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Preoperative evaluation      workshop       Ahmad abou leila          PGYIV        Ahmad Abou Leila-AUBMC
Patient disease      Anesthesia            surgery                         Satisfied                       Readmitted     ...
Anesthesiologist role            Preoperative evaluation                    Uncover the patient                       risk...
Steps for preop evaluationAsses patient risk                  Asses surgical risk                     Ahmad Abou Leila-AUBMC
Patient risk• History• Physical exam• Lab and radiology testing         Ahmad Abou Leila-AUBMC
Preop evaluation steps                                                   Labs andAcute history                      Physic...
Acute history• History of present illness• Exercise tolerance  – Surgery is major stress  – Good exercise tolerance  – Hew...
Chronic history• Chronic medical problems• Medications and allergies• social history  – smoking (packet per year, cessatio...
Physical exam• Air way• Cardiac• Lungs              Ahmad Abou Leila-AUBMC
As a routine in order to   complete our preop evaluation we send thepatient to lab or radiology                Ahmad Abou ...
Labs or radiology Only when indicated     Ahmad Abou Leila-AUBMC
Tutorial on preop evaluation       Ahmad abouleila         Ahmad Abou Leila-AUBMC
Acute HistoryAssessment of present illness  Physiologic disturbances    What is the surgery?        Ahmad Abou Leila-AUBMC
What is the SurgeryElective or emergent(LIFE SAVING)Elective one can wait and optimizedLife saving no anesthesia clearance...
The pathologic impact       Ahmad Abou Leila-AUBMC
Acute historyAssess exercise toleranceAssessment of Cardiac and    pulmonary reserve       Ahmad Abou Leila-AUBMC
Good exercise Tolerance meanthat the heart will not fail upon       the surgical stress          Opposite is true    excel...
Able to climb the 4th floorwithout dyspnea,chest pain     Good exercise tolerance  Take care in patient who suffer   from ...
HIGH RISK                         Low RISKAhmad Abou Leila-AUBMC
Acute history    NPO status Risk of Aspiration  Ahmad Abou Leila-AUBMC
What is the minimum fasting hours               for 6 hours                                4 hours 6 hours                ...
Normal medication allowed with        sips of water          Ahmad Abou Leila-AUBMC
Any fluid u can read print thought it            is clear fluid              Ahmad Abou Leila-AUBMC
Acute historyPresence of concurrent symptoms          Ahmad Abou Leila-AUBMC
In preop evaluation of patient with history of  mild intermittent asthma u find chest  wheezes                   Would u c...
If patient has symptomatic hyperthyroidism   and scheduled for elective surgery                     What should u do      ...
Thyroid stormAhmad Abou Leila-AUBMC
1 year old baby with runny nose, shall we  cancel surgery                              no        If discharge clear ,no fe...
Chronic historyPast medical history    Ahmad Abou Leila-AUBMC
Past medical history     CVS diseasesCAD,HTN,HF,arrythmias      Ahmad Abou Leila-AUBMC
Cardiovascular events are the leading cause of morbidity and mortality peri-operatively       MI accounts for up to 40% of...
A 65-year-old postmenopausal female with a medicalhistory of coronary artery disease (CAD), hypertension,atrial fibrillati...
Patient with uncomplicated MI,hissurgery must be postponed at least              6 weeks          Ahmad Abou Leila-AUBMC
Ahmad Abou Leila-AUBMC
A 54-year-old male gun shot survivor is evaluated prior to surgery for a  herniated lumbar disc. He has had increasing low...
Ahmad Abou Leila-AUBMC
Balloon angioplasty…………2-4weeks         Ahmad Abou Leila-AUBMC
Mayo Clinic Data: Bare Metal               Stents• major adverse cardiac events (MACE)  after non-cardiac surgery (NCS)  d...
Mayo Clinic Data: Drug Eluting               Stents• MACE after NCS was independent of time  post-placement• 6.4% (0-90d)•...
You are evaluating a patient who is scheduled for cataract surgery. She is 78-years-old and has a complicated medical hist...
Which one of the following surgical procedures is associatedwith the highest risk for perioperative myocardial ischemia   ...
Ahmad Abou Leila-AUBMC
Ahmad Abou Leila-AUBMC
Ahmad Abou Leila-AUBMC
• Low risk Surgery• cardiac risk < 1%  – Endoscopic procedures  – Superficial procedures  – Cataract surgery  – Breast sur...
• Intermediate Risk• cardiac risk < 5%  – Carotid endarterectomy  – Head and neck surgery  – Intraperitoneal and    Intrat...
• High risk• reported risk of adverse cardiac event  >5%  – Emergency surgery  – Aortic procedures  – Peripheral vascular ...
Weksler et. al. Randomized, Prospective Study (n = 989)Patients with DBP between 110 and 130 mmHg were randomlyallocated t...
Resting ECG• Class I (definite indication)  – Recent ischemic symptoms  – Major / intermediate clinical predictors and hig...
Multivariate logistic regression was applied to evaluate the relation between ECGabnormalities and cardiovascular deathRel...
