pre-operative care professor magdy amin riad professor of otolaryngology. ain shames university...
TRANSCRIPT
![Page 1: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/1.jpg)
Pre-operative care
Professor Magdy Amin RIAD
Professor of Otolaryngology. Ain shames University
Senior Lecturer in OtolaryngologyUniversity of Dundee
![Page 2: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/2.jpg)
Pre-operative consultation
• Ensure that indication for operation is still valid.• Identify any other medical condition.• Discuss options with patient / relatives.• Consent.• Prophylactic antibiotic • Prophylactic DVT. • Pain control.• Nutrition
![Page 3: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/3.jpg)
Pre-operative investigations• FBC :all patients.• U & E : all patients.• ECG : all patients > 40 years.• Chest x-ray : all patients >30 years• Liver functions : all patients. • Hepatitis : ?all patients
• Echocardiogram : abnormal ECG, ischemic heart , heart failure.
• Clotting screen: anticoagulants, abnormal LFTs• Calcium: Thyroid and Laryngectomy.• Pulmonary functions: abnormal chest x-ray, partial
Laryngectomy, Oesophagectomy.
![Page 4: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/4.jpg)
Significant History (Suggests increased risk for sedation)
• Stridor • Significant Snoring • Sleep Apnea • Advanced Rheumatoid Arthritis • Dysmorphic Facial Features • Down's Syndrome • Upper Respiratory Infections
![Page 5: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/5.jpg)
Mallampati modified test.
![Page 6: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/6.jpg)
Airway Examination
Normal – Opens mouth normally (Adults: greater than 2 finger
widths or 3 cm)
– Able to visualize at least part of the uvula and tonsillar pillars with mouth wide open & tongue out (patient sitting)
– Normal chin length (Adults: length of chin is greater than 2 finger widths or 3 cm)
– Normal neck flexion and extension without pain / paresthesias
![Page 7: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/7.jpg)
Airway Examination
Abnormal Exam – Small or recessed chin
– Inability to open mouth normally
– Inability to visualize at least part of uvula or tonsils with mouth open & tongue out
– High arched palate
– Tonsillar hypertrophy
– Neck has limited range of motion
– Low set ears
– Significant obesity of the face/neck
![Page 8: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/8.jpg)
Airway assessment: predictive testsSensitivity = 50-60%
• Mallampati modified test.Visibility of pharyngeal structures.• Patil test.Thyro-mental distance <6.5cm• Mandibular protrusion.Class C : inability to protrude lower incisors beyond
the upper.• Wilson test.• Radiological assessment of the mandible and
cervical spine.
![Page 9: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/9.jpg)
CLASSIFICATION OF OPERATIONClass Definition
• Clean Operations
in which no inflammation is encountered .
The respiratory, alimentary or genitourinary tracts are not entered.
There is no break in aseptic operating theatre technique.
![Page 10: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/10.jpg)
CLASSIFICATION OF OPERATIONClass Definition
Clean-contaminated Operations
in which the respiratory, alimentary or genitourinary tracts are entered
but without significant spillage.
![Page 11: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/11.jpg)
CLASSIFICATION OF OPERATIONClass Definition
Contaminated Operations
where acute inflammation (without pus) is encountered.
or where there is visible contamination of the wound.
Examples include gross spillage from a hollow viscus during the operation
or compound/open injuries operated on within four hours.
![Page 12: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/12.jpg)
CLASSIFICATION OF OPERATIONClass Definition
Dirty Operations:
In the presence of pus.
where there is a previously perforated hollow viscus,
or compound/open injuries more than four hours old.
![Page 13: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/13.jpg)
ASA CLASSIFICATION OF PHYSICAL STATUS
1 =A normal healthy patient
2 =A patient with a mild systemic disease
3 = A patient with a severe systemic disease that limits activity, but is not incapacitating
4 =A patient with an incapacitating systemic disease that is a constant threat to life
5 =A moribund patient not expected to survive 24 hours with or without operation
![Page 14: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/14.jpg)
American Society of Anesthesiologists Patient
Classification
ASA 1• A normal, healthy patient. The pathological process
for which surgery is to be performed is localized and does not entail a systemic disease.
