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PERIOPERATIVE SCORES & CLASSIFICATIONS

AIRWAY

Mallampatti

Score of III or greater predictive of a difficult airway; most sensitive, but low specificity

  • Class I; all visible; hard palate, soft palate, pillars, fauces, uvula
  • Class II; uvula partially obscured
  • Class III; base of uvula only
  • Class IV; only hard palate visible

Interincisor gap

<3cm abnormal 

Ability to prognath
  • Class A; able to protrude lower incisors anterior to upper incisors
  • Class B; lower incisors reach margin of upper incisors
  • Class C; lower incisors cannot protrude to the upper incisors 

Thyromental distance

Distance from the tip of the thyroid cartilage to the tip of the mandible with full neck extension and mouth closed
<6.5cm predictive of increased risk

Has been modified to include ratio of TMD to body height, or as thyromental height

Sternomental distance

Distance from the upper border of the manubrium to the tip of the mandible with full neck extension and mouth closed

<12.5cm predictive of increased risk 

Neck extension

Tip of mandible > occipital protruberance

Incisor plane movement <20 degrees predictive of risk

Cormack Lehane
  • Grade 1; most of the glottis is visible
  • Grade 2; only the posterior extremity of the glottis is visible
  • Grade 2a; when the posterior cords are visible
  • Grade 2b; when only the base of the arytenoids are visible
  • Grade 3; only the epiglottis is visible, no part of the glottis visible
  • Grade 3a; when the epiglottis can be lifted from the posterior pharyngeal wall
  • Grade 3b; when it cannot be lifted (bougie introducer not useful)
  • Grade 4; not even the epiglottis can be seen

CRISIS MANAGEMENT, RESUSCITATION, FLUID MANAGEMENT

Anaphylaxis severity
  • Grade I; generalised cutaneous signs
  • Grade II; moderate multiorgan involvement
  • Grade III; severe multiorgan involvement
  • Grade IV; cardiorespiratory arrest
  • Grade V; death 
Haemorrhagic shock class
  • Class I; <15%, <750ml, PR <100, normotensive, RR 14-20, UO >30, slightly anxious
  • Class II; 15-30%, 750-1500ml, PR 100-120, normotensive, RR 20-30, UO 20-30, mildly anxious
  • Class III; 30-40%, 1500-2000ml, PR 120-140, hypotensive, RR 30-40, UO 5-15, anxious/confused
  • Class IV; >40%, >2000ml, PR >140, hypotensive, RR >35, UO negligible, confused/lethargic
Paediatric dehydration scale
  • Mild; <4%, no clinical signs, increased thirst
  • Moderate; 4-7%, delayed CRT, increased RR, decreased turgor
  • Severe; ≥7%, very delayed CRT, mottled skin, signs of shock (tachycardia, hypotension, consciousness), deep acidotic breathing, decreased turgor

GENERAL ANAESTHESIA & SEDATION

ANZCA depth of sedation
  • Anxiolysis
  • Conscious sedation
  • Deep sedation
  • General anaesthesia 
Michigan Sedation Score
  • 0; awake, alert
  • 1; minimally sedated, appropriate response
  • 2; moderately sedated, responds to vocal/tactile stimulation
  • 3; deeply sedated, responds to deep stimulation/pain
  • 4; unrousable

Awareness, Modified Brice questionnaire

What was the last thing you remember before going to sleep?
What is the first thing you remember after waking up?
Do you remember anything between going to sleep and waking up?
Did you dream during your procedure?

What was the worst thing about your operation?

