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ELECTIVE SURGERY ON

PATIENT WITH
RESPIRATORY DRUGS
Sabella Trinolaurig
Rina Desdwi Utami
Christian Ade

INTRODUCTION
Safe and efficient surgical and anesthesia practice
requires an optimized patient.

Inadequate preoperative preparation contributory


factor to perioperative mortality

Preoperative Evaluation Goals

Documentation of the conditions for which surgery is needed


Assessment of the patients overall health status
Uncovering of hidden condition that could cause problems during & after surgery
Preoperative risk determination
Optimization patients medical condition reduce preoperative morbidity &
mortality
Development of an appropriate perioperative care plan
Education to patient about surgery, anesthetic, intra and postoperative pain
treatment reduce anxiety & facilitating recovery
Reduce cost, hospital stay, reduce cancellation, increase patients satisfaction

INTRODUCTION
Pulmonary disease

>>> risk for pulmonary and non

pulmonary perioperative complication

Postoperative complication : occurence of an unexpected


change that affects the patients welfare or deviates from
the expected outcome after a surgical procedure.

PPC occur within 30 days after surgical prosedure

INTRODUCTION
The co-morbidities and the nature of the procedure are
considered when managing medications preoperatively.

Instructions to patient to continue or discontinue drugs


will likely improve outcome more than testing will.

Pulmonary Complication :

Major
Respiratory failure
Mechanical Ventilation &/
intubation >48 h
Pneumonia

Minor
Purulent tracheobronchitis
Atelectasis
Bronchospasm

Sweizer BJ. Basic Standarts For Preanesthesia Care : Preoperative Evaluation and

Thomas J. Gal. Perioperative Approach to Patients with Respiratory Disease. International Anesthesia

How to reduce ?
Achieve adequate preoperative
evaluation
complication, perioperative
morbidity & hospital stay
Recomendation : patients with previous Respiratory Disease evaluated by
a Pulmologist.

Surgeryrelated
aspects
Anesthesia
-related
aspects
Patientrelated
aspects

Intracavity procedure induced major


changes in respiratory system compared to
peripheral prosedure
Surgical time >3 h
Emergency surgery
General anesthesia and its prolonged use
Use of neuromuscular blocking agents and its
prolonged use

Advanced age (>60 years)


Partial/ total dependence daily and instrumental
activity
Cigarette smoking
BMI 40 km/m2
Preexisting chronic lung disease

3. Blood Test
(urea >21
mg/dl, albumin
< 3,5 mg/dl,
creatinin > 1,5
g/dl)
4. Chest X-ray
(patient with
prior
cardiopulmonar
y disease, >40
years,
medium/surger
y)
5. Pulmonary
function

6. Arterial
blood
gases :
.Patient
with
chronic
lung
disease
.Moderatesevere
airway
Electrocardiogram
obstruction
Echocardiography

Preoperative Assessment
1. Medical
History
2. Physical
Examination
Initial evaluation is
clinical
Complementary
examination should
be requested based
on this assessment

Patient with Pulmonary


arterial hypertension
(PAH)

Sweizer BJ. Basic Standarts For Preanesthesia Care : Preoperative Evaluation and

Thomas J. Gal. Perioperative Approach to Patients with Respiratory Disease. International Anesthesia

Hippokratia. Preoperative Evaluation and Preparation for Anesthesia and Surgery.

Abbitan Gaelle. Preoperative Preoperative Medication Management for Noncardiac

A Guide To The Admistration of Medicines in The Perioperative Period. Version 2.

A Guide To The Admistration of Medicines in The Perioperative Period. Version 2.

