Preoperatíve

anesthesiologic assesment

Risk of anesthesia

Preadmission
clinic (PAC)
Premedication
The operatíve/anesthesiologic risk
Operation/anesthesia effects the entire
organism, and carries certain risks for the
patient.
The patient should be in the possible best
condition for an elective operation to
reduce the risk of the procedure.
The risk of the operation/anesthesia
should never exceed the benefits of the
procedure!
 Evaluation of risk

Risk of
Benefits of the complications
operation or death
What does the patient (What can he
win? loose?)
 The anesthesia risk
 Mortality associated with anesthesia:
Anesthesia and surgical mortality
- In many cases it is difficult to distinguish

 Morbidity associated with anesthesia

– Immediate complications/ Late complications
– Reversible, short live complications
– Permanent damages (brain, palsy, etc.)
 One anesthesia-death is one more than
acceptable!
The statistical probability of anesthesia
death is 100 000:1 (2-4?) -”acceptable”??
..and if the one person is my near relative
…?
Sometimes it is difficult to see the real
cause;
Sometimes the media are creating a „crime”
- default/negligence where there is none.
The most important question: is the structure
we are working safe enough???
 Factors influencing the risk of
anesthesia
Physical state of the patient, age
Special risk factors
(cardiorespiratory and other complications)
Urgency of the operation
(immediate, urgent, scheduled, elective)
The degree of the surgical stress –
– Type of operation
– Length of operation
Technical conditions/equipment, monitoring,
essential services
Subjective circumstances and conditions:
Training and experience of the anesthetist
Readiness, fatique of the physicians
Risk according to the severity of
the operation
Low risk
– Small interventions, blood loss <200ml (pl.inquinal hernia,
arthroscopy)
Medium risk
– Medium severe surgical intervention, (laparoscopic
cholecystectomy, tonsillectomy,TUR) blood loss <1000 ml
High risk
– Long abdominal, thoracic, intracranial surgery with more
than 1000ml blood loss,
high quality postoperative therapy necessary
(morbidity, mortality elevated)
 Risk according to urgency
Vital urgency
„Simple” urgency
Elective - hospitalised
day cases

The minimum of necessary surgical information:

Surgical status, previous findings, surgical plan
(type of operation), plan of postoperative
rehabilitation
 Sürgős beavatkozások
Immediate (vital) urgency (periculum in vita)
No preparation is possible (e.g. liver rupture)
„Simple” urgency (short preparation possible)
Has to be done within a couple of hours
(acute abdomen, arterial obstruction)
Has to be done on the same day (e.g. open fractures)
Has to be done in a couple of days
Relative uregency (weeks?)
Proper preparation is possible and necessary
(e.g. tumor surgery)
Classification of the physical status of the patient
according to the American Society of Anesthesiologists
(ASA)
ASA 1 (I) ”Normal”, healthy patient
ASA 2 (II) Mild systemic diseases
ASA 3 (III) Severe systemic disease
that limits activity
ASA 4 (IV) Incapacitating disease
(constant treat to life)
ASA 5 (V) Moribund patient

For emergency cases an „E” is added before classification

(e.g. ASA class EIV)
 Mortality and ASA risk categories

ASA 1 2 3 4 5
Mortality
in>6000 pts 0,1% 0,7% 3,5% 18,3% 93,3%
(Germany)

The preoperative preparation of the patient may be a very important

factor of anesthesia risk!
With good preparation also the physical state can be influenced.
Special risk factors not included in
ASA categories

Urgency
Obesity
Full stomach !!!!!
Rithm disturbances
Electrolite/acid-base
imbalance, metabolic disturbances
Drog abuse
Alcohol abuse, smoking
Inadequate preparation, lack of information
 USA closed clames Caplan 1994

Complication %-of all Paid sum $ (from-to)

claims $

Death 37 171.000 750.000-4.000.000

Nerve injury 15 17.500 188.000-2.100.000
Lasting cerebral injury 12 700.000 10.000-6.000.000
Airway injuries 4 14.250 15 - 200.000
Newborn - complications 4 325.500 25.000- 5.400.000
Pneumothorax 3 26.250 500 – 4.000.000
Eye injury 3 25.000 145 - 1.000.000
Aspiration 3 150.000 25.000 -4.500.000
Awakening during 3 18.000 430 - 305.100
surgery
The incidence of respiratory problems was 34% - these were found responsible
for 85% of lethal cases!!!
(cardiovascular complications 6%)
„Near accidents” - the whole therapeutic
chain has to be checked!
Active human error?
Latent negligence? System error?

