Pre-operative, I ntra-operative

and post-operative Evaluation

related Systemic Diseases;
I nitial Assesment


T. Realsyah Renardi
The preoperative evaluation consists of gathering
information about the patient and formulating an
anesthetic plan. The overall objective is reduction of
perioperative morbidity and mortality.

Inadequate preoperative planning and errors in
patient preparation are the most common causes of
anesthetic complications.

Anesthesia and elective surgery should not proceed
until the patient is in optimal medical condition.
If any procedure is performed without
the patient's consent, the physician
may be liable for assault and battery.

The intra-operative anesthesia records
serves many purposes. It functions as
a useful intraoperative monitor, a
reference for future anesthetics for that
patient, and as a tool for quality
assurance.
Routine Pre-operative Anesthetic
Evaluation
I- History:-

1- Current problem
2- Other known problems
3- Medication history
4- Previous anesthetics ; surgery &
obstetric deliveries.
5- Family history.
6- Last oral intake.

7- Review of organ systems:-

General ( including activity level ).
Respiratory.
Cardiovascular.
Renal.
GIT.
Hematological.
Neurological.
Psychiatric.
Endocrinal.
..
Preoperative management
Areas to investigate in
preop history.

Previous adverse
responses related to
anesthesia

Allergic Reactions
Sleep apnea
Prolonged skeletal muscle
paralysis
Delayed awakening
Nausea and vomiting
Adverse responses in
relatives


Central Nervous
System
Cerebrovascular insufficiency
Seizures

Cardiovascular System
Exercise Tolerance
Angina
Prior MI
HTN
Claudication

Lungs
Exercise Tolerance
Dyspnea and Orthopnea
Cough and Sputum Production
Cigarette consumption
Pneumonia
Recent upper resp. tract
infection

Liver
Alcohol Consumption
Hepatitis

Kidneys
Nocturia
Pyuria

Skeletal and Muscular
Systems
Arthritis
Osteoporosis
Weakness


Endocrine System
Diabetes mellitus
Thyroid gland dysfunction
Adrenal gland dysfunction

Coagulation
Bleeding tendency
Easy bruising
Hereditary coagulopathies
Reproductive System
Menstrual History
STDs

Dentition
Dentures
Caps
II- Physical Examination

Vital signs.
Airway.
Heart.
Lungs.
Extremities.
Neurological Examination.
Physical Exam:

CNS
Level of Consciousness
Evidence of peripheral,
sensory or skeletal muscle
dysfxn



CV
Auscultation of heart
Systemic blood pressure
Peripheral pulses
Veins
Peripheral edema

Lungs
Auscultation of Lungs
Pattern of breathing

Upper Airway
Cervical spine mobility
Temporomandibular mobility
Tracheal mobility
Prominent central incisors
Diseased or artificial teeth
Ability to visualize uvula
Thyromental distance

III- Laboratory Evaluation
Hematocrite or Hemoglobin
concentration :
- All menstruating women.
- All patients over 60 years.
- All patients who are likely to
experience significant blood loss & may
require transfusion.
Serum glucose & Creatinine.
ECG & Chest X-ray.
Lab Test
CXR




ECG
Clinical indications
Pneumonia, pulmonary
edema,
Atelectasis,mediastinal or
pulmonary masses,pulm.
HTN,cardiomegaly, Advanced
COPD with blebs, PE


Hx of CAD,Age > 50, HTN,
chest pain, CHF, diabetes,
PVD, SOB, DOE,palpitations,
murmurs
Lab test

LFT




Renal fxn testing





Clinical
Indications
Hx of Hepatitis, Cirrhosis,
portal HTN, GB or biliary
tract disease, Jaundice


HTN, increased fluid
overload, diabetes,
urinary problems, dialysis
pts
Lab Test
CBC


Coagulation testing


Pregnancy testing
Clinical Indications
Hematologic disorder,
bleeding, malignancy,
Chemo/radiation tx, renal ds.,
highly invasive or trauma sx.

Bleeding disorder hx.,
Anticoagulant meds, Hepatic
ds.


Sexually active, time of last
menstrual period.
IV- ASA Classification
The American Society of Anesthesiologists(ASA) physical
status classification serves as a guide, to allow communication
among anesthesiologists about clinical conditions of patients.
A way to predict their anesthetic/surgical risks -the higher ASA
class, the higher the risks.

