how to prepare patients for surgery and how to follow up patients after the operations

1. Anesthetic Preparations
For Surgery
Prepared By:
Dr. Othman Ismat Abdulmajeed
Cardiac Anesthetist
Hawler Medical College
othman.abdulmajeed@med.hmu.edu.iq
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2. The Aim..
• Clinical Assessment..
• Anesthetic Assessment..
• What investigations we need ?
• What are the risks of having anesthesia ?
• Postoperative Care..
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3. Clinical Assessment
• Ideally, every patient should be seen by an anesthetist prior to
surgery in order to identify, manage and minimize the
anesthesia risk.
• Traditionally, this occurring when the patient was admitted, usually
the day before an elective surgical procedure. However, if at this
time the patient was found to have any significant co-morbidity,
surgery was often postponed, and with no time to admit a different
patient operating time was wasted.
• Recently, in an attempt to improve efficiency, There is a significant
changes in the preoperative management including the
introduction of clinics for anesthetic assessment.
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4. The Preoperative
assessment..
A variety of models of ‘preoperative’ or ‘anesthetic
assessment’ clinic exist; the following is intended to outline
their principal functions:
Stage 1:-
Although not all patients need to be seen by an anesthetist in
a preoperative assessment clinic, all patients do need to be
assessed by an appropriately trained individual, who may
take a history, examine the patient, and order investigations
according to the local protocol.
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5. The primary aim is to identify patients who:
• have no coexisting medical problems.
• having a coexisting medical problems that is well
controlled and does not impair daily activities, like
hypertension.
• require only baseline investigations.
• have no history of anesthetic difficulties.
Having fulfilled these criteria, patients can then be listed for
surgery. At this stage, the patient will usually be given
preliminary information about anesthesia.
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6. On admission, these patients will need to be seen by a member
of the surgical team, to ensure that there have not been any
significant changes since attending the clinic, and by the
anesthetist who will:
• confirm the findings from the preoperative assessment.
• check the results of baseline investigations.
• explain the options for anesthesia appropriate for the
procedure.
• have the ultimate responsibility for deciding it is safe to
proceed.
• obtain consent for anesthesia.
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7. Stage 2:-
Clearly not all patients are as described in stage1, common
reasons for patients not meeting the above criteria include:
• coexisting medical problems that are previously undiagnosed,
for example diabetes, hypertension.
• medical conditions that are less than optimally managed, for
example angina.
• abnormal baseline investigations.
These patients will need to be sent for further investigations, for
example ECG, PFT and ECHO, or be referred to the appropriate
specialist for advice or further management before being
reassessed.
The findings of the further investigations then dictate whether or
not the patient needs to be seen by an anesthetist.
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8. Stage 3:-
Patients that will need to be seen by an anesthetist in the
preoperative clinic are those who:-
1. have concurrent disease, and are symptomatic
despite optimal treatment.
2. previous anesthetic difficulties, like difficult intubation.
3. have the potential for difficulties, like obesity.
4. previous or family history of apnea after anesthesia.
5. are to undergo complex surgery.
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9. The consultation will allow the anesthetist to:-
A. make a full assessment of the patient’s medical
condition.
B. evaluate the results of investigations or advice
from other specialists.
C. request any additional investigations.
D. review any previous anesthetics given.
E. decide on the most appropriate technique.
F. begin the consent process, explaining and
documenting.
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10. The ultimate aim is to ensure that once a patient is
admitted for surgery, their intended procedure is not
cancelled as a result of them being “unfit” or because
their medical condition has not been adequately
investigated.
Clearly the time between the patient being seen in
the assessment clinic and the date of admission for
surgery cannot be excessive; 4-6 weeks is usually
acceptable.
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11. The Anesthetic assessment
The anesthetic assessment consist of taking a history,
examining each patient followed by any appropriate
investigations.
When performed by non-anesthetic staff, a protocol is
often used to ensure all the relevant areas are
covered.
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12. A. Present and Past Medical History :-
Within the patient’s medical history aspects relating to
the cardiovascular and respiratory systems are
relatively more important to the anesthetist than the
other areas.
1. Cardiovascular System:
Enquire specifically about symptoms of ischemic
heart disease,heart failure,hypertension,valvular heart
disease,conduction defects, Arrhythmias,peripheral
vascular disease, previous (DVT) or (PE).
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13. Patients with a proven history of myocardial infarction
(MI) are at a greater risk of further infarction
perioperatively .
Heart failure is one of the most important predictors of
perioperative complications.
Untreated or poorly controlled hypertension may lead to
exaggerated cardiovascular responses during anesthesia.
Both hypertension and hypotension can be precipitated .
The American Heart Association has produced
guidance for perioperative cardiovascular evaluation.
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14. NYHA functional classification
Class I Cardiac disease without physical limitation
Class II Cardiac disease with slight physical limitation
Class III Cardiac disease with marked physical limitation
Class IV Cardiac disease limiting any physical activity
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New York Heart Association classification of
cardiac function

