Persiapan Anestesi.ppt

8/11/2019 Persiapan Anestesi.ppt

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PREOPERATIVE

PREPARATION

Department Anesthesiology &Reanimation Medical Faculty

Malahayati University


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Preoperative preparation

Preoperative visit

Assess the risk of anesthesia and surgery

Informed consentFasting

Premedication


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Preoperative visitInadequate pre op.preparation

may be a major contributory factor

to the perioperative morbidity &mortality. It is essensial that

anesthetist visits every patient

before surgery.


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The purpose of it :Establish rapport with the patient

Meet the doctor with the patient

Discuss possible causes of anxietyregarding anesthetic and surgical manner

Explain how the patient will be cared forduring and after anesthesia and about painrelief

Establish a doctor-patient relationship that

reduces patient anxiety by building trust &respect

Assessment of physical status

Order special investigations


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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(pyknic)


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Successful approach (Buskirk)

Treat all patients as human being

Be friendly, explain your visit & your plan

Be patient & sympatheticListen to his concern, answer all questions

in understanding and warm manner

Allay patients fears


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Comparison of Preoperative Visit and

Pentobarbital (2mg/kg i.m) (% of

Patients)

Felt Drowsy Felt Nervous Adequate

Preparation

Control Group 18 58 35

Pentobarbital Only 30 61 48

Preoperative Visit 26 40 65

Pentobarbital andPreoperative Visit 38 38 71

Source : Data from Egbert LD et al : The value of the

preoperative visit by the anesthetist JAMA 185:553, 1963


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History and physical

examinationPersonal and family historyHereditary conditions associated with

anesthesia : porphyria, malignant

hyperthermia, haemophiliaPrevious operations & anesthetics

Allergies

Medications drug interaction

Habits : alcohol and smoking

Diseases of CVS and respiratory

systems


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AlcoholismImpairment of liver function

Heart cardiac arrhythmia

Cardiac contractility decrease

Cardiomyopathy

Kidney diuretic effect by inhibitingADH

Plasma catecholamine increase

Metabolic & respiratory acidosis fromalcohol intoxication

Increases the anesthetic requirement


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Smoking

Ciliary function reduce, disturbingtracheobronchial clearance

Increase production and thicken ofsputum

Strong risk factor for coronary heart

disease and occlusive peripheral arterialdisease

Systolic hypertension is potentiated


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Decrease cerebral blood flow and

increase risk of strokeIncrease gastric volume & acidity

Increase COHb level, decrease blood

O2content & O2delivery to tissueIncrease catecholamine : CVS

responses & O2requirement increase

Respiratory complication increase 5-7times


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Recomendations

COHb fall to normal level stop smoking48 hours preoperatively

Reduction of sputum volume & post op

complications stop smoking 4 weekspre operatively


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Physical examination

General condition : name, age, weight.

B.P. pulse rate & temperature.

Cardiopulmonary examination including- Cyanosis in finger tips

- V. jugularis engorgement


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Obesity (W/H2more than 30)

oAirway problems

o Mechanical ventilation is impaired

tendency to hypoventilation e.c. fixthorax & elevated diaphragm

o Easily developed hypoxia e.c.

- FRC is reduced

- V/Q ratios are low


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Difficult estimate circulatory volume byV.J. pressure and difficulty invenipuncture

CVS disorders :

Hypertension 3X more

Ischemic H.D 2X more

CVD/CVA 3X more

DM 3-4 X more

Increase gastic volume, acidity &pressure


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Physical examination

General condition : name, age, weight.

B.P. pulse rate & temperature.

Cardiopulmonary examination including- Cyanosis in finger tips

- V. jugularis engorgement


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Airway :

- Neck : stout, short, sunker cheeks,distance from mentum to hyoid ( 5cm)

- Mouth : mouth opening, loose ordamage teeth, protruding upperincissors

Vertebral column : anatomicaldeformities may render some blocks inpractical


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Laboratory testing

Routine lab.test in pts who are apparentlyhealthy (history & clinical exam) areinvariably of little use and wasting.

Blood : Hb, leuco all female, male > 50,

major surgery, clinically indicated

Ureum, creatinine pt > 50, renal &hepatic diseases, diabetes, abnormalnutritional state


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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

A th i k f th i d


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Assess the risk of anesthesia and

surgery

ASA (American Society of Anesthesiologist)grading system

Class I : A normally healthy individual, thepathology which surgery is needed only

localized Class II : A patient with mild or moderate

systemic disease

Class III : A patient with severe systemicdisease that is not incapacitating (limitsthe pt activity)


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Class IV : A patient with incapacitatingsystemic disease that is a constantthreat to life

Class V : A moribund patient who is not

expected to survive 24 hour with orwithout operation

Class E : Added as a support for

emergency operation. All pts induced inASA I-V that need emergency operationget a higher ASA grade


