EVALUATION AND
MANAGEMENT
1. +You
2. Search
3. Images
4. Maps
5. Play
6. YouTube
7. News
8. Gmail
9. Drive
10. Calendar
11. More
1. Translate
2. Mobile
3. Books
4. Offers
5. Wallet
6. Shopping
7. Blogger
8. Finance
9. Photos
10. Videos
11.
12. Even more
Account Options
1.
2. Sign in
English
Spanish
French
Detect language
Translate text or webpage
Indonesian
English
Spanish
BAB 18 m PRE OPERATIF
EVALUASI DAN MANAJEMEN
I. PENDAHULUAN. Tujuan dari pra operasi
evaluasi untuk mengurangi risiko pasien dan
morbiditas operasi, serta untuk meningkatkan
efisiensi dan mengurangi biaya (Hata TM, Movers
JP:.. evaluasi pra operasi dan manajemen Dalam
Barash PG, Cullen BF, Stocking RK [eds]:
Anestesi Klinis, pp 475-501. Philadelphia,
Lippincott Williams & Wilkins, 2006).
A. Komisi Bersama untuk Akreditasi
Kesehatan Organisasi (JCAHO) mensyaratkan
bahwa semua
pasien menerima evaluasi pra operasi anestesi. B.
American Society of anestesi (ASA) memiliki
disetujui Standar Dasar untuk Perawatan Pra-
anestlietic,
yang menguraikan persyaratan minimum untuk
evaluasi pra operasi. C. Pelaksanaan evaluasi pra
operasi didasarkan pada
premis bahwa hal itu akan mengubah perawatan
pasien dan meningkatkan
hasil.
1. Berdasarkan pemeriksaan sejarah dan fisik, tes
laboratorium yang tepat dan konsultasi pra operasi
harus diperoleh.
2. Dipandu oleh pemeriksaan sejarah dan fisik, ahli
anestesi harus memilih anestesi yang tepat dan
rencana perawatan.
II. KONSEP PERUBAHAN DALAM EVALUASI
PRE OPERATIF
A. rime pertama anestesi melakukan anestesi melihat
pasien mungkin hanya sebelum anestesi dan
pembedahan (lihat sebelumnya oleh orang lain di
klinik evaluasi pra operasi).
B. Teknologi informasi telah membantu ahli anestesi
di pratinjau pasien mendatang yang akan dibius
(kuesioner pra operasi dan program komputer
berbasis).
2 74 Mempersiapkan Anesthesi a
TABEL 1S-1
Airway KLASIFIKASI SISTEM
Kelas
Visualisasi langsung
. Pemandangan laryngoscopic (pasien duduk} ^ '
2 78 Mempersiapkan Anestesi
Tabi-E 08-06 Januari
Stratifikasi risiko JANTUNG UNTUK PROSEDUR
bedah noncardiac
TINGGI (risiko yang dilaporkan jantung sering '>
5%) • • ^ ^ ^ A,, vS;:.. ^ ^ • operasi besar Emergent,
terutama pada orang tua!.'; IS.C. ^ ^ fW9 '^ aorta.
dan pembuluh darah besar lainnya:? • '? ^ "AIII'S ® .
3; ^ ^ *' ^ • Peripheral vaskular • • • '- ^ •' f ^ 'i'-' S'S,
^ ^ ^ - 'prosedur bedah Diduga berkepanjangan ',
terkait dengan ^ Arge:.' - ';
shirt cairan dan / atau kehilangan darah''. ^. ^ ^ y f
INTERMEDIATE (risiko jantung dilaporkan
umumnya <5 ^ o)'' "'" "karotis endarterectomy <' •:
Kepala dan leher.
Intraperitoneal dan intrathoracic,., ^ Ortopedi.
'Prostat' A
RENDAH (risiko jantung dilaporkan umumnya
<1%) prosedur Endoskopi, • 'prosedur superfisial
Cataract
Payudara
a. Prosedur perifer dilakukan sebagai bedah rawat
berhubungan dengan kejadian yang sangat rendah
morbiditas dan mori'ality.
b. Proceduies berisiko tinggi termasuk pembuluh
darah utama,
perut, dada, dan bedah ortopedi. D. Pentingnya E:;
Toleransi ercise
1. Toleransi latihan adalah salah satu mos:
determinan penting nf perioperatif risiko dan
kebutuhan untuk pengujian lebih lanjut dan
pemantauan invasif.