– Lack of attention
– Lack of knowledge
•Failures of the training
– Violation of rules
•Jujdgement of competence
•Tiredness, overwork
•Working place atmosphera

Strategies for controlling risk!!!

Rami L, Grimaud D. Aneszteziológia és Intenzív Terápia 2005/3
 The most important decision:

Advantages of the planned surgery?

(What does the patient gain - surgical point of
view)

How high is the risk of cancelling / postponing the operation?

Risk of the operation? (anesthesiologic points of view)

How high is the risk of complications?
Could we improve the situation?
Aim of preoperative assesment and
of the preparation of the patient
Operation of the patient at the best timepoint in
the possible best condition
Selection of the optimal anesthesiologic method
Reduction of hospitalisation time
Rational, economic procedures
Reduction of the perioperative risk factors
(mortality and morbidity reduction)
 Risk because of urgency
Full stomach – risk of aspiration
Lack of preparation
– Physical, laboratory, radiologic, cardiologic, etc. Findings?

Risk caused by the basic problem

– e.g. severe bleeding, shock state…

Insufficient personal conditions, missing team

members and eguipment
e.g. monitors, competent doctors …

We have to find the balance between the grade of urgency and

the „acceptable” deficiencies + risk factors!
 A preoperative NPO
Mendelson (1946)!

Hours before Allowed orally:

surgery
Clear liquids (except: alcohol, milk, coffe)
2-3
Mother milk
4
Milk, light solid food
6
Normal solid food (meat, fat…)
8

CAVE: protracted emptying – trauma, stress, DM, alkoholism, GI problems!

Patterns of Gastric Emptying in Healthy People and in Patients with Diabetic Gastroparesis

Camilleri M. N Engl J Med 2007;356:820-829

 Preoperative assesment
History
Physical examination
Previous documentation
Laboratory and special diagnostic procedures
Consultation with colleguages of other
specialities
Plan for the preoperative anesthesiologic
preparation/therapeutic interventions
Design of the anesthesiologic method and of the
postoperative care
Information of the patient, informed consent
 Preoperative anesthesiologic
preparation I.
Site:
Preadmission anesthesiology clinic (or unfortunately
sometimes the ward or even OR)
Time:
In ideal case some (5-14) days before the scheduled
intervention (sufficient time for the necessary
investigations, therapy)
Responsible person:
Anesthetist in cooperation with consultants of other
specialities
 Preoperative anesthesiologic
preparation II.
Methods:
History
Questioning of the patient
Documents of previous investigations, hospital treatments
Special anamnestic questions (bleeding disorders, possible gravidity, etc)
Medication
Alcohol, tobacco abuse
Physical investigation
– General
– Special (eg. Intubation difficulties, venous access, etc.)
– Measured parameters (BP, HR, temperature)
Laboratory investigations
Individual decisions
Blood group crossmatching
Imageing methods – e.g. chest X ray, sonography, CT…
Functional tests – e.g. stress ECG, respiratory function test
Specialist consilium
 Individual planning of the
necessary investigations
Minimum (routine) investigations
(short, small operation ASA class I patient)
History, physical examination
urine, quantitative blood chemistry, (crossmatching)
Maximum investigation (serious operation, ASA III-V)
History, physical examination
Urin, routine laboratory, qualitative/quantitative blood chemistry
Ionogramm, hepatic and renal function tests, blood sugar, se. proteins
Bood group crossmatched, blood gases, acid/base status
Chest X ray, ECG, respiratory funcion tests
Additional investigations according to the diagnosis
and accompanying diseases
Screening tests
Breast, rectal, stool, gravidity test, etc.
 Preoperative anesthesiologic
preparation III.
Competency of the anesthesiologist:
– Assessment of anesthesia tolerance of the
patient
– Planning of the anesthesia preparation
– Discussion with the patient, informed consent
– Choice of the anesthesia method
– Plan of the postoperative anesthesia care
(RR, ICU?)
– Perioperative analgesia
 Preoperative anesthesiologic
preparation IV.

