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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