• Example: An otherwise healthy patient scheduled for a cosmetic procedure.
![Page 15: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/15.jpg)
American Society of Anesthesiologists Patient
Classification
ASA 2
A patient with systemic disease, caused either by the condition to be treated or other pathophysiological process, but which does not result in limitation of activity.
Example: a patient with asthma, diabetes, or hypertension that is well controlled with medical therapy, and has no systemic sequelae
![Page 16: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/16.jpg)
American Society of Anesthesiologists Patient
Classification
ASA 3
A patient with moderate or severe systemic disease caused either by the condition to be treated surgically or other pathophysiological processes, which does limit activity.
Example: a patient with uncontrolled asthma that limits activity, or diabetes that has systemic sequelae such as retinopathy
![Page 17: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/17.jpg)
American Society of Anesthesiologists Patient
Classification
ASA 4 A patient with severe systemic disease that is
a constant potential threat to life.
Example: a patient with heart failure, or a patient with renal failure requiring dialysis.
![Page 18: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/18.jpg)
American Society of Anesthesiologists Patient
Classification
ASA 5 A patient who is at substantial risk of death within 24 hours,
and is submitted to the procedure in desperation.
Example: a patient with fixed and dilated pupils status post a head injury.
![Page 19: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/19.jpg)
American Society of Anesthesiologists Patient
Classification E Emergency status
This is added to the ASA designation only if the patient is undergoing an emergency procedure.
Example: a healthy patient undergoing sedation for reduction of a displaced fracture would be an ASA 1E
![Page 20: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/20.jpg)
co-morbidity and duration of operation
• Risk index 0 = when neither risk factor is present
• Risk index 1 = when either one of the risk factors is present
• Risk index 2 = when both risk factors are present.
![Page 21: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/21.jpg)
PROBABILITY OF WOUND INFECTION BY TYPE OF WOUND AND RISK INDEX
Risk Index
0 1 2
Clean 1.0% 2.3% 5.4%
Clean-contam. 2.1% 4.0% 9.5%
Contaminated 3.4% 6.8% 13.2%
![Page 22: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/22.jpg)
Summary of Fasting Recommendations to Reduce the Risk of Pulmonary Aspiration
• Ingested Material Minimum Fasting Period (hours)
– Clear liquids 2 – Breast milk 4– Infant formula 6– Non-human milk 6– Light meal 6
![Page 23: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/23.jpg)
Risk factors for DVT
• Age >40 years• Obesity• Varicose veins• High oestrogen pill• Previous DVT or PE• Malignancy • Infection• Heart failure / recent infarction• Polycythaemia /thrombophilia • Immobility ( bed rest over 4 days)• Major trauma
![Page 24: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/24.jpg)
Risk factors for DVT
![Page 25: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/25.jpg)
Incidence of DVT and fatal pulmonary embolism
in hospital patients
• Low risk = <10% ,<0.01%
• Moderate risk =14% , 0.5%
• High risk = 40-80% , 5%
• Incidence of fatal pulmonary embolism in high risk patients increases 500 folds.
![Page 26: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/26.jpg)
Prophylaxis against DVT
![Page 27: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/27.jpg)
Pre-operative investigations
• FBC :all patients.• U & E : all patients.• ECG : all patients > 40 years.• Echocardiogram : abnormal ECG, ischemic heart ,
heart failure.• Liver functions : all patients.• Clotting screen: anticoagulants, abnormal LFTs• Calcium: Thyroid and Laryngectomy.• Pulmonary functions: abnormal chest x-ray,
partial Laryngectomy, Oesophagectomy.
![Page 28: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/28.jpg)
Routine Preoperative care for the Adult Patient
1. Avoid taking aspirin or aspirin-containing products for 2 weeks prior to surgery unless approved by physician
2. Discontinue nonsteroidal anti-inflammatory medications 48 to 72 hours before surgery
![Page 29: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/29.jpg)
Routine Preoperative care for the Adult Patient
3. Bring a list or container of current medications
4. Bring an adult escort who can drive if they are having an outpatient procedure with sedation or general anesthesia
5. Wear loose clothing that can easily be removed (eg, avoid clothing that pulls on and off over the head)
![Page 30: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/30.jpg)
Routine Preoperative care for the Adult Patient
6. Instruct the patient to bathe/shower/shampoo the evening before or morning of surgery.
Men should be cleanly shaved.
