1. بسم الله الرحمن الرحيم
Role of Anesthesiologist in Peri-Operative Period essam manaa assistant professor & consultant anesthesia dept. , kkuh

2. Lecture Objectives..
Students at the end of the lecture will be able to:
Obtain a full history and physical examination including allergies, current medications, past anesthetic history, family anesthetic history
Understand how patient co-morbidities can affect the anesthetic plan
Able to plan an anesthetic for a basic surgical procedure
Understand risk stratification of a patient undergoing anesthesia

3. An Anesthesiologist or Anaesthetist is a physician trained in anesthesia and perioperative medicine. They provide medical care to patients in a wide variety of (usually acute) situations. Anesthesiologists are responsible for ensuring the delivery of anesthesia safely to patients in virtually all health care settings, including all major medical and tertiary care facilities. 

4. Pre-Anesthesia Clinic
KKUH

5. Stages of the Peri-Operative Period
Pre-Operative
From time of decision to have surgery until admitted into the OR theatre.

6. Intra-Operative
Time from entering the OR theatre to entering the Recovering Room or Post Anesthetic Care Unit (PACU)

7. Post-Operative
Time from leaving the RR or PACU until time of follow-up evaluation (often as out-patient)

8. Preoperative visit Preoperative Preparation Preoperative Evaluation
Preoperative Medication

9. Preoperative Preparation
To educate about anesthesia , perioperative care and pain management to reduce anxiety
To determine which lab test or further medical consultation are needed
To choose care plan guided by patient's choice and risk factors
Benefits from surgery ← → Risk of complications

10. Preoperative Evaluation & Medication
- A thorough history
- Habits (smoking, alcohol)
- Medications (herbals, Drugs) and allergies
Physical exam
- Complete review of systems i.e. Functional Status (METs)
Pre-op medication

11. METs = metabolic equivalents.
Functional Status Assessment
Poor functional capacity is associated with increased cardiac complications in noncardiac surgery. A patient's functional capacity can be expressed in metabolic equivalents (METs). One MET equals the oxygen consumption of a 70-kg, 40-year-old man in a resting state.
Excellent (>7 METs)
Moderate (4 to 7 METs)
Poor (<4 METs)
Squash
Jogging (10-minute mile)
Scrubbing floors
Singles tennis
Cycling
Climbing a flight of stairs
Golf (without cart)
Walking 4 mph
Yardwork (e.g., raking leaves, weeding, pushing a power mower)
Vacuuming
Activities of daily living (e.g., eating, dressing, bathing)
Walking 2 mph
Writing
METs = metabolic equivalents.

13. Patient Related Risk Factors
Age
Obesity
Smoking
General health status
Chronic obstructive pulmonary disease (COPD)
Congestive heart failure

14. e.g Smoking
Smoking history of 40 pack / year 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%)

15. Risk Stratification
(1) Cardiac

16. This is a multi-factorial index of cardiac risk in the non-cardiac surgical setting. It was developed for preoperative identification of patients at risk from major perioperative cardiovascular complications. The data were derived retrospectively in 1977 from 1001 patients undergoing non-cardiac surgery. 
Patients with scores >25 had a 22% incidence of death, with a 56% incidence of severe cardiovascular complications.
Patients with scores <26 had a 4% incidence of death, with a 17% incidence of severe cardiovascular complications.
Patients with scores <6 had a 0.2% incidence of death, with a 0.7% incidence of severe cardiovascular complications.
Multifactorial index of cardiac risk in noncardiac surgical procedures
Goldman L, Caldera DL, Nussbaum SR
N Engl J Med 1977; 297:  

17. (2) ASA Physical Status (Br J Anaesth 2004;93:393–399.)
ASA 1 Healthy patient without organic biochemical or psychiatric disease.
ASA 2 A Patient with mild systemic disease (controlled hypertension or diabetes without systemic effects). No significant impact on daily activity. Unlikely impact on anesthesia and surgery.
ASA 3 Significant or severe systemic disease that limits normal activity (controlled congestive heart failure (CHF), stable angina, old heart attack, poorly controlled hypertension, morbid obesity, chronic renal failure). Significant impact on daily activity. Likely impact on anesthesia and surgery.
ASA 4 Severe disease that is a constant threat to life or requires intensive therapy (symptomatic COPD, symptomatic CHF, hepatorenal failure) . Serious limitation of daily activity.
ASA 5 Moribund patient who is equally likely to die in the next 24 hours with or without surgery (multiorgan failure, sepsis syndrome).
ASA 6 Brain-dead organ donor
“E” Added to the classifications indicates emergency surgery.
**Mortality rates of the individual classes showed considerable variation, with 0-0.3% for ASA I, % for ASA II, % for ASA III, % for ASA IV and % ASA V
(Br J Anaesth 2004;93:393–399.)

19. #: Surgery Low Risk* Low risk surgery Operating room confirmed
Endoscopic procedures
Superficial procedures
Cataract surgery
Breast surgery
Ambulatory surgery
*Cardiac risk <1%
Testing does not change management

20. #: Active Cardiac Conditions
Evaluate and treat per current guidelines (Many patients need a cardiac cath.)
Active Cardiac conditions
Consider Operating Room
1- Unstable coronary syndromes
2- Decompensated heart failure
3- Significant arrhythmias
4- Severe valvular disease

21. Airway Evaluation

22. Airway Evaluation (cont.)
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

23. Airway Evaluation (cont..)
Jaw Movement
Receding mandible
Inability to sublux lower incisors beyond upper incisors
Protruding Maxillary Incisors (buck teeth)

24. Airway Evaluation (cont..)
Mallampati Score
Sitting position, protrude tongue, don’t say “AHH”
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

26. Airway Evaluation (cont…)
Laryngoscopy view: Cormack and Lehane
Grade I: complete glottis visible  Grade II: anterior glottis not seen  Grade III: epiglottis seen, but not glottis  Grade IV: epiglottis not seen

27. Preoperative Lab. 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.

29. Preoperative Lab. Testing (Cont.)
Procedure based indications
Low risk
Intermediate risk
Base line creatinine
High risk
CBC, Electrolytes
PFTs for lung reduction surgery

30. Preoperative Lab. Testing (Cont..)
Disease-based indications
Anemia
CBC
Bleeding disorder
CBC, LFTs, PT, PTT
Cardiovascular
CBC, creatinine, CXR, ECG, lytes
Diabetes
Creatinine, electrolytes, glucose, ECG
Hepatic disease
CBC, creatinine, lytes, LFTs, PT
Malignancy
CBC, CXR

31. Preoperative Lab. Testing (Cont..)
Pulmonary disease
CBC, ECG, CXR
Renal disease
CBC, Cr, lytes, ECG RA
CBC, ECG, CXR, C-spine (atlantoaxial subluxation)
AP C-spine, AP odontoid view and lateral flexion and extention.
Sleep apnea
CBC, ECG
Smoking >40 pack year

32. Preoperative Lab. Testing (Cont…)
Therapy-based indications
Radiation therapy
CBC, ECG, CXR
Warfarin PT
Digoxin
Lytes, ECG, Dig level
Diuretics
Cr, lytes, ECG
Steroids
Glucose, ECG

34. Q & A

35. Thank You 