dr doug campbell division of anesthesiology february 3 rd 2006 l.
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Dr Doug Campbell Division of Anesthesiology February 3 rd 2006. Pre-operative assessment. Goals of preoperative assessment. History and physical examination to determine relevant tests and consultations Guided by patient choice and medical risk factors choose a plan of care

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dr doug campbell division of anesthesiology february 3 rd 2006
Dr Doug Campbell

Division of Anesthesiology

February 3rd 2006

Pre-operative assessment

goals of preoperative assessment
Goals of preoperative assessment
  • History and physical examination to determine relevant tests and consultations
  • Guided by patient choice and medical risk factors choose a plan of care
  • Informed consent
  • Educate patient about anaesthesia, pain management and perioperative care
  • Reduce patient care costs
questions
Questions

What is the risk of proceeding versus the benefit to the patient?

Can we modify these risks before surgery?

mortality related to anaesthesia
Mortality related to anaesthesia
  • Approx 1:26,000 anaesthetics
  • One third of deaths are preventable
  • Causes in order of frequency
    • inadequate patient preparation
    • inadequate postoperative management
    • wrong choice of anaesthetic technique
    • inadequate crisis management
presenting complaint
Presenting complaint

Why does the patient need an operation now?

  • Is it acute/chronic illness?
  • Presenting symptoms?

e.g. anaemia, cachexia, pain, seizures etc

  • What are the pathophysiological consequences?

e.g. thyroid mass

    • Local - stridor, SVC obstruction
    • Systemic - hypo/hyperthyroidism
associated medical conditions
Associated medical conditions

Given the presenting problems are there any other conditions I am worried the patient could have?

  • Bowel ca. - liver mets with abnormal LFTs, abnormal coagulation, impaired drug metabolism
  • Peripheral vascular disease - IHD, carotid disease, HT, renal disease, COAD
other medical conditions
Other medical conditions

Any other problems that may affect

perioperative morbidity and mortality?

  • cardiac disease
  • respiratory disease
  • arthritis
  • endocrine disease - diabetes, obesity etc

What is the patients functional capacity?

functional capacity
Functional capacity
  • 1 MET Can you dress yourself?
  • 4 MET Can you climb a flight of stairs?
  • 10 MET Can you participate in strenuous activities (swimming, tennis,football)
anaesthetic history assessment
Anaesthetic history/assessment
  • Family history
  • Previous anaesthetics
    • PONV
    • allergy
    • malignant hyperpyrexia
    • difficult airway
    • difficult IV access
airway assessment
Airway assessment

Best done by an anaesthetist

Certain features of concern

  • small mouth
  • poor dentition
  • limited neck mobility
  • scars/surgery/anatomical abnormalities
  • obesity
slide17

Why would this man’s airway

be difficult to manage?

drug history
Drug history

Very useful, often forgotten

  • Current medications
  • ALLERGY
  • Medic alert bracelets
  • Smoking/alcohol history
  • Other drugs of abuse!
perioperative medications
Perioperative medications
  • Take all usual medications
    • Antihypertensives
    • Beta blockers
    • Statins
  • Think about discontinuing/replacing
    • Aspirin
    • Anticoagulants
    • Diabetic medications
    • MAOIs
summary
Summary
  • History and physical most important assessors of disease and risk
  • ASA and functional status good predictors of risk
  • Lab tests have some usefulness
    • add little in low risk patients
    • may add false + ves
    • add expense
case example
Case example

You are an orthopaedic House Surgeon

Your Registrar tells you

“ There is a fractured femur in ED, get it ready for theatre.”

What are you going to do?

case example31
Case example

A 49 yr old Samoan woman presents for

elective hemicolectomy. She has a 10 yr

history of NIDDM . She takes glipizide

and metformin

What are you going to do?

case example32
Case example

An 81 yr old man presents for elective

TURP. He has atrial fibrillation, has had

previous TIAs and is on warfarin.

What are you going to do?

case example33
Case example

A 76 year old man with PVD presents for

femoro-popliteal bypass surgery. He has

an ejection systolic murmur on

auscultation.

What are you going to do?