PR EM ED IC AT ION

BY ALIF
MODERATOR : DR. JASMINE
CONTENTS
• General principles
• Objectives
• GA Forms
• Assessments
• Investigation
• Risk & Consent
• Fasting Guidelines
• Medications
GENERAL PRINCIPLES
• Personnel
– Preferably by the person conducting the anesthesia
– Convey to the concerning personnel

• Timing
– Performed at an appropriate time to allow adequate preparation
– Consider significant comorbid / anesthetic concerns /
multidiscipline
GENERAL PRINCIPLES
• Pre-op Admission
– For further medical evaluation prior major surgery

• Conduct
– In OT for daycare
– Inpatient
– Clinic
– Emergency
GENERAL OBJECTIVE
• To prepare and optimize a patient for surgery
• Aim to reduce morbidity & mortality
 SPECIFIC OBJECTIVES
• Ensure patient in optimal state of health
– Make precise medical diagnosis
– Evaluate the extent of organ disease
– Review medication
– Review/order investigations
– Optimize medical condition
– Referrals to relevant disciplines
– Assess physiologic limitations
SPECIFIC OBJECTIVES…
• Plan anesthetic managements appropriately
– Identify anesthetic risks,
– Nature/complexity of surgery
– Review past anesthetic history
– Prepare equipment/anesthetic technique
– Post operative management
SPECIFIC OBJECTIVES…
• Obtain informed consent
– Educate on anesthetic procedure, risks & care plan
– Develop rapport
– Help reduce anxiety & facilitate conduct of anesthesia
SPECIFIC OBJECTIVES…
• Others
– Chest physiotherapy, breathing exercise
– Cessation of smoking
– GXM
– ICU/HDW booking
GA FORMS
PREV. ANESTHETIC HX
• Difficult airway
• PONV
• Malignant Hyperthermia
• Allergy
• Difficult IV access
• Awareness
• PDPH
• Death in the family
ASSESSMENTS
• ASA Physical status classification
• General physical examination
• NYHA
• METS
• Airway
• Associated pathology
– Tumor size/vascularity
– Airway compression
– Abdominal compression
GENERAL EXAMINATIONS
• General Mental status, BMI
• CVS Blood pressure, murmurs
• Resp Abnormal breathing pattern
• GI Mass, prev. scars
• MSK kyphoscoliosis
• Skin Infection
• Neuro periheral neuropathy
NYHA
METS
• MET: Ratio of the work metabolic rate to the resting metabolic rate
• 1 MET = 1 kcal/kg/hour = 3.5 ml/kg/min = energy cost of sitting quietly
AIRWAY ASSESSMENT
• In general : BMI, short neck, syndromic facies
• Case by case: airway burn, neck mobility/soft tissue mass, pregnancy
• Face: Deformity
• Mouth: Mallampati, mouth opening, tongue, jaw protrusion
• Teeth : Edentulous, prominence
• Neck : ROM, TMD, neck circumference
Mallampati classification
Cormack-Lehane Grading
CL1
CL2a
CL2b
CL3
CL4
INVESTIGATIONS
• Selectively performed to guide assessment
• Depends on:
– Age
– Co-morbid
– Extent of surgical procedure
INVESTIGATIONS
• Routine investigations
– For asymptomatic without clinical abnormality
– Based on age & nature of surgery

• Relevant investigations
– For associated medical condition
– Irrespective of age or nature of surgery
CONSENTS
• Separate written consent from surgical consent
• Obtain from parent/guardian for underaged
• Emergency settings consent can be provided by 2
consultants/specialists
RISK DISCLOSURE
• Planned anaesthetic procedure
• Alternative anaesthetic procedures
• Possible risks & complications
• Benefit vs risks of each technique
• High risk consent
 Everyday Risks Risk Level Clionical Risks

1:1 PONV (1:4)

Very high Dizziness (1:5)
Oral trauma (1:20)
1:10
Difficult intubation (1:50)
High
Perioperative death (1:200)
Death per year (1:100) 1:100 Failed intubation (1:500)
Moderate
Aspiration (1:3000)
1:1000 Failed intubation & ventilation (1:5000)
Low
Traffic death per year (1:8000) Anaphylaxis (1:10,000)
Death by accident at home (1:11,000) 1:10,000
Spontaneous epidural abscess
Very low
(1:10,000)
1:100,000 Epidural haematoma
Rail accidents per year Minimal (1:150,000-200,000)
(1:140,000) Death d/t anaesthesia
1:1,000,000 (1:180,000)
Negligible
Spontaneous epidural hematoma
(1:1,000,000)
1:10,000,000
Minute
Death by lightning
(1:10,000,000
1:100,000,000
FASTING GUIDELINES

Preoperative fasting recommendation from College of Anaesthesiologist Guideline 2008

MEDICATIONS
• Sedations
– Midazolam 0.5-0.7 mg/kg p.o
– Diazepam 0.2 mg/kg p.o.
• Acid Prophylaxis
– Ranitidine 150mg ON & OT call p.o
– 0.3M Na Citrate 30ml OT call
• EMLA cream
MEDICATIONS
AVOID Sedatives
• Ill, septic, elderly
• Potential difficut airway
• Daycare
• Neurosurgical
• Neonates & infants <6months
MEDICATIONS
AWARE
• Anticoagulants
• Antidepressant
• Antihypertensive
• OHA
• Antifailures
• Bronchodilators
REFERENCES
• Anaesthetic Clinic Protocols, Ministry of Health Malaysia, 2012
• Recommendations on Pre-Anaesthetic Assessments, College of Anaesthesiologist
Academy of Medicine Malaysia, 2014
• Evaluation of an improved scoring system for the grading of direct laryngoscopy, S. M.
Yentis and D. J. H. Lee. Anaesthesia, 1998, 53, pages 1041–1044
• Manual of Anaetshesia, CY. Lee 2006
• Oxford Handbook of Anaeshesia 4th ed. 2016