PREOPERATIVE

PREPARATION

Riza Cintyandy
RS. Jantung & Pembuluh
darah Harapan Kita Jakarta

PREOPERATIVE EVALUATION
Aim :
To reduce the risk associated with surgery &
anesthesia
To increase the quality of perioperative care
To restore the patient to the desired level
of function
To obtain the patients inform consent

Semua pemeriksaan, persiapan, sistem skoring

rencana tindakan bedah maupun anestesi

waktu pelaksanaan

jenis anestesi yang dipergunakan

penyulit anestesi

persiapan obat-obatan, darah, cairan IV

perawatan pascabedah (ICU/ rg. Rawat)

biaya, inform consent

dll

PERSIAPAN PRA BEDAH

Riwyt peny,
Riwayat
fungsi organ, (otak, jantung, ginjal, hepar )
Anamnesa
Terapi saat ini, alergi, pemasangan stent, riwyt pemeriksaan, dll
Riwyt peny,
Riwayat
fungsi organ, (otak, jantung, ginjal, hepar )
Anamnesa
Terapi saat ini, alergi, pemasangan stent, riwyt pemeriksaan, dll

PHYSICAL STATUS
P1. A normal healthy patient
P2. A patient with mild systemic disease
P3. A patient with severe systemic disease
P4. A patient with severe systemic disease that is a
constant threat to life
P5. A moribund patient who is not expected to survive
without the operation
P6. A declared brain-dead patient whose organs are being
removed for donor purposes
American Society of Anesthesiologists

Pemeriksaan
Airway

GCS

PCS

Eye
opening

Spontaneous
To verbal stimuli
To pain
None

4
3
2
1

Ditto

Verbal

Oriented
Confused
Inappropriate words
Non specific sounds
None

5
4
3
2
1

Oriented
Words
Vocal sounds
Cries
None

Motor

Follows commands
Localises pain
Withdraws in response to
pain
Flexion in response to pain
Extension in response to pain
None

6
5
4
3
2
1

Ditto

5
4
3
2
1

TRAUMA SCORE
Trauma Score
16
13
10
7
4
1

% Survival
99
93
60
15
2
0

Pain Rating Scales

Mild

Moderate

Pain threshold
Pain tolerance

Severe

10

CHOOSING PAIN KILLER AND ITS COMBINATIONS

10 Pain Intensity Scale

Mild
paracetamol
or/+
NSAID

adjuvant
analgesic

10

Moderate

Severe

NSAID

weak opioid

adjuvant
analgesic

Strong opioid

NSAID

adjuvant
analgesic

FASTING GUIDELINES
Adult

Food : 6 hour

Clear fluid : 2 hour

Infant & pediatric

Formula milk & food : 6 hour

Breast milk: 4 hour

Clear fluid : 2 hour

PERSIAPAN PREOPERATIF PASIEN DGN

KELAINAN JANTUNG UNTUK
OPERASI NON JANTUNG

Pasien dengan kelainan jantung yang

menjalani operasi non jantung meningkat
Komplikasi Perioperatif yang sering terjadi
berhubungan dengan :
Myocardial infarction (MI)
Arrhythmias
Pulmonary insufficiency

KONTRAINDIKASI ABSOLUT UNTUK ANESTESIA

Akut/ recent MI 7-30 hari

Dekompensasi kordis akut/ tidak stabil

lakukan terapi terlebih dahulu (optimalisasi)

Penyakit jantung iskemik yang tidak stabil

Severe aritmia

Total AV block transient pacemaker

Penyakit katup jantung berat (severe valve

disease, misal AS severe)

Yang lain adalah kontraindikasi RELATIF

PRINSIP

Pembedahan elektif atau less urgent

Penyakit jantung yg membutuhkan terapi surgikal
untuk penyakit jantungnya, pertimbangkan
urgensinya
Pembedahan Emergensi
Pembedahan dengan resiko sedang atau tinggi
OPTIMALKAN kondisi jantung dan penderita:
- Tatalaksana Medikamentosa (diuretik,
Inotropik, dll)
- Tatalaksana Topangan Mekanik ( IABP,
pacemaker)

