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COURSE OUTLINESTHE FORMAT OF THE COURSEKNOWLEDE AND SKILLS THAT CAN BE
GAINED.COURSE PROGRAMECOURE OBJECTIVESREQUIRE MATERIALS:TEXT BOOKS
Anesthesia Rotation bookASSESSMENT
POLICY OF MISSED WORK (ATTENDENCE REQUIREMENT)
FINAL EXAMCONTACT INFORMATION DEPARTMENT 71597 Dr walid tel 71816 Dr osama bleep 2158QUESTIONS
Clinical Objectives for Medical Students in (044) Anesthesia and CPR Course
At the end of the course the student will be able to understand and practice:
1- Pre-anesthesia assessment and evaluation Able to take history from patient Able to open PAC System to get information and
investigation. Interpretation of preoperative data relevant to
anesthetic plan. Consultations
2- Orientation with anesthesia equipment in O.R. Anesthesia machine Anesthesia circuits Laryngoscopes – tubes – LMA – Airways Epidural set Spinal set Monitors - Anesthesia Record Anesthetics Drugs : I.V. drugs Inhalational &
Muscle Relaxants Resuscitation Drugs During Anesthesia Crystalloids & Colloids Fluids
3- Post-operative Care Unit OrientationsCase Scenarios: Interactive Case Discussion
4- Surgical ICU Rounds & Discussions about Management of critically I’ll patient Monitoring of critically I’ll patient Ventilators Common Cases in ICU
Head injury management
Sepsis management
Role Of Anesthesiologist In pre-Opertive period
Anesthesia
The word is derived from the Greek words an, which means “without” and aithesia which means “feeling”
The use of medical anesthesia was first reported in 1846
The development of anesthesia has made today’s modern surgical techniques possible
Basic Principles of Anesthesia
“Triad of General Anesthesia”need for unconsciousnessneed for analgesianeed for muscle relaxation and loss of
reflexes
Anesthetic assessment andpreparation for surgery
Purposes of the Preoperative Evaluation1. Obtain medical history
2. Review current physical status
3. Order additional tests / consultation
4. Answer questions
Overview.
The preanesthetic evaluation has specific objectives including:
- Establishing a doctor-patient relationship,
- Becoming familiar with the surgical illness and coexisting medical conditions,
Developing a management strategy for perioperative anesthetic care,
- Obtaining informed consent for the anesthetic plan.
The overall goals of the preoperative assessment are to reduce perioperative
morbidity and mortality and to allay patient anxiety.
Stages of the Peri-Operative Period
Pre-Operative
From time of decision to have surgery until
admitted into the OR theatre.
Stages of the Peri-Operative Period
Intra-Operative
Time from entering the OR theatre to entering
the Recovering Room or Post Anesthetic Care
Unit (PACU)
Stages of the Peri-Operative Period
Post-Operative
Time from leaving the RR or PACU until time of
follow-up evaluation (often as out-patient)
Purposes of thePreoperative Evaluation
1. Reassure patient / allay anxiety2. Order preoperative medications3. Obtain informed consent4. Document the record5. Develop anesthetic care plan
Medical History
1. Review the chart
2. Review previous records
3. Interview the patient
The Chart Review
Demographic DataHeight / weightVital signsDiagnosis
The Chart Review
History and Physical ExamNote any abnormalitiesDon’t assume that all problems are listed
The Chart Review
1. Medications Routine medications at home Meds ordered in hospital
2. Lab / x-ray results
3. Consultations
Old Hospital Records
1. Available in same institution
2. Previous diagnosis
3. Previous treatment
Old Hospital Records
Review prior anesthesia recordInduction dosesAirway difficultyWork-up
Benefits from surgery ←→ Risk of complications
Age ObesitySmokingGeneral health statusChronic obstructive pulmonary disease
(COPD)Asthma
Patient related risk factors(pulmonary)
Smoking
Important risk factor Smoking history of 40 pack years or more →↑risk of
pulmonary complications stopped smoking < 2 months : stopped for > 2
months 4:1(57% : 14.5%) quit smoking > 6 months : never smoked = 1:1
(11.9% : 11%)
Risk Stratification
Revised Cardiac Risk Index High risk surgery (vascular, thoracic) Ischemic heart diseaseCongestive heart failureCerebrovascular disease Insulin therapy for diabetesCreatinine >2.0mg/dL
Active Cardiac Conditions
Unstable coronary syndromesUnstable or severe anginaRecent MI
Decompensated HFSignificant arrhythmiasSevere valvular disease
Minor Cardiac Predictors
Advanced age (>70)Abnormal ECG
LV hypertrophyLBBBST-T abnormalitiesRhythm other than sinus
Uncontrolled systemic hypertension
Surgical Risk Stratification
High Risk Vascular (aortic and major vascular)
Intermediate Risk Intraperitoneal and intrathoracic, carotid, head and
neck, orthopedic, prostateLow Risk
Endoscopic, superficial procedures, cataract, breast, ambulatory surgery
Risk Stratification
ASA physical statusASA 1 – Healthy patient without organic
biochemical or psychiatric disease.ASA 2- A Patient with mild systemic disease. No
significant impact on daily activity. Unlikely impact on anesthesia and surgery.
