emoval at bedside, return to OR. CUFF LEAK TEST (deflate cuff, listen for leak — adequate suggests airway open) before high-risk extubation.22:T5de,AIRWAY ASSESSMENT — predict BOTH difficult mask ventilation (DMV) and difficult intubation (DI) SEPARATELY because they reflect different anatomy. DIFFICULT MASK MNEMONIC: MOANS — Mask seal compromise (beard, midface trauma, NG tube), Obese (BMI >26), Aged >55, No teeth (loss of facial structure), Stiff lungs/snoring (OSA, ↓ compliance). MOANS predicts DMV in ~5%; impossible mask ~0.15%. DIFFICULT INTUBATION MNEMONIC: LEMON — LOOK externally (face shape, prognathism, large beard, tumor, neck mass); EVALUATE the 3-3-2 RULE (mouth opening ≥3 finger-breadths between incisors; hyoid-to-mentum distance ≥3 finger-breadths; thyroid-to-mouth-floor distance ≥2 finger-breadths); MALLAMPATI class III-IV (visualize on phonation, sitting up, tongue out); OBSTRUCTION (tumor, infection, foreign body, swelling); NECK MOBILITY (extension limited — RA, AS, c-spine immobilization, prior neck surgery/radiation). Other DI predictors: short thyromental distance <6 cm, BMI >35, history of difficult intubation, OSA. ASA: no single test reliably rules out difficult intubation; combine multiple. ANTICIPATED DIFFICULT BOTH: AWAKE FIBEROPTIC INTUBATION recommended (preserves spontaneous ventilation as backup); have surgical airway equipment AND personnel; informed patient; sedation cautious (preserve airway tone); topical anesthesia + glycopyrrolate. UNANTICIPATED DIFFICULT: ASA algorithm 2022 — call for help early, optimize position (HELP), VL, SGA rescue, CICO declaration if all fails.23:T507,PERIOPERATIVE β-BLOCKADE — once-promoted, now nuanced. POISE TRIAL (Lancet 2008): 8351 patients, perioperative metoprolol succinate 100 mg starting DAY OF SURGERY → ↓ non-fatal MI 30% BUT ↑ TOTAL MORTALITY 33% + ↑ STROKE 2× (from hypotension/bradycardia → cerebral hypoperfusion). DECREASE TRIALS subsequently flagged for fraud, withdrawn — diminished prior evidence base. CURRENT GUIDANCE (ACC/AHA 2014, ESC 2022): (1) CONTINUE CHRONIC β-blocker through perioperative period — abrupt withdrawal precipitates rebound HTN/tachycardia/MI/sudden death. Goal HR <80 (some <70). (2) START PERIOPERATIVE β-blocker ONLY in SELECT cases — revised cardiac risk index (RCRI) ≥3 risk factors (high-risk surgery, ischemic heart disease, CHF, CVA, insulin-dep DM, Cr >2), planned major VASCULAR surgery; (3) START EARLY (1-2+ weeks pre-op) for TITRATION — gentle uptitration to goal HR/BP; do NOT start day of surgery; (4) avoid in acute decompensated heart failure, asthma exacerbation, severe bradycardia, AV block. INTRAOPERATIVE: keep HR <80, treat tachycardia (esmolol 10-50 mg, metoprolol 1-5 mg titrated); maintain MAP >70-80 in CAD; AVOID hypotension (worse outcomes than mild tachycardia). POSTOPERATIVE: continue β-blocker; monitor HR + BP; treat MI per standard.24:T6d3,PERIPROCEDURAL ANTICOAGULATION — balance THROMBOEMBOLIC vs BLEEDING risk. WARFARIN: hold 5 days pre-op (allows INR drift toward 1.0); CHECK INR day of surgery — TARGET <1.5 (proceed if <1.5, delay or vitamin K 1-2 mg PO if higher). BRIDGE THERAPY (LMWH while warfarin held) — INDICATED ONLY for HIGH thromboembolic risk: (1) mechanical MITRAL valve, (2) any mechanical valve with prior thromboembolism, (3) atrial fibrillation with CHA2DS2-VASc ≥4 OR recent stroke <3 mo, (4) recent VTE <3 mo, (5) severe thrombophilia. BRIDGE = LMWH (enoxaparin 1 mg/kg q12h or 1.5 mg/kg daily); START when INR <2; LAST DOSE ≥24 h pre-op. NOT INDICATED for routine AF (BRIDGE TRIAL NEJM 2015 — bridging in non-valvular AF ↑ bleeding 3-fold without ↓ thromboembolism). DOACs (apixaban, rivaroxaban, edoxaban, dabigatran): NO BRIDGING NEEDED (short half-life, predictable PK). HOLD based on procedure bleeding risk + renal function: low-bleed-risk procedure: hold 24 h (CrCl ≥50); high-bleed-risk: hold 48 h (CrCl ≥50), longer if renal impairment. NEURAXIAL: longer hold (48-72 h DOAC, INR <1.5 warfarin) — risk of spinal/epidural hemato

General Principles of Anesthesia

General Principles of Anesthesia

A patient with poorly controlled diabetes (HbA1c 9.5%), stable CAD on aspirin and statin, and BMI 38 presents for elective lap chole. The most appropriate ASA classification is: