OBJECTIVES 3.

Assess clinically relevant parameters of tissue and organ status to

1. Enumerate the various methods of perioperative evaluation ensure that the flow of oxygenated blood through the
2. Discuss the value of perioperative evaluation microcirculation is sufficient to support aerobic metabolism at the
3. Apply the evaluation results to prognosticate patient outcomes cellular level.
4. Design a patient-centered perioperative plan.
Why “monitor”?
 to be Aware,
 to take timely Action,
 to clinically Assess effects of these actions

COURSE COVERAGE
A. Systems Evaluation
 Cardiovascular system
o BP/PR/MAR
o EKG
o Measures of cardiac function
 Respiratory/Pulmonary system
o ABG/Ventilation-Perfusion
o Oximetry/Capnometry
 Renal
o Urine Output
o Bladder pressure
 Neurologic
o Intracranial Pressure
MONITOR o Electroencephalography
 Lat. Monere – “to warn or advise” o Transcranial Ultrasound
1. Provide advanced warning of impending deterioration in the status  Others (Hepatic, Hematologic, Endocrinologic)
of one or more organ systems. o CT/BT/PT/PTT, LFT, FBS
2. To allow the clinician to take appropriate actions in a timely fashion B. Applications
and prevent or ameliorate any physiologic derangement; Titrate  NEWS/MEWS
therapeutic interventions.  MRA

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 Perioperative Monitoring covers several phases: PREOPERATIVE PREPARATION OF THE PATIENT
o Preoperative 1. The need for surgery
o Intraoperative
o Postoperative  Guided by the pillars of Medical Ethics
Although there a commonalities in some parameters, some are o Patient’s right to choose or refuse treatment (Autonomy)
applied during the particular phase. o Acting in the best interest of patient (Beneficence)
o First do no harm/primum non nocere (non-maleficence)
o Treated with respect (Dignity)
APPROACH TO PREOPERATIVE EVALUATION
o Informed consent and truth-telling (honesty and
Organ Systems Co-morbid factors: truthfulness)
1. Cardiovascular 1. Age o Equitable use of health resources (Justice)
2. Pulmonary 2. Functional status  Open understandable communication sans Paternalism
3. Renal 3. Nutritional Status  Pathophysiologic correlation and prognostication
4. Hepatobiliary 4. Obesity The role of good communications skills to enhance patient-doctor
5. Endocrine 5. Anesthesia risk relationship is of paramount importance to create an atmosphere of
6. Immunologic
Trust.
7. Hematologic
The surgical indications/need for surgery and the global picture of
A Risk Management Plan is unique to every patient depending on the disease must be understood by the patient. This requires the
the risks uncovered and managed perioperatively. Most co-morbid Health Provider to be Able (Training, Talent, Technology-aware),
factors are Independent predictors of perioperative courses. Available and Afable [Cuanang J., 1973]
Common preventable complications after non-cardiac surgery that Paternalism – acts of authority by the physician in directing care and
may be prevented by enhanced perioperative care -Pearse RM- distribution of resources to patients. This will hinder patient
These include: autonomy and engagement despite the physician’s desire to act in
o Pneumonia and Respiratory failure the best interest of the patient.
o Superficial and deep wound infection
o Myocardial infarction and Arrhythmias 2. Perioperative decision-making
o Severe pain
 timing of surgery
o Pulmonary embolism
 site of surgical procedure
o Acute kidney injury
 type of anesthesia
o Acute confusion or delirium
 patient preparation
o Cardiac arrest
 support system
o Stroke
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 After being fully and honestly appraised of the disease condition Physiologic Basis of CardioPulmonary (CP) monitoring
by competent health providers, the patient should be part of the o Synthesis of ATP via TCA (Kreb’s) cycle, requires the
decision-making process. continuous delivery of oxygen by matching ventilation
Awareness of the existing health and support systems will with perfusion.
positively impact on the patient’s decision-making process in o Ventilation (V) refers to the flow of air into and out of the
terms of allocation of available resources and psychosocial alveoli [O2 Delivery, DO2]; then to O2 diffusion from
concerns. hemoglobin in red blood cells into the mitochondria (O2
utilization).
o Perfusion (Q) refers to the flow of blood to alveolar
3. Perioperative evaluation
capillaries.
 Guided by findings on the history and physical examination,
V is affected by airway patency, RR >> O2 Sat
demographic or epidemiologic data or patterns of disease
Q is influenced by HR, BP, Cardiac Output (QT ), >> O2 utilization
progression.
 To identify and quantify any co-morbidity that may have an
impact on the outcome of the surgical procedure. PHYSIOLOGIC BASIS OF CP MONITORING
 To uncover problem areas that may require further investigation  In normoxemic state, hormonal milieu and mechanical workload of
or optimization. contractile tissues will affect aerobic metabolism
 In the hypoxemic state, increased DO2 cannot compensate for the
In the patient-centered, organ system-based perioperative
decrease in VO2 and will reach the point of critical oxygen delivery
planning, patient engagement is most important. Physician-
(DO2crit) >>> clinically, the Maximum Aerobic Rate (MAR)
patient relationships guided by the pillars of medical ethics
 MAR= [220-age in yrs] x 0.75]
become the foundation of future applications of perioperative
Ventilation-Perfusion matching/coupling
parameters.
o The V/Q ratio is the ratio between the ventilation and the perfusion
affects the alveolar/arterial levels of oxygen and carbon dioxide.
GOALS OF HEMODYNAMIC MONITORING
o Normal V (ventilation) is 4L of air per minute.
To ensure that the flow of oxygenated blood through the
o Normal Q (perfusion) is 5L of blood per minute.
microcirculation is sufficient to support aerobic metabolism at the o So Normal V/Q ratio is 4/5 or 0.8.
cellular level (mitochondria). o When oxygen availability is inadequate [low O2 Sat], oxygen delivery
May be influenced by cardiac output (HR x SV), hemoglobin (DO2)/perfusion is initially compensated for by increased HR. But
concentration of the blood or oxygen content of arterial blood (O2 the compensatory tachycardia has its limits – this is the maximum
saturation) aerobic rate – beyond which, NO metabolic cycling will occur.

