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.