National Board Ex- 6 Book .pmd - National Board Of Examination

yet to be validated and should be used as an adjunct to clinicaljudgment.Table 4: Estimation of perioperative riskA. Severity of Sleep Apnoea based on sleep studyNone ........................................................................................... 0Mild ........................................................................................... 1Moderate ........................................................................................... 2Severe ........................................................................................... 3B. Invasiveness of surgery and anesthesiaSuperficial surgery under local or peripheralNerve-block anesthesia without sedation .......................... 0Superficial surgery with moderate sedation orGeneral anesthesia .......................………………………….. 1Peripheral surgery with spinal or epiduralAnesthesia (with not more than moderatesedation) ........................................................................................1Peripheral surgery with general anesthesia 2Airway surgery with moderate sedation 2Major surgery,general anesthesia 3Airway surgery,general anesthesia 3C. Requirement for post-operative opioidsNone …………………………………. 3Low dose oral opioids…………………………………. aHigh dose oral opioids, parenteral, orNeuraxial opioids…………………………………. 3Estimation of perioperative riskOveral score = Score of A plus the greater of the score foreither B or CScore = 4: Increased perioperative riskScore > 4 : Significantly increased perioperative riskAirway changes-Obesity hasbeen identified as an independentrisk factor for difficult maskventilation [Table 5]. Theanatomical changes in the upperairway lead to increase an increasein incidence of problematictracheal intubation.l Impaired cervical andAtlanto-occipital movementsllFat face, large tongue, largebreasts, excessive palatalpharyngealtissueRestricted mouth openingl Difficult laryngoscopy -Incidence of ‘problematic’intubation is 5% when neckcircumference >40cm and35% when > 60 cm at thelevel of the thyroidcartilage[Fig 3].l Awake intubation upto 8% [> 175% IBW awakeintubation is recommended]Fig 3: Neck circumferenceTable5 : Obesity and airway managementDifficult mask ventilation Difficult laryngoscopy Difficult IntubationFleshy cheeks Double chin Excessive folds ofLarge tongue Cervical/ Upper Pharyngeal tissue foldsPharyngeal tissue folds thoracic pad of fat Anterior larynxRestricted neck Submental fatmovementsLarge breastsLarge tonguePharyngeal tissue folds60Journal of Postgraduate Medical Education, Training & ResearchVol. II, No. 5, September-October 2007