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 PULSE PRESSURE
 PP = sysBP – BPdia
 Normal = 40-60 mmHg
 Wide PP may indicate change in cardiac function or structure
 valvular regurgitation
 aortic stiffening
 severe iron deficiency anemia
 hyperthyroidism
 increased risk for atrial fibrillation and coronary artery disease

Pulse pressure (PP), defined as the difference between systolic

blood pressure (SBP) and diastolic blood pressure (DBP), is a
pulsatile component of the blood pressure (BP) curve as
opposed to mean arterial pressure (MAP), which is a steady
component. Measuring your pulse pressure may help your
ARTERIAL BLOOD PRESSURE
doctor predict if you're at risk for a heart event, including a heart
NON-INVASIVE attack or stroke. If your pulse pressure is greater than 60 it's
 A complex function of both cardiac output and vascular input considered a risk factor for cardiovascular disease, especially for
impedance.
older adults.
1. Auscultation of the Korotkoff sounds
2. Detection of oscillations in the pressure within the bladder of the The systemic pulse pressure is approximately proportional to
cuff. The width of the cuff should be approximately 40% of its stroke volume, or the amount of blood ejected from the left
circumference. ventricle during systole (pump action) and inversely proportional
3. Doppler stethoscope (reappearance of the pulse produces an to the compliance (related to Elasticity) of the aorta
audible amplified signal) or a pulse oximeter (reappearance of the A wide/high pulse pressure can be due to high blood pressure
pulse is indicated by flashing of a light-emitting diode).
or atherosclerosis, fatty deposits that build up on your arteries.
4. Photoplethysmography uses the transmission of infrared light to
Additionally, iron deficiency anemia and hyperthyroidism can
estimate the amount of hemoglobin (directly related to the volume
of blood) in a finger placed under a servo-controlled inflatable cuff. lead to an increase in pulse pressure. A high pulse pressure is
often associated with increased risk of heart attack or stroke,
particularly in men.

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 Stiffness of the body's largest artery, the aorta, is the leading Preload is also affected by two main body "pumps":
cause of increased pulse pressure in older adults. High blood 1. Respiratory pump - Intrapleural pressure decreases during
pressure or fatty deposits on the walls of the arteries inspiration and abdominal pressure increases, squeezing
(atherosclerosis) can make your arteries stiff. The greater your local abdominal veins, allowing thoracic veins to expand
pulse pressure, the stiffer and more damaged the blood vessels and increase blood flow towards the right atrium.
are thought to be. 2. Skeletal muscle pump - In the deep veins of the legs,
Treating high blood pressure usually reduces pulse pressure surrounding muscles squeeze veins and pump blood back
Following a healthy lifestyle is also important. Heart-smart towards the heart. This occurs most notably in the legs.
strategies include getting regular exercise, not smoking, limiting Once blood flows past valves it cannot flow backwards and
alcohol and reducing the amount of salt in your diet. therefore blood is “milked” towards the heart.
Increasing preload will exacerbate pulmonary or systemic
DETERMINANTS OF CARDIAC PERFORMANCE congestion and edema, which occurs when end-diastolic pressure
PRELOAD is greater than 20 mmHg. Therefore, increasing preload is not a
 Preload - the stretch of ventricular myocardial tissue at the end of viable option for increasing cardiac output in heart failure
diastole just prior to the next contraction determined by the end- patients.
diastolic volume (EDV); the amount of ventricular stretch at the end Increased heart rate augments metabolic demands and can
of diastole
further reduce performance by increasing myocardial cell death.
 For the RV, central venous pressure (CVP) approximates RV end-
diastolic pressure (EDP). For the LV, pulmonary artery occlusion Increased circulating volume and preload ultimately overwhelm
pressure (PAOP) approximates LV end-diastolic pressure Frank-Starling mechanism and heart's ability to maintain forward
flow, resulting in worsening of lung vasculature congestion.
Preload is increased by the following: The Frank-Starling Law states that the stroke volume of the left
o  central venous pressure (CVP), e.g., from dereased
ventricle will increase as the left ventricular volume increases due
venous compliance due to sympathetic activation;
to the myocyte stretch causing a more forceful systolic
o  blood volume;
o respiratory augmentation; contraction. The Frank-Starling Relationship is an intrinsic property
o  skeletal pump activity of myocardium by which increased length (or ventricular volume)
o  ventricular compliance results in enhanced performance during the subsequent
o  atrial contraction contraction.

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 AFTERLOAD Increasing the force of contraction expels more blood from the
 the force resisting fiber shortening once systole begins; the amount left ventricle, so that cardiac output increases when the preload
of resistance the heart must overcome to open the aortic valve and
increases. This preload is generally expressed as the right atrial
push the blood volume out into the systemic circulation
pressure, the pressure which drives filling of the heart.
approximated by calculating systemic vascular resistance, divided
by cardiac output (QT) Cardiac Output is directly influenced by the circulating blood
volume. This is the rationale for computing the allowable blood
CONTRACTILITY loss in a surgical patient. This is the estimated amount of blood
 the inotropic state of the myocardium which can be lost before reaching a critical level.
o Allowable Blood Loss = (Hct_start – Hct_allow) x
HEMODYNAMIC MEASUREMENTS Blood_Vol/Hct_start;
SVR – systemic vascular resistance o where Blood_Vol = 0.07L/kg x Weight in Kgs
Normal – 9-20 mmHg-min/L Stroke volume is (SV) the amount of blood ejected from the
ventricle with each cardiac cycle. It can be readily calculated by
SVR = MAP/QT
subtracting the end-systolic volume from the end-diastolic
MAP = BPdia + ([BPsys – BPdia ]/3) volume. Multiplying the stroke volume by the heart rate yields the
cardiac output, typically reported in liters per minute.
QT = HR x Stroke Volume (cardiac output)
Normal = 4-8L/min
ARTERIAL BLOOD PRESSURE

SV = End-diastolic volume (EDV) - End-systolic volume (ESV) INVASIVE

Normal = 70ml  Intra-arterial pressure monitoring (via Radial Artery)
o complications: distal ischemia, thrombosis, infection, air
CI – cardiac index embolism, thromboembolism
= QT /BSA  Pulmonary Artery Catheterization (PAC)
o complications: wrong placement, rupture of pulmonary
Afterload per se does not alter preload; however, preload vessel, air embolism
changes secondarily to changes in afterload. Increasing afterload o Determines Cardiac Output (QT), Mixed Venous Oximetry
not only reduces stroke volume, but it also increases left
ventricular end-diastolic pressure (LVEDP)

♡
 Commonly utilized in the seriously-ill ICU patients; uses
indwelling intravascular catheters or central catheters.
Gives continuous monitoring parameters (usually
digital/computerized data) to guide management.

