Pre-operative Pre-operative EvaluationEvaluation

Prof. Dr. M.A.LotfiProf. Dr. M.A.Lotfi

Ain-Shams University Ain-Shams University

ConceptConcept

To cure the patient with the To cure the patient with the Minimal Minimal possible risk.possible risk. (Not to remove a (Not to remove a lesion).lesion).

Do not ever Do not ever ChallengeChallenge a disease. a disease.

To To RespectRespect the following patients.the following patients.

Medico legalMedico legal aspects. aspects.

Pre-operative CarePre-operative Care

Assessment (evaluation).Assessment (evaluation). Investigations.Investigations. Counseling.Counseling. On going to theater. On going to theater.

Pre-operative EvaluationPre-operative Evaluation

GeneralGeneral

Specific Specific

Pre-operativePre-operativeThis applied both in evaluation & This applied both in evaluation &

investigationsinvestigations

GeneralGeneral

This include the This include the following:following:

1-General 1-General condition of the condition of the patient.patient.

2-Psychological 2-Psychological condition. condition. ( Specially in ( Specially in major operations).major operations).

SpecificSpecific

This include the This include the following:following:

1-Related to 1-Related to anaesthesia.anaesthesia.

2-Related to the 2-Related to the surgery.surgery.

AssessmentAssessment

Air way. Air way.

Class and grade of surgery.Class and grade of surgery.

General condition of the patient.General condition of the patient.

Nature of surgical intervention is already Nature of surgical intervention is already known.known.

RiskRisk

Anaesthesia:Anaesthesia:

1- Airway.1- Airway.

2- ASA grading.2- ASA grading.

Surgical:Surgical:

1- Grade & type of 1- Grade & type of surgery.surgery.

2- Site of surgery.2- Site of surgery.

AirwayAirway

Incidence of difficult Incidence of difficult intubation reported to intubation reported to range between 0.13 – range between 0.13 – 5.9%5.9%

It can be predicted and It can be predicted and expert anaesthsiologist expert anaesthsiologist is called for the case.is called for the case.

Evaluation is the first Evaluation is the first step in management of step in management of difficult intubation. difficult intubation.

Importance For ENTImportance For ENT

Both the surgeon and the Both the surgeon and the anaesthesiologist compete anaesthesiologist compete for the upper airway.for the upper airway.

Anaesthesia Anaesthesia ENTENT

Introduction & stability It is the Introduction & stability It is the site ofsite of

of the tube. Surgery.of the tube. Surgery.

Significant HistorySignificant History (Suggests increased risk of difficult (Suggests increased risk of difficult

intubation)intubation) Stridor Stridor Significant Snoring Significant Snoring Sleep Apnea Sleep Apnea Advanced Rheumatoid Arthritis Advanced Rheumatoid Arthritis Dysmorphic Facial Features Dysmorphic Facial Features Upper Respiratory Infections Upper Respiratory Infections ObesityObesity

Mallampati modified test.Mallampati modified test.

Class IClass I: Faucial : Faucial pillars, soft palate pillars, soft palate and uvula.and uvula.

Class II:Class II: Faucial Faucial pillars and soft pillars and soft palate. Uvula is palate. Uvula is masked by the masked by the tongue base.tongue base.

Class III:Class III: Only soft Only soft palate is visible.palate is visible.

Wilson Risk TestWilson Risk Test

Airway ExaminationAirway Examination

Normal Normal – Opens mouth normally (Adults: greater than 2 Opens mouth normally (Adults: greater than 2

finger widths or 3 cm) finger widths or 3 cm) – Able to visualize at least part of the uvula and Able to visualize at least part of the uvula and

tonsillar pillars with mouth wide open & tongue tonsillar pillars with mouth wide open & tongue out (patient sitting) out (patient sitting)

– Normal chin length (Adults: length of chin is Normal chin length (Adults: length of chin is greater than 2 finger widths or 3 cm) greater than 2 finger widths or 3 cm)

– Normal neck flexion and extension without pain / Normal neck flexion and extension without pain / paresthesias paresthesias

