Department Anesthesiology & Reanimation Medical Faculty Pattimura University

Preoperative preparationPreoperative visitAssess the risk of anesthesia and surgeryInformed consentFastingPremedication

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Inadequate pre op.preparation may be a major contributory factor to the perioperative morbidity & mortality. It is essensial that anesthetist visits every patient before surgery.

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The purpose of it :Establish rapport with the patientMeet the doctor with the patientDiscuss possible causes of anxiety regarding anesthetic and surgical manner Explain how the patient will be cared for during and after anesthesia and about pain reliefEstablish a doctor-patient relationship that reduces patient anxiety by building trust & respect Assessment of physical statusOrder special investigations

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Fears related to anesthesia (Sheffer)He may tell secretsThe operation will start too soonHe may wake up during surgeryHe may not wake up after surgeryFears of suffocation, mutilation, vomitting & cancer

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Incidence of anxietyType of surgery : G.U.T 80%Possible cancer, disabling85%Sex : women higher than menType of body build :

Asthenic > normal or over weight (pyknic)

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Successful approach (Buskirk)Treat all patients as human beingBe friendly, explain your visit & your planBe patient & sympatheticListen to his concern, answer all questions in understanding and warm mannerAllay patients fears

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Comparison of Preoperative Visit and Pentobarbital (2mg/kg i.m) (% of Patients)

Felt Drowsy

Felt Nervous

Adequate Preparation

Control Group

18

58

35

Pentobarbital Only

30

61

48

Preoperative Visit

26

40

65

Pentobarbital and

Preoperative Visit

38

38

71

Source : Data from Egbert LD et al : The value of the preoperative visit by the anesthetist JAMA 185:553, 1963

History and physical examinationPersonal and family historyHereditary conditions associated with anesthesia : porphyria, malignant hyperthermia, haemophiliaPrevious operations & anestheticsAllergiesMedications drug interactionHabits : alcohol and smokingDiseases of CVS and respiratory systems

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AlcoholismImpairment of liver functionHeart cardiac arrhythmiaCardiac contractility decreaseCardiomyopathy

Kidney diuretic effect by inhibiting ADHPlasma catecholamine increaseMetabolic & respiratory acidosis from alcohol intoxicationIncreases the anesthetic requirement

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SmokingCiliary function reduce, disturbing tracheobronchial clearanceIncrease production and thicken of sputumStrong risk factor for coronary heart disease and occlusive peripheral arterial diseaseSystolic hypertension is potentiated

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Decrease cerebral blood flow and increase risk of strokeIncrease gastric volume & acidityIncrease COHb level, decrease blood O2 content & O2 delivery to tissueIncrease catecholamine : CVS responses & O2 requirement increaseRespiratory complication increase 5-7 times

RecomendationsCOHb fall to normal level stop smoking 48 hours preoperativelyReduction of sputum volume & post op complications stop smoking 4 weeks pre operatively

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Physical examinationGeneral condition : name, age, weight.B.P. pulse rate & temperature.Cardiopulmonary examination includingCyanosis in finger tipsV. jugularis engorgement

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Obesity (W/H2 more than 30)Airway problemsMechanical ventilation is impaired tendency to hypoventilation e.c. fix thorax & elevated diaphragmEasily developed hypoxia e.c. - FRC is reduced- V/Q ratios are low

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Difficult estimate circulatory volume by V.J. pressure and difficulty in venipunctureCVS disorders :Hypertension 3X moreIschemic H.D 2X moreCVD/CVA 3X more

DM 3-4 X moreIncrease gastic volume, acidity & pressure

Physical examinationGeneral condition : name, age, weight.B.P. pulse rate & temperature.Cardiopulmonary examination includingCyanosis in finger tipsV. jugularis engorgement

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Airway :Neck : stout, short, sunker cheeks, distance from mentum to hyoid ( 5 cm)Mouth : mouth opening, loose or damage teeth, protruding upper incissorsVertebral column : anatomical deformities may render some blocks in practical