PHYSICAL STATUS 

ASA
  • I; a normal healthy patient 
  • II; a patient with mild systemic disease
  • III; a patient with severe systemic disease
  • IV; a patient with severe systemic disease that is a constant threat to life  
  • V; a moribund patient who is not expected to survive without the operation  
  • VI; a declared brain-dead patient whose organs are being removed for donor purposes 

The addition of an ‘E’ indicates emergency surgery

Duke Activity Status index

1 MET ~3.5ml/kg/min
  • Poor, <4 MET; ADLs, walk indoors, light housework
  • Intermediate, 4-7 MET; 1 flight of stairs, walk up a hill, walk 1-2 blocks on level ground, moderate house work, garden work, sex, low energy sports
  • Good, >7 MET; heavy housework, running, high energy sports

6MWT

Distance walked on flat ground at normal pace for 6min
Median 500-600m in healthy patients

<300m correlates to ~14ml/kg/min (4 MET), poor perioperative prognosis

INTENSIVE CARE

APACHE II
  • Physiological variables
  • Laboratory variables
  • GCS
  • Age
  • Chronic organ impairment or immunosuppression

Score 0-71 correlates with mortality

RESPIRATORY RISK

BODE index
  • BMI ≤21
  • Obstructive lung disease; FEV1 ≤65
  • Dyspnoea scale score; MMRC
  • Exercise; 6MWT

RESPIRATORY DISEASE

MMRC dyspnoea score
  • 0; no limitation with ordinary activities
  • 1; mild limitation, only when hurrying/uphill
  • 2; moderate limitation, breaks when walking, slower than people of same age
  • 3; severe limitation, breaks after 100m or a few minutes
  • 4; very severe, cannot leave house or breathless with ADLs
COPD severity
  • All; FEV1/FVC <0.7
  • Mild; FEV1 >80% predicted
  • Moderate; FEV1 50-80% predicted
  • Severe; FEV1 30-50% predicted
  • Very severe; FEV1 <30% predicted
Restrictive lung disease severity
  • Mild; FVC or TLC 70-80% predicted
  • Moderate; FVC or TLC 60-70% predicted
  • Severe; FVC or TLC 35-60% predicted
  • Very severe; FVC or TLC <35% predicted
DLCO severity
  • Normal; 75-140% predicted
  • Mild; 60-75% predicted
  • Moderate; 40-60% predicted
  • Severe; <40% predicted

ARDS severity

PaO2/FiO2 ratio

  • Mild; 200-300
  • Moderate; 100-200
  • Severe; <100

SLEEP APNOEA

Sleep apnoea risk, STOPBANG
  • Snores (1)
  • Tiredness; daytime somnolence (1)
  • Observed apnoeas (1)
  • Pressure; hypertension (1)
  • BMI >35 (1)
  • Age >50 (1)
  • Neck size; circumference >40cm (1)
  • Gender; male (1)

Score ≥3 indicates high likelihood of OSA 

Sleep apnoea severity, AHI/RDI
  • Mild; 5-15/hour
  • Moderate; 15-30/hour
  • Severe; >30/hour

CARDIOVASCULAR RISK

EuroSCORE
  • Patient related factors; age, sex, pulmonary/vascular/neurological/renal disease, endocarditis, previous cardiac surgery, critical preoperative state
  • Cardiac related factors; angina, LV dysfunction, infarction, pulmonary hypertension
  • Operation related factors; emergency, additional procedure planned, thoracic aortic surgery

High risk >5, predicted mortality ~11% 

Revised Cardiac Risk Index
  • Ischaemic heart disease (1)
  • Cardiac failure (1)
  • Cerebrovascular disease (1) 
  • Insulin therapy (1)
  • Creatinine >180umol/ml (1)
  • High risk surgery – intra-thoracic, intra-abdominal, supra-inguinal vascular (1)

