PREOPERATIVE ANESTHESIA PREPARATION

by Suwarman, dr.,SpAn-KIC, MKes Anesthesiology & Intensive Therapy Department Padjadjaran University/Hasan Sadikin General Hospital

Preoperative preparation
Preoperative visit Assess the risk of anesthesia and surgery Informed consent Fasting Premedication

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

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

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

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 (picnic)

History and physical examination

Personal 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

Alcoholism
Impairment of liver function Heart cardiac arrhythmia Cardiac contractility decrease Cardiomyopathy Kidney diuretic effect by inhibiting ADH Plasma catecholamine increase Metabolic & respiratory acidosis from alcohol intoxication Increases the anesthetic requirement

Smoking
Ciliary function reduce, disturbing tracheobronchial clearance Increase production and thicken of sputum Strong risk factor for coronary heart disease and occlusive peripheral arterial disease Systolic hypertension is potentiated

Decrease cerebral blood flow and increase risk of stroke Increase gastric volume & acidity Increase COHb level, decrease blood O2 content & O2 delivery to tissue Increase catecholamine : CVS responses & O2 requirement increase Respiratory complication increase 5-7 times

Recomendations
COHb fall to normal level stop smoking 48 hours preoperatively Reduction of sputum volume & post op complications stop smoking 4 weeks pre operatively

Physical examination
General condition : name, age, weight. B.P. pulse rate & temperature. Cardiopulmonary examination including - Cyanosis in finger tips - V. jugularis engorgement

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

 Difficult estimate circulatory volume by V.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 gastric volume, acidity & pressure

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

Simple Bedside cardiopulmonary function

Sebarases test : 2-3 deep breaths hold as long as possible Time : 40 seconds normal 30-40 seconds diminished reserve < 20 seconds severely compromised Match test : The ability to blow out a standard match held 6 inches from the open mouth negative max breathing cap low Tilt test

Laboratory testing
Routine 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 indicated Ureum, creatinine pt > 50, renal & hepatic diseases, diabetes, abnormal nutritional state

 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

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 systemic disease that is not incapacitating (limits the pt activity)

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

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.

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 6 hours Gastric emptying is delayed by : anxiety, pain, trauma, and pregnancy.

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

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

Premedication
Objectives 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

Drugs for premedication

Sedativa, tranquilizer Narcotics-analgetics Alkaloid belladona as antisecretion and reduce vagal reflex to the heart from : drugs impuls afferent abdomen, thorax, and eyes Antiemetic

OPERATION CANCELLED
Syok: Anesthesia depression of vital organs syok is worsening. Volume replacement until blood pressure > 80mmHg, good peripheral condition, diuresis is enough Temperature: 380C antipyretica, find focal infection especially respiratory tract

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