Simple Bedside cardiopulmonary functionSebarases test : 2-3 deep breaths hold as long as possibleTime : 40 seconds normal 30-40 seconds diminished reserve < 20 seconds severely compromisedMatch test : The ability to blow out a standard match held 6 inches from the open mouth negative max breathing cap lowTilt test

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Laboratory testingRoutine lab.test in pts who are apparently healthy (history & clinical exam) are invariably of little use and wasting.Blood :Hb, leuco all female, male > 50, major surgery, clinically indicatedUreum, creatinine pt > 50, renal & hepatic diseases, diabetes, abnormal nutritional state

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Blood sugar DM, vascular disease, corticosteroid drugsUrinalysis every pt, very inexpensive and may occasionally reveal an undiagnosed diabetic or UTIChest X Rays : - History of pulmonary and cardiac disease - Tbc endemis - SmokingECG pt > 40, hypertension, history of cardiac disease

Assess the risk of anesthesia and surgeryASA (American Society of Anesthesiologist) grading systemClass I : A normally healthy individual, the pathology which surgery is needed only localizedClass II : A patient with mild or moderate systemic diseaseClass III : A patient with severe systemic disease that is not incapacitating (limits the pt activity)

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Class IV : A patient with incapacitating systemic disease that is a constant threat to lifeClass V : A moribund patient who is not expected to survive 24 hour with or without operationClass E : Added as a support for emergency operation. All pts induced in ASA I-V that need emergency operation get a higher ASA grade

CARDIAC RISK

CRITERIA POINTS

HystoryAge > 70 years 5MI in previous 6 mo 10Physical examinationS3 gallop or jugular vein distension 11Important VAS 3

CRITERIA POINTSElectrocardiogramRhythm other than sinus or premature atrial contraction on last preoperative ECG 7> 5 premature ventricular contractions/m in documented at anytime before operation 7

CRITERIA POINTSGeneral status : PO2 < 60 or PCO2 > 50 mmHg, K < 3.0 or HCO3 < 20 Meq/l, BUN > 50 or Cr > 3.0 mg/dl, abnormal SGOT, signs of chronic liver disease or patient bed ridden from non cardiac causes 3OperationIntraperitoneal, intrathoracic, or aortic operation 3Emergency operation 4TOTAL POSSIBLE POINTS 53

RISK CLASSIFICATION AND OUTCOME BY THE CARDIAC RISK INDEX (CRI) AND AMERICAN SOCIETY OF ANESTHESIOLOGISTS (ASA) CRITERIA

No or Minor

Life-Treatening

Complication

Complication

Cardiac

Deaths

Class

CRI Ponts

CRI

ASA

CRI

ASA

CRI

ASA

1.

0-5

99%

100%

0,7%

0%

0,2%

0%

2.

6-12

93%

97%

5%

2%

2%

1%

3.

13-25

86%

93%

11%

4%

2%

2%

4.

25

22%

78%

22%

17%

56%

5%

Informed consent A patient active knowledgeable authorization to allow a specific procedure to be provided by an anesthesiologist. Consent must be informed to ensure that the patient has sufficient information about the procedures, their risks, and benefits. Obtaining informed consent honors a patients right to self determination whether GA, regional anesthesia, or i.v sedation.

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Without the patients consent, the physicion may liable for assault and battery. When the patient is a minor or otherwise not competent to consent (mentally disturbed or drugs), the consent must be obtained from someone legally authorized to give it, such as parent, guardian, or close relative.Written documentation of the informed consent is included in the patient chart and is signed by the patient or their representative.

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FastingTo prevent aspiration of gastric contentNPO after midnight has been questioned nowadays. Hazard fasting 12 hours : - Hydration is compromised- Fasting for 1 day may deplete liver glycogen & greater risk for hepatic toxicityFasting for 1 day increases FFA lower the threshold to epinephrine induced arrhythmia.Recommendation : NPO 4 hoursGastric emptying is delayed by : anxiety, pain, trauma, and pregnancy.