2. Sebuah toleransi latihan yang sangat baik, bahkan
pada pasien dengan
angina stabil, menunjukkan bahwa miokardium
dapat
menekankan tanpa gagal.
a. Jika pasien dapat berjalan satu mil tanpa menjadi
sesak napas, kemungkinan penyakit arteri koroner
yang luas kecil.
b. Jika pasien mengalami dyspnea berhubungan
dengan nyeri dada saat beraktivitas minimal,
kemungkinan penyakit arteri koroner yang luas
tinggi (terkait dengan risiko perioperatif yang lebih
besar). 2. Ada bukti yang baik untuk menunjukkan
bahwa minimal
pengujian tambahan diperlukan jika pasien mampu
menggambarkan toleransi latihan yang baik.
; Koagulasi ^ tudies
"CKemotherapylf ^''; 'penyakit hepatik" r "Bleeding
gangguan" Antikoagulan!
BUN / kreatinin ^ ^ iiiK i fisiologis usia 2:75 thn.
Kelas C prosedur 'Kardiovaskular Penyakit ginjal
Diabetes Penyakit
Langsung atau digoxin penggunaan penyakit SSP
Tes Fungsi Hati Hati Penyakit Hepatitis paparan
Malnutrisi
Dada X-ray
Fisiologis usia 2:75 yr Car.diovasculardis.ease paru
penyakit Keganasan Terapi Radiasi Tembakau 02:20
tahun pak
Pregnancy Test
Kemungkinan kehamilan
Albumin ... Malnutrisi fisiologis usia 2:75 yr Kelas
prosedur C
3. Studi Koagulasi
a. Penelitian laboratorium yang abnormal tanpa
adanya kelainan klinis rirely akan menyebabkan
periopernrive masalah.
b. Sebuah analisis waktu thromboplasrin protrombin
dan parsial ditunjukkan dengan adanya gangguan
perdarahan sebelumnya (setelah cedera, setelah
pencabutan gigi atau prosedur bedah, dan pada
pasien yang diketahui atau dicurigai penyakit hati,
malabsorpsi atau malnutrisi, dan tertentu
Diazepam
lisan
5-20
Lorazepam
oral, im
l^t
Midazolam
oral (anak)
0,5 mg / kg
• im?;
. 3-5
• IV, •, .....
1-2,5
Morfin
un,.
5-15
Meperjidine ";
• ^ m-. '• •.
. 50-150
Fentanyl
• iy
, 0,05-0,150
^ TransinucQsal
, 5-20 ^ g / kg
Prornethazine '
; ^ "'' Un" "^'' '^" •
• 25-50
Diphenhydramirie
: '' 'Oral, im' '"
'":! 25-75
Cimetidihe - '
• lisan; im, iv
150-300
Ranitidin '•
; - Wal: ^ '- "1 - •..
- '50-200
Famotidine
lisan
20-40
Metoclopramide
,. oral, un, iv,,
•,, -, -. .. V. T5s20-.
i scopplanune Glycopyrrdlate -
•.,. Iiri,. • iv. .
"'•'; •" 6,1-0,3
Antasida
",." Bi: al,, -, • .....
y ,10-30mL
"Efek
''. ^ •,
; "> .. ^, Ti." • •; • • '
M.w '? ^. '11
Saraf pusat
+
++
'• ^
"Fc" ^,
toksisitas sistem
^ ^ I-.
Relaksasi
++
++
- ',:!! + •
+'' ','
gastroesophageal
sfingter
Mydriasis dan
+
++
"6 '.
cycloplegia
+
4'
++
++++
•. .-C;
;:'' I ... 'Ft.
v'W '• • - ~ y •:
VFT ^ S
^^-
^Y
'Efek
Saraf pusat
+
+
+
.. ^. ^ .. ^. ^
toksisitas sistem
Relaksasi
++
+
+
•:. ^ ': + +'
gastroesophageal
sfingter
Mydriasis dan
+
+
+
:6'
cycloplegia
+
4
Select all
TABLE 1S-1
AIRWAY CLASSIFICATION SYSTEM
. Laryngoscopic view
Class Direct visualization (patient seated}^'
TAB1-E 18-2
SCREENING EVALUATION FOR THE PULMONARY SYSTEM
History
Tobacco use Shortness of
breath Cough ' Wheezing:
Stridor,
Snoring or sleep apnea
Recent history, of an upper respiratory tract infection
Physical .Examination
Respiratory rate Chest excursion
Use of accessory muscles Nail
color
Ability to walk or carry on conversation without dyspnea
Auscultation to detect decreased breath sounds, wheezing, stridor,
rales
TABLE 18-3
SCREENING EVALUATION FOR THE CARDIOVASCULAR
SYSTEM
Uncontrolled hypertension Unstable
cardiac disease
Myocardial ischemia (unstable angina)
Congestive heart failure
Valvular heart disease (aortic stenosis, mitral vs-lve prolapse)
Cardiac dysrhythmias
Auscultation of the heart (murmur radiating to the carotids) Bruits over the
carotid arteries Peripheral pulses
276 Preparing for Anesthesia
TABLE 18-4
AMERICAN SOCIETY OF ANESTHESIOLOGISTS (ASA) PHYSICAL
STATUS CLASSIFICATION
Status Disease
state.