Relative Risk of Cardiovascular Death(EKG Findings):Atrial fibrillation                       4.0Left or right bundle bran...
Preoperative       ECHOCARDIOGRAM• Resting Left Ventricular Function: has not  been shown to be a consistent predictor of ...
NO cardiac evaluationEMEREGENCYCABG < 5 years(no new syptoms)Favorable Cardiac workup< 2years (no new syptoms)           A...
Chest conditions Ahmad Abou Leila-AUBMC
5-10% of all surgical patients (and 940% of those undergoing abdominal surgery) will   experience post-operative pulmonary...
POST OPERATIVE Respiratory Failure                             Ahmad Abou Leila-AUBMC
Predictor                                      PointsSurgery AAA                                           27 Thoracic Sur...
Preventive measures• Lung expansion maneuvers (deep-  breathing exercises and incentive  spirometry• Pain control(epidural...
Which of the following would be the most appropriate test               for preoperative evaluation?                    Ah...
PFTS and CXR ordered only in1.Patient symptomatic2.Unexplained dyspnea3.Intrathoracic procedure such as lungvolume reducti...
Past medical history     Diabetes mellitus       CVS risk factor   Intraop hypoglycemia       Gastroparesis      Wound inf...
Prayer sign in DM  Difficult airway    Ahmad Abou Leila-AUBMC
Past medical history          Renal failure   Drug metabolism disturbance      Electrolyte imbalance             Anemia   ...
Chronic historyMedication and allergies      Ahmad Abou Leila-AUBMC
Ahmad Abou Leila-AUBMC
A 70-year-old man with a history of coronary artery disease,hyperlipidemia, and hypertension is admitted with community-ac...
A 66-year-old man with coronary artery disease had a   bare-metal stent placed in his left anterior descendingcoronary art...
A 70-year-old man with hypertension had a stroke 3 months ago for which he takes 81 mg aspirin daily and 5    mg amlodipin...
A patient scheduled for cataract surgery develops urinary    retention 3 days before his scheduled surgery and is hospital...
A 60-year-old woman with hypertension and a myocardialinfarction 1 year ago is hospitalized for cholecystitis and is sched...
POISE trial: B-blockers     increase mortality• metoprolol 100 mg 2-4 hr preop.• Total mortality increased from 2.3 to  3....
Ahmad Abou Leila-AUBMC
Ahmad Abou Leila-AUBMC
Preop evaluation -medication  Oral hypoglycemic               1 day prior surgery       ACEI                       Skip mo...
Ahmad Abou Leila-AUBMC
Patient A.B receiving therapeutic dose of LMWH     What is the optimal timing to stop LMWH preop?                         ...
Preop evaluation -allergies Latex allergy                               Shall we use this tube for intubation            Y...
Penicillin most common medication           causing allergyPatient allergic to penicillin are 3 x more liable to develop a...
Preop evaluation -allergiesAllergic to pencillin ,and 2g of kefzol are sent  to the OR to be giver prior to surgeries     ...
Penicillin                                                      CephalosporinB-lactam ring is unstable in CephalosporinSki...
Ahmad Abou Leila-AUBMC
Allergy to penicillin    Don’t give imipenem      Ahmad Abou Leila-AUBMC
Patients who have experienced pronounced        allergic reactions with penicillins      such as anaphylaxis, angioedema, ...
Preop evaluation -allergiesAllergic to sulfa drugs           Which diuretic is sulfa   Sulfonamides-bactrim               ...
Egg allergy   One of the components of        propofol is eggIs it safe to use propofol in these               patients   ...
Yes it is safePropofol made of the yellow ,whereas  allergy to egg is to white               Ahmad Abou Leila-AUBMC
Ahmad Abou Leila-AUBMC
Chronic historySocial History ,Smoking,and alcohol          Ahmad Abou Leila-AUBMC
Smoking Dec oxygen carrying capacityStimulates sympathetic system     Coronary narrowing        Irritable airway    Postop...
Preop evaluation  Patient A has stopped                         Patient B has stopped    smoking for few days             ...
Alcohol>50 unit per week associated with   Liver enzyme induction and   anesthetic agent tolerance          Ahmad Abou Lei...
Chronic historyCheck the old anesthesia chart         Ahmad Abou Leila-AUBMC
Anesthesia Chart checking    History of difficult airway            Allergies   Complications(PONV,MH)          Ahmad Abou...
What is the absolutecontraindication for use of volatile            agents          Malignant hyperthermia             Ahm...
Preop-physical exam      Ahmad Abou Leila-AUBMC
Physical examination• heart• Lungs• Airway               Ahmad Abou Leila-AUBMC
Heartcongested neck veins,murmurs ,PVD             Ahmad Abou Leila-AUBMC
LungsWheezes,abnormal sounds,cynosis           Ahmad Abou Leila-AUBMC
Airway assessment    Lemon Score    Ahmad Abou Leila-AUBMC
Lemon score• L:Look externally (abnormal faces,facial trauma,large beard,large tongue)• E:Evaluate the 3-3 rule(TM distanc...