Class Definition
1 A normal healthy patient.
2 A patient with mild systemic disease & no
functional limitation.
3 Moderate to severe systemic disease that
result in some functional limitation.
4 severe systemic disease that is a constant
threat to life and functionally incapacitating.
IV- ASA Classification ( continued )
Class Definition
5 A patient who is not expected to survive 24
hours with or without surgery.
6 A brain-dead patient whose organs are being
harvested.
E If the procedure is an emergency, the
physical status is followed by E.
ASA Classification &
preoperative mortality rates
Class Mortality Rate
1 0.06 0.08 %
2 0.27 0.4 %
3 1.8 4.3 %
4 7.8 23 %
5 9.4 51 %
The Anesthetic Plan
1 - Pre-medication.
2 - Types of Anesthesia :-
* General
* Local or Regional anesthesia
* Monitored Anesthesia Care
3 - Intra-operative management.
4 - Post-operative management.
Types of Anesthesia
General :

Airway management.
Induction
Maintenance
Muscle Relaxation
Local or Regional :

Technique.
Agents.

Monitored Anesthesia Care :

Supplemental Oxygen.
Sedation.
Intra-operative management
Monitoring.

Positioning.

Fluid Management.

Special Techniques.
Post-operative management
Pain control.

Intensive Care :
- Post-operative Ventilation.
- Hemodynamic Monitoring.
Postoperative Complications
Pulmonary
- Pneumonia, atelectasis ,fever,
leukocytosis,
- Respiratory failure/mechanical
ventilation
- Pulmonary embolism

Postoperative Complications
Cardiovascular
- Anemia
- Arrhythmias
- Ischemia
- Air embolism
- Hypotension/hypertension
- DVT (both lower and upper limb
Postoperative Complications
Neurological
- Stroke
- Psychosis
Cerebrospinal fluid CSF leak
Bone flap infection Infection, sepsis
Neuropraxia, pressure areas (eg from
compression while on operating table)

Neurological deterioration eg weakness
arachnoiditis
Wound, lines, others

Postoperative Complications
Gastrointestinal

Constipation
- Constipation is an inability to move the bowels
(defecate) for many days.
- Associated with bowel paralysis with stasis of intestinal
contents, interfering with normal digestion and nutrient
absorption.

Vomiting
is a dangerous in patients with depressed consciousness
who are at risk for inhaling (aspirating) their stomach
contents and developing a chemical pneumonitis that all
too frequently progresses to pneumonia
Postoperative Complications
Others

Fever
Many patients have fevers (are "febrile")
in the first 24 to 48 hours following
- Neurosurgery (brain, spine, or nerve)
- Decubitus ulcers
- Musculoskeletal issues eg shoulder
pain, contractures

Is anesthesia safe?
Like airplane?
Anesthesia related deaths:
1940 1/1000
1970 1/10 000
1995 1/250 000
2005 ?
Safety of anesthesia
1950 - 25 000 deaths during 10
8
hours of
anesthesia
2000 - 500 deaths during 10
8
hours of
anesthesia
Airplane risk (very low) - 5 deaths during
10
8
hours of flight
Risk of anaesthesia: 100 x higher
6/6/05 Copyright Quarnstrom Donaldson
Mortality from Anesthesia 1970-1979 U. K.
Mortality from Anesthesia 1970-1979 U. K.
Dentists

1:260,000

Physicians

1:248,000

Single Operator / Anesthetist

1:143,000

One Operator One Anesthetist

1:598,000

Conscious sedation

1:1,000,000
(patient died on a motorcycle later the same day)
Dentists

1:260,000

Physicians

1:248,000

Single Operator / Anesthetist

1:143,000

One Operator One Anesthetist

1:598,000

Conscious sedation

1:1,000,000
(patient died on a motorcycle later the same day)
Dionne, Pharmacologic Considerations in Training of Dentists in
Anesthesia and Sedation, Anes Prog 36:113-116 1989

