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PREOPERATIVE PREPARATION
by
Deddy Koesmayadi, dr.,SpAnKIC
Anesthesiology Department & ReanimasiFaculty Padjadjaran University/Hasan
Sadikin General Hospital
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Preoperative preparation
• Preoperative visit
• Assess the risk of anesthesia and surgery
• Informed consent
• Fasting
• Premedication
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Preoperative visitInadequate 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 patient
– Meet the doctor with the patient
– Discuss possible causes of anxiety regardinganesthetic and surgical manner
– Explain how the patient will be cared for duringand after anesthesia and about pain relief
– Establish a doctor-patient relationship thatreduces patient anxiety by building trust &
respect• Assessment of physical status
• Order special investigations
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Fears related to anesthesia (Sheffer)
• He may tell secrets
• The operation will start too soon
• He may wake up during surgery
• He may not wake up after surgery
• Fears of suffocation, mutilation, vomitting& cancer
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Incidence of anxiety
• Type of surgery :
– G.U.T 80%
– Possible cancer, disabling 85%
• Sex : women higher than men
• Type of body build :
Asthenic > normal or over weight (pyknic)
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Successful approach (Buskirk)
• Treat all patients as human being
• Be friendly, explain your visit & your plan
• Be patient & sympathetic
• Listen to his concern, answer all questions
in understanding and warm manner
• Allay patient’s 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 andPreoperative Visit 38 38 71
Source : Data from Egbert LD et al : The value of the
preoperative visit by the anesthetist JAMA 185:553, 1963
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History and physical examinationPersonal and family history
Hereditary conditions associated with
anesthesia : porphyria, malignant
hyperthermia, haemophilia
Previous operations & anesthetics
Allergies
Medications drug interaction
Habits : alcohol and smoking
Diseases of CVS and respiratory systems
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Alcoholism• Impairment of liver function
• Heart cardiac arrhythmia
– Cardiac contractility decrease
– Cardiomyopathy
• Kidney diuretic effect by inhibitingADH
• Plasma catecholamine increase
• Metabolic & respiratory acidosis fromalcohol intoxication
• Increases the anesthetic requirement
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Smoking
Ciliary function reduce, disturbingtracheobronchial clearance
Increase production and thicken of sputumStrong risk factor for coronary heart disease
and occlusive peripheral arterial disease
Systolic hypertension is potentiated
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Decrease cerebral blood flow and increase
risk of strokeIncrease gastric volume & acidity
Increase COHb level, decrease blood O2
content & O2 delivery to tissueIncrease catecholamine : CVS responses &
O2 requirement increase
Respiratory complication increase 5-7 times
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Recomendations
COHb fall to normal level → stop smoking
48 hours preoperatively
Reduction of sputum volume & post op
complications → stop smoking 4 weeks pre
operatively
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Physical examination
General condition : name, age, weight.
B.P. pulse rate & temperature.
Cardiopulmonary examination including- Cyanosis in finger tips
- V. jugularis engorgement
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Obesity (W/H2 more than 30)
o Airway problems
o Mechanical ventilation is impaired
tendency to hypoventilation e.c. fix thorax& elevated diaphragm
o Easily developed hypoxia e.c.
- FRC is reduced
- V/Q ratios are low
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•Difficult estimate circulatory volume byV.J. pressure and difficulty in venipuncture
• CVS disorders :
– Hypertension 3X more
– Ischemic H.D 2X more
– CVD/CVA 3X more
• DM 3-4 X more
• Increase gastic volume, acidity & pressure
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Physical examination
General condition : name, age, weight.
B.P. pulse rate & temperature.
Cardiopulmonary examination including- Cyanosis in finger tips
- V. 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 incissors Vertebral column : anatomical deformities
may render some blocks in practical
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Simple Bedside cardiopulmonary function
Sebarase’s test : 2-3 deep breaths – hold aslong as possible
Time : ≥ 40 seconds normal
30-40 seconds diminished
reserve< 20 seconds severelycompromised
Match test : The ability to blow out a standardmatch held 6 inches from the open mouthnegative →max breathing cap low
Tilt test
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Laboratory testing
Routine lab.test in pts who are apparentlyhealthy (history & clinical exam) areinvariably of little use and wasting.
