The Preoperative Evaluation: Kuliah Coas

KULIAH COAS

The PreOPERATIVE Evaluation

Department of Anesthesiology, Pain Management and Intensive Care Dr.Wahidin Sudirohusodo Hospital Faculty of Medicine  University of Hasanuddin Makassar ­ Indonesia

INTRODUCTION 



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Relevant information is obtained by a chart review followed by the patient interview. Knowledge of the patient's history when beginning the interview is reassuring to the anxious patient. Although patient age and American Society of Anesthesiologists (ASA) Physical Status Classification

ANESTHETIC HISTORY Old anesthesia records should be reviewed for the following information: a. b.

c. d.

Response to sedative/analgesic premedications and anesthetic agents. Ease of mask ventilation, direct laryngoscopy, and the size and type of laryngoscope blade and endotracheal tube used. Vascular access and invasive monitoring used and difficulties encountered. Perianesthetic complications

FAMILY HISTORY A history of adverse anesthetic outcomes in family members should be evaluated. This history is perhaps best obtained with openended questions, such as “Has anyone in your family experienced unusual or serious reactions to anesthesia?” Patients should be specifically asked about a family history of malignant hyperthermia.

SOCIAL HISTORY 1.Smoking. Eliminating cigarette use for 2 to 4 weeks before elective surgery may reduce airway hyperreactivity and perioperative pulmonary complications. 2. Drugs and alcohol. Acute alcohol intoxication will decrease anesthetic requirements and predispose to hypothermia and hypoglycemia. The routine use of opioids and benzodiazepines may significantly increase the doses needed to induce and maintain anesthesia or to provide adequate postoperative analgesia.

REVIEW OF SYSTEMS 1. A recent history of an upper respiratory infection. 2. Asthma 3. Preexisting coronary artery disease (CAD), which may predispose the patient to myocardial ischemia, ventricular dysfunction, or myocardial infarction with the stress of surgery and anesthesia. 4.Diabetes

5. Untreated hypertension, which is frequently associated with blood pressure lability during anesthesia. 6. Hiatal hernia with esophageal reflux symptoms, which increases the risk of pulmonary aspiration and may alter the anesthetic plan. 7. Likelihood of pregnancy and timing of last menses in women of childbearing age

PHYSICAL EXAMINATION 1.Vital signs a. b. c. d.

Height and weight Blood pressure Resting pulse is noted for rhythm, perfusion (fullness), and rate. Respirations are observed for rate, depth, and pattern while at rest.

2. Head and neck Specific findings that may indicate a difficult airway include: a. Inability to open the mouth. b. Poor cervical spine mobility. c. Receding chin (micrognathia). d. Large tongue (macroglossia). e. Prominent incisors. f. Short muscular neck. g. Morbid obesity.

THE MALLAMPATI CLASSIFICATION

I

II

III

IV

3. Precordium. Auscultation of the heart may reveal murmurs, gallop rhythms, or a pericardial rub.

4. Lungs. Auscultation may reveal wheezing, rhonchi, or rales, which should be correlated with observation of the ease of breathing and use of accessory muscles of respiration.

5. Abdomen. Any evidence of distention, masses, or ascites should be noted, because these might predispose to regurgitation or compromise ventilation.

6. Extremities. Muscle wasting and weakness should be documented, as well as general distal perfusion, clubbing, cyanosis, and cutaneous infection

7. Back. Note any deformity, bruising, or infection.

8. Neurologic examination. Document mental status, cranial nerve function, cognition, and peripheral sensorimotor function.

LABORATORY STUDIESROUTINE A.

Recent hematocrit/hemoglobin level. A hematocrit screen is recommended for neonates up to 6 months of age, women over 50 years of age, and men over 65 years of age.

B. Serum chemistry studies are ordered only when specifically indicated by the history and physical examination.  Hypokalemia. Mild hypokalemia (2.8 to 3.5 mEq/L) should not preclude elective surgery. Efforts to rapidly correct hypokalemia with IV replacement therapy may lead to arrhythmias and cardiac arrest.  Platelet function. A history of easy bruising, excessive bleeding from gums or minor cuts, and family history.  Coagulation studies are ordered only when clinically indicated (e.g., history of a bleeding diathesis, anticoagulant use, or serious systemic illness)

C. An electrocardiogram (ECG) is advisable for men over 40 years of age and women over 50 years of age. Although the resting ECG is not a sensitive test for occult myocardial ischemia, an abnormal ECG mandates correlation with history, physical examination, and prior ECGs and may require further workup and consultation with a cardiologist before surgery. D. Chest radiography should be performed only when clinically indicated (e.g., heavy smokers, the elderly, and patients with major organ system disease including malignancy and symptomatic heart disease).