note - this study was pre pulse oximeter useage
note - this study was pre pulse oximeter useage
6/6/05 Copyright Quarnstrom Donaldson
The Spectrum of Anesthesia
Normal
Anxiolysis
Conscious
Sedation
Deep
Sedation
General
Anesthesia
1. Protective reflexes intact
Patient can independently
and continuously maintain
an airway
Patient can respond
appropriately to verbal
commands
2. Partial loss of
protective reflexes
Inability to
independently maintain
an airway
May not respond to
verbal commands
3. Loss of protective
reflexes
Inability to independently
maintain an airway
No pain sensation or reflex
withdrawal from stimuli
Total unconsciousness
6/6/05 Copyright Quarnstrom Donaldson
Risks of Anesthesia
low
high
N
2
0
Anxiolysis
Local
Anesthesia
Moderate
Sedation
Deep
Sedation
General
Anesthesia
6/6/05 Copyright Quarnstrom Donaldson
AGE VS ANESTHETIC-INDUCED,
CARDIAC ARREST / DEATH
AGE VS ANESTHETIC-INDUCED,
CARDIAC ARREST / DEATH
> 60
> 60
incidence
rate

incidence
rate

1-10
1-10
11-20
11-20
21-30
21-30
31-40
31-40
41-60
41-60
< 1
< 1
0.01
0.01
0.02
0.02
0.03
0.03
0.04
0.04
0.05
0.05
Marx, Anes., 39:54-58, 1973
Marx, Anes., 39:54-58, 1973
6/6/05 Copyright Quarnstrom Donaldson

age range = 21 mo. - 59 yr.
age range = 21 mo. - 59 yr.
0
0
1
1
2
2
3
3
4
4
<10
<10
11-20
11-20
21-30
21-30
31-40
31-40
41-60
41-60
AGE VERSUS SEVERE MORBIDITY/MORTALITY
AGE VERSUS SEVERE MORBIDITY/MORTALITY
Jastak, Anes Prog, 38:39-44 1991
Jastak, Anes Prog, 38:39-44 1991
6/6/05 Copyright Quarnstrom Donaldson

age range = 21 mo. - 59 yr.
age range = 21 mo. - 59 yr.
0
0
1
1
2
2
3
3
4
4
<10
<10
11-20
11-20
21-30
21-30
31-40
31-40
41-60
41-60
AGE VERSUS SEVERE MORBIDITY/MORTALITY
AGE VERSUS SEVERE MORBIDITY/MORTALITY
Jastak, Anes Prog, 38:39-44 1991
Jastak, Anes Prog, 38:39-44 1991
6/6/05 Copyright Quarnstrom Donaldson
Standards for Conscious Sedation
Level 1 minimal sedation - Anxiolysis

Level 2 Moderate Sedation/Analgesia -
Conscious Sedation

Level 3 Deep Sedation/Analgesia

Level 4 Anesthesia
6/6/05 Copyright Quarnstrom Donaldson
Standards for Conscious Sedation
Level 1 minimal sedation - Anxiolysis
A drug-induced state during which patients respond
normally to verbal commands. Although cognitive function
and coordination may be impaired, ventilatory and
cardiovascular functions are unaffected.

Level 2 Moderate Sedation/Analgesia -
Conscious Sedation
Level 3 Deep Sedation/Analgesia
Level 4 Anesthesia
6/6/05 Copyright Quarnstrom Donaldson
Standards for Conscious Sedation
Level 1 minimal sedation - Anxiolysis
Level 2 Moderate Sedation/Analgesia -
Conscious Sedation
A drug-induced depression of consciousness during which
patients respond purposefully to verbal commands, either
alone or accompanied by light tactile stimulation. No
interventions are required to maintain a patient airway and
spontaneous ventilation is adequate. Cardiovascular
function is usually maintained.
Level 3 Deep Sedation/Analgesia
Level 4 Anesthesia
6/6/05 Copyright Quarnstrom Donaldson
Standards for Conscious Sedation
Level 1 minimal sedation - Anxiolysis
Level 2 Moderate Sedation/Analgesia -
Conscious Sedation
Level 3 Deep Sedation/Analgesia
A drug-induced depression of consciousness during which
patients cannot be easily aroused but respond purposefully
following repeated or painful stimulation. The ability to
independently maintain ventilatory function may be
impaired. Patients may require assistance in maintaining a
patent airway, and spontaneous ventilation may be
inadequate. Cardiovascular function is usually maintained.
Level 4 Anesthesia
6/6/05 Copyright Quarnstrom Donaldson
Standards for Conscious Sedation
Joint Commission on Accreditation of Healthcare
Organizations (JCAHO)
Level 1 - None

