Preoperative evaluation and preparation

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Preoperative evaluation and preparation

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Objectives

• Patient data
• Doctor patient relationship
• Anesthetic plan
• Patient consent

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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

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1.Review of patient data

• Surgical condition
• -Condition of disease, symptom of disease
• -Surgical procedure
• -Position of procedure

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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
• mandibular space
• tongue
• teeth
• Mallampati classification

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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
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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
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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

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Laboratory data

• Specific test
• Cardiac evaluation exercise stress test
• Thallium scan
• echocardiogram
• Pulmonary evaluation
• Lung function test
• Spirometry
• Arterial blood gas
  

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Medical consultation

• To define patients condition
• To optimize patients medical condition and
  future management before surgery

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Consent form

• Informed consent involves
• discussing anesthetic management plan,
  alternatives
• potential complication

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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

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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

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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
• 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

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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

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Cardiac disease

• Exercise tolerance
• 4 METs walk at 6 km/hr, run short distance,
  heavy work around house, golf, bowling, dancing

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Cardiac disease

• Patient risk for MI postop
• DM
• Peripheral vascular disease
• HT
• Tobacco used
• Hypercholesterolemia

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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 lt 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

• History of reactive airway Asthma
• Frequency, reversible of symptoms, interval, last
  attack, history of steroid used
• Optimize good condition before elective surgery
• COPDnew 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

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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

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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

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Pulmonary disease

• 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

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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,hypoventilati
  on

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Endocrine disease

• Large mass may distort airway chest x-ray
  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
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Objections

• Anxiolytic and sedation
• Analgesia
• Amnesia
• Hemodynamic stability
• Decrease secretion
• Decrease gastric volume
• Antiemetic
• Facilitate induction of anesthesia
• Antiinfection

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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
• Age and weight
• ASA physical status
• Prior experience
• Patient condition
• Elective or emergency

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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

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1. Benzodiazepine

• 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

• 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

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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
  0.03-0.14 mg/kg for sedation

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3.Phenothiazine

• Mild tranquilizer
• Antiemetic
• Anti histamine
• Dose 25-50 mg/kg oral or rectal

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4. Chloral hydrate

• Sedative
• Anxiolytic
• Amnesia
• Use for children
• dose 30-50 mg/kg oral or rectal

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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

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6. Opioids

• Meperidine (Pethidine)
• Potency 1/10 of MO
• Less histamine release and respiratory depression
• Dose 1-2 mg/kg IM or IV

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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

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6. Opioids

• Caution
• Respiratory and myocardial depression
  Hypotension, Nausea and vomitting
• Spasm of sphincter of Oddi (FentanylgtMOgtpethidine)
  
• MO and pethidine interaction with MAOI (monoamine
  oxidase inhibitor) make markly HT

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7.anticholinergic

• Decrease secretion (antisialogogue)
• Dry airway
• Sedation
• Amnesia
• vagolytic
• Side effects CNS toxicity, relax of esophageal
  sphinter, mydriasis and interfere with sweating

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8.Aspiration prevention

• Benefit for patient risk for pulmonary aspiration
• Pregnant woman
• GE reflux
• Hiatal hernia
• Morbid obesity
• Chronic renal failure

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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

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8.Aspiration prevention

• Proton pump inhibitor
• Omeprazole (losec)
• 40 mg oral
• Nonparticipate antacids
• Neutralize gastric pHgt3.5
• 30 ml oral 30 mins before induction

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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

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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

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10. Hemodynamic stability

• a2-adrenergic agonist(clonidine)
• Sedation
• Decrease anesthetic and opioid requirement
• Decrease sympathetic response
• Dose 5-20 ug/kg
• Hypotension

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10. Hemodynamic stability

• ß-adrenergic blocker (atenolol,propanolol)
• Decrease sympathetic response
• Anxiolytic
• May be benefit in CAD patient
• Dose 50 mg oral

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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

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The end