![Page 31: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/31.jpg)
Routine Preoperative care for the Adult Patient
7. Instruct the patient on oral intake restrictions
and medication schedule as ordered: a. NPO after midnight (including water) b. NPO after clear liquid or light breakfast if
permitted c. AM meds with sip of water if ordered by
physician/anesthesiologist
![Page 32: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/32.jpg)
before going to the operating room
he/she will have to remove:
• 1. Dentures/partial plates
• 2. Glasses/contact lenses
• 3. Appliances/prosthesis
• 4. Makeup/nail polish
• 5. Hairpins/hairpiece
• 6. Undergarments
![Page 33: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/33.jpg)
Surgery grades
![Page 34: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/34.jpg)
ASA grades
![Page 35: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/35.jpg)
Cardiovascular disease
ASA Grade 2: mild systemic disease
ASA Grade 3:severe systemic disease
![Page 36: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/36.jpg)
Respiratory disease
ASA Grade 2: mild systemic disease
![Page 37: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/37.jpg)
Renal disease
![Page 38: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/38.jpg)
Minimum dataset at time of ordering test
![Page 39: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/39.jpg)
Grade 1 surgery (minor)
![Page 40: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/40.jpg)
Grade 1 surgery (minor)
![Page 41: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/41.jpg)
Grade 1 surgery (minor)
![Page 42: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/42.jpg)
Grade 1 surgery (minor)
![Page 43: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/43.jpg)
Grade 1 surgery (minor)
![Page 44: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/44.jpg)
Grade 1 surgery (minor)
![Page 45: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/45.jpg)
Grade 1 surgery (minor)
![Page 46: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/46.jpg)
Grade 1 surgery (minor)
![Page 47: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/47.jpg)
Grade 2 surgery (intermediate)
![Page 48: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/48.jpg)
Grade 2 surgery (intermediate)
![Page 49: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/49.jpg)
Grade 2 surgery (intermediate)
![Page 50: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/50.jpg)
Grade 2 surgery (intermediate)
![Page 51: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/51.jpg)
Grade 2 surgery (intermediate)
![Page 52: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/52.jpg)
Grade 2 surgery (intermediate)
![Page 53: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/53.jpg)
Grade 2 surgery (intermediate)
![Page 54: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/54.jpg)
Grade 2 surgery (intermediate)
![Page 55: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/55.jpg)
Grade 3 surgery
![Page 56: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/56.jpg)
Grade 3 surgery
![Page 57: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/57.jpg)
Grade 3 surgery
![Page 58: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/58.jpg)
Grade 3 surgery
![Page 59: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/59.jpg)
Grade 3 surgery
![Page 60: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/60.jpg)
Grade 3 surgery
![Page 61: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/61.jpg)
Grade 3 surgery
![Page 62: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/62.jpg)
Grade 3 surgery
![Page 63: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/63.jpg)
Grade 4 surgery (major+)
![Page 64: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/64.jpg)
Grade 4 surgery (major+)
![Page 65: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/65.jpg)
Grade 4 surgery (major+)
![Page 66: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/66.jpg)
Grade 4 surgery (major+)
![Page 67: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/67.jpg)
Grade 4 surgery (major+)
![Page 68: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/68.jpg)
Grade 4 surgery (major+)
![Page 69: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/69.jpg)
Grade 4 surgery (major+)
![Page 70: Pre-operative care Professor Magdy Amin RIAD Professor of Otolaryngology. Ain shames University Senior Lecturer in Otolaryngology University of Dundee](https://reader036.vdocuments.site/reader036/viewer/2022062520/56649eec5503460f94bfd62a/html5/thumbnails/70.jpg)
Grade 4 surgery (major+)