Level 2 - conscious sedation - pulse oximeter and
Blood Pressure, ability to resuscitate.
Monitoring YES
Patient assessment - ASA status YES - 1 OR 2
Staff - someone is always with the patient YES
Equipment YES
Informed consent YES
Competent at least one level greater than where
you normally practice if patients slip into next level
Resek, Jayne, MS RN, Anesthesia Today vol.11 No. 2 Fall 2000 p. 2
Pain
Unpleasant sensory and emotional
experience associated with actual or
potential tissue damage

Injection of local anesthetic agents,
corticosteroids, opiates, and
neurolytic agents around nerves can
relieve pain.

Advantages
Reduced postoperative analgesia
requirements

Reduced duration at the hospital


Greater patient satisfaction

Examples
Use of continuous femoral nerve block expedites
rehabilitation efforts
Early ambulation and discharge with decreased side effects
of N/V, drowsiness .


Advantages
Suitable for older and multimorbid patients

Few side effects

Easier monitoring

Continuous nerve block

Suitable for nonoperative cases


Advantages
Fewer complications related to pain:

Tachycardia, hypertension, increased
peripheral vascular resistance
increased myocardial oxygen
consumption

Decreased intestinal motility
postoperative ileus

Decreased vital capacity and FRC with
thoracic and abdominal procedures

Limitations
Additional time is required for
induction and onset of block

Contraindications
Coagulopathy, neuropathies, anatomical
deviations, systemic disease or infection

Need experience & cooperative and
informed patient
Complications
Hematoma , infection

Injury or anesthetic blockade of adjacent structures:

injection of anesthetic into epidural or subarachnoid space
during brachial plexus block = total spinal

Pneumothorax

Nerve damage
Needle trauma or injection into nerve

Systemic local anesthetic toxicity, allergy
Tachycardia and hypertension (epinephrine), tinnitus, metallic
taste in mouth, perioral numbness, seizures, cardiovascular &
CNS depression

Symptoms of lidocaine toxicity

5
10
15
20
25
Convulsions
Unconsciousness
Musclar twitching
Visual disturbance
Lightheadedness
Numbness of tongue
coma
Repiratory arrest
CVS depression
30
W A K E F O R E S T U N I V E R S I T Y S C H O O L O F M E D I C I N E
Early history of regional anesthesia
Koller and Gartner
report local anesthesia
(1884)
Carl Koller
1857 -1944

W A K E F O R E S T U N I V E R S I T Y S C H O O L O F M E D I C I N E
Early history of regional anesthesia
Koller and Gartner
report local anesthesia
(1884)
1884 Halsted injects
cocaine directly into
mandibular nerve and
brachial plexus
William S. Halsted
W A K E F O R E S T U N I V E R S I T Y S C H O O L O F M E D I C I N E
Early history of regional anesthesia
Koller and Gartner
report local anesthesia
(1884)
1884 Halsted injects
cocaine directly into
mandibular nerve and
brachial plexus
1904 Einhorn
discovers procaine
(Novocaine) Procaine
W A K E F O R E S T U N I V E R S I T Y S C H O O L O F M E D I C I N E
Early history of regional anesthesia
Koller and Gartner
report local anesthesia
(1884)
1884 Halsted injects
cocaine directly into
mandibular nerve and
brachial plexus
1904 Einhorn
discovers procaine
(Novocaine)
1943 Lofgren
discovers lidocaine
(Xylocaine)

Lidocaine
W A K E F O R E S T U N I V E R S I T Y S C H O O L O F M E D I C I N E
Chronology of local anesthetics
Cocaine Niemann 1860 Ester
Benzocaine Salkowski 1895 Ester
Procaine Einhorn 1904 Ester
Tetracaine Eisler 1928 Ester
Lidocaine Lofgren 1943 Amide
Chloroprocaine Marks, Rubin 1949 Ester
Mepivacaine Ekenstam 1956 Amide
Bupivacaine Ekenstam 1957 Amide
Ropivacaine Sandberg 1989 Amide
After: Cartwright & Fyhr. Reg Anesth 1988;13:1-12
W A K E F O R E S T U N I V E R S I T Y S C H O O L O F M E D I C I N E
Effects of medical conditions &
drugs on LA dosing & kinetics
Renal failure: accumulation of metabolic
products
Hepatic failure:amide clearance
Cardiac failure; and H2 blockers: hepatic
blood flow and amide clearance
Cholinesterase deficiency or inhibition: ester
clearance
Pregnancy: hepatic blood flow; amide
clearance; protein binding

W A K E F O R E S T U N I V E R S I T Y S C H O O L O F M E D I C I N E
Is there one common mechanism
for LA-induced cardiac death?
Arrhythmias (bupivacaine)?
Left-ventricular depression (lidocaine)?
Resuscitation drug failure (bupivacaine)?
Mechanism probably depends on specific
drug!


