Preoperative Issues in Anaesthesia Assessment Semester 12 Anaesthetics es jr en J = a 7 Mr GB Principles ee eee Aa | 1 Completed health questionnaire ; 64 Year oki man for right hemicolecteny | | 2. Gineal story and eraraneges » Ex smoker, gets breathless walking up | | 3. ASA status: hills 4. Surgical pathology > Type 2 diabetes - taking metformin lea rrsnmedensene » States with the last anaesthetic they had | | “trouble withthe breathing tube" | | eee L ae eine Rerreerians aT lameness aT ASA Status » Most ASA 1 & 2 patients will be | Suitable for day surgery or DOSA ASA Status | » ASA 1 - healthy, no medical problems | > ASA 2 mild systemic disease | + Eg controled HT / asthma | > ASA 3. significant imitations + stable IHD, contoes CCF, COAD, DM > ASA 4 constant threat to life + 9. unstable angina, LVF, severe COAD > Most ASA 3 pationts can be ‘admitted on the day of surgery if: ‘Medical problems stable and recently assessed + Anaesthetic clinic assessment || Failed intubation | Failed intubation > An anaesthetic emergency > ASA difficult airway algorithm > oe for 3% of morbidity and 20% of * Adequate aiway assessment may reduce | qa | > Incidence 1 in 3000 | | (in 300 in obstetes) | ure eprbacal waterd OF opt | earners) | > Obese 42 yearold woman undergoing | | | laparoscopy for pelvic paln > Lithotomy posion, spont. vent. GA with a laryngeal mask > In recovery Sp02 82% despite oxygen, Productive cough a aS . a nut Crew ae ae ee a Most Gols Angin Premony eae eee | eer Aspiration Aspiration > 11% of reported morbisity | > Management is supportive al > Risk factors abe + Position head down, lateral Vall sett pee) letra ees | stoceasy aera + Intubation, oxygenation odin ‘ Sey aaa Uh S tanotcmy postion = | peu + Antibioties only if secondary infectionAnaphylaxis-markers = | | —Suxamethoniumapnoea _| | | » 5% of the population are heterozygous for | ‘an abnormal acetylcholinesterase enzyme » 0.03% of the population are homozygous — > Homozygotes will have a prolonged Paralysis after suxamethonium | administration: =| ‘+ Normal duration 3 - § minutes Liner + Sux apnoea 1 - 4 hours | Suxamethonium apnoea Cholinesterase variants | | suemathie, ce, tase | [ee [ear esi cee | ee he = | oe ae | | “ | | | +24 year man unrging GA ora hat Wy | fractured femur | ed be » Very anxious about anaesthesia | | Says eveyone nn tnay has anaes gta eer ae aaHalothane hepatitis Mr BD » 58 year old man came into ED with a 7 cm laceration to scalp after falling whilst intoxicated » The RN sets up the suture tray with lignocaine 2% with adrenaline > 29 5 Regional Anaesthesia > Local anaesthetic toxicity > Neurological complications | > Epidural abscess | |» Epidural haematoma a | > Post-dural puncture headache , oy Local anaesthetic toxicity > Due to membrane stabilising eect on cells inthe heart and CNS > Mechanisms: |» Winjection | Systemic absorption | > Effects relate to dose, agent, ste, » How much local anaesthetic can you | vasoconstrictor use safely use? (he weighs 70 kg) 4x40 = 149 my | L OSS — Ww Local anaesthetic toxicity |» Tingling around mouth, tongue > Lightheaded, agitated, tremor > Unconsciousness, convulsions | | > Hypotension | > Apnoea Local anaesthetic toxicity > Maximum safe doses: + Lignocaine (Xyocaine) With acrenaine 7 mop *Witout arenaine 4 mghig + Bupivicaine (Marcaine), Ropiveaine (Naropin) + Wit orwihout adrenaline 2 mpg + Note: 1% = 10 mg/m! > Treatment is supportive| ie Normal Values (ECF) | [eM t6-1 sph 736-709 © ana »PCO2 36-44 Per assis 7 F002 Se a4 | *wcos aaa > lure ace nee rey | > Gueose 9-7 200-305 > Anion Gap 12-18 (Nask) -(CI+HC03) aes ali a = | [Sane eeenrioee ee 0 pe Fluid Compartments Normal Daily Requirements | a | scum trnoseran | Tra ae » Normally we require | are + Wator 30 ml/kg (1-2 meg) Sa r9 | + Sodium 1-2 mmol/kg | | + Potassium 1-2 mmol /kg | | | 2 | a | eee | fnleal Aagecn renee] What's in a bag of fluid? Clinical Assessment of | i | | + 0.9% ‘Normal Saline > Ringers Lactate Fluid Deficits 2t "isonma "Solon |General appearance [8 Hemet i aml > Estimate losses |i 48 Decesastg 2 Sates > 4 cardinal signs |" 040% Sane Ley Senet + heartrate ae + blood pressure (and postural drop) 1 Stee Soe > 5% Dentose + wine ouput + Sisto | + central venous pressure | L = _ | l _ Jae sitar me ay Ww bee tequnn thi! le Beh amuein, + (601 # but) Assessing degree of deficit What fluid does a patient