Pt Status

Walter Reed Ambulatory Processing Center Current Guidelines Hgb Pt/PTT PLT T/S K+ Bun/Cr Gluc CXR EKG

Age < 6 mo

X

Age < 40 yr

Female

M>40

Age 40-60 yr Female

F>50

> 60 yrs

X

X

X

X

X

Procedure with Blood loss Associated Conditions

X

Cardiovasc Dz Pulmo Dz

X

X

X

X

X

X

X

X

Smoker > 20 X

X

X

Liver Dz Renal Dz

X X

Diabetes Cancer

X

X

X

X

X

X

X X

X

Pt Status

Hgb Pt/PTT

Anticoagulant X

PLT T/S K+ Bun/Cr

X

Digoxin

X

X

Diuretic

X

X

Corticosteroids

Gluc CXR EKG

X

X

X X

Urinalysis- symptoms of UTI or procedure involving use of prosthetic material

ASA CLASSIFICATION  

Introduced in 1941 to provide a basis for comparison of statistical data Revised in 1961 I Healthy II Mild systemic disease, no functional limitation III Severe systemic disease-definite functional limitation IV Severe systemic disease that is constant threat to life V Moribund patient for heroic procedure VI Organ donation E Emergent Procedure

WHAT DOES THE ASA CLASSIFICATION MISS ? 1. Hx of Airway Problems (i.e. sleep apnea) and examination of the airway 2. Risk & complexity of planned surgical procedure • Low risk = minimal physiologic stress; rarely requires blood transfusion, invasive monitoring, or ICU care. • Medium risk - moderate physiologic stress, e.g., laparoscopic cholecystectomy, abdominal hysterectomy. • High risk = almost always requires blood administration and/or large amounts of fluids, invasive monitoring, and postoperative management in an ICU setting. 3. Potential for adverse reaction due to anesthesia specific disorders 1. Personal / Family history of requiring intubation several hours after minor surgery 2. MH 3. Burns / Deenervation injuries

GUIDELINES FOR NPO STATUS Generally, adults should not eat solids after midnight of the day before surgery but may have clear fluids up to 2 hours before their procedure. Infants or children may have milk, formula, breast milk, or solid food up to 6 hours before surgery and clear liquids up to 2 hours before surgery. More restrictive instructions may be necessary for some patients, such as those with active reflux or those undergoing gastrointestinal tract operations.

PREMEDICATION A. The goals of administering sedatives and analgesics before surgery are to allay the patient's anxiety; prevent pain during vascular cannulation, regional anesthesia procedures, or positioning; and facilitate a smooth induction of anesthesia. It has been shown that the requirement for these drugs is reduced after a thorough preoperative visit by an anesthesiologist. 1. In elderly, debilitated, or acutely intoxicated patients and in those with upper airway obstruction or trauma, central apnea, neurologic deterioration, or severe pulmonary or valvular heart disease, doses of sedatives and analgesics should be reduced or withheld. 2. Patients addicted to opioids and barbiturates should be premedicated sufficiently to prevent withdrawal during or shortly after surgery.

PREMEDICATION A. Sedatives 1. Benzodiazepines a. b. c.

Diazepam (Valium) 5 to 10 mg orally (PO) Lorazepam (Ativan) (1 to 2 mg PO) Midazolam 1 to 3 mg IV or IM

2. Barbiturates 3. Droperidol or IV

0.03 to 0.14 mg/kg IM

B. Opioids are most frequently given in the preoperative setting to relieve pain (e.g., patient with a painful hip fracture) and occasionally when the placement of extensive invasive monitoring devices is planned. Morphine is the primary opioid used, because it has both analgesic and sedative properties. Usual adult doses are 5 to 10 mg IM, 60 to 90 minutes before coming to the operating room.

C. Anticholinergics are seldom used preoperatively. Occasionally useful agents include the following 1.

Glycopyrrolate (0.2 to 0.4 mg IV for adults and 10 to 20 µg/kg for pediatric patients) or atropine (0.4 to 0.6 mg IV for adults and 0.02 mg/kg for pediatric patients) is given IV during ketamine induction and during oral/dental surgery as an antisialagogue.

2.

Scopolamine may be given in combination with morphine IM before cardiac surgery to provide additional amnesia and sedation. The adult dose is 0.3 to 0.4 mg IM.

TERIMA KASIH