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A study to unpremedicated patientsoral intake 150 ml water 2-3 hours pre operatively R.G.V low, pH more alkaline (72%)

150 ml water + ranitidine 150 mg only 2% had RGV > 25 ml pH < 2,5

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To avoid hypoglycemia and thirsty and in order pediatric pts calm & cooperative : - Milk 10 ml/kg 4 hours before surgery - Dextrose 5% 10 ml/kg 2 hours before surgery

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PremedicationObjectives are :Allay anxiety & fearReduce secretionsAnalgesiaEnhance the hypnotic effect of G.A. agentReduces post op nausea and vomittingProduce amnesiaReduction in vagal reflexLimit sympathoadrenal responses

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Drugs for premedicationSedativa, tranquilizerNarcotics-analgeticsAlkaloid belladona as antisecretion and reduce vagal reflex to the heart from :drugsimpuls afferent abdomen, thorax, and eyes

Antiemetic

SedativeSedative in appropiate dose can reduce anxiety and stress, in higher dose become hypnotic.

Barbiturate :Ultra short actingThiopentone / penthotalMethohexitone, hexobarbitoneEspecially detoxification in liver

Medium acting :PentobarbitoneQuinalbarbitoneButobarbitoneA part of them are detoxificated in liver, small part are excreted by kidneyLong acting :Phenobarbitone (Luminal)All of them are excreted by kidney

Barbiturate cerebral protection

Because : cerebral metabolism , cerebral oxigen consumption , C.B.F. , & I.C.P.

Medium ActingMedium acting that most suitable for premedicationdepress CNS, start from cortex, RAS, medulla spinalis, use for anti convulsantdepress myocard bradycardi, cardiac output hypotensionBMR depress liver and kidney functioncrossing placental barrier

Interfere other drugs link and metabolism (enzyme induction)No analgetic effect

Premedication SedativaPentobarbitone sodium / nembutal and quinal barbitone sodium / seconal less depress respiration and circulation, non teratogenic, and because it is detoxificated in liver, suite for kidney function disturbance.Inject 60 mg/cc, i.m, 2 hour pre op.Capsule 50 and 100 mg

Adults dose 1,5-2 mg/kg BW oral, rectalChildren 3-4 mg/kg BW oral, rectalDuration of action : 3-4 hours

Phenobarbitone / luminalBecause the excretion through kidney, barbiturate suite for liver function disturbanceSedative dose 30 50 mgHypnotic dose 100 mg for adult, 3-5 mg/kg BW for children

Tranquilizer : BenzodiazepinesBenzodiazepines : anxiolysis sedation amnesiaPreferable to the barbiturateProduce amnesiaGreater therapeutic indexLess cardiovascular and respiratory deppressionLonger duration of action

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Tranquilizer : PhenothiazinePhenothiazine : sedative-antiemetic, antihistamine (Phenergan), antipiretic (central vasodilatation), central sympatic depression, and minimize the effect of adrenalin in perifer => less tension (Largactil), dose : 25-50 mg oral/i.m

Diazepam- Lorazepam- Midazolam

Diazepam : insoluble in water but lipid soluble - Injection painful (venous irritation) - Absorption from i.m unreliable but rapidly absorbed from GI tract Metabolism principally in the liver produces active metabolites : methyl diazepam, oxazepam, 3-hydroxy diazepam prolonged CNS depression

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Minimal cardiovasculer effectVentilatory response to CO2 depressed increase PaCO2 especially in association with other respiratory depressant Anticonvulsant in tetanus and epilepsyMild muscle relaxant property at spinal cord level and potentiate non depolarizing muscle relaxantRetrogade amnesia especially when combine with meperidine or hyoscineRapidly passes the placental barrier

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Doses oral : 0,2 0,5 mg/kgi.v : 0,1 0,2 mg/kginduction : 0,3 0,5 mg/kg

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MIDAZOLAMThe efect are faster and shorter, duration approximately 60 minutesAnterograde amnesia, has no anticonvulsant effectDose : 0,150,1 mg/kg BW, i.m/i.v adult0,5 mg/kg BW, oral childrenNo pain when injected because of water solublePossibility become phlebitis is small

CBF is decrease ICP decrease cerebral protectionRelaxation effectNot interfere coronary circulation safe for ischemic heart disease, in other way diazepam interfere CVR unsafe

DROPERIDOL/ INAPSINETranquilizer butyrophenone, phenothiazine like effectForced antiemetic, ICP can be decrease because of mild cerebral vasoconstrictionAlpha adenergic receptor blockade hypotensi, it can prevent catecholamine induced arrhythmiaApathisDose : 2,5-5 mg; duration 6-8 hoursSide effect : dyskinetic involuntary movement (extrapyramidal disturbance)Occasionally dysphoric reaction

MorphineNarcotic-analgetic standard for strong pain, euphoriaSedativa-postural hypotension because of vasodilatation and myocard depression (depression of vasomotor center)Constrict the sphincter of gut, peristaltic constipationBMR , addiction-hystamine release positif

Depression of cough reflex post op secret accumulation atelectasisICP rise in intracranial injuryRespiratory center depression CO2 CBF

Parasympatic tone:- Bronchus bronchoconstriction- Eyes myosisThrough placental blood barrierDose : 10-15 mg i.m/s.c, duration until 6 hoursChildren : 0,1 mg/kg bodyweightDisadvantages:Nausea and vomittus not be used in intraocular operationCOPD or asthma worsening

PETHIDINE/ MEPERIDINEDepression of RC, emetic effect, euphoria and dizziness are less than morphineLess histamine release fine for asthmaThrough placental blood barrier not be given before umbilical cord is cutAtropine like effect : saliva dry mouth

eyes mydriasisDose : 50-100 mg

Child : 0,5-1 mg/kg BW; duration 2-4 hours

FENTANYL SUBLIMATEStronged analgetic, 100 x morphineCVS effect are minimal so the histamine releaseDuration : 45-60Dose : 0,05-0,1 g I.m, 1 hour pre.op.Disadvantages:

-Respiratory depression-Bradycardi, miosis-Bronchoconstriction-somatic muscle spasm

ANTAGONIST OF NARCOTICIf RC depression, antagonist of narcotic can be given:Nallorphine 5mg iv Lorvan 1 mg ivNaloxone/ narcane is better for respiratory depressionDose: 0,2-0,4 mg iv

Anticholinergic drugsPerthidin & Phenergan have anticholinergic effectSulfas atropin / alkaloid belladonaanti secretion of salivatory, respiratory tract and sweat glands be aware of patient with feverGlycopyrolat is an antisecretion 2x and more longer than SA , no central effectvagal block, needs a high dose until 1 - 2 mgCNS : Tendency to stimulate CNS, hyoscine sedation

Light bronchodilatorCVS : tachycardi be aware to thyrotoxicosis and ischemic HD, cardiomyopathyGI : intestine and urinary tracts peristaltic constipation and urine retensionBMR be aware to thyrotoxicosisdose : 0,005 - 0,01 mg/kgWBduration of action : im until 90 ; iv 30-45

Combination of those drugs patient comes to the operation room still aware but sleepy, calm, cooperative, there are no complications during and after the operation Doses and drugs combination are decided by patient condition and anesthetis experience and skills

OPERATION CANCELLEDAnemia: Hb < 10gr%

In Research Hb < 10gr% its not increase morbiditas/ mortalitas.If circulating volume is enough, Hb 8 gr% its not necessary to get tranfusionSyok: Anesthesia depression of vital organs syok is worsening. Volume replacement until blood pressure > 80mmHg, good peripheral condition, diuresis is enoughTemperatur: 380C antipyretica, find focal infection

especially respiratory tract

Respiratory InfectionInfluenza, pharyngitis, bronchitis elective operation is delayedAirways instrument :

- trauma of infection mucosa resp. obstruction, spasm, hypersecretion Post operative respiratory complication.- infection spread

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