Perioperative Assessment of the Surgical Patient

Imam GZ

maret 2010

Outline
Discuss anesthesia specific risk Discuss patient specific risk Surgery specific risk Pre-operative laboratory and studies

Reason for evaluation

Anesthesia and surgery are physiologically stressful, invasive interventions which may exacerbate or uncover underlying disease processes Some of the most feared complications include catastophic events such as myocardial infarction,difficulty oxygenating or ventilating, and cerebral vascular accident, among others A proper pre-operative assessment allows the perioperative providers (anesthesiologist and surgeon) the ability to stratify and reduce risk for the patient

Why is anesthesia risky?

There can be difficulty obtaining an airway to adequately oxygenate and ventilate Induction (i.e. going to sleep): time of hemodynamic stress patient may become hypotensive from the induction agents or hypertensive with laryngoscopy and intubation Maintanence (bulk of case): differing degrees of stimulation, fluid shifts, blood loss Emergence (i.e. waking up): physiologically stressful, secure airway may be lost, hypothermia Anaphylactic reactions to medications, injury during laryngoscopy, neuropathy from positioning Even spinal/epidural carries risk: inadequate, need to convert to general, sympathectomy with vasodilation, etc

ENDOTRACHEAL INTUBATION

RISK FACTORS THAT INCREASE PERIOPERATIVE COMPLICATIONS

EXTREMES IN AGE DEHYDRATION MALNUTRITION OBESITY SMOKING DIABETES CARDIOPULMONARY DISEASE DRUG AND ALCOHOL ABUSE BLEEDING TENDENCIES LOW HEMOGLOBIN AND RED CELLS PREGNANCY
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Preoperative preparation patient evaluation

Anaesthesiologist: reviews the patients chart,
evaluate the laboratory data and diagnostic studies such as electrocardiogram and chest x-ray, verify the surgical procedure, examins the patient, discuss the options for anesthesia and the attendant risks and ordered premedication if appropriate
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The physical status classification

Developed by the American Society of Anesthesiologist (ASA) to provide uniform guidelines for anesthesiologists It is an evaluation of anesthetic morbidity and mortality related to the extent of systemic diseases, physiological dysfunction, and anatomic abnormalities Intraoperative difficulties occur more frequently with patients who have a poor physical status classification

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ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation for Noncardiac Surgery Executive Summary
Published in 2002 in Circulation 105:12571267. Eagle KA et al Guidelines for evaluation of cardiac risk

Clinical Predictors of Increased Perioperative Cardiovascular Risk

MAJOR
Unstable coronary syndromes
Acute (<7d) or recent MI (<1mo) with evidence of ischemic risk Unstable or severe angina

Decompensated heart failure Significant arrhythmias

High-grade AV block Symptomatic ventricular arrhythmia SVT uncontrolled rate

Severe valvular disease

Clinical Predictors of Increased Perioperative Cardiovascular Risk

INTERMEDIATE
Mild angina pectoris Previous myocardial infarction (>1mo) by history of pathological Q waves Compensated or prior heart failure Diabetes mellitus (particularly insulin dependent) Renal insufficiency (creatinine >2.0)

Clinical Predictors of Increased Perioperative Cardiovascular Risk

MINOR
Advanced age Abnormal ECG (LVH, LBBB, ST-T abnormalities) Rhythm other than sinus (e.g. a fib) Low functional capacity (e.g. inability to climb one flight of stairs with a bag of groceries) History of stroke Uncontrolled systemic hypertension

Clinical Predictors of Increased Perioperative Cardiovascular Risk

Functional Capacity
Metabolic equivalents 1 MET Can you take care of yourself? Eat, dress, use the toilet? Walk a block or two on level ground 2-3 MPH 4 METs Do light work around the house like dusting or washing the dishes? Climb a flight of stairs? >10 METs Participate in strenuous sports like swimming, singles tennis, football?

Clinical Predictors of Increased Perioperative Cardiovascular Risk

Functional Capacity
Perioperative cardiac and long-term risks are elevated in patients unable to obtain 4-MET demand
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Surgery-specific risk
Two important factors
The type of surgery and degree of hemodynamic stress

Surgery Specific Risk

High (Reported risk >5%)
Emergent major operations, particularly in elderly Aortic and other major vascular surgery Surgical procedures associated with large fluid shifts and/or blood loss
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Surgery Specific Risk

Intermediate (Reported risk <5%)
Carotid endarterectomy Head and neck surgery Intraperitoneal and intrathoracic procedures Orthopedic surgery Prostate surgery

Surgery Specific Risk

Low (Reported risk <1%)
Endoscopic procedures Superficial procedures Cataract surgery Breast surgery
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Day of Surgery
History of present illness NPO status PMH PSH
Problems with anethesia
Malignant hyperthermia Post-operative nausea and vomiting Difficulty with intubation letter from anesthesiologist

Day of Surgery
Allergies
Antibiotics, latex

Vital signs (are vital)

Baseline blood pressure for cerebral autoregulation

Physical examination (directed)

Airway examination Cor Lungs Neurologic (especially if regional technique planned)

Day of Surgery
Laboratory
Eg. Renal function, starting HCT, Platelets Beta HCG women of childbearing age

Imaging
CXR: Trauma, CHF, COPD CT scan in thyroidectomy

Day of Surgery
Assessment of patient
Risk of anesthesia and surgery Monitoring Technique of anesthesia and agents to be used Post-operative care

Chest X-ray?