Ahmad Abou Leila-AUBMC
Ahmad Abou Leila-AUBMC
Ahmad Abou Leila-AUBMC
Ahmad Abou Leila-AUBMC
Ahmad Abou Leila-AUBMC
Ahmad Abou Leila-AUBMC
Labs and radiology     Ahmad Abou Leila-AUBMC
• AnemiaHb ,HctAhmad Abou Leila-AUBMC
Recommended indication for preop           hct•   Any suspicion of anemia•   Patient with renal failure or malignancy•   N...
Blood chemistry•   No blood chemistry are warranted for healthy patient less 65y•   If type B or C surgery to be done gluc...
In the endClass               Physical Status               48 hr mortality  I     NHP < 80 years old                     ...
It is not the challenge to put      the patient asleep,              but   the challenge to keep the  patient safe and sat...
Thank you all for listening     See u in next seminar         Ahmad Abou Leila-AUBMC
From preopevaluation to  anesthesia planning       Ahmad Abou Leila-AUBMC
Red rubber tubeAhmad Abou Leila-AUBMC
PONV risk factors•   Female gender•   Non smoker•   Prior history of PONV•   Inhalation agent•   Opiods•   Neostigmine•   ...
My plan to Prevent PONV• Use propofol as induction agent• Avoid opiods• Avoid sudden movement or change in posture  during...
Patient with Parkinson         Avoid    Metochlopramide      Ahmad Abou Leila-AUBMC
Patient with Parkinson      Drug of choice     diphenhyramine       Ahmad Abou Leila-AUBMC
Intestinal obstruction Avoid metochlopramide      Ahmad Abou Leila-AUBMC
Risk of aspiration or GERD      Metochlopramide        Ahmad Abou Leila-AUBMC
Thank uAhmad Abou Leila-AUBMC
18 year old male patient known to be  previously healthy ,admitted to hospital for  knee arthroscopy         Which ASA cla...
Narr and co-workers at the Mayo   Clinic found no harm fromomitting all laboratory testing for         ASA I patients     ...
65 year old male patient admitted for lap  chole,2months ago he was admitted for  cataract surgery ,he underwent extensive...
Preop evaluation• Patient A has mitral                  Patient B has mitral •  stenosis                                  ...
patient has symptomatic hyperthyroidism  and admitted for emergent sugery                     Thyroid storm         My pla...
Preoperative evaluationPatient A has sickle cell        Patient B has PVD  anemia             What regional anesthesia mus...
Preop evaluation• Patient A has mitral              • Patient B has mitral  stenosis                            regurge   ...
Ventilator setting in COPD•   TV :LOW•   RR:LOW•   FiO2:40%•   I:E =1/3               Ahmad Abou Leila-AUBMC
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Preop evaluation workshop (2)

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Preop evaluation workshop (2)

  1. 1. Preoperative evaluation workshop Ahmad abou leila PGYIV Ahmad Abou Leila-AUBMC
  2. 2. Patient disease Anesthesia surgery Satisfied Readmitted Minor morbidity Major morbidity Death Ahmad Abou Leila-AUBMC
  3. 3. Anesthesiologist role Preoperative evaluation Uncover the patient risk factorsFurther testing consultations Preoperative treatment And optimization Anesthesia plan Ahmad Abou Leila-AUBMC
  4. 4. Steps for preop evaluationAsses patient risk Asses surgical risk Ahmad Abou Leila-AUBMC
  5. 5. Patient risk• History• Physical exam• Lab and radiology testing Ahmad Abou Leila-AUBMC
  6. 6. Preop evaluation steps Labs andAcute history Physical exam Chronic history radiology Ahmad Abou Leila-AUBMC
  7. 7. Acute history• History of present illness• Exercise tolerance – Surgery is major stress – Good exercise tolerance – Hewill tolerate surgical stress.• Fasting hours• Presence of concurrent symptoms – Jaundice,wheezes,GERD,toxic symptoms Ahmad Abou Leila-AUBMC
  8. 8. Chronic history• Chronic medical problems• Medications and allergies• social history – smoking (packet per year, cessation,risk factor) – Alcohol(opiods tolerance,alcoholic cardiomyopathy)• History of prior operations (difficult airway,malignant hyperthermia,PONV Ahmad Abou Leila-AUBMC
  9. 9. Physical exam• Air way• Cardiac• Lungs Ahmad Abou Leila-AUBMC
  10. 10. As a routine in order to complete our preop evaluation we send thepatient to lab or radiology Ahmad Abou Leila-AUBMC
  11. 11. Labs or radiology Only when indicated Ahmad Abou Leila-AUBMC
  12. 12. Tutorial on preop evaluation Ahmad abouleila Ahmad Abou Leila-AUBMC
  13. 13. Acute HistoryAssessment of present illness Physiologic disturbances What is the surgery? Ahmad Abou Leila-AUBMC
  14. 14. What is the SurgeryElective or emergent(LIFE SAVING)Elective one can wait and optimizedLife saving no anesthesia clearance Ahmad Abou Leila-AUBMC
