Transcript
Pre Anaesthetic ClinicPre Anaesthetic Clinic
Dr. P.Sivaraj MD DAAssistant professorDept of Anaesthesiology, GVMCGovt Villupuram Medical College and Hospital.
Definition Definition
The process of clinical assessment that
precedes the delivery of anaesthesia care
Goal Goal AnxietyPlan in intervention and optimiz Facilitate early normalcy Improve out comeEfficient and cost effective CareConsentOption in Pain Control Determine appropriate testDiscuss risk Practice advisory for preanesthesia evaluation: a report by the
American Society of Anesthesiologists Task Force on Preanesthesia Evaluation.American Society of Anesthesiologists Task Force on Preanesthesia Evaluation Anesthesiology. 2002 Feb; 96(2):485-96.
Roizen MF, Foss JF, Fischer SP. Preoperative evaluation. In: Miller RD, editor. Anesthesia. 5th ed. Vol. 1. New York: Churchill-Livingstone; 2000. pp. 824–83.
Cancellation in elective orthopaedic surgery. Koppada B, Pena M, Joshi A Health Trends. 1991; 23(3):114-5 .
Uses Uses Educate the patientsOrganize the resourcesInformed consentFormulate plans for intra operative carePerioperative pain managementPost operative recovery
I. Problem Identification
II. Risk Assessment
III. Preoperative Preparation
IV. Plan of Anesthetic Technique
The purpose of the preoperative visit:The purpose of the preoperative visit:
I. Problem IdentificationI. Problem Identification
● Case History
●Physical examination
●Laboratory investigation
I. Problem IdentificationI. Problem Identification
1. h/o present illness• Cardiovascular : hypertension ; ischemic , valvular or congenital heart
disease; CHF or cardiomyopathy, , arrhythmias
• Respiratory : smoking; COPD; restrictive lung disease; altered control of breathing (obstructive sleep apnea, CNS disorders, etc.)
• Neuromuscular : raised ICP ; TIA's or CVA's; seizures; spinal cord Injury; disorders of NM junction e.g myasthenia gravis, muscular dystrophies ,MH
• Endocrlne : DM; thyroid disease; pheochromocytoma; steroid therapy
• GI - Hepatic : hepatic disease; gastresophageal reflux
• Renal : renal failure
I. Problem IdentificationI. Problem Identification
• Hematologic : anemias; coagulopathies
• Elderly , Children, Pregnancy
2 h/o past illness Chronic diseases Jaundice • Medications and Allergies• Prior Anesthetics• Alcohol, drugs, smoking, activities and exercise tolerance
3. Family history
Physical Examination:Physical Examination:General & Local examination
Evaluation of :
• Upper airway
• Respiratory system
• Cardiovascular system
• Vital signs
Preoperative Laboratory Testing:Preoperative Laboratory Testing:
only if indicated from the preoperative history and physical only if indicated from the preoperative history and physical examination.examination."Routine or standing" pre operative tests should be discouraged"Routine or standing" pre operative tests should be discouraged
-CBC anticipated significant blood loss, suspected hematological disorder (eg.anemia, thalassemia, SCD), or recent chemotherapy.
-Electrolytes diuretics, chemotherapy, renal or adrenal disorders
Investigations Investigations -ECG age >50 yrs ,history of cardiac disease, hypertension, peripheral vascular disease, DM, renal, thyroid or metabolic disease.
-Chest X-rays prior cardiothoracic procedures ,COPD, asthma, a change in respiratory symptoms in the past six months.
-Urine analysis DM, renal disease or recent UTI.
-Echocardiography
-Indirect laryngoscopy
-Pulmonary function tests
Should routine pre-operative testing be abandoned?
Klein AA, Arrowsmith JE Anaesthesia. 2010 Oct; 65(10):974-6.
The preoperative evaluation: use the history and physical rather than routine testing.
Michota FA, Frost SD Cleve Clin J Med. 2004 Jan; 71(1):63-70.
ASA Physical Status Classification System
For emergent operations, you have to add the letter ‘E’ after the classification.
Patient assessment Patient assessment ASA physical status
Cardiac risk1. Goldman multifactorial cardiac risk index
2. Detsky’s multifactorial index
3. Revised Cardiac Risk Index
II. Risk AssessmentII. Risk Assessment
Components for evaluating perioperative risk:
• Patient's medical condition preoperatively• Type or extent of the surgical procedure• Risk from the anesthetic
““Most of the work, however, addresses the operative riskMost of the work, however, addresses the operative risk
according to the patient's preoperative medical status”according to the patient's preoperative medical status”
Types of surgical proceduresTypes of surgical proceduresClass A
Class B
Class CPhysiology, morbidity, blood, invasive
monitor, post op icu
III. Preoperative PreparationIII. Preoperative Preparation
Anesthetic indications:
Anxiolysis, sedation and amnesia. e.g. benzodiazepine(diazepam ,lorazepam)
Analgesia e.g. narcotics
Drying of airway secretions e.g. atropine, glycopyrrolate
Reduction of anesthetic requirements ,
Facilitation of smooth induction
Patients at risk for GE reflux : ranitidine ,metoclopramide , sodium citrate
Preoperative preparationsPreoperative preparationsSurgical indications:
- Antibiotic prophylaxis for infective endocarditis.