Blood : Hb, leuco all female, male > 50, major
surgery, clinically indicated
Ureum, creatinine
pt > 50, renal &hepatic diseases, diabetes, abnormalnutritional state
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Blood sugar DM, vascular disease,
corticosteroid drugs Urinalysis every pt, very inexpensive and may
occasionally reveal an undiagnosed diabetic or UTI
Chest X Rays :
- History of pulmonary and cardiac disease
- Tbc endemis
- Smoking
ECG pt > 40, hypertension, history of cardiac
disease
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Assess the risk of anesthesia and surgery
ASA (American Society of Anesthesiologist)grading system
Class I : A normally healthy individual, the pathology which surgery is needed only
localized Class II : A patient with mild or moderate
systemic disease
Class III : A patient with severe systemicdisease that is not incapacitating (limits the ptactivity)
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Class IV : A patient with incapacitatingsystemic disease that is a constant threat tolife
Class V : A moribund patient who is not
expected to survive 24 hour with or withoutoperation
Class E : Added as a support for emergency
operation. All pts induced in ASA I-V thatneed emergency operation get a higher ASA grade
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CARDIAC RISK
CRITERIA POINTS
Hystory
- Age > 70 years 5
- MI in previous 6 mo 10
Physical examination
- S3 gallop or jugular vein distension 11
- Important VAS 3
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CRITERIA POINTS
Electrocardiogram
- Rhythm other than sinus or
premature atrial contraction on
last preoperative ECG 7
- > 5 premature ventricular
contractions/m in documented at
anytime before operation 7
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CRITERIA POINTS
General 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 riddenfrom non cardiac causes 3
Operation
- Intraperitoneal, intrathoracic, or aortic
operation 3
- Emergency operation 4
TOTAL POSSIBLE POINTS 53
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RISK CLASSIFICATION AND OUTCOME BY
THE CARDIAC RISK INDEX (CRI) AND
AMERICAN SOCIETY OFANESTHESIOLOGISTS (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%
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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 patienthas sufficient information about the procedures,
their risks, and benefits.
Obtaining informed consent honors a patient’s right
to self determination whether GA, regionalanesthesia, or i.v sedation.
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Without the patient’s 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 issigned by the patient or their representative.
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Fasting
To prevent aspiration of gastric content NPO 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 toxicity
Fasting 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 patients
oral 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 & fear
• Reduce secretions
•Analgesia
• Enhance the hypnotic effect of G.A. agent
• Reduces post op nausea and vomitting
• Produce amnesia• Reduction in vagal reflex
• Limit sympathoadrenal responses
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Drugs for premedication
Sedativa, tranquilizer
Narcotics-analgetics
Alkaloid belladona as antisecretion andreduce vagal reflex to the heart from :
– drugs
– impuls afferent abdomen, thorax, andeyes
Antiemetic
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Sedative
Sedative in appropiate dose can reduceanxiety and stress, in higher dose become
hypnotic.
Barbiturate :
• Ultra short acting
– Thiopentone / penthotal
– Methohexitone, hexobarbitone
– Especially detoxification in liver
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• Medium acting :
– Pentobarbitone – Quinalbarbitone
– Butobarbitone
– A part of them are detoxificated in liver, small part are excreted by kidney
• Long acting :
– Phenobarbitone (Luminal)
– All of them are excreted by kidney
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Barbiturate ⇒cerebral protection
Because : cerebral metabolism ↓, cerebraloxigen consumption ↓, C.B.F. ↓, & I.C.P. ↓
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Medium Acting
Medium acting that most suitable for
premedication
•depress CNS, start from cortex, RAS,medulla spinalis, use for anti convulsant
• depress myocard ⇒bradycardi, cardiac
output ↓ ⇒ hypotension
• BMR ↓• depress liver and kidney function
• crossing placental barrier
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• Interfere other drugs link and metabolism
(enzyme induction)
• No analgetic effect
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Premedication ⇒Sedativa
Pentobarbitone sodium / nembutal andquinal barbitone sodium / seconal ⇒ less
depress respiration and circulation, nonteratogenic, and because it is detoxificatedin liver, suite for kidney functiondisturbance.