  15. 15. The pathologic impact Ahmad Abou Leila-AUBMC
  16. 16. Acute historyAssess exercise toleranceAssessment of Cardiac and pulmonary reserve Ahmad Abou Leila-AUBMC
  17. 17. Good exercise Tolerance meanthat the heart will not fail upon the surgical stress Opposite is true excellent exercise tolerance in patients with stable angina means that myocardium can be stressed withoutLeila-AUBMC Ahmad Abou failing
  18. 18. Able to climb the 4th floorwithout dyspnea,chest pain Good exercise tolerance Take care in patient who suffer from back pain,poor exercise tolerance not due to limited cardiopulmonary reserve Ahmad Abou Leila-AUBMC
  19. 19. HIGH RISK Low RISKAhmad Abou Leila-AUBMC
  20. 20. Acute history NPO status Risk of Aspiration Ahmad Abou Leila-AUBMC
  21. 21. What is the minimum fasting hours for 6 hours 4 hours 6 hours 2 hours Ahmad Abou Leila-AUBMC
  22. 22. Normal medication allowed with sips of water Ahmad Abou Leila-AUBMC
  23. 23. Any fluid u can read print thought it is clear fluid Ahmad Abou Leila-AUBMC
  24. 24. Acute historyPresence of concurrent symptoms Ahmad Abou Leila-AUBMC
  25. 25. In preop evaluation of patient with history of mild intermittent asthma u find chest wheezes Would u cancel the case Yes if the condition not optimized If patient has severe persistent asthma With optimal treatment Still wheezing Stable and proceed Ahmad Abou Leila-AUBMC With good preparation and minimal instrumentation
  26. 26. If patient has symptomatic hyperthyroidism and scheduled for elective surgery What should u do Cancel the case and refer to endocrinologist Ahmad Abou Leila-AUBMC
  27. 27. Thyroid stormAhmad Abou Leila-AUBMC
  28. 28. 1 year old baby with runny nose, shall we cancel surgery no If discharge clear ,no fever,no wheezes ,normal cxr Don’t cancel Ahmad Abou Leila-AUBMC
  29. 29. Chronic historyPast medical history Ahmad Abou Leila-AUBMC
  30. 30. Past medical history CVS diseasesCAD,HTN,HF,arrythmias Ahmad Abou Leila-AUBMC
  31. 31. Cardiovascular events are the leading cause of morbidity and mortality peri-operatively MI accounts for up to 40% of perioperative fatalities. Ahmad Abou Leila-AUBMC
  32. 32. A 65-year-old postmenopausal female with a medicalhistory of coronary artery disease (CAD), hypertension,atrial fibrillation, and dyslipidemia presents to theemergency department (ED) complaining of an acute onsetof leg pain. Further testing and evaluation reveals that shehas an acute arterial emboli and needs immediateembolectomy. Her heart rate is 85 bpm. As the medicalconsultant, what is the MOST APPROPRIATE next step?A. Complete a full preoperative evaluation, including a stress test, because she will need a vascular procedure.B. Ask the patient about her physical activity so you can calculate her metabolic equivalents (METs) because she will have an intermediate-risk surgery.C. Evaluate her postoperatively for signs and symptoms of a myocardial infarction (MI).D. Ask for surgery to be delayed for 2 days until a ß blocker lowers her heart rate to between 55 and 65 bpm slowly. Ahmad Abou Leila-AUBMC
  33. 33. Patient with uncomplicated MI,hissurgery must be postponed at least 6 weeks Ahmad Abou Leila-AUBMC
  34. 34. Ahmad Abou Leila-AUBMC
  35. 35. A 54-year-old male gun shot survivor is evaluated prior to surgery for a herniated lumbar disc. He has had increasing lower back pain for the past year that is poorly controlled with pain medications. He also had a non-ST-segment elevation MI and underwent cardiac catheterization with coronary artery stent placement 2 weeks ago with a subsequent stress test that did not show any residual ischemia. His ECG shows a normal sinus rhythm. Which statement is MOST CORRECT?A. This patient is at low risk for cardiac complications because his stress test was negative.B. Because the patient had a negative stress test, he no longer has any red flag/active cardiac conditions.C. Depending on the type of stent placed, elective surgery may be contraindicated for up to 1 year.D. If a bare-metal stent (BMS) was placed, the patient can safely proceed to surgery in 1 week. Ahmad Abou Leila-AUBMC
  36. 36. Ahmad Abou Leila-AUBMC
  37. 37. Balloon angioplasty…………2-4weeks Ahmad Abou Leila-AUBMC
  38. 38. Mayo Clinic Data: Bare Metal Stents• major adverse cardiac events (MACE) after non-cardiac surgery (NCS) decreased with increased time post- BMS placement• 10.5% (< 30d)• 3.8% (31-90d)• 2.8% (> 90d)• and that bleeding complications were not associated with antiplatelet therapy within a week of surgery [Nuttal et. al. Anesthesiology 109: 588, 2008] Ahmad Abou Leila-AUBMC
