Preoperative evaluation and preparation
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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
1.Review of patient data
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
Airway evaluation
History of difficult intubation
Head and neck examination for airway
evaluation
Face
Oral cavity : mouth opening
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
Thyromental distance
Difficult intubation
Mouth opening less than 3 cm.
Limitation of neck movement
Micrognatia
Macroglossia
Protusion of teeth
Short neck
Morbid obesity
3.Laboratory data
Value of testing
Risk and costs benefits
Preoperative testing: base on indication
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
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
Consent form
Informed consent involves
discussing anesthetic management plan,
alternatives
potential complication
Record preoperative form
ASA physical Classification
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.
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
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
Cardiac disease
Interval between MI time and surgery less
than 6 mo is more likely with reinfarction
Perioperative cardiovascular risk
clinical predictors
surgical procedure
exercise tolerance
Cardiac disease
Clinical
predictors
Majors:
unstable angina,
decompensated heart failure, significant
arrhythmia, severe valvular disease
Cardiac disease
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
Cardiac disease
Exercise tolerance
4 METs: walk at 6 km/hr, run short distance,
heavy work around house, golf, bowling,
dancing
Cardiac disease
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
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
Hypertension
Aggressive treatment associated with
reduction in long term risk
Continue medication until day of surgery:
ACEI and diuretic may be discontinue
Pulmonary disease
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
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
Pulmonary disease
Continue medication
Aerosol medication before surgery
Risk reduction of pulmonary complication
Smoking cessation
Education of lung expansion maneuver and
deep breath exercise(incentive spirometry)
for postop
Treatment of obstruction
Antibiotic
Hydration
Pulmonary disease
Sleep apnea
associated with difficult airway
airway obstruction
cardiac disease: cor pulmonale
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
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
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
Premedication
Objections
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
Medication
Good for amnesia and sedation
No best drug for preop medication
Deteminant of drug choice and dose
Age
and weight
ASA physical status
Prior experience
Patient condition
Elective or emergency
1.Benzodiazepine
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
1. Benzodiazepine
Lorazepam:
more amnesia 4 times than valium
slow onset,long duration
Not appropriate for premedication
Dose 25-50 ug/kg oral
1.Benzodiazepine
Midazolam (dormicum) :
water soluble
not pain on injection
short duration
stable hemodynamic
dose: 0.07-0.15 mg/kg
decrease dose with old age
1.Benzodiazepine
Caution
Potentiate with opioid in respiratory
depression
Psychomotor depression; agitation
Amnesia
Decrease blood pressure
2. Butyrophenone
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
Mild tranquilizer
Antiemetic
Anti histamine
Dose: 25-50 mg/kg oral or rectal
4. Chloral hydrate
Sedative
Anxiolytic
Amnesia
Use for children
dose: 30-50 mg/kg oral or rectal
5. Opioids
Morphine
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
Meperidine (Pethidine)
Potency 1/10 of MO
Less histamine release and respiratory depression
Dose : 1-2 mg/kg IM or IV
6. Opioids
Fentanyl
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
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
Decrease secretion (antisialogogue)
Dry airway
Sedation
Amnesia
vagolytic
Side effects: CNS toxicity, relax of
esophageal sphinter, mydriasis and interfere
with sweating
8.Aspiration prevention
Benefit for patient risk for pulmonary
aspiration
Pregnant woman
GE reflux
Hiatal hernia
Morbid obesity
Chronic renal failure
8.Aspiration prevention
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
8.Aspiration prevention
Proton pump inhibitor
Omeprazole (losec)
40 mg oral
Nonparticipate antacids
Neutralize gastric pH>3.5
30 ml oral 30 mins before induction
8.Aspiration prevention
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
9.Antiemetic
Prevent nausea and vomitting postop for
high risk group
Give to patient for premedication or
intraoperative period
Ondansetron
5HT3 antagonist
Dose: 4-8 mg IV
Droperidol
Metoclopramide
10. Hemodynamic stability
α2-adrenergic agonist(clonidine)
Sedation
Decrease anesthetic and opioid requirement
Decrease sympathetic response
Dose: 5-20 ug/kg
Hypotension
10. Hemodynamic stability
β-adrenergic blocker
(atenolol,propanolol)
Decrease sympathetic response
Anxiolytic
May be benefit in CAD patient
Dose: 50 mg oral
11. Antibiotics
Prevent bacterial endocarditis in high risk
patient
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