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CARDIAC RISK

CRITERIA

POINTS

Hystory

- Age > 70 years

5

- MI in previous 6 mo 10Physical examination

- S3 gallop or jugular vein distension

11

- Im ortant VAS 3


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CRITERIA

POINTS

Electrocardiogram- Rhythm other than sinus or

premature atrial contraction on

last preoperative ECG 7

- > 5 premature ventricular

contractions/m in documented at

anytime before operation 7


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CRITERIAPOINTS

General status : PO2< 60 or

PCO2> 50 mmHg, K < 3.0 or

HCO3< 20 Meq/l, BUN > 50 or

Cr > 3.0 mg/dl, abnormal SGOT, signs of

chronic liver disease or patient bed ridden

from non cardiac causes 3Operation

- Intraperitoneal, intrathoracic, or aortic

operation 3

- Emergency operation 4

TOTAL POSSIBLE POINTS 53


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RISK CLASSIFICATION AND OUTCOME BY

THE CARDIAC RISK INDEX (CRI) ANDAMERICAN SOCIETY OF

ANESTHESIOLOGISTS (ASA) CRITERIA

No or Minor Life-Treatening

Complication Complication Cardiac Deaths

Class

CRI

Ponts CRI ASA CRI ASA CRI ASA

1. 0-5 99% 100% 0,7% 0% 0,2% 0%

2. 6-12 93% 97% 5% 2% 2% 1%3. 13-25 86% 93% 11% 4% 2% 2%

4. 25 22% 78% 22% 17% 56% 5%


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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 thepatient 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.


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Without the patients consent, the

physicion may liable for assault and

battery. When the patient is a minor orotherwise not competent to consent

(mentally disturbed or drugs), the consent

must be obtained from someone legally

authorized to give it, such as parent,

guardian, or close relative.

Written documentation of the informed

consent is included in the patient chartand is signed by the patient or their

representative.


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To prevent aspiration of gastric contentNPO 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 thethreshold to epinephrine induced arrhythmia.

Recommendation : NPO 4 hours

Gastric emptying is delayed by : anxiety, pain,

trauma, and pregnancy.

Fasting


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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


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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


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PremedicationObjectives are :

Allay anxiety & fear

Reduce secretions

Analgesia

Enhance the hypnotic effect of G.A. agentReduces post op nausea and vomitting

Produce amnesia

Reduction in vagal reflexLimit sympathoadrenal responses


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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


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Sedative

Sedative in appropiate dose can reduceanxiety and stress, in higher dose

become hypnotic.

Barbiturate :

Ultra short acting

Thiopentone / penthotal

Methohexitone, hexobarbitone

Especially detoxification in liver


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Medium acting :

Pentobarbitone Quinalbarbitone

Butobarbitone

A part of them are detoxificated in liver,small part are excreted by kidney

Long acting :

Phenobarbitone (Luminal)

All of them are excreted by kidney


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Barbituratecerebral protection

Because : cerebral metabolism ,cerebral oxigen consumption , C.B.F., & I.C.P.


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Medium Acting

Medium acting that most suitable for

premedication

depress CNS, start from cortex, RAS,

medulla spinalis, use for anti convulsant

depress myocard bradycardi,cardiac output hypotension

BMR

depress liver and kidney function

crossing placental barrier


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Interfere other drugs link and metabolism

(enzyme induction)

No analgetic effect


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Premedication Sedativa

Pentobarbitone sodium / nembutal andquinal barbitone sodium / seconal lessdepress respiration and circulation, non

teratogenic, and because it is detoxificatedin liver, suite for kidney functiondisturbance.

Inject 60 mg/cc, i.m, 2 hour pre op.

Capsule 50 and 100 mg


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Adults dose 1,5-2 mg/kg BW oral, rectal

Children 3-4 mg/kg BW oral, rectal

Duration of action : 3-4 hours

Phenobarbitone / luminal

Because the excretion through kidney,barbiturate suite for liver function

disturbance

Sedative dose 3050 mg Hypnotic dose 100 mg for adult, 3-5 mg/kg

BW for children


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Tranquilizer : Benzodiazepines

Benzodiazepines : anxiolysissedationamnesia

Preferable to the barbiturate

- Produce amnesia- Greater therapeutic index

- Less cardiovascular and respiratory

deppression- Longer duration of action


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Tranquilizer : Phenothiazine

Phenothiazine : sedative-antiemetic,

antihistamine (Phenergan), antipiretic

(central vasodilatation), central sympatic

depression, and minimize the effect ofadrenalin in perifer => less tension

(Largactil), dose : 25-50 mg oral/i.m


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- Diazepam- Lorazepam- Midazolam

Diazepam : insoluble in water but lipid soluble -

Injection painful (venous irritation)