  39. 39. Mayo Clinic Data: Drug Eluting Stents• MACE after NCS was independent of time post-placement• 6.4% (0-90d)• 5.7% (91-180d)• 5.9% (181-365d)• 3.3% (>356d) Rabbitts et. al. Anesthesiology 109: 596, 2008]. Ahmad Abou Leila-AUBMC
  40. 40. You are evaluating a patient who is scheduled for cataract surgery. She is 78-years-old and has a complicated medical history, including diabetes mellitus,hypertension, chronic kidney disease, dyslipidemia, CAD with a 3-vessel coronaryartery bypass graft (CABG) 2 years ago, and a 110 pack/year smoking habit thatended after her CABG. After you take her history and examine her, you determineshe does not have any red flag issues. Which of the statements concerning therest of the preoperative evaluation is MOST ACCURATE? Because this patient has a strong history of CAD, she will need noninvasive cardiac stress testing before her surgery. Because this patient had a CABG in the last 2 years, an evaluation of her MET capacity is unnecessary. Because the planned surgery is a high-risk procedure, the patient needs noninvasive cardiac stress testing before surgery. Because the planned surgery is a low-risk surgery, no further evaluation is needed. Ahmad Abou Leila-AUBMC
  41. 41. Which one of the following surgical procedures is associatedwith the highest risk for perioperative myocardial ischemia Femoropopliteal bypass Pulmonary lobectomy Hip arthroplasty Transurethral resection of the prostate Mastectomy Ahmad Abou Leila-AUBMC
  42. 42. Ahmad Abou Leila-AUBMC
  43. 43. Ahmad Abou Leila-AUBMC
  44. 44. Ahmad Abou Leila-AUBMC
  45. 45. • Low risk Surgery• cardiac risk < 1% – Endoscopic procedures – Superficial procedures – Cataract surgery – Breast surgery Ahmad Abou Leila-AUBMC
  46. 46. • Intermediate Risk• cardiac risk < 5% – Carotid endarterectomy – Head and neck surgery – Intraperitoneal and Intrathoracic – Orthopedic surgery – Prostate surgery Abou Leila-AUBMC Ahmad
  47. 47. • High risk• reported risk of adverse cardiac event >5% – Emergency surgery – Aortic procedures – Peripheral vascular surgery – Prolonged surgical procedures associated with large volume shifts or high EBL Ahmad Abou Leila-AUBMC
  48. 48. Weksler et. al. Randomized, Prospective Study (n = 989)Patients with DBP between 110 and 130 mmHg were randomlyallocated to admission for BP control, followed by surgery,versus 10 mg intranasal nifedipine and immediate surgeryno statistically significant differences in postoperative complications(no neurologic or cardiovascular complications in either group).However, the average hospitalization time was significantly longer (12vs. 6 days, p = 0.003) Howell: Metaanalysis and Retrospective/Cohort StudiesNo significant relationship between admission bloodpressure and outcome Ahmad Abou Leila-AUBMC
  49. 49. Resting ECG• Class I (definite indication) – Recent ischemic symptoms – Major / intermediate clinical predictors and high or intermediate risk procedure• Class II (probably warranted) – Asymptomatic diabetics – History of cardiac revascularization – Asymptomatic man > 45 yo or woman > 55 yo – Prior hospitalization for cardiac causes• Class III (not indicated) – Asymptomatic patient; low risk procedure Ahmad Abou Leila-AUBMC
  50. 50. Multivariate logistic regression was applied to evaluate the relation between ECGabnormalities and cardiovascular deathRelative Risk of Cardiovascular Death(EKG Findings):Patients with abnormal ECG findings had a greater incidence of cardiovascularAtrial fibrillation 4.0death than those with normal ECG results (1.8% vs 0.3%; adjusted OR 4.5, CILeft to 6.0). bundle branch block3.3 or right 2.0Left ventricular hypertrophy 1.8Premature ventricular complexes 2.3Pacemaker rhythm 4.4Q-wave 2.4STD 2.1Any abnormal EKG 4.5 Ahmad Abou Leila-AUBMC
  51. 51. Relative Risk of Cardiovascular Death(EKG Findings):Atrial fibrillation 4.0Left or right bundle branch block 2.0Left ventricular hypertrophy 1.8Premature ventricular complexes 2.3Pacemaker rhythm 4.4Q-wave 2.4STD 2.1Any abnormal EKG 4.5 Ahmad Abou Leila-AUBMC
  52. 52. Preoperative ECHOCARDIOGRAM• Resting Left Ventricular Function: has not been shown to be a consistent predictor of perioperative ischemic events [ACC/AHA Guidelines}Patients with poor functional status shouldundergo noninvasive testing unless low-risksurgery is planned Ahmad Abou Leila-AUBMC
  53. 53. NO cardiac evaluationEMEREGENCYCABG < 5 years(no new syptoms)Favorable Cardiac workup< 2years (no new syptoms) Ahmad Abou Leila-AUBMC