require? > Replacement of sses |. >Maintanance tid > Continued replacement of ongoing losses: ‘consider the hd and elect conan af Studs et + 0.9 gate ut sgh in and Sila Sowa hast hgh inte ana COS, urine varies markedly (best to measure) 4/ 4 | Blood loss estimation | > Normal blood volume is 60 ml/kg > When the patients normovolaemic + blood loss = 60 x weight x Fabian 2 (nmi) Storing He ee || Ms ET > A70 year old woman with three days of nausea and vomiting (suspected SBO) >» Wt60 kg m > BP 105160, HR 104, our, JVP not, an dele de visable 3 > Nasogastric tube draining 100 mh 5=/p/. of T&L > at is wilyou oer? | 3-6 Leles as = Neurological complications a Epidural ‘| | Neurological complications » Mechanisms: | Bret tome «+ Haemormhage + Local anaesthetic toxicity + Infection (rare) Post-dural puncture headache » Apostural headache, usually within 24-48 > Often severe occipital to cervical, with tinnitus, | blurted vision, diplopia > Due to continued CSF leak, causing traction on meningesl vessels and nerves, Ic» Incidence increased with — + Young, female, pregnancy 1 Lange neces, beveled needs, multiple stamps 1 Pro POPH Neurological complications » May be as common as 4 in §000 (temporary) and 1 in 20000 (permanent) > Typically parasthesiae, foot drop, sphincter problems > Related to: + Epidural > spinal + Multiple attempts + Difficult patents + Coagulopathy Post-dural puncture headache > Treatment + Bodrest Sivas 1 Anaigests: asin + cates? 1H persstent epidural blood patch enaestntsts) > Differential | Merino, aracmnoxtis aMalignant hypertherm > Ahypermetabolic disorder caused by an abnormal muscle response to volatile anaesthetics or suxamethonium > Familial susceptibility - AD > 60% mortality unless treated early » Signs include hypercapnia, tachycardia, hyperthermia (late, severe) > Investigations: metabolic acidosis Malignant hyperthermia > Differential diagnosis: + Thyroid storm + Phaeochromocytoma + Septicaemia + Neurolept malignant syndrome + Other causes of hypercapnia Malignant hyperthermia Malignant hyperthermia > Bleceon miroscopy of muscle biopsy: Malignant hyperthermia > Management + Discontinue triggering agents + Abandon procedure, cal for help > Dantrolene 2 mg/kg repeated 4 Total body cooling «Treat complications (acidosis, hyperkalaemia, renal fale, arrhythmias) > Muscle biopsy for susceptibility Halothane hepatitis > Immune-mediated hepatotoxicity > Usually repeated exposures » Covalent binding of a halothane ‘metabolite to hepatic SER causes antigen ‘expression > Estimated incidence 1 in 3000 - 30000 > Treatment is supportive (may include liver transplant)Bins (A KAAS ETT acto tren VP Yee tahiont 1 comflettly- Rdsked Pp pruerb copie Rapid Sequence Induction Ms DM > Suction under the plow > Crycoid pressure > 38 year old woman for laparoscopic > Suxamethonium 1.5 mg/kg | appencicectomy Dont ventite ging > Induction with propofol and fentanyl Le > Given rocuronium for muscle relaxation woke > Within 1 minute: HR 120 a BP 67/30 torent High PIP CN -qyale) L Anaphylaxis > Type-t immune reaction > Common agents + Muscle relaxants + Thiopentone + Antbotce > Symptoms may be difficult to detect under anaesthesia + fash, hypotension, fc venation, taenycardia Anaphylaxis Anaphylaxis » Treatment: (S0—~ ket «te sia tem 30D meg Adult 2 Suppor patient + 100% oxygen, mids + Adenine to e9tmg — COb~fld Ba college Antihistamines, hydrocortisone «Iu > Investigations (tryptase, skin prick tests)> Serious > Overall death rate i soar one Airway assessment | > Dentition | >"1-2-3 rule + Temporomandbular joint (1 finger) + Intrincisor distance (2), + Thyromental distance (3) » Neck movement (35 degrees) > Mallampati score » Chart review + Were they easily intubated before? Investigations » Preoperative investigations are of two types: + A Indicated investigations + B. Screening tests + ORR over 65 ys + Goose over 65 yrs = ECG over 40 yrs + UBE, FRE tor aimost eveyone Anaesthesia Complications > Minor compkatons qreconnen [7b ‘complications are rare about 1 in 80000 - = = > Usual medications on the day of surgery » Aspiration prophylaxis en is > Anxiolysis / analgesia ifindicated | ( pnttana, Mallampati score “ & St za G40 iam BY tory Consider Preoperative orders except + Anticoagulants (stop 5 - 14 days prior) J + Insulin (hospital protoco) ) + Oral hypogtycaemics (withold) ef yt Laryngoscopy fan brerfos longi