High risk 3 or greater, predicted MACE ~15%

CARDIAC DISEASE

NYHA heart failure scale
  • I; no symptoms/limitation with ordinary physical activity
  • II; mild symptoms/limitation during ordinary activity
  • III; marked symptoms/limitation during less-than-ordinary activity
  • IV; symptoms even at rest
LVEF
  • Mild; LVEF 45-55%
  • Moderate; LVEF 30-45%
  • Severe; LVEF <30%
Canadian Cardiovascular Society angina grading scale
  • I; no symptoms with ordinary physical activity
  • II; mild symptoms/limitation during ordinary activity
  • III; marked symptoms/limitation during less-than-ordinary activity
  • IV; symptoms even at rest
AS severity, AVA
  • Normal; 4-6cm2
  • Mild; 1.5-2cm2
  • Moderate; 1-1.5cm2
  • Severe; <1cm2,
  • Critical; <0.7cm2
AS severity, pressure gradient
  • Mild; <25mmHg
  • Moderate; 25-40mmHg
  • Severe; 40-50mmHg
  • Critical; >50mmHg
AS severity, velocity
  • Mild; 2.5-3m/s
  • Moderate; 3-4m/s
  • Severe; >4m/s
MS severity, AVA
  • Normal; 4-6cm2
  • Mild; 1.5-2cm2
  • Moderate; 1-1.5cm2
  • Severe; <1cm2,
  • Critical; <0.7cm2
MS severity, pressure gradient
  • Mild; <5mmHg
  • Moderate; 5-10mmHg
  • Severe; >10mmHg
AR/MR severity, regurgitant fraction
  • Mild; <30%
  • Moderate; 30-50%
  • Severe; >50%
Pulmonary hypertension, mPAP
  • Mild; mPAP 25-40mmHg
  • Moderate; mPAP 40-55mmHg
  • Severe; mPAP >55mmHg
Pulmonary hypertension, PASP
  • Mild; 25-50mmHg
  • Moderate; 50-70mmHg
  • Severe; >70mmHg

THROMBOSIS/BLEEDING RISK

CHA2DS2VASc
  • Congestive heart failure (1)
  • Hypertension (1)
  • Age >75 (2)
  • Diabetes (1)
  • Stroke/TIA/VTE (2)
  • Vascular disease (1)
  • Age 65-75 (1)
  • Sex female (1)
Score ≥5 considered high risk, >5% risk of stroke
Maximum score of 9 ~15% risk of stroke
 
HAS-BLED
  • Hypertension (1)
  • Abnormal renal/hepatic function (1)
  • Stroke (1)
  • Bleeding tendency (1)
  • Labile INR (1)
  • Elderly, age >65 (1)
  • Drugs (antiplatelet), alcohol (1)

Score ≥3 considered high risk, >5% risk of bleeding

NEUROLOGICAL DISEASE 

GCS
  • Eye; spontaneous (4), opens to voice (3), opens to pain (2), does not open (1)
  • Verbal; appropriate (5), disoriented (4), inappropriate/incoherent (3), incomprehensible (2), none (1)
  • Motor; follows commands (6), localises to pain (5), withdraws to pain (4), decorticate (3) decerebrate (2), none (1)
AVPU
  • Alert; GCS 15
  • Voice; responds to vocal stimuli, GCS 12
  • Pain; responds to painful stimuli, GCS 8
  • Unresponsive; GCS 3
TBI
  • Mild; GCS 13-15
  • Moderate; GCS 9-12
  • Severe; GCS 3-8
GMFCS
  • Level I; good function
  • Level II; mobility devices
  • Level III; mobility devices and sometimes uses wheelchair
  • Level IV; mostly uses wheelchair
  • Level V; wheelchair at all times

Myasthenia gravis

Prediction of postoperative ventilatory requirement (Leventhal criteria)
  • Duration of disease ≥6 years
  • Chronic respiratory disease
  • Pyridostigmine dose >750 mg/day
  • VC <2.9L
Subarachnoid – WFNS
  • Grade 1; GCS 15 without motor deficit
  • Grade 2; GCS 13-14 without motor deficit
  • Grade 3; GCS 13-14 with motor deficit
  • Grade 4; GCS 7-12
  • Grade 5; GCS 3-6
Subarachnoid – Fisher grade
  • Grade 1; no SAH blood
  • Grade 2; diffuse but not clots, layers <1mm thick
  • Grade 3; localised/vertical blood >1mm thick
  • Grade 4; presence of intracerebral or intraventricular clot
Subarachnoid – Hunt & Hess
  • Grade 0; unruptured aneurysm
  • Grade 1; asymptomatic, mild headache, nuchal rigidity
  • Grade 2; moderate-severe headache, nuchal rigidity, no neurological deficit other than CN palsy
  • Grade 3; drowsiness, confusion, mild focal neurological deficit
  • Grade 4; stupor, hemiparesis, vegetative disturbances
  • Grade 5; coma, decerebrate rigidity, moribund

