PREOPERATIVE EVALUATION

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PREOPERATIVE EVALUATION:

PREOPERATIVE EVALUATION ANESTHESIOLOGY

GOALS:

The preoperative evaluation consists of gathering information about the patient and formulating an anesthetic plan. The overall objective is reduction of perioperative morbidity and mortality. GOALS

ROUTINE PREOPERATIVE ANESTHETIC EVALUATION:

History Current problem Other known problems Medication history Allergies Drug intolerances Present therapy : prescription/non prescription Non therapeutic : Alcohol and tobacco Previous anesthetics, operation and, if applicable obstetric history and pain history. Family history Review organs systems Last oral intake ROUTINE PREOPERATIVE ANESTHETIC EVALUATION

ROUTINE PREOPERATIVE ANESTHETIC EVALUATION:

Physical examination Vital sign Airway Heart Lungs Extremities Neurological examination Laboratories evaluation ROUTINE PREOPERATIVE ANESTHETIC EVALUATION

ANESTHETIC PLAN:

Premedication Type of Anesthesia : General Anesthesia Airway management Induction Maintenance ANESTHETIC PLAN

ANESTHETIC PLAN:

Regional Anesthesia Technique Agent Monitor anesthesia care Supplemental oxygen Sedation ANESTHETIC PLAN

ANESTHETIC PLAN:

Intra-operative management Monitoring Positioning Fluid management Special techniques ANESTHETIC PLAN

ANESTHETIC PLAN:

Post-operative management Pain control Intensive care postoperative ventilation hemodynamic monitoring ANESTHETIC PLAN

SYSTEMS APPROACH:

Airway Basic concern of the anesthesiologist is always the patients airway SYSTEMS APPROACH

COMPONENTS OF THE AIRWAY PHYSICAL EXAMINATION:

Length of upper incisor Relation of maxillary and mandibular incisors during normal jaw closure Relation of maxillary and mandibular incisors during voluntary protrusion of mandible Interincisor distance visibility of uvula Shape of palate Compliance of mandibular space Thyromental distance Length of neck Thickness of neck Range of motion of head and neck COMPONENTS OF THE AIRWAY PHYSICAL EXAMINATION

MALLAMPATI CLASSIFICATION:

Class - Direct visualization - L aryngoscopic view I soft palate, fauces , uvula, pillars Entire glottic II soft palate, fauces , uvula Posterior commissure III soft palate, uvular base Tip of epiglottis IV hard palate only No glottal structure MALLAMPATI CLASSIFICATION

SYSTEM APPROACH:

Pulmonary Pulmonary complication remain a major cause of morbidity and mortality for patients undergoing surgery and anesthesia. SYSTEM APPROACH

PULMONARY:

Perioperative pulmonary complications include : atalectasis , pneumonia, bronchitis, bronchospasm,hypoxemia , exacerbation of COPD,and respiratory failure requiring mechanical ventilation The site and type of surgery are the strongest predictors of complications PULMONARY

PULMONARY:

Patient related factors Patient with pre existing pulmonary disease should include assessment of the type and severity of the disease, as well as the reversibility PULMONARY

POTENTIAL RISK FACTORS FOR POST OPERATIVE PULMONARY COMPLICATIONS:

RISK FACTOR TYPE OF SURGERY Smoking coronary by pass, abdominal ASA Class > II thoracic or abdominal Age > 70 yr thoracic or abdominal Obesity thoracic or abdominal COPD thoracic or admonimal POTENTIAL RISK FACTORS FOR POST OPERATIVE PULMONARY COMPLICATIONS

PULMONARY:

Tobacco smoking increased carboxyhemoglobin levels, decrease ciliary function and increase sputum production and stimulation of CV system 2 nd to nicotine. cessation of smoking for 2 days cessation for 4-8 weeks to reduce rate of postoperative pulmonary complications Administer a bronchodilator such as albuterol preoperatively PULMONARY

PULMONARY:

Asthma During interview important to elicit information regarding inciting factor, severity, reversibility, and current status. Frequent use of bronchodilators, hospitalization for asthma and requirement for systemic steroids. Perioperative steroids as prophylaxis for severe asthmatic PULMONARY

PULMONARY:

Obstructive sleep apnea Obstruction of upper airway during sleep leading to episodic oxygen desaturation and hypercarbia Propensity for airway collapse and sleep deprivation, patient are susceptible to respiratory depressant and airway effects of sedatives, narcotics and inhaled anesthetics PULMONARY

SYSTEM APPROACH:

Cardiovascular Preoperative evaluation Clinical risk indices physical status index of ASA to Goldman Cardiac risk index Preoperative cardiac testing SYSTEM APPROACH

AMERICAN SOCIETY OF ANESTHESIA (ASA) PHYSICAL STATUS CLASSIFICATION:

Class Definition P1 A normal healthy patient P2 A patient with mild systemic disease ( no functional limitations ) P3 A patient with severe systemic disease that is a constant threat to life ( some functional limitations ) P4 A patient with severe systemic disease that is a constant threat to life (functionality incapacitated) P5 A moribund patient who is not expected to survive without operation P6 A brain dead patient whose organs are being removed for donor purposes E if procedure is and emergency, the physical status is followed by “E” AMERICAN SOCIETY OF ANESTHESIA (ASA) PHYSICAL STATUS CLASSIFICATION

GOLDMAN INDEX PREOPERATIVE CARDIAC EVALUATION:

Preoperative third heart sound jugular venous distention Myocardial infarction in the preceding six months More than five premature ventricular contractions per minute documented at any time before operation Cardiac rhythm other than sinus rhythm or presence of premature atrial contractions on preoperative electrocardiogram Age over 70 years Intraperitoneal , intrathoracic or aortic operation Emergency operation Important aortic valvular stenosis Poor general medical condition GOLDMAN INDEX PREOPERATIVE CARDIAC EVALUATION

CARDIAC RISK STRATIFICATION FOR NONCARDIAC SURGICAL PROCEDURES IN PATIENTS WITH KNOWN CORONARY ARTERY DISEASE:

High (reported cardiac risk often > 5%) emergent major operation, particularly in elderly. aortic and other major vascular peripheral vascular anticipated prolonged surgical procedures associated with large fluid shifts and blood loss Intermidiate (reported cardiac risk generally < 5%) carotid enarterectomy head and neck intraperitoneal and intrathoracic orthoaedic prostate Low (reported cardiac risk generally < 1%) Endoscopic procedures Cataract and breast CARDIAC RISK STRATIFICATION FOR NONCARDIAC SURGICAL PROCEDURES IN PATIENTS WITH KNOWN CORONARY ARTERY DISEASE

CARDIOVASCULAR:

Cardiovascular test Electrocardiogram Information of patient’s myocardium and coronary circulation. Abnormal Q waves in high risk patient are highly suggestive of past MI. CARDIOVASCULAR

SYSTEM APPROACH:

Endocrine system Diabetes mellitus Most common endocrinenopathy Hyperglycemia, blood glucose > 200 mg/ dL DM increased risk of CAD,hypertension , congestive heart failure and perioperative MI At intermediate risk SYSTEM APPROACH

Diabetes mellitus:

Perioperative stress may increase serum glucose concentration 2 nd to the released of cortisol and catecholamine. Control of glucose within a range of 100-150 mg/ dL Administer insulin in the form of infusion or regular infusion Diabetes mellitus

THYROID AND PARATHYROID DISEASE:

History and clinical manifestation Thyroid function test more sensitive Thyroid-stimulating hormone (TSH) Thyrotropin Thyroxine (T4) Triiodothyronine (T3) Hyperparathyroidism usually have hypercalcemia,indicating the need of serum calcium level THYROID AND PARATHYROID DISEASE

PREOPERATIVE LABORATORY TESTING:

PREOPERATIVE LABORATORY TESTING

Complete Blood Count and Hemoglobin concentration:

Baseline hematocrit is indicated in any procedure with a risk of blood loss Hemoglobin level of 7 g/ dL is acceptable in patient without systemic disease In patient with systemic disease signs of inadequate systemic oxygen delivery ( tachypnea and tachydia ) are an indication for transfusion Complete Blood Count and Hemoglobin concentration

Electrolytes:

Creatinine and glucose has been recommended in older patient Blood urea nitrogen and creatinine are indicated in patient with systemic disease or on medication that affect kidney Electrolytes

Coagulation studies:

Have significant impact on the surgical procedure and perioperative management. PT and PTT analysis are indicated in patient with history of bleeding problems Bleeding time advocated to determining the presence of qualitative platelet defect Avoid regional anesthesia in patient with clinical bleeding diathesis Coagulation studies

Pregnancy testing:

Pregnancy testing should be limited to female patient who believe they are pregnant or cannot tell if they are pregnant. To avoid specific agent that may harmful to the fetus Pregnancy testing

Chest X-Rays:

Can identify abnormalities that may lead to delay or cancellation of planned surgical procedure or modification of perioperative care. Pneumonia, pulmonary edema, pulmonary nodules or mediastinal mass Chest X-Rays

PREOPERATIVE MEDICATION:

PREOPERATIVE MEDICATION

GOALS:

Relief of anxiety Sedation Amnesia Analgesia Drying of airway secretions Prevention of autonomic reflex responses Reduction of gastric fluid volume and increased pH Anti emetic drug Reduction of anesthetic requirements Facilitation of smooth induction of anesthesia Prophylaxis against allergic reaction GOALS

Anesthetic management:

Preoperative Psychological preparation Preoperative Medicine Anesthetic management

Psychological preparation:

Preoperative visit and interview with patient and family members Explain anticipated events and the proposed anesthetic management in an effort to reduce anxiety and allay apprehension An informative and comforting preoperative visit may replace many milligrams of depressant medication Psychological preparation

Preoperation medication:

Patient condition, patient physical status and age must be considered Surgical procedure and its duration are important factors Must know patient weight Time and route of administration is important Preoperation medication

Sedatives – Hypnotics and Tranquilizers:

Benzodiazepines anxiolysis , amnesia, and sedation site of actions in CNS, little depression of ventilation and CV wide therapeutic index with low toxicities S.E : CNS depression Sedatives – Hypnotics and Tranquilizers

Benzodiazepines:

Lorazepam 5-10x more potent than diazepam slow onset and length of action Diazepam associates with phlebitis Midazolam 2-3x more potent than diazepam quicker onset and more rapid recovery due to lipid solubility and rapid distribution to peripheral tissues Benzodiazepines

Opioids:

The analgesic properties and respiratory depressant effects of opioids usually go hand in hand. The decrease in the carbon dioxide drive at the medullary respiratory center may be prolonged. Consider supplemental oxygen for patient receiving opioids premedications . Nausea and vomiting Choledochoduodenal sphincter spasm. Not with fentanyl and meperidine Opioids

PowerPoint Presentation:

Fentanyl Synthetic opioid agonist 75 – 125x more potent than morhine Rapid onset of action Peak plasma concetration 6-7 minutes after iv administration 1-2 microgram/kg IV for preoperative analgesia Morphine Onset after IV administration 20 mins Meperidine 10x more potent than morphine

Gastric Fluid pH and Volume:

Summary of fasting recommendations to reduce the risk of pulmonary aspiration Ingested material > minimum fasting period(hr) clear liquids 2 breast milk 4 infant formula 6 nonhuman milk 6 light meal 6 Gastric Fluid pH and Volume

PowerPoint Presentation:

Drug that can alter gastric fluid volume and increase pH or gastric acid: H2 receptor antagonist - cimetidine , ranitidine(50-200mg orally), famotidine (40 mg orally) : inc gastric pH Antacids - 0.3 sodium citrate(single dose): neutralize acid but inc gastric fluid volume Proton Pump inhibitors - Omeprazole (40mg parenteraly ): inc gastric pH Gastrokinetic agents Metoclopramide (5-10mg parenteraly ): dopamine antagonist stimulate upper GI motility

Antiemetics:

Risk score for postoperative nausea and vomiting: female gender prior history of motion sickness or postoperative nausea Nonsmoking Use of postoperative opioids Prophylaxis: droperidol , metochlopramide , ondansetron and dexamethasone Antiemetics

Anticholinergic drugs:

Indications Antisialagogue Drying of the upper airway for intraoral operations and instrumentation of airways Sedation and Amnesia scopolamine > atropine cross BBB Vagolytic actions prevention reflex bradycardia Antidote : physostigmine 1-2 mg IV Anticholinergic drugs

Antibiotics:

Cephalosporine cover the microbes on the skin. For intestinal surgery anaerobic negative and gram negative coverage needed Vancomycin or clindamycin for alternative in allergic patient Antibiotics

Difference in Preoperative Medication between pediatric and adult patients:

Physiological factors in Pediatric patients Age is the most important aspect 6-8 months: no emotional upset preschool child: with emotional upset 5yr to adolescent: easier to communicate and offer reassurance Adolescent: anxious and apprehensive Difference in Preoperative Medication between pediatric and adult patients

DifferencAe in Preoperative Medication between pediatric and adult patients:

Pharmacologic preparation Sedative-Hypnotic Benefit after 6month-1year Midazolam (0.5-0.75 mg/kg orally) Ketamine (5-10mg/kg IM) for combative child DifferencAe in Preoperative Medication between pediatric and adult patients

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