Transcript Preoperative evaluation and preparation

Preoperative evaluation
and preparation
อ.พญ.ธัญยธรณ์ พันธ์ภานุสิทธิ์,พบ.,ว.ว. (วิสญั ญีวิทยา)
ภาควิชาวิสัญญีวิทยา
วิทยาลัยแพทยศาสตร์กรุ งเทพมหานครและวชิรพยาบาล
Objectives
Patient data
 Doctor – patient relationship
 Anesthetic plan
 Patient consent
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1.Review of patient data
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Medical record
Interview history
History of underlying disease,
medication,
functional capacitance,
previous anesthetic history,
family history,
smoking and alcoholic use,
review of system,
psychological support
Airway evaluation
1.Review of patient data

Surgical condition
-Condition of disease, symptom of
disease
-Surgical procedure
-Position of procedure
2. Physical examination
Vital signs
 General appearance
 HEENT
 Respiratory system
 CVS system
 Abdomen
 Extremities and spine
 Neurologic system
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Airway evaluation
History of difficult intubation
 Head and neck examination for airway
evaluation
 Face
 Oral cavity : mouth opening
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mandibular space
tongue
teeth
Mallampati classification
Airway evaluation
Mentothyroid distance : normal 6 cm.
 Mentosternal distance : normal 15 cm
 Mentohyoid distance : normal 3 FB
 Neck movement: flexion and extension of
neck, history of radiation
 Nasal cavity
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Thyromental distance
Difficult intubation
Mouth opening less than 3 cm.
 Limitation of neck movement
 Micrognatia
 Macroglossia
 Protusion of teeth
 Short neck
 Morbid obesity
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3.Laboratory data
Value of testing
 Risk and costs benefits
 Preoperative testing: base on indication
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Laboratory data
อายุ (ปี )
ผูช้ าย
ต่ากว่า 40
40-60
มากกว่า 60
ผูห้ ญิง
Hb / Hct
ECG,
BUN / Glucose
Hb/Hct ECG,
BUN /Glucose
Hb/Hct
ECG/CXR
BUN/Glucose
Hb/Hct
ECG/CXR
BUN/Glucose
Laboratory data
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CBC : Hb 7g/dl in healthy patient
Hb 10 g/dl in CAD
Red blood cell morphology, plt. count
Blood chemistry: Glucose
BUN/Cr
Coagulogram
Liver function test
CXR
Urinalysis, pregnancy test
ECG
Laboratory data
Specific test:
 Cardiac evaluation: exercise stress test
Thallium scan
echocardiogram
 Pulmonary evaluation
Lung function test
Spirometry
Arterial blood gas
Medical consultation
To define patient’s condition
 To optimize patient’s medical condition
and future management before surgery
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Consent form
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Informed consent involves
discussing anesthetic management plan,
alternatives
 potential complication
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Record preoperative form
ASA physical Classification
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Class1
normal healthy patient
Class 2
A patient with mild systemic disease and no
functional limitations
Class 3
A patient with moderate or severe systemic
disease that results in some function limitation
Class 4
A patient with severe systemic disease that is
threat to life and functionally incapicitating
Class 5
A moribund patient who is not expected to
survive 24 hours with or without surgery
(Class 6 A brain-dead patient whose organs are being
harvested)
E for Emergency case
NPO Guideline
NPO 6-8 hr. before surgery
 Clear liquid diet for 2 hr.
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Children
 Clear
liquid 2 hr
 Breast milk 4 hr
 Infant formula 6 hr
 solid diet 8 hr.
Guideline used for patient with no proble
with gastric emptying time
Premedication
Psychological support
 Medications
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Cardiac disease
Signs and symptoms of unstable angina,
congestive heart failure, arrhythmia
 clinical of chest pain,heart failure and
arrhythmia should be treated before
elective surgery
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Cardiac disease
Interval between MI time and surgery less
than 6 mo is more likely with reinfarction
 Perioperative cardiovascular risk
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clinical predictors
 surgical procedure
 exercise tolerance
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Cardiac disease
 Clinical
predictors
 Majors:
unstable angina,
decompensated heart failure, significant
arrhythmia, severe valvular disease
Cardiac disease
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Surgical procedure
High: Emergency major, vascular surgery,
prolong operation with large fluid shift
 Intermediate: carotid endarterectomy,head
and neck, intraperitoneal, ortho, prostate
 Low: endoscope, breast, superficial
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Cardiac disease
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Exercise tolerance
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4 METs: walk at 6 km/hr, run short distance,
heavy work around house, golf, bowling,
dancing
Cardiac disease
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Patient risk for MI postop
DM
Peripheral vascular disease
HT
Tobacco used
Hypercholesterolemia
Cardiac disease
Risk associated with surgical influence
decision to make further test
 Perioperative morbidity may be decreased
with beta blocker
 Continue medication except anticoagulant
or antifibrinolytic:
aspirin,warfarin,ticlopidine etc.