ASA Class 1
ASA Class 2
ASA Class 3
ASA Class 4
No organic, physi(ilogic,;bijeK;Ji^ ,
ASA Class 5
psychiatric disturbani.^KjI^.aB
Mild to moderate SysteniitJi'dKtilip may not
be related to tlig'jrea^ofll
, surgery . ,. . ':''.^"ISiyl
Severe systemic disturban.c^tliai.fcih may
not be related to thfiieasO^ surgery .
'':' 1^'6^'i^.^'t-"
Severe systemic disturbance thac<is;life{:^ '
threatening with or withoutsurgery.': fc:,
Moribund patient who has little chance.of ^
survival but is submitted tasurgery; as a"
last resort (resuscitative effort) '?''.;,;:.-
•i-;'1.
Emergency operation
(E)
TABLE 18-5
CLINICAL PREDICTORS OF INCREASED PERIOPERATTVE
CARDIOVASCULAR RISK (MYOCARDIAL INFARCTION,
CONGESTIVE HEART FAILURE)
Major Unstable coronary syndromes
Recent myocardialinfarction
Unstable or severe angina.
Decornpensated congestive heart failure Significant arrhythmias
High-grade atriovetitricular block
Symptomatic ventricular arrhythmias
Supraventricular arrhythmias with uncontrolled ventricular rate Severe
valvular disease
Intermediate
Mild angina pectoris
Prior myocardial infarction by history or pathological Q waves
Compensated or prior congestive heart failure
Diabetes mellitus
Minor
Advanced age Abnormal ECG (left ventricular hypertrophy, left bundle-branch
block, ST-T abnormalities) Rhythm other than sinus (atrial fibrillation) Low
functional capacity (inability to climb one flight of stairs with
a bag of groceries) History of stroke
Uncontrolled systemic hypertension
TABI-E 1 8-6
CARDIAC RISK STRATIFICATION FOR NONCARDIAC SURGICAL
PROCEDURES
HIGH (reported cardiac risk often'>5%) ••.^^^A,,vS.;:^•.!^ Emergent major
operations, particularly in the elderly'; iS.C.^.fW9^'^ Aortic and other major
vascular : • '^"aiii'S®.3;?^^*'^ • Peripheral vascular • • •'
-^ •'f^' i'-'S'S;^?^^-' Anticipated prolonged surgical procedure', associated
with^arge:.'-';
fluid shirts and/or blood loss ''.^.^y^f
INTERMEDIATE (reported cardiac risk generally <5^o)''"'"" Carotid
endarterectomy <'•:. Head and neck
Intraperitoneal and intrathoracic ,.,^ Orthopedic
. ' Prostate 'A
LOW (reported cardiac risk generally <1%) Endoscopic procedures
, •' Superficial procedures Cataract
Breast
TABLE 18-7
RECOMMENDED LABORATORY TESTING
Blood Count ; Coagulation ^tudies
Neonates "CKemotherapylf^'' ;' Hepatic
Physiologic age 2:75 yr Class C disease" !r" Bleeding disorder"
procedure Malignancy Renal Anticoagulants
disease Tobacco use BUN/Creatinme ^ ^iiiK i
Anticoagulant use Physiologic age 2:75 yr. Class
Electrolytes C procedure ' Cardiovascular
Renal disease disease Renal disease
Diabetes Diabetes
Diuretic, digoxin, or steroid use Direct or digoxin use CNS
CNS disease disease
Blood Glucose Physiologic age Liver Function Tests Hepatic
£75 yr Class C procedure disease Hepatitis exposure-
Diabetes Steroid use CNS Malnutrition
disease Chest X-ray
ECG Physiologic age 2:75 yr
Physiologic age 2:75 yr Class C Car.diovasculardis.ease
procedure Cardiovascular Pulmonary disease
disease Pulmonary disease Malignancy Radiation
Radiation Therapy Diabetes Therapy Tobacco 2:20 pack
Digoxin use CNS disease years
Pregnancy Test
Possible pregnancy
Albumin ... Malnutrition
Physiologic age 2:75 yr Class
C procedure
3. Coagulation Studies
a. Abnormal laboratory studies in the absence of clinical
abnormalities will rirely lead to periopernrive problems.
b. A prothrombin and partial thromboplasrin time analysis is
indicated in the presence of previous bleeding disorders
(following injuries, after tooth extraction or surgical
procedures, and in patients with known or suspected liver
disease, malabsorption or malnutrition, and on certain
Preoperative Evaluation and Management 285
TABLE 18-8
AREAS TO BE DISCUSSED DURING A PREOPRRATTVE INTERVIEW
Review medical history with patient ' ;"
Coexisting diseases i'')6?