HEPATIC DISEASE

Child-Pugh score
  • Bilirubin; >50 (3), 35-50 (2), <35 (1)
  • INR; >2.3 (3), 1.7-2.3 (2), <1.7 (1)
  • Albumin; <28 (3), 28-35 (2), >35 (1)
  • Encephalopathy; severe grade 3-4 (3), mild/moderate grade 1-2 (2), none (1)
  • Ascites; severe (3), mild/moderate (2), none (1)
  • Class A; score 5-6, perioperative mortality 10%
  • Class B; score 7-9, perioperative mortality 30%
  • Class C; score 10-15 (decompensated), perioperative mortality 80%, 1-year survival 40%
MELD score
  • Bilirubin
  • INR
  • Creatinine

Score ≤9 3 month mortality 4%
Score ≥40 3 month mortality 100%

RENAL DISEASE

RIFLE
  • Risk; creatinine x1.5, U/O <0.5ml/kg/hr for 6h
  • Injury; creatinine x2, U/O <0.5ml/kg/hr for 12h
  • Failure; creatinine x3, U/O <0.3ml/kg/hr for 24h or anuria for 12h
  • Loss; persistent ARF for >4 weeks
  • ESRD; end-stage renal disease for >3 months
KDOQI
  • Grade 1; eGFR >90ml/min/1.73m2
  • Grade 2; eGFR 60-90ml/min/1.73m2
  • Grade 3; eGFR 30-60ml/min/1.73m2
  • Grade 4; eGFR 15-30ml/min/1.73m2
  • Grade 5; eGFR <15ml/min/1.73m2 or dialysis

TRAUMA

Revised trauma score
  • GCS; 0-4
  • SBP; 0-4
  • RR; 0-4

Score ≥6 mortality >90% 

Hypothermia severity
  • Mild; 32-35
  • Moderate; 28-32
  • Severe; <28

OBSTETRICS

WHO modified classification of maternal cardiovascular risk
  • Class I;  no detectable increased risk of maternal mortality and no/mild increase in morbidity
  • Class II; small increased risk of maternal mortality or moderate increase in morbidity
  • Class III; significantly increased risk of maternal mortality or severe morbidity
  • Class IV; extremely high risk of maternal mortality or severe morbidity

PAEDIATRICS

APGAR score
  • Activity/tone; active (2), flexed (1), absent activity (0)
  • Pulse; >100 bpm (2), <100 bpm (1), absent (0)
  • Grimace/reflex; active (3), some flexion (2), flaccid (0)
  • Appearance/colour; pink (2), blue extremities only (1), blue/pale (0)
  • Respiration; vigorous (2), slow/irregular (1), absent (0)
  • Score 0-3 severely depressed
  • Score 4-6 moderately depressed
  • Score 7-10 excellent 
Neonatal Facial Coding Scale
  • Brow bulge (1)
  • Eye squeeze (1)
  • Deepened nasolabial burrow (1)
  • Open lips (1)
  • Mouth stretch (1)
  • Taut tongue (1)
  • Tongue protrusion (1)
  • Chin quiver (1)

Score ≥3 pain likely

FLACC
  • Facial expression; 0-2
  • Legs position/activity; 0-2
  • Activity; 0-2
  • Cry; 0-2
  • Consolability; 0-2
Score ≥4 pain likely

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