  54. 54. Chest conditions Ahmad Abou Leila-AUBMC
  55. 55. 5-10% of all surgical patients (and 940% of those undergoing abdominal surgery) will experience post-operative pulmonary complicationsObese patients do have a higher incidence of pulmonarythrombotic complications[Gutt Am J Surg 189: 14, 2005] Ahmad Abou Leila-AUBMC
  56. 56. POST OPERATIVE Respiratory Failure Ahmad Abou Leila-AUBMC
  57. 57. Predictor PointsSurgery AAA 27 Thoracic Surgery 21 NSGY, upper abdominal, or peripheral <=10 0.5% 14vascular 11-9 2.2% 20-27 5.0% Neck 11 28-40 11.6% Emergency 11 >40 30.5%Albumin < 30 g/dL 9BUN > 30 mg/dL 8Partially or fully dependent 7COPD 6Age >= 70 6Age 60-69 6

Risk Ahmad Abou Leila-AUBMC
  58. 58. Preventive measures• Lung expansion maneuvers (deep- breathing exercises and incentive spirometry• Pain control(epidural analgesia)• Preoperative education• intermittent positive pressure breathing and CPAP, while effective, are not recommended due to their high cost Ahmad Abou Leila-AUBMC
  59. 59. Which of the following would be the most appropriate test for preoperative evaluation? Ahmad Abou Leila-AUBMC
  60. 60. PFTS and CXR ordered only in1.Patient symptomatic2.Unexplained dyspnea3.Intrathoracic procedure such as lungvolume reduction Ahmad Abou Leila-AUBMC
  61. 61. Past medical history Diabetes mellitus CVS risk factor Intraop hypoglycemia Gastroparesis Wound infection Difficult airway Ahmad Abou Leila-AUBMC
  62. 62. Prayer sign in DM Difficult airway Ahmad Abou Leila-AUBMC
  63. 63. Past medical history Renal failure Drug metabolism disturbance Electrolyte imbalance Anemia Uraemic gastroparesis Ahmad Abou Leila-AUBMC
  64. 64. Chronic historyMedication and allergies Ahmad Abou Leila-AUBMC
  65. 65. Ahmad Abou Leila-AUBMC
  66. 66. A 70-year-old man with a history of coronary artery disease,hyperlipidemia, and hypertension is admitted with community-acquired pneumonia. On his second hospital day he has aseizure. A computed tomography scan reveals a 5-cm mass withevidence of midline shift. He is taking clopidogrel and aspirinafter having a recent coronary artery stent placed 4 weeks ago.The neurosurgeon says your patient will need to go to theoperating room in the next 7 days. What would be the optimalmanagement of this patient’s antiplatelet medications? A. Discontinue both aspirin and clopidogrel immediatelyso that the antiplatelet effects will be minimal when your patient goes to surgery. B. Discontinue aspirin and clopidogrel and start your patient on UFH. C. Continue aspirin and clopidogrel until the day before surgery. D. Discontinue aspirin and clopidogrel and start your patient on a glycoprotein IIb/IIIa inhibitor until surgery. Ahmad Abou Leila-AUBMC
  67. 67. A 66-year-old man with coronary artery disease had a bare-metal stent placed in his left anterior descendingcoronary artery 3 weeks ago. He has gallstones and wantshis gallbladder removed. Which of the following is the most appropriate management plan?A. Postpone the surgery until he has had at least 6 weeks of dual antiplatelet therapy with aspirin and clopidogrel. Then proceed with surgery while the patient is taking aspirin.B. Discontinue his aspirin and clopidogrel and proceed with the surgical procedure using LMWH as a bridging antithrombotic agent.C. Discontinue his aspirin and clopidogrel and proceed with the surgical procedure using eptifibatide as a bridging antithrombotic agent.D. Discontinue his aspirin and clopidogrel and proceed with the surgical procedure using bivalirudin for bridging anticoagulation. Ahmad Abou Leila-AUBMC
  68. 68. A 70-year-old man with hypertension had a stroke 3 months ago for which he takes 81 mg aspirin daily and 5 mg amlodipine daily. He is scheduled for a dentalextraction. What is the best preoperative recommendation to manage his aspirin therapy?A. Do not stop aspirin before surgery.B. Stop aspirin 1 to 3 days before surgery.C. Stop aspirin 5 to 7 days before surgery.D. Stop aspirin 10 to 14 days before surgery. Ahmad Abou Leila-AUBMC
  69. 69. A patient scheduled for cataract surgery develops urinary retention 3 days before his scheduled surgery and is hospitalized. A Foley catheter is inserted and the urologist recommends starting tamsulosin. The ophthalmologist decides to proceed with scheduled surgery because the patient is already in the hospital. The patient’s blood pressure is 120/80 mm Hg. Which of the following is most correct about management of tamsulosin in the perioperative period?A. Continue tamsulosin preoperatively to minimize ongoing prostatic obstruction.B. Continue tamsulosin preoperatively to avoid rebound hypertension (if it is stopped).C. Discontinue tamsulosin preoperatively to avoid floppy iris syndrome.D. Discontinue tamsulosin preoperatively to avoid intraoperative hypotension. Ahmad Abou Leila-AUBMC
