1. Pre-operative Assessment Done by:- Majed Alturkistani

2. History and Physical Indication for surgery surgical /anesthetic Hx: previous anesthetics/complications, previous intubations, medications, drug allergies PMHx CNS: seizures, stroke, raised intracranial pressure (ICP), spinal disease CVS : coronary artery disease (CAD), myocardial infarction (MI), congestive heart failure (CHF), hypertension (HTN), valvular disease, dysrhythmias, peripheral vascular disease (PVD), conditions requiring endocarditis prophylaxis, exercise tolerance, NYHA class Respiratory: smoking, asthma, chronic obstructive pulmonary disease (COPD), recent upper respiratory tract infection (URTI), sleep apnea Gl: Gastroesophageal reflux disease (GERD), liver disease Renal: insufficiency, dialysis. Hematologic: anemia, coagulopathies. MSK: conditions associated with difficult intubations - arthritides (e.g. rheumatoid arthritis), cervical tumours, cervical infections/abscess, trauma to cervical spine, Down syndrome, scleroderma, obesity, conditions affecting neuromuscular junction (e.g. myasthenia gravis). Endocrine: diabetes, thyroid, adrenal disorders other: morbid obesity, pregnancy, ethanol/other drug use FHx: malignant hyperthermia. atypical

3. Functional Capacity or (METs) Defined as the ratio of metabolic rate (and therefore the rate of energy consumption) during a specific physical activity to a reference metabolic rate. 1 MET = 3.5 mL O2 uptake/KG per min O2 uptake of a 40 y/o, 70 kg male sitting upright

4. Specific Activity Scale 1. Sit upright 2.Eat, dress, use toilet, make bed 3.Walk around house, shower 4.1 flight stairs, walk up hill, 2 block @ 2mph 5.Light house work, dust, wash dishes, golf, bowl 6.2 flights of stairs, walk on flat @ 4mph, 7.Sex 8.Scrubbing floors, weight lifting, moving furniture 9.Broke the bed/neighbors called the cops sex 10.Shovel snow 11.Doubles tennis, swing dancing 12.Recreational Sports: Singles tennis, soccer, basketball, skiing, jogging 13.Competitive sports

5. Relation To Surgery < 4 METs Significantly Increases Risk MI, HF, Arrhythmia regardless of Surgical Risk Functional CapacityComplication Rate 5% 4 – 10 METs 1 – 5% > 10 Mets < 1%

6. Physical Examination Airway. Focus Clinical systemic examination. Bony land mark for regional anesthesia. General assessment for nutrition, hydration and Mental Status. Pre-existing motor or sensory deficit. Site for IV, Central or PA catheter.

7. Airway Assessment Likely hood of difficult intubation, Ability to assume sniffing position. No single test specific or sensitive Mallampati score Thyromental distance Mouth opening Tongue size Dentition

8. Mallampati Score

9. Investigation

10. Fasting Protocol 8 hours after a meal that includes meat, fried or fatty food. 6 hours after a light meal such as toast and crackers) or after ingestion of infant formula or non - human milk. 4 hours after ingestion of breast milk or jello. 2 hours after clear fluid & (water,black coffee. tea carbonated beverages,juice without pulp).

11. ASA Classification

12. Optimization by medication Medication Medication to start Aspiration \ Na citarte, Ranitidine. Infective Endocarditis \ AB. DVT Prophylaxis \ Heparine SC. Adrenal Suppression \ Steroid coverage. Anxiety \ Benzodiazpines Medication to stop Oral Hypoglycaemic + antidepressant. Medication to adjust insulin prednison, Coumadin and Bronchodialtor.

13. HTN Mild to moderate HTN —> OK Target sBP < 180 mmHg, dBP <110mmHG.

14. CAD <3 months after MI - 37% patients may re-infarct. 3-6 months after MI -15% >6 months after MI - risk remains constant at 5%.

15. Thank You