Airway ExaminationAirway Examination

AbnormalAbnormal – Small or recessed Small or recessed

chin chin – Inability to open Inability to open

mouth normally mouth normally – Inability to visualize Inability to visualize

at least part of uvula at least part of uvula or tonsils with mouth or tonsils with mouth open & tongue out open & tongue out

– High arched palate High arched palate – Tonsillar hypertrophy Tonsillar hypertrophy – Neck has limited Neck has limited

range of motion range of motion – Low set ears Low set ears – Signficant obesity of Signficant obesity of

the face/neckthe face/neck

Airway assessment: predictive Airway assessment: predictive teststests

Sensitivity = 50-60%Sensitivity = 50-60% Mallampati modified test:Mallampati modified test:Visibility of pharyngeal structures.Visibility of pharyngeal structures. Patil test:Patil test:Thyro-mental distance <6.5cmThyro-mental distance <6.5cm Mandibular protrusion:Mandibular protrusion:Class C : inability to protrude lower incisors beyond Class C : inability to protrude lower incisors beyond

the upper.the upper. Wilson test.Wilson test. Radiological assessment of the mandible and Radiological assessment of the mandible and

cervical spine.cervical spine.

Classification of OperationsClassification of Operations

Clean Surgery.Clean Surgery.

Clean-Contaminated.Clean-Contaminated.

Contaminated.Contaminated.

Dirty.Dirty.

Clean OperationsClean Operations

In which no inflammation is In which no inflammation is encountered .encountered .

The respiratory, alimentary or The respiratory, alimentary or genitourinary tracts are not entered.genitourinary tracts are not entered.

There is no break in aseptic There is no break in aseptic operating theatre technique.operating theatre technique.

Clean-contaminated Clean-contaminated OperationsOperations

In which the In which the respiratory, respiratory, alimentary or alimentary or genitourinary genitourinary tracts are entered. tracts are entered.

but without but without significant spillage.significant spillage.

Contaminated OperationsContaminated Operations Where acute inflammation Where acute inflammation (without pus)(without pus) is is

encountered.encountered.

Or where there is visible contamination of Or where there is visible contamination of the wound.the wound.

Examples include gross spillage from a Examples include gross spillage from a hollow viscus during the operation hollow viscus during the operation

Or compound/open injuries operated on Or compound/open injuries operated on within four hours.within four hours.

Dirty OperationsDirty Operations

In the presence of pus.In the presence of pus. where there is a previously where there is a previously

perforated hollow viscus,perforated hollow viscus, Or compound/open injuries more Or compound/open injuries more

than four hours old.than four hours old.

PROBABILITY OF WOUND PROBABILITY OF WOUND INFECTIONINFECTION

Risk IndexRisk Index 0 1 20 1 2

Clean 1.0% 2.3% 5.4%Clean 1.0% 2.3% 5.4%

Clean-contam. 2.1% 4.0% 9.5%Clean-contam. 2.1% 4.0% 9.5%

Contaminated 3.4% 6.8% 13.2%Contaminated 3.4% 6.8% 13.2%

Grades of SurgeryGrades of Surgery

Grade I Grade I (Minor)(Minor) Excision of a Excision of a skin lesion or drainage of skin lesion or drainage of abscess. abscess.

Grade II Grade II (Intermediate)(Intermediate) Tonsillectomy, correction of Tonsillectomy, correction of nasal septum, nasal septum, arthroscopy…….arthroscopy…….

Grade III Grade III (Major)(Major) Thyroidectomy, total Thyroidectomy, total abdominal hysterectomy….abdominal hysterectomy….

Grade IV Grade IV (Major+)(Major+) Radical Radical neck dissection, joint neck dissection, joint replacement, lung replacement, lung

operations…operations…

Grades of surgeryGrades of surgery

This can help in estimating:This can help in estimating: 1- Expected time.1- Expected time. 2- Morbidity & risk.2- Morbidity & risk. 3- Need for blood transfusion. 3- Need for blood transfusion.

DVT is related directly to the duration DVT is related directly to the duration of surgery.of surgery.

General ConditionGeneral Condition

This will determine: This will determine:

1- What sort of general investigations 1- What sort of general investigations to be done.to be done.

2- The degree of risk.2- The degree of risk.

3- Expected morbidity.3- Expected morbidity.

American Society of Anesthesiologists American Society of Anesthesiologists Patient ClassificationPatient Classification

1 =A normal healthy patient1 =A normal healthy patient

2 =A patient with a mild systemic disease2 =A patient with a mild systemic disease

3 = A patient with a severe systemic disease that 3 = A patient with a severe systemic disease that limits activity, but is not incapacitatinglimits activity, but is not incapacitating

4 =A patient with an incapacitating systemic 4 =A patient with an incapacitating systemic disease that is a constant threat to lifedisease that is a constant threat to life

5 =A moribund patient not expected to survive 24 5 =A moribund patient not expected to survive 24 hours with or without operationhours with or without operation

ASA 1ASA 1 A normal, healthy patient. The A normal, healthy patient. The

pathological process for which surgery pathological process for which surgery is to be performed is localized and is to be performed is localized and does not entail a systemic disease.does not entail a systemic disease.

Example: An otherwise healthy patient Example: An otherwise healthy patient scheduled for a cosmetic procedure.scheduled for a cosmetic procedure.

ASA 2 A patient with systemic disease, caused

either by the condition to be treated or other pathophysiological process, but which does not result in limitation of activity.

Example: a patient with asthma, diabetes, or hypertension that is well controlled with medical therapy, and has no systemic sequelae

ASA 3ASA 3 A patient with moderate or severe A patient with moderate or severe

systemic disease caused either by the systemic disease caused either by the condition to be treated surgically or other condition to be treated surgically or other pathophysiological processes, which does pathophysiological processes, which does limit activity.limit activity.

Example: a patient with uncontrolled asthma Example: a patient with uncontrolled asthma that limits activity, or diabetes that has that limits activity, or diabetes that has systemic sequelae such as retinopathy systemic sequelae such as retinopathy

ASA 4ASA 4 A patient with severe systemic A patient with severe systemic

disease that is a constant potential disease that is a constant potential threat to life.threat to life.

Example: a patient with heart failure, Example: a patient with heart failure, or a patient with renal failure or a patient with renal failure requiring dialysis.requiring dialysis.

ASA 5ASA 5 A patient who is at substantial risk of A patient who is at substantial risk of

death within 24 hours, and is death within 24 hours, and is submitted to the procedure in submitted to the procedure in desperation.desperation.

Example: a patient with fixed and Example: a patient with fixed and dilated pupils status post a head dilated pupils status post a head injury. injury.

Emergency Status (E)Emergency Status (E)

This is added to the This is added to the ASA designation only ASA designation only if the patient is if the patient is undergoing an undergoing an emergency emergency procedure.procedure.

Example: a healthy Example: a healthy patient undergoing patient undergoing sedation for reduction sedation for reduction of a displaced of a displaced fracture would be an fracture would be an ASA1 E.ASA1 E.

Risk factors for DVTRisk factors for DVT Age >40 yearsAge >40 years ObesityObesity Varicose veinsVaricose veins High oestrogen pillHigh oestrogen pill Previous DVT or PEPrevious DVT or PE Malignancy Malignancy InfectionInfection Heart failure / recent infarctionHeart failure / recent infarction Polycythaemia /thrombophilia Polycythaemia /thrombophilia Immobility ( bed rest over 4 days)Immobility ( bed rest over 4 days) Major traumaMajor trauma Duration of surgery.Duration of surgery.

Incidence of DVT and fatal Incidence of DVT and fatal pulmonary embolismpulmonary embolism

Low risk = <0.01%Low risk = <0.01% Moderate risk = 0.5%Moderate risk = 0.5% High risk = 5%High risk = 5%

High risk is 500 times the low risk.High risk is 500 times the low risk.

Pre-operative counselling Pre-operative counselling

Ensure that indication for Ensure that indication for operation is still valid.operation is still valid.

Identify any other medical Identify any other medical condition.condition.

Discuss options with patient / Discuss options with patient / relatives.relatives.

Consent.Consent. Prophylactic antibiotic Prophylactic antibiotic Prophylactic against DVT. Prophylactic against DVT. Pain control.Pain control. Nutrition.Nutrition.Discussed with patient & his Discussed with patient & his

relatives.relatives.