CORONARY ARTERY DISEASE

Proper

preoperative evaluation of these patients is

crucial to identify those with either acute MI or
unstable angina
The overall mortality and infarction rate after non
cardiac surgery was reduced significantly soon after
PTCA (within 11 days)
Elective non cardiac surgery should be postponed for
2-4 weeks after coronary stenting to permit
completion of mandatory antiplatelet regimen,
thereby reducing the risk of stent thrombosis and
bleeding complications

AMERICAN COLLEGE OF CARDIOLOGY/ AMERICAN HEART

ASSOCIATION

Revised 1996 guidelines on perioperative

cardiovascular evaluation for non-cardiac surgery
2002-2007
Combining:
Clinical predictors
Coronary evaluation and therapy given
Patients functional capacity
Risks in various kinds of non-cardiac surgery

CAD CLINICAL PREDICTORS

Major

clinical predictors

Unstable coronary syndromes

Decompensated congestive heart failure (CHF)
Significant arrhythmias
Severe valvular disease

Intermediate

clinical predictors

Mild angina pectoris

Prior myocardial infarction
Compensated or prior CHF
Diabetes mellitus
Renal insufficiency

Minor

clinical predictors

Advanced age
Abnormal ECG
Rhythm other than sinus
Low functional capacity
History of stroke
Uncontrolled systemic hypertension

TYPES OF SURGERY
High

risk

Emergency major operations, particularly in the elderly

Aortic & other major vascular surgery
Peripheral vascular surgery
Anticipated prolonged surgical procedures associated with large fluid shifts
&/or blood loss

Intermediate

risk

Carotid endarterectomy
Head and neck surgery
Intraperitoneal and intrathoracic surgery
Orthopaedic and prostate surgery

Low

risk

Endoscopic procedures
Superficial procedures
Cataract surgery
Breast surgery

ACC/AHA GUIDELINES

J Am Coll Cardiol, 2007; 50:17071732

Stepwise Approach to Preoperative Cardiac

Assessment
Need for emergency
noncardiac
surgery

Yes

Operating room

Vigilant perioperative
and postoperative
management

No

Active
cardiac
conditions

Yes

Evaluate and treat

per ACC/AHA
Guidelines

Consider
Operating Room

No

Low Risk
Surgery

Yes

Proceed with
planned surgery

Yes

Proceed with
planned surgery

No

Asymptomatic and
good functional
capacity
No

Manage based on
clinical risk factors

Stepwise Approach to Preoperative Cardiac

Assessment
Need for emergency
noncardiac
surgery

Yes

Operating room

Vigilant perioperative
and postoperative
management

No

Active
cardiac
conditions

Yes

Evaluate and treat

per ACC/AHA
Guidelines

Consider
Operating Room

No

Low Risk
Surgery

Yes

Proceed with
planned surgery

Yes

Proceed with
planned surgery

No

Asymptomatic and
good functional
capacity
No

Manage based on
clinical risk factors

Functional Capacity
1. Correlates with maximum oxygen
uptake on treadmill testing
2. Demonstrated predictor of future
cardiac events
3. Poor functional capacity may
hide low threshold cardiac
symptoms

ESTIMATED ENERGY REQUIREMENTS FOR

VARIOUS ACTIVITIES
1 MET

Can you take care of yourself ?

Eat, dress, or use the toilet ?
Walk indoors around the house ?
Walk a block or two on level ground at 2 to 3 mph or 3.2 to
4.8 km per h ?

4 METs

Do light work around the house like dusting or washing dishes ?

Climb a flight of stairs or walk up a hill ?
Run a short distance ?
Do heavy work around the house like scrubbing floors or lifting or moving
heavy furniture ?
Participate in moderate recreational activities like golf, bowling, dancing,
doubles tennis, or throwing a baseball or football ?

Greater than
10 METs

Participate in strenuous sports like swimming, single tennis, football,

basketball, or skiing?

STEP 1

Need for noncardiac surgery

Emergency
surgery

Urgent or elective surgery

STEP 2

No

STEP 3

Recent coronary evaluation

Medical management and

risk factor modification

yes

Recent coronary angiogram or

stress test ?

Favorable result
and no change
in symptoms
Operating
room

Unfavorable result or change

in symptoms

Clinical
predictors

Major clinical
predictors

Consider delay or cancel

noncardiac surgery

Recurrent
symptoms or
signs?

yes

No

STEP 4

No

yes

Coronary revascularization
within 5 yr

Postoperative risk
stratification and risk
factor management

Operating
room

STEP 5
Consider coronary
angiography

Subsequent care dictated

by findings and treatment
results

Intermediate clinical
predictors

Minor or no clinical
predictors

Go to step 6

Go to step 7

STEP 6

Clinical predictors

Functional capacity

Intermediate clinical predictors

High surgical
risk
procedure

Surgical risk

STEP 8

Noninvasive
testing

Moderate or
excellent
( > 4 METs)

Poor
(< 4 METs)

Noninvasive
testing

Low Risk

High Risk
Invasive
testing

Consider coronary
angiography

Subsequent care dictated by

findings and treatment
results

Intermediate
surgical risk
procedure

Operating
room

Low
surgical risk
procedur

Postoperative risk
stratification and
risk factor reduction

STEP 7

Functional capacity

STEP 8

Minor or no clinical predictors

Clinical predictors

Poor
(< 4 METs)

Surgical risk

High surgical
risk
procedure

Noninvasive
testing

Noninvasive
testing

Intermediate
or low
surgical risk
procedure

Low Risk

High Risk
Invasive
testing

Moderate or
excellent
( > 4 METs)

Consider coronary
angiography

Subsequent care dictated by

findings and treatment
results

Operating
room

Postoperative risk
stratification and
risk factor reduction

SUGGESTION

1.

If the patient has a severe cardiac disease, irrespective

of the nature of surgery (except perhaps really minor
surgery), the risk is high.

2.

If the patient has a mild cardiac disease, the patient

can be treated almost like normal.

3.

If the patient has a moderate cardiac disease, risk

stratification based on the nature of surgery and
functional assessment is necessary.

ANESTHETIC GOALS
1.

2.

3.
4.
5.
6.

Avoiding extremes of hemodynamic disturbances

(blood pressure (BP), tachycardia, hipercarbia,
hypertermia, aritmia)
Monitoring of cardiac ischemia (ECG, direct arterial
pressure monitoring along with pulmonary artery (PA)
catheter, TEE)
Hemodynamic control (anesthetic technique and
pharmacological agents)
Beta blockers preventing perioperative cardiac
morbidity
Adequate doses of analgesics (morphine 5-10 mg or
sufentanyl or fentanyl 5-10 g/kg)
Cardiac support ( inotrope or mechanical devices)

HYPERTENSIVE

Which hypertensive patients have increasing

perioperative risks?

Will lowering preoperative blood pressure

decrease the risks?

How long and how should blood pressure be

controlled before elective surgery?

History of chronic hypertension with/without

therapy

HYPERTENSIVE

Patients with cerebral, coronary or renovascular

abnormalities

Preoperative antihypertensive therapy for a few

weeks/months can reduce morbidity, especially
in severe hypertension (3-4 weeks ideally)

Moderate hypertension: duration of therapy can

be shorter

Antihypertensive medication continued to the

time of surgery, except ACE-I

ABP be kept within 10~20% of preoperative level

GULA DARAH, ALBUMIN, SGOT/PT, UREUM, KREATININ, AKI,

ARITMIA

Gula darah tinggi : pasien DM/bukan? Asidosis, pelepasan katekolamin akibat kondisi saki

Terima Kasih