SCORES USED IN CLINICAL ANAESTHESIA

ANAESTHETIC FUNDAMENTALS

AIRWAY MANAGEMENT

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

Jaw protrusion
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
Best view achieved at direct laryngoscopy

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

ASA

The addition of an ‘E’ indicates emergency surgery

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

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?

PAIN MANAGEMENT

Numerical Rating Scale

0-10, 0 – no pain, 10 worst possible pain

Neonatal Facial Coding Scale

Score ≥3 pain likely

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)

FLACC
≥4 pain likely

Facial expression; 0-2
Legs position/activity; 0-2
Activity; 0-2
Cry; 0-2
Consolability; 0-2

REGIONAL ANAESTHESIA

GOOD ANAESTHESIA PRACTICE

PROFESSIONALISM

SAFETY & QUALITY

PERIOPERATIVE CARE

INTENSIVE CARE MEDICINE

APACHE II
Score 0-71 correlates with mortality

Physiological variables
Laboratory variables
GCS
Age
Chronic organ impairment or immunosuppression

ARDS severity
PaO2/FiO2 ratio

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

PERIOPERATIVE MEDICINE

PHYSIOLOGICAL RESERVE

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 housework, 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

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

Frailty

Many tools published

Physical Frailty Phenotype screening tool; fatigue, resistance, aerobic capacity, illnesses, loss of weight, score 0-5, >2 considered frail
Clinical frailty scale; score 0-9 based on severity
Frailty index; divides the number of health deficits by the total number of potential deficits, score 0-1, >0.25 considered frail
Reported Edmonton Frail Scale; nine components, score 0-18, >7 considered frail

RESPIRATORY

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

ARISCAT score

Predicts risk of postoperative pulmonary complications, score >44 is high ~42% risk

Age
SpO2
Recent respiratory infection
Preoperative anaemia
Surgical incision
Duration of surgery
Emergent

BODE index

Predicts COAD mortality

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

STOPBANG
Score ≥3 indicates higher likelihood of OSA

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)

Sleep apnoea severity, AHI/RDI

Mild; 5-15/hour
Moderate; 15-30/hour
Severe; >30/hour

CARDIOVASCULAR

EuroSCORE

Predicts risk of perioperative cardiovascular mortality, high risk >5 predicted mortality ~11%

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

Revised Cardiac Risk Index
Predicts risk of periopartive MACE, high risk >2, predicted MACE ~15%

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)

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

HAEMATOLOGICAL

CHA2DS2VASc

Predicts risk of thrombotic events, score >4 considered high risk ~5% risk of stroke, maximum score 9 ~15% risk of stroke

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)

HAS-BLED
Predicts risk of haemorrhagic events, score >2 considered high risk ~5% risk of haemorrhagic events

Hypertension (1)
Abnormal renal/hepatic function (1)
Stroke (1)
Bleeding tendency (1)
Labile INR (1)
Elderly, age >65 (1)
Drugs (antiplatelet), alcohol (1)1

NEUROLOGICAL

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

NEUROMUSCULAR

Leventhal criteria

Prediction of postoperative ventilatory requirement in the setting of myasthenia gravis

Duration of disease ≥6 years
Chronic respiratory disease
Pyridostigmine dose >750 mg/day
VC <2.9L

GASTROINTESTINAL

Child-Pugh score

Class C; score 10-15 (decompensated), perioperative mortality 80%, 1-year survival 40%

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)

MELD score
Score ≥40 3 month mortality 100%

Bilirubin
INR
Creatinine

RENAL

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

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

Revised trauma score
Score ≥6 mortality >90%

GCS; 0-4
SBP; 0-4
RR; 0-4

Hypothermia severity

Mild; 32-35
Moderate; 28-32
Severe; <28

Traumatic brain injury

Mild; GCS 13-15
Moderate; GCS 9-12
Severe; GCS 3-8

SPECIALTY PATIENT GROUPS

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
Score 0-3 severely depressed
Score 4-6 moderately depressed
Score 7-10 excellent

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)

SURGICAL SPECIALTIES

ANAESTHESIA IN OUTSIDE AREAS

CARDIAC SURGERY, INTERVENTIONAL CARDIOLOGY

GENERAL SURGERY, UROLOGY, GYNAECOLOGY, ENDOSCOPY

HEAD & NECK, EAR, NOSE & THROAT, DENTAL SURGERY

NEUROSURGERY, NEURORADIOLOGY

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

SCORES