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Lecture : Pre-operative assessment & premedication Dr. Wael Khrais

Anaphylactic reaction : It could happen any time & anywhere . So the golden rule for you : dont ever never give IV medication at home . Because anaphylactic will kill the patient , because you dont have any skills for the management for upper airway , for oxygen sources & intubation ,etc.. The most dangerous thing is the intravenous injection mainly the Antibiotics . The Antibiotics , its very serious to take history , if the patient has allergy to penicillin ,theres 10 % cross reaction like any other antibiotic . So this is the nightmare for anesthetist when we intuse the patient. The last thing to prescribe premedication frequent , the patient when he is going to have operation or nightmare operation , definitely his sympathetic system is over activated . You know we have the brain , spinal cord , but we have an involuntary nervous system we call this autonomic nervous system , this system works when youre sleeping , because when yor are asleep your heart will be still working , your lung & liver is still working . But when youre nervous , sympathetic will be overriding the parasympathetic system which is system of fight and flight . When the sympathetic system is over stimulated , glycogen stored in the liver will be stimulated to increase glucose in the blood , BP will be high , Heart rate will be high , the blood will be distributed from the organs to the muscles to prepare yourself for fighting . So, if the system is over activated , you will be not in good position to anesthetize you . In this case , explanation to the patient usually helps to calm him down. But, if its failed we have to
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give him some sort of benzodiazepine , like diazepam , lorazepam , temazepam to help him to calm down . Important things for preoperative assessment is the past medical history The anesthetist must have good knowledge in medicine , and we used to say: medicine is medicine . Because , if the patient he has high BP , diabetic , heart failure , we should approach the patient knowing what is waiting for the patient . If we gave him general anesthetic . past surgical history , we have to know the patient has general anesthetics before , and if he has a problem with the anesthesia like apnea Allergies, you have to ask the patient if he or she has allergy . Its the prime responsibility of the anesthetist to ask about allergy . The NPO , period of starvation . Usually, for elective cases we use to starve the patient for 6 hours . 6 hours are enough for the patient to be fasting . GA ( General Anesthesia ) : reversible loss of consciousness , the patient become unaware about the surrounding , the upper way flexes not intact ( not respond to verbal command ) . When you give anesthetic, if vomiting happens when the patient is awake or semi awake, regurgitations happens when the patient is deeply comatose . so , we should ask the patient to fast for 6 hours . When you eat something and you have an incident, I cant apply to this case 6 hours !

M.P. = Mallampati Anesthetist job is to make sure that the upper airways will not cause a problem, many people have died from anesthetics! How the doctor will make sure of these things? 1- General appearance of the patient : obese , short neck ,scar in face , limitation in mouth opening .
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2- We have to ask the patient to make full flexion & extension of the head , towards right & left 3- We have to ask the patient to open the mouth fully, so that the TMJ is free. These are not enough , We have to make a test which is mallampati score . Mallampati score is used to predict the ease of intubation. A high Mallampati score (class 3 or 4) is associated with more difficult intubation as well as a higher incidence of sleep apnea .

Technique The Mallampati score is assessed by asking the patient (in a sitting posture) to open his/her mouth and protrude the tongue as much as possible. The anatomy of the oral cavity is visualized; specifically, whether the base of the uvula, faucial pillars (the arches in front of and behind the tonsils) and soft palate are visible. Scoring may be done with or without phonation. Depending on whether the tongue is maximally protruded and/or the patient asked to phonate, the scoring may vary. Modified Mallampati Scoring:

Class I: Soft palate, uvula, fauces, pillars visible. Class II: Soft palate, uvula, fauces visible. Class III: Soft palate, base of uvula visible. Class IV: Only hard palate visible

While Mallampati classes I and II are associated with relatively easy intubation, classes III and IV are associated with increased difficulty.

Note : instead of making a traditional way of intubation , we make fibro optic awake intubation ( people will die from free to intubate ) , the patient will be unconscious , paralyzed .
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If you cannot intubate or ventilate, you will lose the patient , because you didnt expect that this is unexpected difficult intubation , so we apply local anesthetic in the upper way , after that we also make fibro optic bronchoscope ( while the patient is awake )

Drugs :
1- Warfarin : we should stop warfarin 3 days before the operation 2- M.A.O.I should be stopped also 3- Contraceptive pills: for family planning... Should also be stopped before the operation, ( if a female was taking contraceptive pills , the operation elective should be postponed for 6 weeks , because these pills participate in Deep Venous thrombosis & death . But , if this female came to us life sealing situation , I have to anathesiate , because the is dying , in this case we have to give Heparin to counteract the effect of contraceptive pills 4- Antihypertensive: Patients undergoing antihypertensive therapy should be carefully monitored preoperatively by observation for interactions between antihypertensive and anesthetic agents and minimizing interruption schedules for antihypertensive therapy. Hypertension is one of the most common underlying diseases observed in patients undergoing dental treatment. During induction of general anesthesia, patients with hypertension may exhibit significant increases in heart rate and blood pressure, though the agents used for this often cause hypotension 5- Diabetic drugs : Patients with diabetes should be scheduled to undergo their procedures as the first case of the day. This will allow them more time during the day to recover and perhaps be able to start back on a reasonably normal diet. Some diabetics will be asked to take less than their normal dose of insulin. A few diabetics might even omit taking any insulin until the procedure is over and they are capable of eating or drinking again. All diabetic patients should have their blood sugar tested immediately before the operation and again when they arrive

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in the recovery room. Some patients also have their blood sugar tested during the procedure by their anesthesiologist.

Smoking
3rd World countries suffering from the scourge of anesthesia because of the increasing number of smokers . 1- Cigar smoking : Carbon monoxide percentage in your blood will reach 15% . Carbon monoxide when it reached your body, angioaffinity of hemoglobin is 240 times more that oxygen . 2- Carbon monoxide makes nicotine sympathetic stimulation 3- Increase Secretion of acid in the stomach = peptic ulcer 4- Irritation of the mucosa, lining of the nose . This will damage the wall of respiratory tract, so there will be increase in retention of secretion .

Alcohol Apparently, we used to ask the patient : you drink alcohol . sometimes , I have to double or triple the dose of anesthesia . LAB Each one after the age of 51 must do sigmoidoscopy every 5 years. Chest X-ray After the age of 45 you have to do chest x-ray test .

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Goldmans discovered risk factors for anesthesia

Summary:

ASA 1 : A normal healthy patient. ASA 2 : A patient with mild systemic disease. ASA 3 : A patient with severe systemic disease. ASA 4 : A patient with severe systemic disease that is a constant threat to life. ASA 5 : A moribund patient who is not expected to survive without the operation. ASA 6: A declared brain-dead patient for donor purposes. whose organs are being removed

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Some instructions from Dr. Wael Khrais ( for your knowledge )

1- When you apply assessment to the patient , you have to respect the patient , you should wear well . 2- You should introduce yourself to the patient 3- You should offer the patient local anesthetic 4- Be HONEST ^_^

At the end of my talks, I would like to thank you all for good listening to me

A student asked: according to smoking, How far a smoking patient does it affect topical or local anesthetics ? Answer: if youre planning to have General anesthetics, you have to stop smoking 6 weeks. If its difficult, you have to stop smoking 12 hours before the operation (halflife of Carbon oxide is 12 hours)

Done by : Majd M. Hidmi Forgive me for any mistake , I tried my best !

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