- Absorption from i.m unreliable but rapidly

absorbed from GI tract

Metabolism principally in the liver produces activemetabolites : methyl diazepam, oxazepam, 3-

hydroxy diazepam prolonged CNS depression


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Minimal cardiovasculer effect

Ventilatory response to CO2depressedincrease PaCO2especially inassociation with other respiratorydepressant

Anticonvulsant in tetanus and epilepsy

Mild muscle relaxant property at spinalcord level and potentiate non

depolarizing muscle relaxantRetrogade amnesia especially whencombine with meperidine or hyoscine

Rapidly passes the placental barrier


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Doses

oral : 0,20,5 mg/kgi.v : 0,10,2 mg/kg

induction : 0,30,5 mg/kg


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MIDAZOLAM

The efect are faster and shorter, duration

approximately 60 minutes

Anterograde amnesia, has no anticonvulsanteffect

Dose : 0,150,1 mg/kg BW, i.m/i.v adult

0,5 mg/kg BW, oral children No pain when injected because of water

soluble

Possibility become phlebitis is small


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CBF is decrease ICP decrease cerebral

protection Relaxation effect

Not interfere coronary circulation safe for

ischemic heart disease, in other waydiazepam interfere CVR unsafe

DROPERIDOL/ INAPSINE


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DROPERIDOL/ INAPSINE

Tranquilizer butyrophenone, phenothiazine like effect

Forced antiemetic, ICP can be decrease because of

mild cerebral vasoconstriction

Alpha adenergic receptor blockade hypotensi, itcan prevent catecholamine induced arrhythmia

Apathis

Dose : 2,5-5 mg; duration 6-8 hoursSide effect : dyskinetic involuntary movement

(extrapyramidal disturbance)

Occasionally dysphoric reaction


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Morphine

Narcotic-analgetic standard for strongpain, euphoria

Sedativa-postural hypotension because

of vasodilatation and myocard depression(depression of vasomotor center)

Constrict the sphincter of gut, peristaltic constipation

BMR , addiction-hystamine releasepositif


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Depression of cough reflex post op secret accumulation atelectasis

ICP rise in intracranial injury

Respiratory center depression CO2CBF


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PETHIDINE/ MEPERIDINE

Depression of RC, emetic effect, euphoria anddizziness are less than morphine

Less histamine release fine for asthma

Through placental blood barrier not be givenbefore umbilical cord is cutAtropine like effect : saliva dry mouth

eyes mydriasis

Dose : 50-100 mgChild : 0,5-1 mg/kg BW; duration 2-4 hours


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FENTANYL SUBLIMATE

Stronged analgetic, 100 x morphine

CVS effect are minimal so the histamine release

Duration : 45-60

Dose : 0,05-0,1 g I.m, 1 hour pre.op.Disadvantages:

-Respiratory depression

-Bradycardi, miosis

-Bronchoconstriction

-somatic muscle spasm


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ANTAGONIST OF NARCOTIC

If RC depression, antagonist of narcotic can be

given:

Nallorphine 5mg iv Lorvan 1 mg iv

Naloxone/ narcane is better for

respiratory depressionDose: 0,2-0,4 mg iv

Anticholinergic drugs


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Anticholinergic drugsPerthidin & Phenergan have anticholinergic

effect

Sulfas atropin / alkaloid belladona

anti secretion of salivatory, respiratory

tract and sweat glands be aware of

patient with fever

Glycopyrolat is an antisecretion 2x and

more longer than SA , no central effect

vagal block, needs a high dose until 1 -2 mg

CNS : Tendency to stimulate CNS,

hyoscine sedation


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Light bronchodilator

CVS : tachycardi be aware tothyrotoxicosis and ischemic HD,

cardiomyopathy

GI : intestine and urinary tractsperistaltic constipation and urineretension

BMR be aware to thyrotoxicosisdose : 0,005 - 0,01 mg/kgWB

duration of action : im until 90 ; iv 30-

45


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Combination of those drugs

patient comes to the operationroom still aware but sleepy, calm,

cooperative, there are no

complications during and after theoperation

Doses and drugs combination are

decided by patient condition and

anesthetis experience and skills

OPERATION CANCELLED


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OPERATION CANCELLED

Anemia: Hb < 10gr%

In Research Hb < 10gr% its not increasemorbiditas/ mortalitas.

If circulating volume is enough, Hb 8 gr% its notnecessary to get tranfusion

Syok: Anesthesia depression of vital organs

syok is worsening. Volume replacement untilblood pressure > 80mmHg, good peripheralcondition, diuresis is enough

Temperatur: 380C antipyretica, find focal infection

especially respiratory tract


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Influenza, pharyngitis, bronchitis electiveoperation is delayed

Airways instrument :

- trauma of infection mucosa resp.obstruction, spasm, hypersecretion Postoperative respiratory complication.- infection spread

Respiratory Infection


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Persiapan Anestesi.ppt