W A K E F O R E S T U N I V E R S I T Y S C H O O L O F M E D I C I N E
Treatment of LA CV toxicity
Follow ACLS guidelines
Substitute amiodarone for
lidocaine
Substitute vasopressin for
epinephrine
Consider cardiopulmonary
bypass or lipid infusion if
standard drugs fail
W A K E F O R E S T U N I V E R S I T Y S C H O O L O F M E D I C I N E
Postoperative management
PACU Guidelines

STANDARD I
ALL PATIENTS WHO HAVE RECEIVED GENERAL
ANESTHESIA, REGIONAL ANESTHESIA OR
MONITORED ANESTHESIA CARE SHALL RECEIVE
APPROPRIATE POSTANESTHESIA MANAGEMENT.
W A K E F O R E S T U N I V E R S I T Y S C H O O L O F M E D I C I N E
STANDARD II
A PATIENT TRANSPORTED TO THE PACU SHALL BE
ACCOMPANIED BY A MEMBER OF THE ANESTHESIA CARE
TEAM WHO IS KNOWLEDGEABLE ABOUT THE PATIENT'S
CONDITION. THE PATIENT SHALL BE CONTINUALLY
EVALUATED AND TREATED DURING TRANSPORT WITH
MONITORING AND SUPPORT APPROPRIATE TO THE
PATIENT'S CONDITION.

STANDARD III
UPON ARRIVAL IN THE PACU, THE PATIENT SHALL BE RE-
EVALUATED AND A VERBAL REPORT PROVIDED TO THE
RESPONSIBLE PACU NURSE BY THE MEMBER OF THE
ANESTHESIA CARE TEAM WHO ACCOMPANIES THE
PATIENT
W A K E F O R E S T U N I V E R S I T Y S C H O O L O F M E D I C I N E
STANDARD IV
THE PATIENT'S CONDITION SHALL BE EVALUATED
CONTINUALLY IN THE PACU.

STANDARD V
A PHYSICIAN IS RESPONSIBLE FOR THE DISCHARGE OF
THE PATIENT FROM THE POSTANESTHESIA CARE UNIT.
W A K E F O R E S T U N I V E R S I T Y S C H O O L O F M E D I C I N E
Discharge Criteria
Post anesthetic discharge scoring (PADS)
system is a simple cumulative index that
measures the patient's home readiness.
Five major criteria: (1) vital signs, including
blood pressure, heart rate, respiratory rate, and
temperature; (2) ambulation and mental
status; (3) pain and PONV; (4) surgical
bleeding; and (5) fluid intake/output.
Patients who achieve a score of 9 or greater
and have an adult escort are considered fit for
discharge (or home ready).
W A K E F O R E S T U N I V E R S I T Y S C H O O L O F M E D I C I N E
Vital Signs: 2 = Within 20% of the preoperative
value, 1 = 20%40% of the preoperative value, 0 =
40% of the preoperative value
Ambulation: 2 = Steady gait/no dizziness 1 = With
assistance 0 = No ambulation/dizziness
Nausea and Vomiting: 2 = Minimal 1 = Moderate
0 = Severe
Pain: 2 = Minimal 1 = Moderate 0 = Severe
Surgical Bleeding: 2 = Minimal 1 = Moderate 0 =
Severe
W A K E F O R E S T U N I V E R S I T Y S C H O O L O F M E D I C I N E
Perioperative medications
Take all usual medications
Antihypertensives
Beta blockers
Statins

Think about discontinuing/replacing
Aspirin
Anticoagulants
Diabetic medications
MAOIs
W A K E F O R E S T U N I V E R S I T Y S C H O O L O F M E D I C I N E
Questions