 Digitalis : discontinue except in severe
arrhythmia
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Hypertension
History of end organ damage: cardiac
ischemia, renal, neurological
 Elective surgery should be delayed if
DBP ≥ 110 mmHg with or without new
onset of headache but if no sign of end
organ damage surgery or LVH may be
proceed
 In DM keep DBP < 90mmHg
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Hypertension
Aggressive treatment associated with
reduction in long term risk
 Continue medication until day of surgery:
ACEI and diuretic may be discontinue
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Pulmonary disease
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History of reactive airway Asthma
Frequency, reversible of symptoms, interval, last
attack, history of steroid used
Optimize good condition before elective surgery
COPD:new onset of bronchospasm,dyspnea
and reduced exercise tolerance should be
indicated to delay elective surgery
Recent URI is controversial , elective surgery
should be delayed several weeks
Pulmonary disease
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Smoking cessation
24 hr: decrease carboxyhemoglobin
 2-3 day: increase ciliary function
but increase secretion
 1-2 wk: decrease secretion
 4-8 wks: decrease postop pulmonary
complication
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Pulmonary disease
Continue medication
 Aerosol medication before surgery
 Risk reduction of pulmonary complication
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Smoking cessation
 Education of lung expansion maneuver and
deep breath exercise(incentive spirometry)
 for postop
 Treatment of obstruction
 Antibiotic
 Hydration
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Pulmonary disease
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Sleep apnea
associated with difficult airway
 airway obstruction
 cardiac disease: cor pulmonale
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Endocrine disease
Diabetes Mellitus
 Current medication
 Progression of end organ damage
atherosclerosis : risk for silent MI
 Autonomic dysfunction
 Hyperglycemic condition
 Risk for joint stiffness: TM joint
 Discontinue medication day of surgery
Endocrine disease
Thyroid
 Clinical manifestation of hyperthyroid or
hypothyroid
 Hyperthyroid: palpitation, weight loss, heat
intolerance, moist skin thyroid strom
 Hypothyroid: bradycardia, cold intolerance,
slow mental function
hypothermia,hypoventilation
Endocrine disease
Large mass may distort airway: chest xray include neck or CT
 Medication continue
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Endocrine disease
Adrenal cortical suppression: tumors of
adrenal cortex, pituitary tumor,prolonged
use of steroid
 Cushing syndrome: truncal obesity, moon
face, hypovolumia
 Correct Electrolyte and steroid supplement
before surgery
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Renal disease
CRF
 urine, dialysis, type of dialysis,last
dialysis,serum K, Hct. and platelet function
 CRF patient: congestive heart failure,
hyper K, plt. dysfunction,anemia
 After dialysis: hypovolumia
 FULL STOMACH
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Premedication
Objections
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Anxiolytic and sedation
Analgesia
Amnesia
Hemodynamic stability
Decrease secretion
Decrease gastric volume
Antiemetic
Facilitate induction of anesthesia
Antiinfection
Psychological premedication
Describe anesthetic technique available
and risk
 Describe what to expect in OR
 Describe duration and time to return
 Describe postop pain management
 Psychological support
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Medication
Good for amnesia and sedation
 No best drug for preop medication
 Deteminant of drug choice and dose
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 Age
and weight
 ASA physical status
 Prior experience
 Patient condition
 Elective or emergency
1.Benzodiazepine
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Diazepam (valium): anxiolytic,
anticonvulsion, muscle relaxation,
respiratory depression
pain with IM or IV injection
 peak effect 30 mins (oral)
 duration 20 hrs.
