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
- 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
Has been modified to include ratio of TMD to body height, or as thyromental height
Sternomental distance
<12.5cm predictive of increased risk
Neck extension
Tip of mandible > occipital protruberance
Incisor plane movement <20 degrees predictive of risk
- 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
- Grade I; generalised cutaneous signs
- Grade II; moderate multiorgan involvement
- Grade III; severe multiorgan involvement
- Grade IV; cardiorespiratory arrest
- Grade V; death
- 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
- 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
- Anxiolysis
- Conscious sedation
- Deep sedation
- General anaesthesia
- 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 worst thing about your operation?
PHYSICAL STATUS
- 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
- 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
<300m correlates to ~14ml/kg/min (4 MET), poor perioperative prognosis
INTENSIVE CARE
- Physiological variables
- Laboratory variables
- GCS
- Age
- Chronic organ impairment or immunosuppression
Score 0-71 correlates with mortality
RESPIRATORY RISK
- BMI ≤21
- Obstructive lung disease; FEV1 ≤65
- Dyspnoea scale score; MMRC
- Exercise; 6MWT
RESPIRATORY DISEASE
- 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
- All; FEV1/FVC <0.7
- Mild; FEV1 >80% predicted
- Moderate; FEV1 50-80% predicted
- Severe; FEV1 30-50% predicted
- Very severe; FEV1 <30% predicted
- 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
- 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
- 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
- Mild; 5-15/hour
- Moderate; 15-30/hour
- Severe; >30/hour
CARDIOVASCULAR RISK
- 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%
- 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
- 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
- Mild; LVEF 45-55%
- Moderate; LVEF 30-45%
- Severe; LVEF <30%
- 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
- Normal; 4-6cm2
- Mild; 1.5-2cm2
- Moderate; 1-1.5cm2
- Severe; <1cm2,
- Critical; <0.7cm2
- Mild; <25mmHg
- Moderate; 25-40mmHg
- Severe; 40-50mmHg
- Critical; >50mmHg
- Mild; 2.5-3m/s
- Moderate; 3-4m/s
- Severe; >4m/s
- Normal; 4-6cm2
- Mild; 1.5-2cm2
- Moderate; 1-1.5cm2
- Severe; <1cm2,
- Critical; <0.7cm2
- Mild; <5mmHg
- Moderate; 5-10mmHg
- Severe; >10mmHg
- Mild; <30%
- Moderate; 30-50%
- Severe; >50%
- Mild; mPAP 25-40mmHg
- Moderate; mPAP 40-55mmHg
- Severe; mPAP >55mmHg
- Mild; 25-50mmHg
- Moderate; 50-70mmHg
- Severe; >70mmHg
THROMBOSIS/BLEEDING RISK
- 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)
- 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
- 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)
- Alert; GCS 15
- Voice; responds to vocal stimuli, GCS 12
- Pain; responds to painful stimuli, GCS 8
- Unresponsive; GCS 3
- Mild; GCS 13-15
- Moderate; GCS 9-12
- Severe; GCS 3-8
- 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
- Duration of disease ≥6 years
- Chronic respiratory disease
- Pyridostigmine dose >750 mg/day
- VC <2.9L
- 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
- 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
- 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
- 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%
- Bilirubin
- INR
- Creatinine
Score ≤9 3 month mortality 4%
Score ≥40 3 month mortality 100%
RENAL DISEASE
- 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
- 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
- GCS; 0-4
- SBP; 0-4
- RR; 0-4
Score ≥6 mortality >90%
- Mild; 32-35
- Moderate; 28-32
- Severe; <28
OBSTETRICS
- 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
- 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
- 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
- Facial expression; 0-2
- Legs position/activity; 0-2
- Activity; 0-2
- Cry; 0-2
- Consolability; 0-2