- Prophylaxis against DVT for high risk patients : low-dose heparin or aspirin, intermittent calf compression, or warfarin
Preoperative preparationsPreoperative preparationsCo-existing Disease indications:
• Some medications should be continued on the day of surgery e,g Beta -blockers, thyroxine, anti hypertensive, nitrates ,antiepileptic, bronchodilators
• Others are stopped e.g oral hypoglycemics, Tricyclic ani depressant inhibitors and MAO inhibitors
• Steroids within the last six months may require supplemental steroids
INGESTED MATERIALMINIMUM FASTING PERIOD, APPLIED TO ALL AGES (hr)
Clear liquids 2
Breast milk 4
Infant formula 6
Nonhuman milk 6
Light meal (toast) 6
Fasting Recommendations Fasting Recommendations
IV. Plan of Anesthetic TechniqueIV. Plan of Anesthetic Technique
1. Is the patient's condition optimal?
2. Are there any problems which require consultation or special tests? “Please assess and advise “
3. Is there an alternative procedure which may be more appropriate?
4. What are the plans for postoperative management of the patient?
5. What premedication if any is appropriate?
Finally, we plan our anesthetic technique :
1.Local
2. Regional anesthesia
2. General anesthesia
3. Combination
Cancelling casesCancelling cases
Control temptation of taking up every cases
Inadequate preparation
Communication
“The surgeon should not demand or insist on a
particular technique or the capability of the
anaesthesiologist to manage the particular
technique” – John Alfred Lee
Early anesthesia evaluation of the ambulatory surgical patient: does it really help?
Twersky RS, Lebovits AH, Lewis M, Frank D J Clin Anesth. 1992 May-Jun; 4(3):204-7.
Recommendations Recommendations ASA Task Force has recommended that
preanaesthesia evaluations should be performed prior to the day of surgery for patients with high severity of disease and/or undergoing procedures of high surgical invasiveness
Practice advisory for preanesthesia evaluation: a report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation.American Society of Anesthesiologists Task Force on Preanesthesia Evaluation Anesthesiology. 2002 Feb; 96(2):485-96.
Reduction in excessive Reduction in excessive preoperative testingpreoperative testing
60–75% of preoperative tests ordered are medically unnecessary.
Kaplan EB, Sheiner LB, Boeckmann AJ, Roizen MF, Beal SL, Cohen SN, Nicoll CD JAMA. 1985 Jun 28; 253(24):3576-81.
•Existing literature suggests that 30-60% of abnormalities discovered on routine preoperative tests are ignored.
Roizen MF. More preoperative assessment by physicians and less by laboratory tests. N Engl J Med 2000;342:204-205.
•Given this fact, routine preoperative testing without documentation of abnormalities actually may lead to more medico-legal risk.
•In general, it is safe to use test results that were performed and were normal within the previous four months, given that no change has occurred in the patient's clinical status.
•One study reported that only 0.4% of such tests repeated at the time of surgery were abnormal and could have been predicted by the patient's history.
Smetana GW, Macpherson DS. The case against routine preoperative laboratory testing. Med Clin North Am 2003;87:7-40.
REDUCTION IN REDUCTION IN SUBSPECIALTY CONSULTSSUBSPECIALTY CONSULTS
The effect of alterations in a preoperative assessment clinic on reducing the number and improving the yield of cardiology consultations.
Tsen LC, Segal S, Pothier M, Hartley LH, Bader AM Anesth Analg. 2002 Dec; 95(6):1563-8,
Enhanced operative room Enhanced operative room functioningfunctioning
Value of preoperative clinic visits in identifying issues with potential impact on operating room efficiency.
Correll DJ, Bader AM, Hull MW, Hsu C, Tsen LC, Hepner DLAnesthesiology. 2006 Dec; 105(6):1254-9;
References References Development and effectiveness of an
anesthesia preoperative evaluation clinic in a teaching hospital.
Fischer SP Anesthesiology. 1996 Jul;
85(1):196-206.
References References Economic benefits attributed to opening
a preoperative evaluation clinic for outpatients.
Pollard JB, Zboray AL, Mazze RI Anesth
Analg. 1996 Aug; 83(2):407-10.
References References Telemedicine versus face to face patient
care: effects on professional practice and health care outcomes.
Currell R, Urquhart C, Wainwright P, Lewis R Cochrane Database Syst Rev. 2000; (2):CD002098.
Assessing telemedicine: a systematic review of the literature.
Roine R, Ohinmaa A, Hailey D CMAJ. 2001 Sep 18; 165(6):765-71.
References References Cost-effective preoperative evaluation
and testing. Fischer SP Chest. 1999 May; 115(5
Suppl):96S-100S.
Preoperative testing: moving from individual testing to risk management. Pasternak LR Anesth Analg. 2009 Feb; 108(2):393-4.
References References
More preoperative assessment by physicians and less by laboratory tests
Roizen MF N Engl J Med. 2000 Jan 20;
342(3):204-5.
top related