 Dose: 0.1-0.2 mg/kg oral
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1. Benzodiazepine
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Lorazepam:
more amnesia 4 times than valium
 slow onset,long duration
 Not appropriate for premedication
 Dose 25-50 ug/kg oral
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1.Benzodiazepine
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Midazolam (dormicum) :
water soluble
 not pain on injection
 short duration
 stable hemodynamic
 dose: 0.07-0.15 mg/kg
decrease dose with old age
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1.Benzodiazepine
Caution
 Potentiate with opioid in respiratory
depression
 Psychomotor depression; agitation
 Amnesia
 Decrease blood pressure
2. Butyrophenone
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Droperidol ; good antiemetic, sedation ,
Caution : dysphoria
decreased BP (adrenergic block)
extrapyramidal sypmtoms
(antidopaminergic)
Dose: 0.01-0.02 mg/kg IM/IV for antiemetic
0.030.14 mg/kg for sedation
3.Phenothiazine
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Mild tranquilizer
Antiemetic
Anti histamine
Dose: 25-50 mg/kg oral or rectal
4. Chloral hydrate
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Sedative
Anxiolytic
Amnesia
Use for children
dose: 30-50 mg/kg oral or rectal
5. Opioids
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Morphine
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Analgesia
Respiratory depression
Myocardial depression
Nausea and vomitting
Histamine release
Caution with asthma patient, spasm of sphinter
of oddi
not recommend for infant
Dose: 0.1-0.2 mg/kg IM or IV
6. Opioids
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Meperidine (Pethidine)
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Potency 1/10 of MO
Less histamine release and respiratory depression
Dose : 1-2 mg/kg IM or IV
6. Opioids
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Fentanyl
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No histamine release
Rapid onset
Short duration 30 mins
More potency than MO 100 times
Dose : 1-2 ug/kg IV or IM or oral transmucosal
6. Opioids
Caution
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Respiratory and myocardial depression:
Hypotension, Nausea and vomitting
Spasm of sphincter of Oddi
(Fentanyl>MO>pethidine)
MO and pethidine interaction with MAOI
(monoamine oxidase inhibitor) make markly
HT
7.anticholinergic
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Decrease secretion (antisialogogue)
Dry airway
Sedation
Amnesia
vagolytic
Side effects: CNS toxicity, relax of
esophageal sphinter, mydriasis and interfere
with sweating
8.Aspiration prevention
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Benefit for patient risk for pulmonary
aspiration
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Pregnant woman
GE reflux
Hiatal hernia
Morbid obesity
Chronic renal failure
8.Aspiration prevention
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H2 antagonist
Cimetidine 200-400 mg oral /IM/IV
 Peak effect 60 mins
 May prolong other drug effect
 Ranitidine 150-300 mg oral 50-100 mg IV
or IM
 No drug interaction
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8.Aspiration prevention
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Proton pump inhibitor
Omeprazole (losec)
 40 mg oral
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Nonparticipate antacids
Neutralize gastric pH>3.5
 30 ml oral 30 mins before induction
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8.Aspiration prevention
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Metoclopramide(plasil)
Decrease gastric emptying time
 Increase lower esophageal sphincter
 Decrease nausea
 Dose 5-10 mg IV or oral 1 hr before
surgery
 Caution: Do not use with gut obstruction
patient
Extrapyramidal symptom
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9.Antiemetic
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Prevent nausea and vomitting postop for
high risk group
Give to patient for premedication or
intraoperative period
Ondansetron
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5HT3 antagonist
Dose: 4-8 mg IV
Droperidol
Metoclopramide
10. Hemodynamic stability
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α2-adrenergic agonist(clonidine)
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Sedation
Decrease anesthetic and opioid requirement
Decrease sympathetic response
Dose: 5-20 ug/kg
Hypotension
10. Hemodynamic stability
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β-adrenergic blocker
(atenolol,propanolol)
Decrease sympathetic response
 Anxiolytic
 May be benefit in CAD patient
 Dose: 50 mg oral
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11. Antibiotics
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Prevent bacterial endocarditis in high risk
patient
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Ampicillin 3 g oral 1 hr before surgery,then 1.5
g 6 hr after first dose
Ampicillin 2 g IM/IV 30 mins before ,then 1 g
or amoxycillin 1.5 g after first dose
Erythromycin 800 mg oral 2 hr before, then
400 mg 6 hr after first dose or
Clindamycin 300 mg oral/IV 1 hr before, then
150 mg 6 hr after first dose
The end