Page 37 - TNFlipTest

Toronto Notes 2019 Pre-Operative Assessment
• PMHx
■ Neuro: seizures, TIA/strokes, raised ICP, spinal disease, aneurysm, conditions affecting
neuromuscular junction (e.g. myasthenia gravis)
■ CVS: angina/CAD, MI, CHF, HTN, valvular disease, dysrhythmias, peripheral vascular disease
(PVD), conditions requiring endocarditis prophylaxis, exercise tolerance, CCS/NYHA class
(Cardiology and Cardiac Surgery, C35 sidebar for New York Heart Assocaition Classification)
■ Respiratory: smoking, asthma, COPD, recent upper respiratory tract infection (URTI), sleep apnea
■ GI: GERD, liver disease, NPO status
■ Renal: acute vs chronic renal insufficiency, dialysis, chronic kidney disease
■ Hematologic: anemia, coagulopathies, blood dyscrasias
■ MSK: arthritides (e.g. rheumatoid arthritis, scleroderma), cervical spine pathology (e.g. cervical
tumours, cervical infections/abscesses, trauma to cervical spine, previous cervical spine surgery),
cervical spine instability (e.g. Trisomy 21)
■ Endocrine: DM, thyroid disorders, adrenal disorders
■ other: morbid obesity, pregnancy, ethanol/recreational drug use
Physical Exam
• weight,height,BP,heartrate,respiratoryrate,oxygensaturation
• focusedphysicalexamoftheCNS,CVS,andrespiratorysystems
• generalassessmentofnutrition,hydration,andmentalstatus
• airwayassessmentisdonetodetermineintubationdifficulty(nosingletestisspecificorsensitive)and
ventilation difficulty
■ cervical spine stability and neck movement – upper cervical spine extension, lower cervical spine
flexion (“sniffing the morning air” position – Figure 5, Panel C)
■ Mallampati classification
■ “3-3-2 rule”
◆ 3 of patient’s own fingers can be placed between the incisors (incisor distance)
◆ 3 fingers along the floor of the mandible between the mentum and hyoid bone (hyoid-mental
distance)
◆ 2 fingers in the superior laryngeal notch (thyroid-mouth distance)
◆ thyromental distance (distance of lower mandible in midline from the mentum to the thyroid
notch); <3 finger breadths (<6 cm) is associated with difficult intubation
◆ mouth opening (<2 finger breadths is associated with difficult intubation)
◆ anterior jaw subluxation (<1 finger breadth is associated with difficult intubation)
■ tongue size
■ dentition, dental appliances/prosthetic caps, existing chipped/loose teeth – pose aspiration risk if
dislodged and must inform patients of rare possibility of damage
■ nasal passage patency (if planning nasotracheal intubation) ■ assess potential for difficult ventilation
• examinationofanatomicalsitesrelevanttolinesandblocks
■ bony landmarks and suitability of anatomy for regional anesthesia (if relevant) ■ sites for IV, CVP, and pulmonary artery (PA) catheters
Anesthesia A3
Evaluation of Difficult Airway
LEMON
Look – obesity, beard, dental/facial abnormalities, neck, facial/neck trauma Evaluate – 3-3-2 rule
Mallampati score (≥3)
Obstruction – stridor, foreign bodies, masses Neck mobility
To Assess for Ventilation Difficulty
BONES
Beard
Obesity (BMI>26)
No teeth
Elderly (age>55) Snoring Hx (sleep apnea)
3
Mandible
Hyoid Thyroid
cartilage
3
2
I II
Full view of uvula (body and base of uvula)
Tonsils
Body and base of uvula
Post-pharyngeal wall
Figure 1. Mallampati classification of oral opening
III
Figure 3. Laryngeal views
IV
Figure 2. 3-3-2 Rule
Tonsillar pillars
Tonsillar pillars
and tonsils (partial view)
IV Hard palate Tongue
Epiglottis
I
Vocal fold
III
Base of uvula
Other structures not visible
Arytenoids II
©Aileen Lin 2019
© Betty Lee
©Aileen Lin 2019