ELECTROCARDIOGRAPHIC MONITORING
 Detects abnormalities in Rate (tachy/bradycardia) and Rhythm
(dysrhythmias) or combinations thereof – best seen in a long lead II
 ECG patterns of interest include repetitive changes in the
morphology of the T-wave [T-wave alternans (TWA)] and heart rate
variability
 Precordial lead V4 is the most sensitive for detecting perioperative CHOOSING WISELY
ischemia and infarction  No risk factors* for heart disease or symptoms suggesting possible
heart disease → No need for ECG
An ECG test helps screen and diagnose a variety of cardiac
o *Age≥40 yrs., smoking history, lifestyle, diet, alcohol intake,
problems. It’s the most common way to check if your heart is
stress, blood pressure, Diabetes mellitus, obesity,
healthy or monitor existing heart diseases. History and Physical hyperlipidemia,
Exam and Labs are valid for 30 days. EKG's that are normal are
valid for 90 days. Evidence-based ECG monitoring will impact on the distribution of
ECG can detect a heart problem that might lead to a stroke or resources and prevent over-indication.
even uncover a past problem such as a previous heart attack. An ECG gives two major kinds of information. First, by measuring
time intervals on the ECG, a doctor can determine how long the
Such ECG results would be classified as abnormal ECG.
electrical wave takes to pass through the heart. Finding out how
Often, it is the preferred method to detect these problems and is long a wave takes to travel from one part of the heart to the next
frequently used, for example, to confirm and monitor atrial shows if the electrical activity is normal or slow, fast or irregular.
fibrillation (AFib), a condition that leads to blood clots that can Second, by measuring the amount of electrical activity passing
result in stroke. Arrhythmias, It can also detect heart defects, through the heart muscle, a cardiologist may be able to find out if
heart inflammation, cardiac arrest, poor blood supply, coronary parts of the heart are too large or are overworked.
artery disease or heart attack.

♡
 The Revised Cardiac Risk Index (RCRI), also known as Lee Index
(1999). Because validation studies have shown its effectiveness, it
represents the most recommended tool for rapid perioperative
risk assessment. In 2009 and 2014, the European Society of
Cardiology (ESC) and the European Society of Anaesthesiology
(ESA) included the index into their preoperative cardiac risk
assessment and management guidelines for non-cardiac surgery.
It also received a recommendation from the American College of
Cardiology (ACC) and the American Heart Association (AHA)

CVS RISK PREDICTORS (RVRI)

 Estimates the patient’s risk for perioperative cardiac complications.
 Derived from Goldman’s Criteria

Patients requiring pre-operative Cardiac Clearance include, but are

not limited to:
o Patients with complex medical history
o Patients with co-morbidities including hypertension
o obesity
o diabetes
o COPD
o sleep apnea
o dyslipidemia

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 NEW YORK HEART ASSOCIATION (NYHA) HEART FAILURE RISK OF CARDIAC DEATH AND NONFATAL MYOCARDIAL
CLASSIFICATION INFARCTION FOR NON-CARDIAC SURGICAL PROCEDURES

The New York Heart Association (NYHA) functional classification of heart RISK FOR
failure is widely used in practice and in clinical studies. It is based on PROCEDURE
symptom severity and the amount of exertion needed to provoke symptoms. Aortic and major vascular surgery, peripheral
A normal heart's ejection fraction may be between 50 and 70 percent. You HIGH (>5%)
vascular surgery
can have a normal ejection fraction measurement and still have heart failure
Intraperitoneal or (5%) intrathoracic surgery,
(called HFpEF or heart failure with preserved ejection fraction). Brain INTERMEDIATE
Natriuretic Peptide (BNP), a hormone released in response to volume carotid endarterectomy, head and neck
(5%)
XXXXexpansion and increased wall stress of cardiac myocytes, is the key surgery, orthopedic surgery, prostate surgery
X diagnostic indicator of heart failure. High levels of BNP are a sign of high Ambulatory surgery, breast surgery,
X cardiac filling pressure and can aid in the diagnosis of heart failure. BUN, LOW (<1%) endoscopic procedures, superficial
X creatinine, and a CBC are included in the initial workup. procedures, cataract surgery

♡
 S-MPM SCORING SYSTEM FOR ESTIMATING RISK OF 30-DAY
A thorough cardiac risk assessment is essential for patients
MORTALITY AFTER NON-CARDIAC SURGERY
undergoing non-cardiac surgery, due to the high mortality rate
(32-69%) of patients who experience a perioperative MI. Thirty-day mortality after non-cardiac surgery can be
Identifying these patients in advance allows for optimization with accurately predicted using a simple and accurate risk score based
tailored medical therapy and adjustment of anesthetic and on information readily available at the bedside. This risk index
surgical plan, to minimize physiological stress. may play a useful role in facilitating shared decision making,
No cardiac testing is routinely indicated for low-risk, developing and implementing risk-reduction strategies, and
asymptomatic individuals. Cardiac testing should be considered guiding quality improvement efforts.
for those who have cardiac symptoms, have a cardiac history, The authors of the Surgical Mortality Probability Model (S-
or have elevated cardiac risk (such as those who are MPM) attempted to realign the risk assessment before each
undergoing elevated risk procedure or have multiple cardiac risk operation in a situation of limited time, financial and personnel
factors) resources. It contains in a simplified form the two most
[Preoperative Cardiac Risk Assessment. David Raslau, MD, MPH, et. al., important risk components―patient risk and operational risk.
Published:February 24, 2020 S-MPM CLASS LEVELS AND ASSOCIATED RISK OF MORTALITY
DOI:https://doi.org/10.1016/j.mayocp.2019.08.013] CLASS POINT TOTAL MORTALITY
I 0-4 <0.5%
ASA PS CLASSIFICATION II 5-6 1.5-4.0%
ASA PS DEFINITION III 7-9 >10%
I A normal healthy patient
II A patient with mild systemic disease
III A patient with severe systemic disease
A patient with severe systemic disease that is a constant
IV
threat to life
A moribund patient who is not expected to survive
V
without the operation
In cases where the procedure is an “Emergency”, the ASA
classification has a letter “E” as a subscript.