L.H. Degani-Costa et al. Preoperative Evaluation of The Patient with Pulmonary Disease. Rev Bras

Asthmatic patient
Poor control ( > 20%
variability in PEFR (Peak
Expiratory Flow Rate)

Doubling the dose of


inhaled steroids 1 week
prior surgery

Very Poor control

Review by A Physician
1 week course of oral
prednisolone (20-40
mg/day)

Intraoperative
Anesthesia

Adequacy of
alveolar
ventilation,
perfusion

Respiratory
impairment

Blood
oxygenation

L.H. Degani-Costa et al. Preoperative Evaluation of The Patient with Pulmonary Disease. Rev Bras

Inhaled anesthetics (isoflurane, sevoflurane) reduce ventilation


induce lung injury (VILI) isoflurane induces protective effects
during ischemia-reperfusion & lung injury induced by endotoxin
or zymosan
Balanced anesthesia should be used in patients with obstructive
lung disease due to the action of inhaled bronchodilator
Interscalene brachial plexus block with >> of LA ipsilateral
diaphragmatic paralysis ovoided in severe chronic lung
disease
Fluid replacement with caution based on macro and microhemodinamic parameters

Anxious Patient, treated with apropriate


premedication
Avoid drugs associated with histamine released (ex.
Morphine, d-tubocurarine, atracurium, mivacurium)
Intubation provokes bronchospasm, carried out with
adequate anaesthesia, usually with opioid cover.
Poorly controlled asthma, regional techniques is
ideal
If General Anaesthesia is needed, use short acting
anaesthetics agents.
Extubate and recover in sitting position, breathing
oxygen.
Sweizer BJ. Basic Standarts For Preanesthesia Care : Preoperative Evaluation and

Postoperative Care
Adequate analgesia is vital
Avoid analgesics that depress the respiratory system
Mild pain use simple analgesics (dipyrone, paracetamol) &
hormonal/ non-hormonal anti-inflammatory drugs

Moderate-Severe pain ketamine, dexmedetomidine

Postoperative Care
Oxygen adnistered : minor surgery until the patient fully awake
major surgery 2-4 L/min for 72 hours

Maintaince of hydration with IV fluids until oral intake is


sufficient

Usual anti-asthmatic medication resumed immediately


Review dose and route of administration of steroid daily

Postoperative Care
Regular nebuliser therapy with additional nebulised
bronchodilators as needed.

Patient with severe resp. disease often malnourished &


weak early resumption of normal oral intake is
important if delayed (more than 5 days) enteral
feeding

L.H. Degani-Costa et al. Preoperative Evaluation of The Patient with Pulmonary Disease. Rev Bras

KETAMINE

(C1-581, 2-O-chloro-phenyl-2-methylaminocyclohexanone)

Pencyclidine (C1-395)
1958

Ketamine (C1-581)
1960s
(1 of 200 pencyclidine derivates)

Chiral centre with 2 optical


isomer (enantiomers)
Molecular weight 238
pKa : 7.5
S-(+)-ketamine afinity >> R-(-)ketamine

Aniruda Pai and Mark Heining. Continuing Education in Anesthesia, Critical Care and Pain : Ketamine. British Journa

High lipid solubility (5-

10x > thiopental)


Crosses blood-brain
barrier faster
Cyclohexanone ring
demethylation
&hydroxilation
Metabolites conjugated
& excreted in urine.
Elimination clearance :
1000-1600 ml/min or 1220 ml/min/kg ~ liver
blood flow (women >>>)
S(+) isomer higher
clearance than R(-)
S(+)
>>
Aniruda Pai and Mark Heining. Continuing Education in Anesthesia, Critical
Caredemethylation
and Pain : Ketamine.
British Journa

Mechanism of Action
Non-competitive antagonism at the N-methyl-D-aspartate

(NMDA) receptor Ca2+ channel pore primarily mechanism


Nteraction with mu & kappa opioid receptor afinity for this
receptor 10x less than NMDA channel
Antagonistic interaction with monoaminergic, muscarinis,
nicotinic receptors
Produce anticholinergic symptoms (e.g tachycardia,
bronchodilatation)

Management of patient with


Asthma ?
R-(-)-enantiomer more
potent relaxant of
acethylcoline-induced
airway smooth muscle
contraction than the S(+) enantiomer
differential action on
receptor-linked calcium
channels.

Ketamine has
minimal effects
on central
respiratory drive
As effective as
halotane in
preventing
bronchospasm

TERIMA
KASIH

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