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Emory Montgomery
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+ + Learning Objectives The Pre-operative Evaluation Learn how to complete an airway examination. Learn how to classify the ASA status for each patient.

List the indications for a preoperative stress test.

1 + + Learning Objectives The Pre-operative Evaluation Learn how to complete an airway examination. Learn how to classify the ASA status for each patient. Learn how to estimate the energy requirements for various activities. Neesann Marietta, M.D. Learn how to stratify the risk of non-cardiac surgical procedures. List the indications for a preoperative stress test. Department of Anesthesia, Pain, & Critical Care Beth Israel Deaconess Medical Center + Case 1: 55 yo Scheduled for Laparoscopic Herniorrhaphy Pt is a 55 yo male scheduled for laparoscopic inguinal herniorrhaphy. He comes to PAT clinic for his preoperative assessment. What is the goal for this visit? How do you plan on evaluating the pt? What other sources of information may be helpful? Why is it important to review pt s medications and allergies? Why is it important to ask about family members reaction to anesthesia? Getting started Preoperative evaluation allows anesthesiologists to anticipate & prepare in advance for difficult airways & other potential challenges. In most cases, H&P alone is all you need to determine if the pt s preoperative conditions may be optimized prior to surgery. Obtain previous anesthetic records to check for ease of intubation and response to anesthetic agents. Reviewing the pt s medication and allergies to avoid potential drug interactions. Ask what type of reaction an allergy is because pts will often equate adverse reactions (e.g. nausea) to allergies. Inquire about OTCs and herbal supplements Always ask if family members have ever had an unusual reaction or allergy to anesthesia as this could alert you to the possibility of malignant hyperthermia.

2 Case 1 + Exercise Tolerance Jim Jackson is a 55 yo Caucasian male with PMH of GERD, hyperlipidemia, and HTN.. He has an inguinal hernia that bothers him when he works out. Medications include 40 mg PO simvastatin, 25 mg PO hydrochlorothiazide, 40mg PO omeprazole, 100 mg metoprolol, and 325 mg PO ASA Allergies: None Past Surgical Hx: T&A as a child, left shoulder surgery 4/09 (Mac 3, Grade I view, easy intubation) Social Hx: Manager at Stop & Shop, Former smoker quit 3 years ago. 30 pack-year, Social drinker Family Hx: Diabetes in maternal side. Denies unusual reaction to anesthesia among his relatives Exercise capacity: He walks at least 2 miles every day to work. He exercises at the gym 2-3X/week. He plays in a soccer league. ROS: Denies chest pain, palpitations, SOB 1 MET 4 MET > 10 METs Can perform ADLs Walk around the house Walk a block or two on level ground at 2-3 mph Light work around the house (dusting, washing dishes) Climb a flight of stairs or walk up a hill Walk on level ground at 4mph Heavy work around house (scrubbing floors, lifting, moving heavy furniture) Moderate activities (golf, bowling, dancing) Strenuous sports (swimming, football, basketball, skiing) Likelihood of serious adverse event is inversely related to the # of blocks that can be walked! Strong evidence suggests that additional work-up is unnecessary if pt has good exercise capacity. + Pre-op evaluation What is the pt s functional status? Pt plays soccer - a rigorous sport. His functional capacity is >10 METs

+ Airway Classification System + Laryngoscopic View Class Direct Visualization

fauces, uvula Soft palate, uvular base Entire glottis Posterior commisure Tip of

the pt to open his mouth and stick out his tongue.

3 + Airway Classification System + Laryngoscopic View Class Direct Visualization Laryngoscopic view I II III Soft palate, fauces, uvula, pillars Soft palate, fauces, uvula Soft palate, uvular base Entire glottis Posterior commisure Tip of epiglottis IV Hard palate only No glottal structures + Airway Examination You ask the pt to open his mouth and stick out his tongue. This is what you see Mallampati II What is the Mallampati classification?

4 Components of the Airway Physical Examination Airway Exam Component Length of upper incisors Relation of maxillary and mandibular incisors during normal jaw closure Relation of maxillary and mandibular incisors during voluntary protrusion of mandible Visibility of uvula Shape of palate Thyromental distance Length of neck Thickness of neck Range of motion head/neck Suggestive of Difficulty with Intubation Long compared to rest of dentition Prominent overbite Pt can t bring mandibular incisors anterior to maxillary incisors Not visible with protruded tongue High arched or very narrow < 3 three fingerbreadths Short neck Thick neck Pt can t touch tip of chin to chest or is unable to extend neck + Airway evaluation Why is it important to assess dentition? + Airway evaluation + Physical Examination It is important to evaluate dentition because 1) it can serve as screening tool for difficult intubation (e.g. overbite, etc) 2)Damage to teeth is a common complication so it is important to document the condition of teeth before anesthesia. Be extra careful during direct laryngoscopy in pts with poor dentition. Document loose/chipped teeth prior to going back to OR for medicolegal purposes. BP: 140/90, HR 67 bpm, RR 15, O2: 99% Room Air 110kg, 72 in, BMI 32.8 Gen: NAD, cooperative, fit HEENT: No JVD, No carotid bruits b/l, Good dentition CV: RRR, no m/r/g Lungs: CTAB Abdomen: reducible left-sided inguinal hernia, negative rebound/guarding