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AMERICAN COLLEGE OF SURGEONS NATIONAL SURGICAL QUALITY Consideration in surgical operations is one of Risk-Benefit
IMPROVEMENT PROGRAM RISK CALCULATOR Ratio. Among high risk patients, non-invasive of medical
 The ACS NSQIP surgical risk calculator is a decision-support tool options are preferred.
based on reliable multi-institutional clinical data, which can be used METs = metabolic equivalents. A MET is the ratio of the rate of
to estimate the risks of most operations.
energy expended during an activity to the rate of energy
 It will allow clinicians and patients to make decisions using
empirically derived, patient-specific postoperative risks. expended at rest. One MET is defined as the energy you use
when you're resting or sitting still (1 kcal/kg/hour). An activity
The *American College of Surgeons – National Surgical Quality that has a value of 4 METs means you're exerting four times the
Improvement Program Surgical Risk Calculator estimates the
energy than you would if you were sitting still.
chance of an unfavorable outcome (such as a complication or
A healthy 50-year-old man should have a capacity of at least
death) after surgery. The risk is estimated based upon information
the patient gives to the healthcare provider about prior health 9.2 METs;
history. The estimates are calculated using data from a large a healthy 50-year-old woman should clock in at 8.2 METs or
number of patients who had a surgical procedure similar to the one higher, according to a recent study on women's fitness in the
the patient may have. New England Journal of Medicine.
The risk estimate only takes certain information into account. There For men age 20, 13.5 METs; age 30, 11.4 METs; age 40, 10.3
may be other factors that are not included in the estimate which METs.
may increase or decrease the risk of a complication or death. These Another way to estimate METs is by measuring your heart rate,
estimates are not a guarantee of results. the number of times your heart beats per minute. During bouts
A complication after surgery may happen even if the risk is low. of vigorous exercise, your heart rate should reach 65 to 90
This information is not intended to replace the advice of a doctor or percent of the maximum.
healthcare provider about the diagnosis, treatment, or potential
outcomes.
ACS is not responsible for medical decisions that may be made
based on the risk calculator estimates, since these estimates are
provided for informational purposes. Patients should always
consult their doctor or other health care provider before deciding
on a treatment plan.

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 PULMONARY RISK PREDICTORS
1. Increasing age
2. Lower albumin level,
3. Dependent functional status
4. Significant weight loss
5. Obesity
6. Concurrent comorbid conditions such as impaired sensorium,
previous stroke, congestive heart failure, acute renal failure, chronic
steroid use, and blood transfusion.
7. Specific pulmonary risk factors include COPD, smoking,
preoperative sputum production, pneumonia, dyspnea, and
obstructive sleep apnea.

A comprehensive preoperative evaluation must include

assessment of the risk of postoperative pulmonary complications.
Patient-specific Risk Factors include Chronic lung disease, Smoking,
Functional Status, Congestive Heart Failure
Procedure-specific Risk Factors include Surgical Site, Anesthetic
Technique, Postoperative Care requirements

RESPIRATORY MONITORING
1. Gas exchange (ABGs)
2. Acid-Base Balance
3. Respiratory Failure
4. Oxygen delivery
5. Pulse oximetry
6. Pulse CO-Oximetry
7. Capnometry
8. Capnography

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 RENAL RISK PREDICTORS
 Preoperative creatinine level ≥2.0 mg/dl is an independent risk
factor for cardiac complications.
 Dehydration and electrolyte abnormalities
 Associated diabetic nephropathy

Creatinine levels in the blood can vary depending on age, race

and body size. A creatinine level of >1.2 for women and >1.4 for
men may be an early sign that the kidneys are not working
properly. As kidney disease progresses, the level of creatinine in
the blood rises. In general, however, normal creatinine levels range
from 0.9 to 1.3 mg/dL in men and 0.6 to 1.1 mg/dL in women
These are utilized in tandem with chest x-ray. who are 18 to 60 years old. Normal levels are roughly the same for
Especially important among smokers. It is suggested that people over 60.
smokers should REFRAIN from smoking for at least two weeks The amount of blood the kidneys can make creatinine-free each
prior to surgery. minute is called the creatinine clearance. Creatinine clearance in
Pulse Oximetry provides continuous non-invasive monitoring a healthy young person is about 95 milliliters (mL) per minute for
of the oxygen saturation of arterial blood (SaO2); especially women and 120 mL per minute for men. This means each minute,
useful in the titration of FiO2 and PEEP for mechanically that person's kidneys clear 95 to 120 mL of blood free of
ventilated patients creatinine. The GFR can vary depending on age, sex, and size.
Pulse CO-oximetry provides continuous non-invasive Generally, the creatinine clearance is a good estimation of the
measurement of oxidative states of hemoglobin to obviate glomerular filtration rate.
serial blood draws, potential postsurgical hemorrhage and Creatinine clearance (CrCl) is an estimate of Glomerular Filtration
more judicious use of blood transfusion Rate (GFR); however, CrCl is slightly higher than true GFR because
Capnometry is the measurement of CO2 in the airway creatinine is secreted by the proximal tubule (in addition to being
throughout the respiratory cycle; measures the partial filtered by the glomerulus). Several formulas (Cockcroft-Gault,
pressure of CO2 in arterial blood (PaCO2) Schwartz) can be used in computing for the CrCl. Clearance is
Capnography allows the confirmation of endotracheal often measured as milliliters per minute (mL/min) or milliliters
intubation and continuous assessment of ventilation, integrity per second (mL/s). Normal values are: Male: 97 to 137 mL/min
of the airway, operation of the ventilator and CP function (1.65 to 2.33 mL/s). Female: 88 to 128 mL/min (1.496 to 2.18
mL/s).