Chest X-ray
Clinical characteristics to consider:
Smoking, COPD, recent respiratory infection, cardiac disease If the above are stable, no unequivocal indication

Functional Capacity
I cant walk one flight of steps because my legs hurt!

PREOPERATIVE MEDICATIONS
ANTICHOLINERGICS: Glycopyrrolate (robinal) decreases respiratory secretions. ANTIANXIETY: Lorazepam (ativan) reduces anxiety. HISTAMINE-2 RECEPTOR ANTAGONIST: Cimetidine (tagamet) decreases gastric acidity and volume. NARCOTICS: Demerol (meperidine) decreases the amount of anesthesia needed to sedate the client. SEDATIVES: Midazolam (versed) promotes sleep or conscious sedation and decrease anxiety. ANTIBIOTICS: Kanamycin (Kantrex) destroy enteric microorganisms.

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Informed Consent
Information on the surgical procedure is provided by the physician Explanation includes permission a client gives after an explanation of the risks, benefits, and alternatives A signed form, witnessed by a nurse is evidence that consent has been obtained If the client is mentally confused, unconscious, or mentally incompetent, the clients spouse, nearest blood relative, or someone with durable power of attorney for the clients health care must sign the consent form.

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Types of anesthesia
1. General Anesthesia (inhaled or intravenously) refers to drug induced depression of the central nervous system that produces analgesia, amnesia and unconsciousness (affects whole body). 2. Regional anesthesia is a form of local anesthesia that suspends sensation and motion in body region or part; the client remains awake. Continuous monitoring is required in the event the block is not totally effective and the client experiences pain or reactions to blocking agents (e.g. nausea, cardiovascular collapse). Regional anesthesia differs in terms of location and size of the anatomic area anesthetized and the volume and type of anesthesia agent used.

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3.

4.

Spinal Anesthesia is local anesthesia injected into the subarachniod space at lumbar level to block nerves and suspend sensation and motion to the lower extremities, perineum, and lower abdomen. Conduction Blocks suspend sensation and motion on various groups of nerves such as epidural block (i.e. anesthetic into space around the dura mater); Para vertebral block (i.e. produces anesthesia of the chest, abdominal wall and extremities) and Tran sacral (caudal) block (i.e. anesthesia of the perineum).

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SPINAL ANASTHESIA

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Choice of anesthesia
The patients understanding and wishes regarding the type of anesthesia that could be used The type and duration of the surgical procedure The patientss physiologic status and stability The presence and severity of coexisting disease The patients mental and psychologic status The postoperative recovery from various kinds of anesthesia Options for management pf postoperative pain Any particular requiremets of the surgeon There is major and minor surgery but only major anesthesia
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Perioperative monitoring
Undergeneral anesthesia: monitoring Inspired oxygen analyzer(FiO2) which calibrated to room air and 100% oxygen on a daily basis Low pressure disconnect alarm, which senses pressure in the expiratory limb of the patient circuit Inspiratory pressure Respirometer (these four devices are an integral part of most modern anesthesia machine ECG BP-automated uni Heart rate Precordial or esophagel stethoscope Temp

Perioperative monitoring
Pulse oximeters End tidal carbon dioxide (ECO2) Peripheral nerve stimulatorif muscle relaxants are used Foly catheter For selected patint with a potential risk of venous air embolism a doppler probe may placed over the right atrium Invasive: arterial pressure mesurements, central venous pressure Pulmonary artery catheter and continous mixed venous oxygen saturation measured

Perioperative monitoring
For special conditions other monitors as transcutaneous O2 and CO2 transesophageal echocardiography Electroencephalogram Cereral or neurological may be used

INITIAL POSTOPERATIVE ASSESSMENTS Level of consciousness. Vital signs. Effectiveness of respirations. Presence or need for supplemental oxygen. Location of drains and drainage characteristics. Location, type, and rate of intravenous fluid. Level of pain and need for analgesia. Presence of a urinary catheter and urine volume.

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Conclusion
Preoperative evaluation is necessary to stratify risk to the patient The evaluation delineates patient clinical factors as well as extent of surgery The patient, surgeon, anesthesiologist are aware of the perioperative risk and may plan therapy accordingly

Thanks for your attention!!