  70. 70. A 60-year-old woman with hypertension and a myocardialinfarction 1 year ago is hospitalized for cholecystitis and is scheduled for a laparoscopic cholecystectomy in 1 week.Her medications include an aspirin, metoprolol 25 mg twice a day, and a statin. Her blood pressure is 110/70 mm Hg and her pulse is 64 BPM. What is the best perioperative recommendation for her ß-blocker therapy?A. Stop the metoprolol 2 to 3 days before surgery.B. Stop the metoprolol on the morning of surgery.C. Continue the metoprolol preoperatively.D. Increase the dose of the metoprolol to 50 mg twice a day to slow her heart rate to less than 60 BPM. Ahmad Abou Leila-AUBMC
  71. 71. POISE trial: B-blockers increase mortality• metoprolol 100 mg 2-4 hr preop.• Total mortality increased from 2.3 to 3.1% at 30 days.• An important exclusion criteria in POISE was "receiving a β-blocker or their physician planned to start one perioperatively“• [Devereaux et al. Lancet 31: 371, 2008] Ahmad Abou Leila-AUBMC
  72. 72. Ahmad Abou Leila-AUBMC
  73. 73. Ahmad Abou Leila-AUBMC
  74. 74. Preop evaluation -medication Oral hypoglycemic 1 day prior surgery ACEI Skip morning dose Plavix 7 days before ticlopidine 14 days before warfarin 3-4 days Ahmad Abou Leila-AUBMC
  75. 75. Ahmad Abou Leila-AUBMC
  76. 76. Patient A.B receiving therapeutic dose of LMWH What is the optimal timing to stop LMWH preop? A-12hrs B-18hrs Therapeutic LMWH doses should be stopped 24hrsProphylactic LMWH doses should be stopped 12 hrs Ahmad Abou Leila-AUBMC
  77. 77. Preop evaluation -allergies Latex allergy Shall we use this tube for intubation Yes because they are made of PVC not latex Avoid red rubber tube And adhesives Ahmad Abou Leila-AUBMC
  78. 78. Penicillin most common medication causing allergyPatient allergic to penicillin are 3 x more liable to develop allergy to other medication Ahmad Abou Leila-AUBMC
  79. 79. Preop evaluation -allergiesAllergic to pencillin ,and 2g of kefzol are sent to the OR to be giver prior to surgeries What is the cross allergencity between Cephalsporins and pencillin Shall I give or not Ahmad Abou Leila-AUBMC
  80. 80. Penicillin CephalosporinB-lactam ring is unstable in CephalosporinSkin tests have not confirmed cross reactivityThere is risk of cross allergenicity between 1st generation Cephalosporin and Ahmad Abou Leila-AUBMCpenicillin
  81. 81. Ahmad Abou Leila-AUBMC
  82. 82. Allergy to penicillin Don’t give imipenem Ahmad Abou Leila-AUBMC
  83. 83. Patients who have experienced pronounced allergic reactions with penicillins such as anaphylaxis, angioedema, or bronchospasm should not receive therapy containing a cephalosporin or imipenem.Aztreonam may be safely administered to patients with a history of penicillin allergy Ahmad Abou Leila-AUBMC
  84. 84. Preop evaluation -allergiesAllergic to sulfa drugs Which diuretic is sulfa Sulfonamides-bactrim drug and comonly used in the OR sulfonylureas Ahmad Abou Leila-AUBMC
  85. 85. Egg allergy One of the components of propofol is eggIs it safe to use propofol in these patients Ahmad Abou Leila-AUBMC
  86. 86. Yes it is safePropofol made of the yellow ,whereas allergy to egg is to white Ahmad Abou Leila-AUBMC
  87. 87. Ahmad Abou Leila-AUBMC
  88. 88. Chronic historySocial History ,Smoking,and alcohol Ahmad Abou Leila-AUBMC
  89. 89. Smoking Dec oxygen carrying capacityStimulates sympathetic system Coronary narrowing Irritable airway Postoperative infection Ahmad Abou Leila-AUBMC
  90. 90. Preop evaluation Patient A has stopped Patient B has stopped smoking for few days smoking for 8 weeks prior prior or OR How cessation of smoking Affect the outcome of anethesia In these 2 patients Decrease in the pulmonary complication Improve cilliary functionIncrease in air way reactivity Decrease carboxy HB Increase tissue oxygenation Ahmad Abou Leila-AUBMC
  91. 91. Alcohol>50 unit per week associated with Liver enzyme induction and anesthetic agent tolerance Ahmad Abou Leila-AUBMC
  92. 92. Chronic historyCheck the old anesthesia chart Ahmad Abou Leila-AUBMC
  93. 93. Anesthesia Chart checking History of difficult airway Allergies Complications(PONV,MH) Ahmad Abou Leila-AUBMC
  94. 94. What is the absolutecontraindication for use of volatile agents Malignant hyperthermia Ahmad Abou Leila-AUBMC