Minimum Information for Minimum Information for ordering investigations. ordering investigations.

Age.Age.

ASA grading & associated co ASA grading & associated co morbidity.morbidity.

Grade & class of surgery.Grade & class of surgery.

Type of surgery; total laryngectomy, Type of surgery; total laryngectomy, block dissection.block dissection.

InvestigationsInvestigations

General:General:

Done to all patients depending on Done to all patients depending on other factors than the surgery other factors than the surgery scaduled. scaduled. (cardiac, renal…….).(cardiac, renal…….).

Specific:Specific:

Related to the scaduled surgical Related to the scaduled surgical procedure. procedure. (partial laryngectomy need (partial laryngectomy need pulmonary function).pulmonary function).

Pre-operative InvestigationsPre-operative Investigations

General:General: 1- FBP 1- FBP all patients.all patients.

2- Clotting screen 2- Clotting screen all patients and those on all patients and those on anticoagulants.anticoagulants.

3- Liver function.3- Liver function. 4- ECG 4- ECG all patients > 40Ys.all patients > 40Ys.

5- Echocardiogram5- Echocardiogram Abnormal ECG, ischemic heart…. Abnormal ECG, ischemic heart….

6- Chest x-ray 6- Chest x-ray All patients >30Ys. All patients >30Ys.

7- Blood sugar level.7- Blood sugar level.

Grade I (minor)Grade I (minor)

Grade I (minor)Grade I (minor)

Grade II surgery (intermediate)Grade II surgery (intermediate)

Grade III (Major)Grade III (Major)

Summary of Fasting Recommendations Summary of Fasting Recommendations to Reduce the Risk of Pulmonary to Reduce the Risk of Pulmonary

AspirationAspiration Ingested MaterialIngested Material     Minimum Fasting Minimum Fasting

Period Period

(Hours)(Hours)– Clear liquids 2 Clear liquids 2

– Breast milk 4Breast milk 4– Infant formula 6Infant formula 6– Non-human milk 6Non-human milk 6– Light meal 6Light meal 6

Routine Preoperative care for the Routine Preoperative care for the Adult PatientAdult Patient

1. Avoid taking aspirin or aspirin-containing 1. Avoid taking aspirin or aspirin-containing products for 2 weeks prior to surgery unless products for 2 weeks prior to surgery unless approved by physicianapproved by physician

2. Discontinue nonsteroidal anti-inflammatory 2. Discontinue nonsteroidal anti-inflammatory medications 48 to 72 hours before surgerymedications 48 to 72 hours before surgery

3. Bring a list or container of current 3. Bring a list or container of current medications medications

4. Bring an adult relative who can drive if 4. Bring an adult relative who can drive if they are having an outpatient procedure they are having an outpatient procedure with sedation or general anesthesia with sedation or general anesthesia

Routine Preoperative care for the Routine Preoperative care for the Adult PatientAdult Patient

5. Wear loose clothing that can easily be 5. Wear loose clothing that can easily be removed (eg, avoid clothing that pulls on removed (eg, avoid clothing that pulls on and off over the head).and off over the head).

6. Instruct the patient to bathe/shower the 6. Instruct the patient to bathe/shower the evening before or morning of surgery. evening before or morning of surgery.

Men should be cleanly shaved.Men should be cleanly shaved.7. Instruct the patient on oral intake 7. Instruct the patient on oral intake

restrictions and medication schedule as restrictions and medication schedule as ordered: ordered:

a. NPO after midnight (including water) a. NPO after midnight (including water) b. NPO after clear liquid or light breakfast if b. NPO after clear liquid or light breakfast if

permitted permitted

On going to the operating On going to the operating roomroom

He/she will have to He/she will have to remove:remove:

1. Dentures/partial 1. Dentures/partial plates plates

2. Glasses/contact 2. Glasses/contact lenses lenses

3. 3. Appliances/prosthesis Appliances/prosthesis

4. Makeup/nail polish 4. Makeup/nail polish 5. Hairpins/hairpiece 5. Hairpins/hairpiece