Info

particularly with cardiovascular, respiratory, psychotropic and endocrine drugs (Table 2.3).

Social history

Symptoms of diseases associated with tobacco, alcohol and drug addiction should be sought.

Physical examination

There is agreement that a thorough history and physical examination are most important in assessing intercurrent illness.

Airway [3]

The following steps are helpful in predicting a difficult intubation (see also Table 2.4):

2. Examination of the teeth: Teeth can make intubation difficult. Teeth at risk of damage should be protected with a rubber tooth guard and false teeth must be removed. Features of special interest include:

• prominent upper incisors (buck teeth);

• maxillary overbite.

3. Examination of the neck:

• flexion of the neck (chin-to-chest manoeuvre);

• extension of the head (with the neck flexed) is accomplished by extension of the occipito-atlantoid and atlanto-axial joints;

• thyromental or Patil distance (anterior neck) should measure at least three finger breadths.

Upper respiratory tract

It may be necessary to examine the ears, nose and throat specifically for evidence of active infection, but also of bleeding or malignancy. Children presenting for anaesthesia who are pyrexial should have an ENT examination.

Lower respiratory tract

It is particularly important to seek evidence of active infection as well as acute deterioration in chronic conditions.

Cardiovascular system

Ischaemic heart disease may be silent. Nevertheless, positive physical findings can be very useful. The combination of gallop rhythm, expiratory crepitations, peripheral oedema

Table 2.4. Predictors of difficult intubation.

Factor Severity Points

90-110 1

110 2

Head and neck Over 90° 0

Under 90° 2 Jaw movement Interincisor gap (IG) >5 cm (3 finger 0 Breadths), or subluxation1

IG gap <5 cm and neutral teeth 1

IG gap <5 cm and no subluxation 2

Receding mandible Normal 0

Moderate 1

Severe 2

Buck teeth Normal 0

Moderate 1

Severe 2

From [4], with permission from the BMJ Publishing Group. A total score of >2 points predicts 75% of difficult intubations, with 12.1% false alarms. A score of >4 points predicts only 42% of difficult intubations, but with a lower incidence of false alarms of 0.8%.

tSubluxation refers to the forward protrusion of the lower incisors beyond the upper incisors.

Figure 2.1. Maximal oropharyngeal aperture. (a) Good visualisation of faucial pillars, soft palate and uvula, Class 1. (b) Class 4: none of the structures seen. Class 2 (not shown): uvula not seen; pillars and soft palate seen. Class 3 (also not shown): uvula and pillars not seen; soft palate seen. Laryngoscopy is likely to be easier in classes 1 and 2 and difficult in classes 3 and 4. (From Mallampati SR, Gatt SP, Gugino LD et al. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaes Soc J 1985; 32: 429-434, with permission.)

Figure 2.1. Maximal oropharyngeal aperture. (a) Good visualisation of faucial pillars, soft palate and uvula, Class 1. (b) Class 4: none of the structures seen. Class 2 (not shown): uvula not seen; pillars and soft palate seen. Class 3 (also not shown): uvula and pillars not seen; soft palate seen. Laryngoscopy is likely to be easier in classes 1 and 2 and difficult in classes 3 and 4. (From Mallampati SR, Gatt SP, Gugino LD et al. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaes Soc J 1985; 32: 429-434, with permission.)

and venous engorgement suggests cardiac failure. Abnormalities of the pulses can contribute towards the assessment of arrhythmias, valvular conditions, atherosclerosis and congenital malformations. Diastolic murmurs and previously unrecorded systolic murmurs warrant further assessment.

Risk stratification

Many studies have provided data useful in establishing a priori categories of risk. Clearly, epidemiological conclusions made regarding patient populations cannot be extrapolated to individuals.

ASA status

The American Society of Anesthesiologists' (ASA) classification is shown in Table 1.1. Some have found it strongly predictive of mortality after general anaesthesia and surgery. Its limitations are based on the exclusion of age, sex and type of surgery in assessment [5].

Confidential enquiry into perioperative deaths reports [6]

The confidential enquiry into perioperative deaths (CEPOD) is a multispecialist investigation into perioperative fatalities in England and Wales (Table 2.5). Its recommendations constitute important guidelines regarding safety trends. Some of the more important points highlighted in recent years are:

• preoperative assessment and treatment;

• skill and experience;

• supervision of trainees;

• perioperative monitoring;

• prevention of thromboembolism;

• intensive care facilities;

• postmortem examinations.

Table 2.5. CEPOD. Classification of operations.

Emergency

Immediate life-saving operations simulta

Defeat Drugs and Live Free

Defeat Drugs and Live Free

Being addicted to drugs is a complicated matter condition that's been specified as a disorder that evidences in the obsessional thinking about and utilization of drugs. It's a matter that might continue to get worse and become disastrous and deadly if left untreated.

Get My Free Ebook


Post a comment