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Preoperative assessment and risk stratification (Risks and pitfalls of…
Preoperative assessment and risk stratification
preoperative visit
anamnesis
patients personal data
main diagnosis;
functional capacity (MET’s, NYHA, CCS)
co-morbidities (ASA-PS);
past operations and interventions;
history of complications during
anesthesia;
allergies;
medication;
NYHA
Physical examination:
Symptoms of current disease,
CirculatiON
Respiration
Neurological status.
Airways assesment
ATEWAY ASSESMENT
Mallampati Score
Class 1: Full visibility of tonsils, uvula and soft palate
Class 2: Visibility of hard and soft palate, upper portion of tonsils and uvula
Class 3: Soft and hard palate and base of the uvula are visible
Class 4: Only Hard Palate visible
Cormack & Lehane Grading
Grade I - visualization of entire laryngeal aperture
Grade II - visualization of posterior part of the laryngeal aperture
Grade III - visualization of epiglottis only
Grade IV - not even the epiglottis is visible
Patients’ consent to:
General anaesthesia;
Anaesthesiological procedures
Regional anaesthesia procedures – peripheral blocks, spinal blockades, etc.
Preoperative orders:
noninvasive diagnostis, ie.: ECG,TTE
laboratory tests, ie.: BNP, CRP
consultations: cardiologist,internist, blood products and cross match,
antibiotic prophylaxis
premedicatioN
risk assessment
surgical
Tissue injury associated with surgical intervention elicits a stress response, which increases myocardial oxygen demand.
NSQIP:
type of surgery
functional status
elevated creatinine
ASA class
age
Lee index:
ischaemic heart disease
heart failure
stroke or TIA
renal dysfunction
insulin treated diabetes mellitus
Beta blockers should be continued during perioperative period.
statins should be continued during perioperative period.
Continuation of ACEIs / ARBs during perioperative period should be considered in patients with heart failure.
Patients after PCI with DES / BMS should receive antiplatelet therapy without interruptions through recommended time.
specific disease
Patients with known VHD, scheduled for intermediate or high risk procedures, require actual TTE evaluation.
Continuation of oral antiarrhythmic drugs before surgery is recommended.
Evaluation of AKI according to either KDIGO / AKIN / RIFLE classification is recommended.
monitoring
ECG should be used during all surgical procedures.
TOE should be used intraoperatively for diagnostic purposes in all cases of circulation deterioration.
Routine use of PAC in not recommended.
glucose level by insulin therapy preoperatively below 180 mg/dL is recommended.
Anaemia contributes to organ failure and should be avoided in patients with risk factors.
Risks and pitfalls of general and regional anesthesia
Some of the factors that can increase risk of complications include:
Smoking, sleep apnea, Obesity, High blood pressure, Diabetes, medical conditions involving heart, lungs or kidneys, Medicationsn, that can increase bleeding, heavy alcohol use, Drug allergies, History of adverse reactions to anesthesia
Rare complications, which may occur more frequently in older adults or in people with serious medical problems, include: Temporary mental confusion, Lung infections, Stroke, Heart attack, Death
The most critical moments:
induction / intubation – difficult airways
intraoperative myocard ischaemia; intraoperative low
cardiac output syndrome; anaphylactic shock; hypovolemic
shock / haemorrhage;
recovery from GA and extubation / transfer to postoperative
recovery room
side effects of GA: vomiting, shivering, confusion, memory loss, dizziness, bladder problems, sore throat, lips and/or dental damage;
Complications
a serious allergic reaction to the anaesthetic (anaphylaxis)
an inherited reaction to the anaesthetic (malignant hiperthermia)
death – this is very rare
Complications are more likely to occur in:
major surgery or emergency surgery
presence of any other illnesses
smoking patients
overweighted patients.
risk of regional anas
bleeding/hematoma
infection
nerve/spinal cord injury
spinal (postdural puncture) headache
factor THAT LEAD TO intraoperative awareness:
Emergency surgery, Cesarean surgery, Depression, Heart or lung problems, Daily alcohol use, Lower anesthesia doses than necessary, Errors by the anaesthesiologist
BIS < 40 IS CONSIDERED DEEP GA
Perioperative risk in patients with
Carcinoid syndrome – perioperative administration of octreotide (Sandostatin) is recommended.
Myasthenia – avoid non-depolarising muscle relaxants.
treatment with choline esterase inhibitors (ie.: pirydostygmin = Mestinon) should be continued in pre-, intra- and post- operative period.
Malignant hyperthermia – avoid succinylocholine and inhaled anesthetics; apply dantrolene.