5 + Concerns? + Pre-op evaluation You ve done a thorough H&P. Do you have any concerns? Is there anything you want to ask him about in more detail? The pt has GERD. To reduce risk of aspiration, he may require rapid-sequence induction since his heartburn is not optimally controlled with his proton-pump inhibitor. You ask the pt more details questions about his reflux He says that he just started the omeprazole a few months ago. He has noticed an improvement, but says he still notices symptoms in the morning and when he reclines. + ASA Physical Status Classification + Pre-op evaluation ASA Class I II III IV V VI E (emergency) State A normal healthy pt Mild-to-moderate systemic disturbances with no functional limitations. Ex. HTN, DM, morbid obesity, extremes of age Severe systemic disturbances that results in functional limitations Ex. Poorly controlled HTN, DM with vascular complications, angina pectoris, previous MI Severe systemic disturbance that is constant threat to life Ex. CHF, unstable angina, advance renal, hepatic, pulmonary disease Moribund pt who has little chance of survival w/o operation Organ donor Any pt in whom an emergency operation is required What would you say his ASA status is? Miller,R.D., Stoelting, R.K., Basics of Anesthesia 5 th edition, Ch 13

6 + Pre-op evaluation His comorbidities include GERD, HLD, and HTN but his medical conditions do not cause him any functional limitations. His ASA status is II. What instructions do you provide Mr. Jackson before he goes home? Are there any other tests or consultations that you would like to order? What is your overall assessment of Mr. Jackson. Does this affect your anesthetic plan? Pre-op evaluation Instructions provided: Do not eat or drink after midnight the morning of your surgery except for a small sip of H20 to take your metoprolol (shown to decrease perioperative morbidity) and your prilosec. Telling pts to stop eating/drinking after midnight is easier to follow versus instructing them to stop 6 hrs before surgery. Furthermore, there is always the chance that a surgery may start earlier than scheduled. Ingested Material Clear liquids Breast Milk Infant formula Light meal Minimum Fasting Period 2 hrs 4 hrs 6 hrs 6 hrs Overall, Mr. Jackson is a good candidate for surgery. He is relatively healthy. However, his GERD is a little concerning because he still has symptoms. He should take his PPI the morning of surgery. He may need to get a non-particulate acid in the pre-op holding area. Rapid sequence induction should be part of the anesthetic plan. + Labs/Consultations What are the pre-operative test recommendations in asymptomatic pts for elective operations? None. In the past, many preoperative tests were ordered based on just age. Currently, the ASA recommends ordering tests and labs based on a patient s comorbidities, history, and physical examination. Miller,R.D., Stoelting, R.K., Basics of Anesthesia 5 th edition, Ch 13

+ Pre-Op Evaluation + Case 2: 65 yo Female Scheduled for Bilateral Mastectomy Evelyn Lopez is a 66 yo with recently diagnosed non-invasive breast cancer, hyperlipidemia, DM II, HTN, CKD with baseline

7 + Pre-Op Evaluation + Case 2: 65 yo Female Scheduled for Bilateral Mastectomy Evelyn Lopez is a 66 yo with recently diagnosed non-invasive breast cancer, hyperlipidemia, DM II, HTN, CKD with baseline Cr 1.4. Medications: Lipitor 20 mg, metformin 500mg BID, metoprolol 100mg PO BID, Aspirin 81 mg QD, multivitamin Past Surgical History: appendectomy 91, cholecystectomy 95, TAH-SBO (> 30 yrs ago) (All surgeries performed at outside hospital) Family Hx: Mother and father died of CAD. Brother died of an MI at 55 yrs. Children are healthy. Social Hx: Never smoked, Denies ROH Exercise tolerance: Has not been getting much exercise during last 6 mo. because she experiences chest pain. She forgot to tell her PCP about her sx during her last appointment since she was distraught over her breast cancer diagnosis. + Airway Examination + Airway examination What is Mrs. Lopez s Mallampati classification? Mallampati Class III

+ Physical Examination BP 135/85, HR 88 bpm, RR 15, O2: 98% Room Air 100 kg, 64 in., BMI 37.8 Gen: NAD, cooperative, morbidly obese HEENT: No carotid bruits, thyroid not enlarged. No JVD.