15. 2. Respiratory System: chronic obstructive pulmonary
disease, chronic bronchitis, emphysema, asthma and
infection.
3. Rheumatoid disease: causes limited movements of joints.
4. Diabetes: increase incidence of IHD and renal
dysfunction.
5. Chronic renal failure: anemia and electrolyte
disturbance.
6. Jaundice: altered drug metabolism, coagulopathy.
7. Neuromuscular disorders: poor respiratory function.
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16. B. Previous anesthetics and operations:-
• Ask about any perioperative problems for example
nausea, vomiting, awareness, jaundice.
• Ask if any information was given postoperatively,
for example difficulty with intubation, delayed
recovery.
• Whenever possible, check the records of previous
anesthetics to rule out or clarify problems such as
difficult intubation, drug allergy.
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17. C. Family History:-
All patients should be asked wether any family
members have experienced problems with
anesthesia; for example a history of prolonged
apnoea.
D. Drug History & Allergies:-
The number of medications taken rises with age.
Many commonly prescribed drugs for example: B-
blocker have important interactions with drugs used
during anesthesia.
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18. The Examination
• This concentrates on the CVS and RS, The
remaining systems are examined if problems
relevant to anesthesia have been identified in the
history.
• If a regional anesthesia is planned, the appropriate
anatomy (e.g. lumbar spine for central neural
block) is examined.
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19. • Cardiovascular System: examine for,
arrhythmias, heart failure, hypertension, valvular heart
disease, peripheral vascular disease.
Don’t forget to inspect the peripheral veins to identify
any potential problems with I.V. access.
• Respiratory System: examine for,
respiratory failure, atelectasis, consolidation, pleural
effusion, impaired ventilation.
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20. • Nervous System:
Chronic disease of the central and peripheral nervous
systems should be identified, and any evidence of
motor or sensory impairment recorded.
• Musculoskeletal System:
Note any restriction of movement and deformity if a
patient has connective tissue disorders. Patients
suffering from chronic rheumatoid disease frequently
have a reduced muscle mass, peripheral
neuropathies and pulmonary involvement.
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21. The Airway
The airway of the patient must be assessed in order to
predict those patients who may be difficult to intubate.
A- Observation of the patient’s anatomy. Look for:
1. limitation of mouth opening
2. receding mandible
3. position, number and health of teeth
4. size of the tongue
5. soft tissue swelling at the front of the neck
6. limitations in flexion and extension of the cervical spine.
Finding any of these suggests that intubation may be more
difficult. 21

22. B- Simple Bedside Test
1- Mallampati Test.
2- Thyromental Distance.
3- Calder Test: The patient is asked to protrude the
mandible as far as possible. The lower incisors will lie
either anterior to, aligned with, or posterior to the
upper incisors. The latter two suggest a reduced view
at laryngoscopy.
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23. Mallampati Test
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24. Thyromental Distance
• With the head fully extended
on the neck, the distance
between the bony point of the
chin and the prominence of
the thyroid cartilage is
measured.
• A distance of <7cm suggests
difficult intubation.
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25. Risk Associated With
Anesthesia
One of the most commonly asked questions of anesthetist is
“What are the risk of having an anesthetics?”.These can be
divided into two groups:
1. Minor. These are not life threatening and can occur even
when anesthesia has apparently been uneventful. They
include:
• failed I.V. access.
• cut lip, damage to teeth, caps, crowns .
• sore throat.
• headache.
• Postoperative nausea and vomiting.
• urine retention.
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26. 2. Major Risk. These may be life-threatening events.
They include :
• aspiration of gastric contents.
• hypoxic brain damage.
• myocardial infarction.
• cerebrovascular accident
• nerve injury.
• chest infection.
• renal failure.
• death.
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27. Post Anesthesia Care
Each patient in the recovery unit should be cared
for in an area equipped with:
• oxygen supply
• ECG monitoring
• Pulse oximetry
• non-invasive blood pressure (NIBP) monitor
• suction apparatus
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28. Postoperative
Complications
1. Hypoxia
2. Hypotension
3. Hypertension
4. Postoperative nausea & vomiting (PONV)
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29. Postoperative Analgesia
Postoperative pain sequels are:
1. CVS: Tachycardia, Hypertension.
2. Respiratory: decreased of vital capacity & tidal
volume, chest infection, Basal atelectasis.
3. GIT: nausea and vomiting, ileus.
4. other effects: urinary retention, DVT, pulmonary
embolus.
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30. Risk Factors for PONV
• Patient Factors: Gender, Age, Anxiety, History of motion
sickness, Previous PONV, Obesity, Delayed gastric
emptying.
• Anesthetic Factors:
a- Drugs like opioids.
b- Technique like gastric insufflation.
• Surgical Factors: Emergency operation, ENT surgery,
Gynecological procedures, GIT surgery, Ileus, Gastric
distension.
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31. Sequelae of Anesthesia
• Eye trauma.
• Airway trauma.
• Musculoskeletal trauma.
• Skin damage.
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33. Thank you
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