PreanestheticPreanesthetic Evaluation Evaluation of the Surgical patientof the Surgical patient
마취과 R3 이 재 우
I. Preoperative I. Preoperative Assessment of surgical Assessment of surgical patient for anesthesiapatient for anesthesia
issue of appropriate preopeative preparation – ambiguous and frustrating
surgical procedure performed with anesthesia assistance require some form of preanesthetic evaluation– anesthesia is greater risk than surgery itself– preanesthetic process affect clinical safety and org
anizational integrity– appropriately prepared patient prevents clinical mo
rbidity
II. Cause of simple process II. Cause of simple process to become more complexto become more complex
surgeon vs. anesthesiologist selection of procedureprocess controlpreoperative evaluation uintno consistent system for risk assessme
ntmultiple professional society
III. PreanestheticIII. Preanesthetic evaluationevaluation portion of general process of preoperative eval
uation preanesthetic activity
– enhance safety, comfort, efficiency of process for patient and clinical staff
focus – safe anesthesia and performance of surgery
acute or chronic medical condition– refer to their primary care provider or organization
IV. Risk classification ( 1 )IV. Risk classification ( 1 )
Saklad's system– Meyer Saklad, 1941– first attempt to stratify risk for patient– type of anesthesia and nature of surgery ar
e not consideration– four preanesthesia risk category ( ASA PS 1
-4 )
IV. Risk classification ( 2 )IV. Risk classification ( 2 )
American Society of Anesthesiologists system– modified Saklad's system– add fifth category– limited application– table - 1
IV. Risk classification ( 3 )IV. Risk classification ( 3 )
Johns Hopkins Risk Classification System (JHRCS)– evaluate preoperative medical
condition and nature of surgery as independent
– nature of surgery is major determinant of risk
– table – 2
V. Patient and Procedure V. Patient and Procedure SelectionSelection
change in surgical technology, perioperative care, and postoperative management
preoperative admissionoutpatient procedureDischarge
VI. Time of EvaluationVI. Time of Evaluation
common assumptionutility of preoperative evaluation before t
he day of surgery is scant and inconclusive
Twersky - evaluate on day of surgery
VII. Personnel performing VII. Personnel performing the Evaluationthe Evaluation
anesthesiologist– retain all preanesthetic interview responsibility– directly involve with patient's care and ensure appr
opriate information assessment of patient with significant medical
problem– not performed by anesthesiologist– provided by patient's primary care provider
standard form for review ( table - 3 ) time of assessment ( table – 4)
VIII. Laboratory Testing ( 1 VIII. Laboratory Testing ( 1 ))
costly issue associated with surgery cost of care and convenience of patient is maj
or concern key consideration for relevant to anesthesia
– anesthesia is safety condition– prevalence of condition in both symptomatic and a
symptomatic patient– test sensitivity and specificity– Cost
VIII. Laboratory Testing ( 2 VIII. Laboratory Testing ( 2 ))
reasonable test– positive finding in history and P/E– need for baseline value in anticipation
of significant change due to surgery and medical intervention
– patient's inclusion in population at higher risk
IX. CommunicationIX. Communication
appropriate determination of patient medical status and laboratory te
st– surgeon, all practitioners operate