8 + Physical Examination BP 135/85, HR 88 bpm, RR 15, O2: 98% Room Air 100 kg, 64 in., BMI 37.8 Gen: NAD, cooperative, morbidly obese HEENT: No carotid bruits, thyroid not enlarged. No JVD. Good dentition, Thyromental distance < 3 fingerbreadths, good neck ROM, adequate mouth opening, short neck CV: RRR, no m/r/g Lungs: CTAB, no wheezes/rhonci, no use of accessory muscles of respiration Abdomen: obese, no organomegaly, no rebound/guarding Extremities: No clubbing/cyanosis/edema Is there anything you want to know more about? Her chest pain is concerning. You want to know more.. Mrs. Lopez tells you that she started noticing her chest pain approximately 6 months ago. At first it came on with activity such as yard-work and walking up stairs. It only occurred every so often. During the past few months, it has been occurring more frequently and with activity such as walking to the mailbox and sometimes even at rest. It goes away with time or when she sits down. She describes the pain as a pressure-sensation. She denies radiation down her arm or jaw. She denies diaphoresis. She has been meaning to tell her PCP about it, but she has been consumed with other stressful events in her life. What are your other concerns? Her airway evaluation raises concern that she may be a difficult airway. Her mallampati score is 3, her neck is short, she is morbidly obese, and her thyromental distance is < 3 fingerbreadths. It would be a good idea to have extra airway tools such as video laryngoscope in the OR during induction. It would be helpful to retrieve her previous anesthetic records from the outside hospital. + Independent RFs Associated with Perioperative Cardiac Events High-Risk Surgery History of Ischemic Heart Disease Congestive Heart Failure Cerebrovascular Disease DM requiring insulin therapy Preoperative serum Creatinine >2.0 mg/dl Presence of 0, 1, 3, or > 3 variables is asso with cardiac complication rates of.4%,.9%, 7%, and 11%, respectively. Pts with > 2 variables are at moderate (7%) to high (11%) risk for perioperative cardiac events Image from

9 + Stratification of Surgical Procedure Risk High Intermediate Low Emergent operation Aortic or other major vascular Peripheral vascular Long surgeries asso. with large fluid shifts/blood loss Carotid endarterectomy Head & Neck Intraperitoneal Intrathoracic Orthopedic Prostate Endoscopic Superficial Cataract Breast Cardiac Risk >5% Cardiac Risk <5% Cardiac Risk <1% Does Mrs. Jackson s chest pain require further work-up? + Pre-op Evaluation Mrs. Jackson absolutely needs her CP worked up. Her CP is characteristic of unstable angina. She has multiple risk factors for CAD DM, HLD, morbid obesity, HTN, and strong family hx. *Presence of unstable angina has been associated with high perioperative risk of MI*! Start out with an ECG. Obtain a previous ECG if possible to compare if anything has changed. Obtain serum Creatinine, BUN, and potassium because of her CKD. What tests would you start off with? What other labs would you order?

+ Mrs. Lopez s ECG + Cardiovascular Tests Pathological Q waves & T wave inversions present in inferior leads (II, III, AVF) suggestive of old infarct. Which pts need further cardiac work-up like Mrs.

10 + Mrs. Lopez s ECG + Cardiovascular Tests Pathological Q waves & T wave inversions present in inferior leads (II, III, AVF) suggestive of old infarct. Which pts need further cardiac work-up like Mrs. Lopez? What is the abnormality? What is the next step in management? Image from Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions, known cardiovascular disease, or cardiac risk factors for patients 50 years of age or greater Pts with active cardiac condition such as unstable angina, congestive heart failure, significant dysrhythmias, and severe valvular disease should undergo noninvasive stress testing before non-cardiac surgery. Mrs. Jackson was sent to a cardiologist. Her dobutamine stress echocardiography was abnormal. She underwent cardiac catheterization which showed 90% occlusion of the RCA. A bare-metal stent was placed in the right coronary artery, and she was started on Plavix. Her chest pain resolved following catheterization. She underwent bilateral mastectomy under general anesthesia six weeks after cardiac catheterization w/o complication. Fleisher, L. A. et al. Circulation 2007;116:e418-e500

11 + References pgs Miller,R.D., Stoelting, R.K., Basics of Anesthesia 5 th edition, Ch 13, pgs Fleisher, L.A. et al. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular and Care for Noncardiac Surgery. Circulation 2007; 116 e418-e500

Preoperative Risk. Geoffrey C Zarrella DO FACC. Assessment

Preoperative Risk. Geoffrey C Zarrella DO FACC. Assessment Preoperative Risk Geoffrey C Zarrella DO FACC Assessment your late add ons keep calm use your tools stick to your guns PURPOSE OF THE PREOP EVAL ASSESS PERIOP RISK CAN INFORM DECISION TO PROCEED OR