– Inject 60 mg/cc, i.m, 2 hour pre op. – Capsule 50 and 100 mg
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– Adults dose 1,5-2 mg/kg BW oral, rectal
– Children 3-4 mg/kg BW oral, rectal
– Duration of action : 3-4 hours
Phenobarbitone / luminal
– Because the excretion through kidney,
barbiturate suite for liver function disturbance
– Sedative dose 30 – 50 mg
– Hypnotic dose 100 mg for adult, 3-5 mg/kg BWfor children
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Tranquilizer : Phenothiazine
Phenothiazine : sedative-antiemetic,
antihistamine (Phenergan), antipiretic
(central vasodilatation), central sympaticdepression, and minimize the effect of
adrenalin in perifer => less tension
(Largactil), dose : 25-50 mg oral/i.m
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- 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 producesactive metabolites : methyl diazepam,
oxazepam, 3-hydroxy diazepam prolonged
CNS depression
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• Minimal cardiovasculer effect
• Ventilatory response to CO2 depressedincrease PaCO2 especially in association
with other respiratory depressant
• Anticonvulsant in tetanus and epilepsy• Mild muscle relaxant property at spinal cordlevel and potentiate non depolarizingmuscle relaxant
• Retrogade amnesia especially whencombine with meperidine or hyoscine
• Rapidly passes the placental barrier
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Doses
oral : 0,2 – 0,5 mg/kgi.v : 0,1 – 0,2 mg/kg
induction : 0,3 – 0,5 mg/kg
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MIDAZOLAM
The efect are faster and shorter, duration
approximately 60 minutes
Anterograde amnesia, has no anticonvulsant effect
Dose : 0,15–0,1 mg/kg BW, i.m/i.v →adult
0,5 mg/kg BW, oral →children
No pain when injected →because of water soluble Possibility become phlebitis is small
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CBF is decrease → ICP decrease → cerebral
protection Relaxation effect
Not interfere coronary circulation → safe for
ischemic heart disease, in other way diazepaminterfere CVR →unsafe
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DROPERIDOL/ INAPSINE
Tranquilizer butyrophenone, phenothiazine like effect
Forced antiemetic, ICP can be decrease because of mild
cerebral vasoconstriction
Alpha adenergic receptor blockade → hypotensi, it can
prevent catecholamine induced arrhythmia
Apathis
Dose : 2,5-5 mg; duration 6-8 hoursSide effect : dyskinetic involuntary movement
(extrapyramidal disturbance)
Occasionally dysphoric reaction
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Morphine
Narcotic-analgetic standard for strong pain,euphoria
Sedativa-postural hypotension ⇒because of vasodilatation and myocard depression(depression of vasomotor center)
Constrict the sphincter of gut, peristaltic ↓ ⇒constipation
BMR ↓, addiction-hystamine release positif
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Depression of cough reflex post op ⇒ secret
accumulation ⇒atelectasis
ICP rise in intracranial injury
Respiratory center depression ⇒CO2 ↑⇒
CBF ↑
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Parasympatic tone:
- Bronchus →bronchoconstriction- Eyes →myosis
Through placental blood barrier
Dose : 10-15 mg i.m/s.c, duration until 6 hoursChildren : 0,1 mg/kg bodyweight
Disadvantages:
• Nausea and vomittus →not be used in intraocular operation
• COPD or asthma →worsening
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PETHIDINE/ MEPERIDINE
• Depression of RC, emetic effect, euphoria anddizziness are less than morphine
• Less histamine release→fine for asthma
• Through placental blood barrier →not be given before umbilical cord is cut
• Atropine like effect : saliva →dry mouth
eyes→mydriasis• Dose : 50-100 mg
Child : 0,5-1 mg/kg BW; duration 2-4 hours
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FENTANYL SUBLIMATE
• Stronged analgetic, 100 x morphine
• CVS effect are minimal so the histamine release
• Duration : 45’-60’• Dose : 0,05-0,1 µg I.m, 1 hour pre.op.
• Disadvantages:
-Respiratory depression
-Bradycardi, miosis
-Bronchoconstriction
-somatic muscle spasm
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ANTAGONIST OF NARCOTIC
If RC depression, antagonist of narcotic can be given:
• Nallorphine 5mg iv→Lorvan 1 mg iv
• Naloxone/ narcane is better for respiratory
depression
• Dose: 0,2-0,4 mg iv
Anticholinergic drugs
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Anticholinergic drugsPerthidin & Phenergan have anticholinergic effect
• Sulfas atropin / alkaloid belladona• anti secretion of salivatory, respiratory tract
and sweat glands ⇒be aware of patient
with fever • Glycopyrolat is an antisecretion 2x and
more longer than SA , no central effect
• vagal block, needs a high dose until 1 - 2mg
• CNS : Tendency to stimulate CNS,
hyoscine sedation
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• Light bronchodilator
• CVS : tachycardi ⇒ be aware tothyrotoxicosis and ischemic HD,
cardiomyopathy
• GI : intestine and urinary tracts peristaltic ↓ ⇒constipation and urine retension
• BMR ↑ ⇒be aware to thyrotoxicosis
• dose : 0,005 - 0,01 mg/kgWB• duration of action : im until 90’ ; iv 30’-45’
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• Combination of those drugs →patient
comes to the operation room stillaware 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
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OPERATION CANCELLED
• Anemia: Hb < 10gr%
In Research Hb < 10gr%→it’s not increase morbiditas/
mortalitas.
If circulating volume is enough, Hb 8 gr%→it’s notnecessary to get tranfusion
• Syok: Anesthesia→depression of vital organs→syok is
worsening. Volume replacement →until blood pressure >80mmHg, good peripheral condition, diuresis is enough
• Temperatur: 380C→antipyretica, find focal infection
especially respiratory tract
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Respiratory Infection• Influenza, pharyngitis, bronchitis →elective
operation is delayed
• Airways instrument :
- trauma of infection mucosa →resp. obstruction,
spasm, hypersecretion →Post operative respiratory
complication.
- infection spread
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