Competency of the consultant specialist:

– Specialist opinion about the status of the
patient, diagnosis, therapeutic advice;
– Help in order to optimize the conditions…
– …and reduce the operative risk
Indication for preoperative chest x
ray
Cardiorespiratory disease,
metastatic cancer,
no
Big operaqtion, age over X ray necessary for proper
40 years assesment of the patient

yes
yes
Good results at chest X
no Chest X ray no
ray within one year
necessary

yes

yes
Worsening since Chest X ray not
the last necessary
examination no
 Indication for perioperative ECG
Age: men <40y, women< 50y
no
IHD, vascular disease, big operation,
rhythm disturbances

yes
yes
Negative ECG within 1
year
no
ECG necessary
no

yes

yes
Worsening of ECG not necessary
status
no
 Indication for preoperative
respiratory function tests
COPD, chr.bronchitis, asthma
yes
Chest deformities,
neuromuscular diseases,
dyspnoea

no

Thoracotomy? Fresh results

yes (within 3 months

no no

yes
Pulmonary Pulmonary
function test function test
unnecessary indicated
 Premedication I.
Aim of premedication:
Anxiolysis, sedation
Reduction of the dose of indunction anesthetics
Reduction of secretions
Attenuation of vagal and sympathoadrenal refllexes
Elevation of gastric pH values
Prevention pf postoperative nausea and emesis (PONV)
Amnesia
 Premedication II
Prescription of medicaments
– Benzodiazepines (anxiolysis, sedation, amnesia)
diazepam, temazepam, lorazepam, midazolam !
– Opioids (analgesia, sedation)
fentanyl, pethidin, alfentanil sufentanil
– Butyrofenons (sedation, antiemesis)
dehydrobenzperidol (DHBP)
– Anticholinergic agents (antisialague, amnestic, antivagal)
atropin, glycopyrrolat, (hyoscin)
– Antacids
Sodium citricum, H2 antagonists, omeprazol, metoclopramid
• b-receptor blockers (antinocicepcion)
atenolol, esmolol
• a2 receptor agonists (anesthesia potenciation,
reduction of central NE effects
clonidin, dexmedetomidin
• Phenotiazins (central antiemesis, sedation, antiallergic, anticholinerg)
 Risk of venous thromboembolism
Low risk Medium risk High risk (DVT>10-
20%, PE 1-5%)

Short surgical Medium or long general-, Pelvic fractures-

interventions urologic, gynecologic, neuro-, traumatol., ortop. surgery
whithout other cardiac-, vascular-, thoracic-
risk factors (RF) surgery, >40 years, RF >2
Pelvic tumor operations
Medium long Serious trauma, burns Extended surgery,
surgery, Anticoncipients trauma
whithout other Obesitas, smoking Medical disease +
RFs thrombophilia
Paresis, immobility
Small trauma, Medical disease + DVT, PE in Critical lower limb
medical diseases the pt’s history ischaemia
Small trauma + immobilisation
 Perioperative patient care
Simple
Continuous observation
Knowledge of surgical processes
Monitoring
Patient’s parameters: circulation, breathing,
temperature, muscle relaxation, CNS activity…
Parameters on the anesthesia machine, ventillator
 Documentation
Anesthesia record

– Graphic plots: continuously registered parameters

– BP, pulse, CVPy…..
– O2 saturation, ETCO2, pressures……

– Intra- and postoperative investigations, sampling

– Medication, infusions

– Urine output

– Important events
– Complications