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 RENAL MONITORING Basis for risk assessment
Urine output Secondary to the loss of hepatic reserve capacity and because
 a gross indicator of renal perfusion, with patent Foley catheter of other systemic derangements that are the result of liver
 Normal output is 0.5ml/kg/hr in adults; 1-2ml/kg/hr in dysfunction (such as hemodynamic impairments), patients with
pediatric patients liver disease have an inappropriate response to surgical stress.
 May reflect hypotension, hypovolemia or low QT These individuals are accordingly at an increased risk of
Blood Pressure bleeding, infection, impaired wound healing, postoperative
 Measures intra-abdominal pressure (IAP) hepatic decompensation, including hepatic coma or death.
Abdominal Compartment Syndrome Therefore, the decision to perform surgery in these patients
 triad of oliguria, elevated peak airway pressure and elevated must be heavily weighed.
IAP impairing perfusion of kidneys and viscera; IAP>20mmHg Prediction of surgical risk is based on the degree of liver
This will rationalize the basic work of a Clinical Clerk-front liner in dysfunction, the type of surgery, and the preclinical status of
patient care. the patient.
ACS is a preventable postsurgical complication The extent of liver dysfunction and type of surgery play key
roles in determining a patient’s specific risk. In addition, liver
HEPATOBILIARY RISK PREDICTOR disease can affect almost every organ and system in the body,
CHILD-PUGH SCORING SYSTEM including the cardiorespiratory and circulatory systems, the
POINTS 1 2 3 brain, the kidneys, and the immune system.
Encephalopathy None Stage I or II Stage III or IV The extent to which secondary manifestations of liver disease
Ascites Absent Sl. controlled Moderate affect these systems may be just as important as the
desp. diuretics manifestations of primary liver dysfunction in predicting the
Bilirubin <2 2-3 >3 outcome after surgery. Such comorbid conditions responsible
(mg/dL) for perioperative morbidity and mortality (eg, coagulopathy,
Albumin (g/L) >3.5 2.8-3.5 <2.8 intravascular volume, renal function, electrolytes, cardiovascular
PT (prolonged <4 4-6 >6
status, and nutritional status) should be identified and
seconds)
addressed before surgery. Optimal preparation may decrease
INR <1.7 1.7-2.3 >2.3
death and complications after surgery. Issues to anticipate and
Class A = 5-6 points; Class B = 7-9 points; Class C = 10-15 points
address include manifestations of acute liver decompensation
including encephalopathy, acute renal failure, coagulopathy,
adult respiratory distress syndrome, and sepsis.

♡
 NEUROLOGIC MONITORING
Areas of Consideration:
The measurement of the physiological activity of the brain and spinal
Liver insufficiency can manifest as spider angiomas, caput
cord.
medusa, ascites, palmar erythema, hepatomegaly,
encephalopathy, cachexia. Biochemically expressed as Intracranial Pressure Monitoring
elevations in hepatocellular enzyme levels:  using ventriculostomy catheter; recommended in patients
o SGPT (AST) with traumatic brain injury (TBI)
o SGOT (ALT) o GCS ≤8 with abnormal CT scan or
o Alkaline Phosphatase o Normal CT scan with 2 or more of the following:
o AST/ALT ratio >2 signifies liver dysfunction  age>40
Other Liver function tests – albumin, prothrombin  unilateral or bilateral motor posturing
time/activity, bilirubins  systolic BP<90mmhg
Child-Pugh Score is a system for assessing the prognosis of  The goal is to ensure that cerebral perfusion pressure is
chronic liver disease, usually cirrhosis. It provides a forecast of adequate to support perfusion of the brain
the increasing severity of the liver disease and an insight into Continuous EEG
survival rate.  permits ongoing evaluation of cortical activity and to monitor
therapy for status epilepticus
Transcranial Doppler UTZ
 evaluate cerebral hemodynamics; an independent predictor
of vasospasm after subarachnoid hemorrhage
The aims of the neuromonitoring during perioperative period are:
1. to detect the brain, spinal cord and peripheral nerve
ischemia immediately and hence prevention from neuronal
injury
2. to measure the depth of anesthesia, especially sedative
effect of anesthetics
3. to evaluate brain death
Intraoperative neuromonitoring can provide valuable
information for a surgeon who performs complex spine surgery
procedures and may prevent injury to a patient.

♡
 ENDOCRINOLOGIC RISK Certain endocrinologic dysfunctions express themselves
 DM – FBS, Post-prandial glucose, HbA1c clinically. These include Diabetes Mellitus, Adrenal diseases,
o watch out for retinopathy, neuropathy and nephropathy Thyroid and parathyroid lesions, and neuroendocrine tumors
 Thyroid function – tachycardia/palpitations and palmar sweating (NETs)
 Adrenal insufficiency – patients who have taken more than 5mg of As with other components of the preoperative medical
prednisone per day for more than 3 weeks within the past year are evaluation, the primary objective is identification and
considered at risk assessment of the severity of endocrine issues before surgery
 Pheochromocytoma – malignant/labile hypertension so that the surgeons, anesthesiologists, and internal medicine
professionals can optimize management accordingly.
This diverse complementary system have common cardiovascular Hypertension/heart disease is a common clinical indicator in
manifestations; should be assessed during cardiopulmonary these endocrinologic conditions.
evaluation.
Evaluation of endocrine issues is a sometimes overlooked yet
important component of the preoperative medical evaluation.
Patients with diabetes, thyroid disease, and hypothalamic-
pituitary-adrenal axis suppression are commonly encountered in
the surgical setting and require unique consideration to optimize
perioperative risk.
For patients with diabetes, perioperative glycemic control has
the strongest association with postsurgical outcomes. The
preoperative evaluation should include recommendations for
adjustment of insulin and noninsulin diabetic medications before
surgery. Recommendations differ based on the type of diabetes,
the type of insulin, and the patient's predisposition to
hyperglycemia or hypoglycemia.
Generally, patients with thyroid dysfunction can safely undergo
operations unless they have untreated hyperthyroidism or severe
hypothyroidism. Patients with known primary or secondary
adrenal insufficiency require supplemental glucocorticoids to
prevent adrenal crisis in the perioperative setting.

♡
 Perioperative management of immunocompromised patient
is mostly directed by the fact that immunosuppression itself does
not cause pathology, but does leave the patient prone to infection.
Immunodeficiency can be broadly characterized as congenital
(primary) or acquired (secondary). The majority of immune
deficiencies that are of interest to the anaesthetist are acquired.
Neutrophils play a vital role in protecting against infection, so the
duration and severity of neutropenia directly correlate with the
total incidence of all infections, including those that are life
threatening. The risk of opportunistic infection increases as the
ANC falls below 1500/μL, and the risk of serious infection
increases as the ANC falls to the severely neutropenic range (<
500/µL).
Vulnerability to infection is extremely high in patients with
agranulocytosis, which is the virtual absence of neutrophils in
peripheral blood, with ANC typically lower than 100/μL.