ASA 3- Significant or severe systemic disease that limits normal activity. Significant impact on daily activity. Likely impact on anesthesia and surgery.
Risk Stratification
ASA 4- Severe disease that is a constant threat to life or requires intensive therapy. Serious limitation of daily activity.
ASA 5- Moribund patient who is equally likely to die in the next 24 hours with or without surgery.
ASA 6- Brain-dead organ donor“E” – added to the classifications indicates
emergency surgery.
Step #1:Is the surgery emergent?
Is the surgery emergent? Operating room*yes
(Next Step)
no
Consider beta-blockade, pain controland other peri-operative management
Step 2: Determine Presence of Active Cardiac Conditions
If none are present, proceed with surgery
Presence of one of these delays surgery for
evaluation
Many patients need a cardiac cath
Step 2
Unstable coronary syndromes
Decompensated heart failure
Significant arrhythmias
Severe valvular disease
Step #2: Active Cardiac Conditions
Active Cardiac conditionsyes Evaluate and treat per current
guidelines
Consider Operating Room
no
(Next Step)
Step 3: Surgery Low Risk?
Low risk surgery includes:1. Endoscopic procedures
2. Superficial procedures
3. Cataract surgery
4. Breast surgery
5. Ambulatory surgery Cardiac risk <1% Testing does not change management
Step #3: Surgery Low Risk?
Low risk surgery
No
Operating roomyes
(Next Step)
Airway Evaluation
Take very seriously history of prior difficulty
Head and neck movement (extension) Alignment of oral, pharyngeal,
laryngeal axes Cervical spine arthritis or
trauma, burn, radiation, tumor, infection, scleroderma, short and thick neck
Airway Evaluation
Jaw Movement Both inter-incisor gap and
anterior subluxation <3.5cm inter-incisor gap
concerning Inability to sublux lower
incisors beyond upper incisors Receding mandible Protruding Maxillary Incisors
(buck teeth)
Airway Evaluation Oropharyngeal visualization Mallampati Score Sitting position, protrude tongue, don’t say “AHH”
Preoperative Testing
Routine preoperative testing should not be ordered.
Preoperative testing should be performed on a selective basis for purposes of guiding or optimizing perioperative management.
Preoperative Testing5
Procedure based.Low risk
Baseline creatinine if procedure involves contrast dye. Intermediate risk
Base line creatinine if contrast dye or >55yr of age.High risk
CBC, lytes & S, creatinine as above.PFTs for lung reduction surgery.
Preoperative Testing
Disease-based indicationsAlcohol abuse
CBC, ECG, lytes, LFTs, PTAnemia
CBCBleeding disorder
CBC, LFTs, PT, PTTCardiovascular
CBC, creatinine, CXR, ECG, lytes
Preoperative Testing
Disease-based indicationsCerebrovascular disease
Creatinine, glucose, ECGDiabetes
Creatinine, electrolytes, glucose, ECGHepatic disease
CBC, creatinine, lytes, LFTs, PTMalignancy
CBC, CXR
Preoperative Testing
Disease-based indicationsPregnancy (controversial)
Serum B-hCG- 7 days, Upreg 3 daysPulmonary disease
CBC, ECG, CXRRenal disease
CBC, Cr, lytes, ECGRA
CBC, ECG, CXR, C-spine (atlantoaxial subluxation) AP C-spine, AP odontoid view and lateral flexion and extention.
Preoperative Testing
Disease-basedSleep apnea
CBC, ECGSmoking >40 pack year
CBC, ECG, CXRSystemic Lupus
Cr, ECG, CXR
Preoperative Testing
Therapy-based indications Radiation therapy
CBC, ECG, CXR Warfarin
PT Digoxin
Lytes, ECG, Dig level Diuretics
Cr, lytes, ECG Steroids
Glucose, ECG
Obtaining a Consult
1. Ask specific questions which you want
answered
2. Talk directly to the consultant
Informed Consent
1. Frequently questioned in malpractice cases
2. Risks / benefits3. Alternatives4. Answer all questions5. Do not deceive the patient
Risks of Anesthesia
1. Determine what the patient wants to know - Do not frighten patients
2. Start with minor risks
3. Proceed to serious risks
Risk associated with anesthesiaand surgery
The question that patients ask
is ‘Doctor, what are the risks of having an anaesthetic?’
These can be divided into two main groups.
MinorThese are not life threatening and can occur even
when anaesthesia has apparently been uneventful. They include:
• failed IV access;• cut lip, damage to teeth, caps, crowns;• sore throat;• headache;• postoperative nausea and vomiting;• retention of urine.
MajorThese may be life-threatening events. They include:• aspiration of gastric contents;• hypoxic brain injury;• myocardial infarction;• cerebrovascular accident;• nerve injury;• chest infection Death
Document the Visit
1. Complete the evaluation form
2. Enter progress notes
3. Have patient sign consent
4. Write appropriate orders
Preanesthesia Clinic
Questions?