoea
Endocrine, renal, liver and other disease
- Epidemiology of diabetes mellitus
- Stiff joint syndrome and the diabetic airway
- Type 1 diabetes mellitus
- Type 2 diabetes mellitus
- Preoperative assessment of the diabetic patient
- Why perioperative glucose control matters
- Target glucose ranges differ by society
- Insulin on the day of surgery
- Thyroid disease before surgery
- The large thyroid mass and the airway
- Clinical manifestations of thyroid and parathyroid diseases
- Phaeochromocytoma
- Adrenal cortical suppression
- Deciding on stress-dose steroids
- Steroid replacement in Cushing syndrome
- Renal disease
- Liver disease and drug handling
- History and examination in liver disease
- Arthritis and anaesthesia
Preoperative laboratory testing
- What a normal reference range means
- The false positive cascade
- Policy on routine preoperative testing
- Indications for a preoperative blood count
- Indications for serum chemistry
- Preoperative haemoglobin measurement
- Coagulation studies before surgery
- Preoperative pregnancy testing
- Preoperative chest x-ray
- Pulmonary function tests
- Arterial blood gas analysis
- Four questions that close the evaluation
Preparing the patient
- Surgery as a teachable moment for smoking cessation
- Benefits of quitting to share with patients
- Herbal and dietary supplements
- Herbal and dietary supplements and their drug interactions
- Herbal and dietary supplements and their drug interactions (continued)
- Herbal and dietary supplements and their drug interactions (continued)
- Herbal and dietary supplements and their drug interactions (continued)
- Perioperative beta-blockers: the evidence
- Beta-blocker recommendations
- Perioperative anticoagulation
- Bridging anticoagulation
- Aspirin before noncardiac surgery
- Statins in the perioperative period
- ACE inhibitors and angiotensin receptor blockers
- Historical basis of aspiration risk criteria
- Who actually aspirates
- Top 10 factors predisposing to aspiration
- Purpose of the ASA fasting guidelines
- Clear liquids: at least 2 hours
- Fasting intervals for milk and solids
- Fasting recommendations for all ages to reduce the risk of pulmonary aspiration
- Drugs used to reduce aspiration risk
- Histamine-2 receptor antagonists
- Cimetidine
- Proton pump inhibitors
- Antacids
- Metoclopramide
Psychological preparation and premedication
- Premedication as the start of the anaesthetic
- The preoperative visit
- Evidence for the preoperative interview
- Choosing a premedication
- Goals and timing of premedication
- Common preoperative medications, doses and administration routes
- Benzodiazepines as premedication
- Midazolam
- Pharmacology of midazolam
- Anxiolysis after oral midazolam syrup in children
- Lorazepam and diazepam
- Administering lorazepam
- Comparison of pharmacologic variables of benzodiazepines
- Diphenhydramine
- Opioids as premedication
- Fentanyl
- The opioid epidemic and preoperative assessment
- Planning for the opioid-dependent patient
- Dexmedetomidine
- Anticholinergic premedication
- Antisialagogue effect
- Vagolytic action
- Comparison of the effects of three anticholinergic drugs
- Central anticholinergic syndrome
- Anticholinergics and body temperature
Antibiotic prophylaxis and summary
- Goals of surgical antibiotic prophylaxis
- Choice of prophylactic antibiotic
- Timing and redosing of prophylactic antibiotics
Key points
- Purpose and responsibility
- Screening and drug history
- Risk assessment and testing
- Optimisation and premedication
- References
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- Barash, Cullen, and Stoelting's Clinical Anesthesia, 9th Edition