  95. 95. Preop-physical exam Ahmad Abou Leila-AUBMC
  96. 96. Physical examination• heart• Lungs• Airway Ahmad Abou Leila-AUBMC
  97. 97. Heartcongested neck veins,murmurs ,PVD Ahmad Abou Leila-AUBMC
  98. 98. LungsWheezes,abnormal sounds,cynosis Ahmad Abou Leila-AUBMC
  99. 99. Airway assessment Lemon Score Ahmad Abou Leila-AUBMC
  100. 100. Lemon score• L:Look externally (abnormal faces,facial trauma,large beard,large tongue)• E:Evaluate the 3-3 rule(TM distance >3fingers,interincisor distance>3fingers)• M:Mallampati score• O:Obstruction(OSA,Head and neck tumor)• N:Neck mobility Ahmad Abou Leila-AUBMC
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  107. 107. Labs and radiology Ahmad Abou Leila-AUBMC
  108. 108. • AnemiaHb ,HctAhmad Abou Leila-AUBMC
  109. 109. Recommended indication for preop hct• Any suspicion of anemia• Patient with renal failure or malignancy• Neonates• Patient older than 75• Any procedure with major blood loss Ahmad Abou Leila-AUBMC
  110. 110. Blood chemistry• No blood chemistry are warranted for healthy patient less 65y• If type B or C surgery to be done glucose ,BUN,albumin are indicated Renal failure patient BUN,Creatinine,electrlytes Post dialysis Ahmad Abou Leila-AUBMC
  111. 111. In the endClass Physical Status 48 hr mortality I NHP < 80 years old 0.07% II Mild systemic disease 0.24% III Severe, not incapacitating systemic 1.4% disease IV Incapacitating disease that is a 7.5% constant threat to life V Moribund pt. not expected to survive 24 8.1% hrs regardless of surgery E Suffix added to class Doubles risk Ahmad Abou Leila-AUBMC
  112. 112. It is not the challenge to put the patient asleep, but the challenge to keep the patient safe and satisfied AHMAD ABOU LEILA Ahmad Abou Leila-AUBMC
  113. 113. Thank you all for listening See u in next seminar Ahmad Abou Leila-AUBMC
  114. 114. From preopevaluation to anesthesia planning Ahmad Abou Leila-AUBMC
  115. 115. Red rubber tubeAhmad Abou Leila-AUBMC
  116. 116. PONV risk factors• Female gender• Non smoker• Prior history of PONV• Inhalation agent• Opiods• Neostigmine• Gynecological ,ophthaologhy surgeries Ahmad Abou Leila-AUBMC
  117. 117. My plan to Prevent PONV• Use propofol as induction agent• Avoid opiods• Avoid sudden movement or change in posture during recovery• Avoid excessive use use of muscle relaxants• Anti emetics – Metochlopramide 10mg 10-15 min before the end of surgery – Zofran 4 mg at the end of surgery – Decadron at induction Ahmad Abou Leila-AUBMC
  118. 118. Patient with Parkinson Avoid Metochlopramide Ahmad Abou Leila-AUBMC
  119. 119. Patient with Parkinson Drug of choice diphenhyramine Ahmad Abou Leila-AUBMC
  120. 120. Intestinal obstruction Avoid metochlopramide Ahmad Abou Leila-AUBMC
  121. 121. Risk of aspiration or GERD Metochlopramide Ahmad Abou Leila-AUBMC
  122. 122. Thank uAhmad Abou Leila-AUBMC
  123. 123. 18 year old male patient known to be previously healthy ,admitted to hospital for knee arthroscopy Which ASA class ASA 1 What type of surgery Type A surgery What lab test should be obtained NONE Ahmad Abou Leila-AUBMC
  124. 124. Narr and co-workers at the Mayo Clinic found no harm fromomitting all laboratory testing for ASA I patients Ahmad Abou Leila-AUBMC
  125. 125. 65 year old male patient admitted for lap chole,2months ago he was admitted for cataract surgery ,he underwent extensive lab testing including CBCD,Chem9,EKG Would u repeat these tests? ASA task forces states that results from medical record within 6 months of surgery are accepted if ther is no dramatic change in the patient medical history Ahmad Abou Leila-AUBMC
  126. 126. Preop evaluation• Patient A has mitral Patient B has mitral • stenosis regurge My plan My plan Avoid tachycardia Avoid bradycardia Ahmad Abou Leila-AUBMC
  127. 127. patient has symptomatic hyperthyroidism and admitted for emergent sugery Thyroid storm My plan 1. Invasive monitoring 2. Big gauge IV 3. Measures to control fever 4. PrepareAhmad Abou Leila-AUBMC Beta blockers 5. Firs dose of PTU administered by NGT
  128. 128. Preoperative evaluationPatient A has sickle cell Patient B has PVD anemia What regional anesthesia must be avoided IV regional anesthesia Ahmad Abou Leila-AUBMC
  129. 129. Preop evaluation• Patient A has mitral • Patient B has mitral stenosis regurge My plan My plan Avoid tachycardia Avoid bradycardia Ahmad Abou Leila-AUBMC
  130. 130. Ventilator setting in COPD• TV :LOW• RR:LOW• FiO2:40%• I:E =1/3 Ahmad Abou Leila-AUBMC

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