IMMUNOLOGIC PREDICTORS
 To optimize immunologic function preoperatively to minimize HEMATOLOGIC AND BLEEDING PREDICTORS
infection risk and wound breakdown  CBC and reticulocyte count to initially assess anemia
 Absolute Neutrophil Count (ANC) to assess risk of developing  Estimate allowable blood loss (ABL)
opportunistic infections o ABL= (Hcts – HctA) x (Blood Vol/Hcts)
 ANC = 10 x WBC count in 1000s x (%PMN + % Bands) o Blood Vol = 0.07L/kg x weight in Kg
o ANC: < 1500 cells/cumm  Neutropenia  Clotting Time, Bleeding Time, Partial Thromboplastin Time,
Prothrombin Time/Activity
In some surgical patients immunosuppression is easily apparent  *Thromboelastography
and directly caused by known underlying disease or treatment. In
others, although induced by the underlying disease,
immunosuppression may be less obvious.

♡
 CO-MORBID FACTORS
Maintaining blood in a liquid state is critical for homeostasis. It allows
blood to supply an adequate delivery of oxygen and nutrients to  Age – An independent risk factor
tissues while also eliminating carbon dioxide and other waste  Co-existing local or systemic disease
products. On the other hand, the ability of blood to convert from a  Comprehensive Geriatric Assessment
liquid to a solid state, in other words, to coagulate, underlies the  Functional Capacity and Frailty Index
mechanism that protects the body from life-threatening  Charlson’s Co-morbidity Index*
exsanguination.  Predicts 10-year survival based on many factors
An ideal test on blood coagulation does not yet exist. Several  ≥3 of the following → 50% postop delirium
commonly used blood tests assess blood coagulation. These tests 1. ≥ 70 yrs of age
include prothrombin time (PT), international normalized ratio 2. self-reported alcohol abuse
(INR), activated partial thromboplastin time (aPTT), platelet count, 3. poor cognitive status
X fibrinogen concentration, D-dimer level, activated clotting time, 4. poor functional status
and whole blood bleeding time (BT). These tests are usually used for 5. abnormal electrolytes/glucose
the clinical diagnosis of coagulopathy and a possible prothrombotic state, 6. non-cardiac thoracic surgery
to monitor anticoagulation therapy, and to assist in the treatment of 7. aortic aneurysm surgery
X bleeding episodes.
X Thromboelastography (TEG) is a promising diagnostic modality that
*Like the Apache II scoring system, the Charlson’s Co-morbidity Index is
X offers several advantages compared to the other tests that have been
included in a downloadable App (Medimath®, MediCalc®)
X mentioned above. The main advantage of TEG testing is its potential to
X deliver immediate goal-oriented and individualized care to a bleeding
patient:
o Global assessment of blood coagulability, including
coagulation cascade, platelet function, and fibrinolysis
o Rapid real-time bedside test with a simple methodology
(point-of-care testing)
o Diagnosis of coagulopathic bleeding
o Guide transfusion therapy and decrease the use of blood
products
o Detect dynamic changes in blood coagulation during
resuscitation
o Predict the clinical efficacy of therapeutic agents affecting
blood coagulability
♡
 FRAILTY SCALE NUTRITIONAL STATUS AS PREDICTOR
SCORING PARAMETERS  History of unintentional weight loss greater than 10% of body
• Unintentional weight loss >4.5kgs in the past year weight over a 6-month period or 5% over a month
• <20th population centile for grip strength (poor grip strength)  Low albumin, transferrin or prealbumin levels
• Self-reported exhaustion  Temporal wasting, cachexia, sarcopenia, ascites, edema
• Low physical activity such that person rarely undertake short walk  Subjective Global Assessment/NRS 2002
• Slowed walking speed (lowest population quartile on 4 minute
walking test)
INTERPRETATION
Healthy person Score 0
Very frail person
 worse outcomes
Score 4—5
 20x likely to end up in
nursing home
Intermediate frailty
 2x likely to have
complications
 50% more time in the Score 2-3
hospital
 will likely need extended
care
FI was developed by Dr. Kenneth Rockwood and Dr. Arnold
Mitnitski at Dalhousie University in Halifax, Nova Scotia, Canada.
The frailty index (FI) is used to measure the health status of older
individuals; it serves as a proxy measure of aging and vulnerability
to poor outcomes. Studies have shown that FI is a significant
predictor of operative morbidity and mortality.
Serum visceral proteins such as albumin and prealbumin have
traditionally been used as markers of the nutritional status of
patients. Prealbumin is nowadays often preferred over albumin due
to its shorter half live, reflecting more rapid changes of the nutritional
state.

♡
 These mediators interact with the sympathetic nervous system,
OBESITY AS RISK PREDICTOR the renin-angiotensin-aldosterone system and individual
 The perioperative mortality rate is significantly increased in organs -such as the pancreas and liver- to effect the alterations
patients with clinically severe obesity (BMI>40 kg/sqm or BMI >35 in physiology that accompany obesity.
kg/sqm with significant co-morbid conditions) Changes in the cardiac system occur as a consequence of the
 Clinically severe obesity is associated with essential hypertension, cardiovascular adaptation to excess body mass and increased
pulmonary hypertension, LVH, CHF, and ischemic heart disease. metabolic demands. Excess body mass requires an increase in
Patients with ≥2 risk factors should undergo noninvasive cardiac intravascular blood volume as well as an increase in cardiac
testing output (mostly from an increase in stroke volume). Over time,
the increase in stroke volume leads to an increase in left
Obesity is associated with conditions such as type 2 diabetes ventricular load, dilation and compensatory left ventricular
(T2DM), chronic kidney disease, depression, stroke and coronary hypertrophy, a known precursor of heart failure.
artery disease (CAD). These comorbidities, in addition to the The etiology of hypertension in the setting of obesity and
type and invasiveness of the surgical procedure, are correlated the metabolic syndrome is multifactorial, resulting from the
with the incidence and severity of postoperative complications. interaction between genetic factors, insulin resistance, sodium
BMI is a global measure of body mass encompassing both retention, activation of the sympathetic nervous system as well
adipose tissue and lean mass. It accounts for neither the as the activation of the renin-angiotensin-aldosterone axis.
proportion of each tissue nor the regional distribution of Arrhythmias in the obese may be precipitated by hypoxemia,
adipose tissue, factors which can have important implications left atrial and ventricular enlargement, electrolyte disturbances
for the clinical assessment of patients. Independent of total from diuretic therapy, increase in plasma catecholamines and
weight, excess adiposity in the central area (visceral or intra- hypercarbia. A robust association between obesity and
abdominal) is associated with higher insulin resistance and risk atrial fibrillation (AF) was demonstrated in a cardiothoracic
of atherosclerotic heart disease than a more peripheral study where patients with a BMI > 40 had a 2.3 fold increased
distribution of fat (gluteofemoral). Consequently, indirect risk of postoperative AF compared to a 1.2 fold increased risk in
measures of central fat distribution, such as waist circumference those with a BMI between 25 and 30.
or waist-to-hip ratio (WHR), may be better markers of obesity- [Ortiz VKwo J. Obesity: physiologic changes and implications for
related comorbidities such as CAD and dyslipidemia . preoperative management. BMC Anesthesiology volume 15, Article
Among the obesity-induced changes in adipose tissue activity is number: 97 (2015)]
the altered secretion of cell-signaling proteins known as
adipokines and the increased production of inflammatory
markers such as TNF-α and IL-6 by resident macrophages.

♡
 PREOPERATIVE CHECKLIST THE FOUR BASIC MONITORS:
1. Medical Risk Assessment  We are NOT auuthorised to start a surgery in the absence of any of
2. Antibiotic prophylaxis – consult CPGs these monitors:
3. Mechanical Bowel Cleansing for bowel surgery o ECG
4. Review of home meds – cardiac drugs, anticoagulants, NSAIDS, o SpO2: arterial O2 saturation
Herbal meds for drug interactions o Blood pressure: NIBP (non-invasive), IBP (invasive)
5. NPO – solids for at least 6 hrs and clear liquids for 2 hrs o + [Capnography]
 The most critical 2 times during anesthesia are: INDUCTION –
RECOVERY.
 Exactly like “flying a plane” induction (= take off) & recovery (=
landing). The aim is to achieve a smooth induction & a smooth
recovery & a smooth intraoperative.

INTRAOPERATIVE MONITORING
ECG
 Rules:
o QRS beep ON must be heard at all times. NO silent monitors
o Remember that your clinical judgement is much more
superior to the monitor. Check peripheral pulsations.
o Cautery  artefacts & fallacies in ECG (noise/electrical
interference)  check radial (peripheral) pulsations
o Arrhythmias  check radial (peripheral) pulsations
INTRAOPERATIVE FACTORS
 The right procedure to the right patient at the right time by the right SpO2
professional  It is the most important monitor. It gives a LOT of information about
 Meticulous technique and careful hemostasis the pt.
o “be kind to the tissues and they will be kind to you”  Definition: % of oxy-Hb / oxy + deoxy-Hb
o “don’t trouble trouble if trouble does not trouble you lest you  Timing of SpO2 monitoring: throughout the surgery: before
get into trouble” induction till after extubation & recovery. It is the LAST monitor to
be removed off the pt before the pt is transferred outside the
Be guided: “primum non nocere”
Competent surgical Team – surgeon, anesthesiologist, intensivist, etc.

♡
 operating room to recovery room. SpO2 monitoring should be o CVS: myocardial ischemia, pulmonary edema
continued in recovery room. o CNS: hemorrhagic stroke, hypertensive encephalopathy
 Waveform of pulse oximeter = plethysmography (arterial  White hypotensive episodes:
waveform). It indicates that the pulse oximeter is reading the o CVS: myocardial ischemia
arterial O2 saturation. Without the waveform pulse oximeter o CNS: ischemic stroke, hypoperfusion state metabolic
readings are unreliable. acidosis, delayed recovery, renal shutdown
 Value:
o SpO2: arterial O2 saturation (oxygenation of the pt) Timing of Monitoring: before induction, throughout the surgery,
o HR after extubation and recovery
o Peripheral perfusion status – loss of waveform in Frequency – every 3 minutes after spinal anesthesia
hypoperfusion states: hypotension & cold extremities o every 5 minutes by default
o Gives an idea about the rhythm from the plethysmography o every 10 minutes among awake patients under local
wave (arterial waveform). anesthesia
 Cannot identify the type of arrhythmia but can Clinical judgement is superior to machine monitors:
recognize if irregularity is present VVVVV o Radial pulse palpable – systolic BP is >90mmHg
o Cardiac arrest o Dorsalis Pedis pulse palpable – systolic BP is >80mmHg
o Superficial Temporal pulse palpable – about 80mmHg
Pulse oximeter tone changes with desaturation from high pitched to low Check for pallor (lips, tongue, nails, conjunctiva)
pitched (deep sound).
SpO2 at Room Air = 96%; patient under GA = 98%-100% [if <96% under GA
at 100% O2, search for cause] Capnography: CO2
<90% - hypoxemia; <85% - severe hypoxemia  Capnography: Continuous CO2 measurement displayed as a
waveform sampled from the patient’s airway during ventilation.
BP  EtCO2: A point on the capnogram. It is the final measurement at the
 NIBP: Non-invasive ABP monitoring = automated endpoint of the pts expiration before inspiration begins again. It is
o Gives readings for: systolic BP, diastolic BP & MAP: usually the highest CO2 measurement during ventilation.
Systolic/diastolic (mean)  Phases of capnogram:
 Value: to avoid and manage extremes of hypotension & HTN. o Baseline: A-B
Systolic BP-Diastolic BP-MAP. o Upstroke: B-C
 Avoid  MAP <60 mmHg (for cerebral & renal perfusion) & o Plateau: C-D
 avoid  diastolic pressure <50 mmHg (for coronary perfusion) o End-tidal: point D
 Risks of HTN episodes: o Downstroke

♡
 o Apnea alarm: disconnection
o O2 sensor failure: unfortunately common in many of our
ventilators
o Flow sensor failure: unfortunately common in many of our
ventilators

CVS HEMODYNAMIC MONITORING

Clinical monitoring:
 Colour: pallor (lips, tongue, nails) = anemia, shock
 Palpate peripheral pulsations every 10 minutes (radial A,
Dorsalis pedis A, Superficial temporal A)
 Normal range: 30—35 mmHg  Capillary refilling time: compress nail bed until it is blanched.
o usually  than arterial PaCO2 by 5-6 mmHg due to dilution After release of pressure refilling should occur within 2 seconds.
by dead space ventilation o If >5s = poor peripheral perfusion/circulation
 Value: data gained from capnography & EtCO2  UOP:
o ETT: Esophageal intubation o Values: indicator of
o Ventilation: hypo & hyperventilation, curare cleft  Good hydration
(spontaneous breathing trials)  Good tissue (renal) perfusion
o Pulmonary perfusion: pulmonary embolism  Good renal function [Urine is the champagne of
o Breathing circuit: disconnection, kink, leakage, obstruction, anesthetists and urologists!!]
unidirectional valve dysfunction. Rebreathing, exhausted o Indications:
soda lime  Lengthy surgery : >4 hrs
o Cardiac arrest: adequacy of resuscitation during cardiac  Major surgery with major blood loss
arrest, and prognostic value (outcome after cardiac arrest)  C-section: to monitor injury to the bladder or
ureter
RESPIRATORY MONITORING  Normal: 0.5-1 ml/kg/hr
 N.B. Various alarms by the ventilator  When the catheter is inserted you must always
 NEVER ignore an alarm by the ventilator note the baseline urine volume at the start of
o Low airway pressure: leakage, disconnection operation.
o High airway pressure: kink, biting of the tube,  Management of oliguria or anuria
bronchospasm, slipped  esophagus o Check that the line is not kinked or disconnected
o Low expired tidal volume: leakage

♡
 o Palpate the urinary bladder (suprapubic fullness), or ask  Especially in pediatrics & geriatrics (extremes of age)
the surgeon to palpate it.  Why is it necessary to avoid hypothermia? (complications of
o Raise BP (MAP >80 mmHg): renal perfusion hypothermia)
o IV fluid challenge o Cardiac arrhythmias: VT & cardiac arrest
o Diuretics o Myocardial depression
o N.B. Sometimes trendleberg position (head down) causes o Delayed recovery (delays drug metabolism)
 UOP. Reversal of this position results in immediate flow o Delayed enzymatic drug metabolism
of urine o Metabolic acidosis (tissue hypoperfusion c anaerobic
glycolysis  lactic acidosis) & hyperkalemia
CNS: AWARENESS
Clinical monitoring: MONITORING AFTER EXTUBATION & RECOVERY
 Signs or pt awareness:  After extubation: immediately fit the face mask on the pt (with a
o Movement, grimacing (facial expression) slight chin lift) and observe the breathing bag:
o Pupils dilated o Good regular breathing with adequate tidal volume
o Lacrimation transmitted to the bag
o Tachycardia o No transmission to the bag  respiratory obstruction
o HTN (improve your support), or apnea (attempt to awaken your pt
o Sweating: is always an alarming/warning sign. Causes: by painful stimulus or jaw thrust)
 Awareness  BP: within 20% of baseline
 Hypoglycemia  SpO2: >92%
 Hypercapnia  Breathing: regular adequate tidal volume
 Thyroid storm (thyrotoxic crisis)  Muscle power: sustained head elevation for 5 seconds, good hand
 Fever grip, tongue protrusion
 Always check the concentration of your vaporizer & make  Level of consciousness: full conscious =
sure that your vaporizer is not empty (below minimum = gives o Obeying orders
a concentration lower than adjusted) o Eye opening
o Purposeful movement
TEMPERATURE MONITORING  Most important: Pt MUST be able to protect his own airway
 Clinical monitoring: your hands
 Monitors: temperature probe: nasopharyngeal, esophageal
 AVOID hypothermia <36’C

♡
 RULES TO NEVER FORGET NATIONAL EARLY WARNING SCORE (NEWS)
 Never start induction with a missing monitor: ECG, BP, SpO2 A score of ≥5 is linked to an increased likelihood of death or ICU
 Never remove any monitors before extubation & recovery admission
 NEVER ignore an alarm by the ventilator Alert fully awake, opens
 ALWAYS remember than your clinical sense and judgement is eyes, obeys
GCS 15
better than & superior to any monitor. You are a doctor you are not commands, motor
a robot. The monitor is present to help you not to be ignored and functions ok
not to be cancel your brain. Verbal responds to voice
GCS 12
 Last but no means least: prompt
o ALWAYS remember that there is NO such thing as “all Pain responds to
GCS 8
monitors disconnected”  check that your pt is ALIVE!! squeeze/sternal rub
Immediately check peripheral & carotid pulsations to make Unresponsive GCS 3
sure that your pt is not ARRESTED!! Once you have ensured
pt safety reattach your monitors once again

POSTOPERATIVE MONITORING
1. Vital signs and Pain Score
2. National Early Warning Score (NEWS)
3. Modified Early Warning Score (MEWS)
4. Fluid and electrolyte balance; Acid-base balance
5. Signs of Airway
6. Obstruction Bleeding
7. Pain management
8. Engage Family
9. System-based health care practices

♡
 KEY POINTS
1. Proficiency and patient safety should be maintained by updating
knowledge and understanding (competence).
2. All vital signs, observations and assessments performed must be
documented and tracked.
3. Using evidence-based tools can make a stressful situation calmer
and more controlled
4. Patient-centered care and system-based medicine should be
utilized (rational allocation of health resources)
5. Patient engagement and education prevents postoperative
complications and… lawsuits

CASE
A 65-year old diabetic male on myocardial vasodilators with a BMI of
32 was re-explored under General Anesthesia for an anastomotic
leak of the colon with intraperitoneal abscesses. Intraoperatively, he
had episodes of hypotension managed with fluids and vasopressors.
At the Recovery Room, his O2 Saturation was 93%. He was febrile (T-
38.6*C), conscious and coherent, BP=108/60, PR=111 bpm,
RR=27/min.
1. Identify the perioperative Risk Factors in this patient.
2. What factor/factors will influence the clinical course of the
patient?
3. Enumerate the monitoring parameters and their end-points.
When to extubate?
4. Compute for the NEWS/MEWS of this patient
5. Enumerate additional data/tests needed to guide management.
6. Design a perioperative monitoring plan for this patient