Chronic drug therapy '':'' ^
Prior anesthetic experience '{{v'' • Describe anesthetic
techniques available and associated rislcs Review planned preoperative
medication and time of scheduled
surgery
Describe what to expect on arrival in the operating room Describe anticipated
duration of surgery and expected time to
return to room Describe methods available to manage
postoperative pain
Patient-controlled analgesia
Neuraxial opioids
TABLE 18-9
GOALS FOR PREOPERATIVE MEDICATION
Relief of anxiety
Sedation
Amnesia
Analgesia
Drying of airway secretions
Prevention of autonomic 'efiex responses
Reduction of gastric fluid volume and increased pH
Antiemetic effects
Reduction of anesthetic requirements
Facilitation of smooth induction of anesthesia
Prophylaxis against allergic reactions
Preoperative Evaluation and Management 287
TABLE 18-10
DETERMINANT OP DRUG CHOICE AND DOSE
Patiepl;;age and weight :;•.;;
ASA physical status classification
Level of anxiety , ,,. . , .
Tolerance for depressant'drugs
Prior adverse experiences'with premedicatioh
Drug'allergies ' "..;•
Elective versus emergency surgery
Inpatient versus outpatient
TABI-t- IS-11
DRUGS USED FOR PHARMACOLOGIC PREMEDICATION
A HI 1. 1 S-,12
SIDE EFFECTS OF OPIOIDS AS USED FOR PHARMACOLOGiC
PREMEDICATION
*.,i:.";'•'•::•^Jf/•.7'•^'.' •ff-T'". *'•'^:f•.•:-•t•'','i.i''•?2 >ft^<•((•4^ •' /^•'•'•l, '•• • •'"'," . •-' .. -V.'',l"
•\..^'-""- •,
l^ause^aD^^itiqil:;^^^ . ^'•i^.y^^^;;
Synergisyle•'eff«:t^;esp^a^yMKe'n^
•:<:;benz9dl^pmesy^^^|^;y^'^ "'••'^i'^ \;" r:;:•;^^^l;";••'• Ortlidyatic
hypotehsioa^,' •i'^-- " •'. ^.^';.-'i;^-' Delayed gastric emptying:"
• ' : : ' '; - .^•'. •'' :' Pruritu^-^^,.^.,'-'--^-':;^^^ ,. . ,'";-'!'.'•::, :
Choledochoduodenal sphincter spasm
TA B 1. h 1 -S - 1 3
SUMMARY OF FASTING RECOMMENDATIONS TO REDUCE THE RISK
OF PULMONARY ASPIRATION"
Minimum fasting penod Ingested material (applied to all ages):
Clear liquids (water, fruit juice 2 hr
without pulp, carbonated
beverages, clear tea, black coffee) Breast milk
4 hr Infant formula 6 hr Nonhuman milk
6 hr Light meal (toast and clear liquids) 6 hr
•'Applies only to healthy patients who are undergoing elective procedures and are not intended for women
in labor. Following these guidelines does not guarantee complete gastric emptying.
1 AB .1- 1.S-1 s
ANT1EMETICS USED TO PREVENT OR TREAT
POSTOPERATIVE NAUSEA AND VOMITING
Droperidol (sedation and dysphpria may. be side efrec^f^]^^^^--. inexpensive,
use limited by rare risk of prolongafionijtrfstKi^^^^ ;QT.c'interval)'
;•'-•:.-^r'.WKi-;.^^'^''^-'''-^'' Metoclopramide (?)'' : ;-)" •?>•',.+ -•'•-
•^-'^•^'^S^i^ T^ansdermalscopolamine patch (apply iseyeral-houts^bS^lo^
•^,: induction of anesthesia):' S :^ •;%•';; •ri1'^' ^'i^-'KiS-leSSgi^S^BpHs'^
Ondahsetron or granisetron ' •^^SftiSS^^-v
292 Preparing for Anesthesia
TABLE 18-16
COMPARATIVE EFFECTS OF ANTICHOLINERGICS"
•• ' ' '" ••"•• •^•{'•>'^\-^',-'^\/-' J-;
•' Atropine Scopolanune ,GJ^copyncolate
Annsialagogue effect ++ : +++ •;.' +++• ::^fif : ¥K'
Sedative and amnesic ::H'-
" effects niH!:,;wi
''.^• ;">..^,:. M.w'?
Central nervous + ++ '•^ "fc"^,
system toxicity ^i- ^ .
Relaxation of ++ ++ -!'!,: +''','
gastroesophageal
sphincter
Mydriasis and + ++ "6'.
cycloplegia
Increased heart rate +++ + + 4'
''Intravenous administration. 0 = none; + = mild; + + = moderate; + + + =
marked.
TABLE 18-17
INDICATIONS FOR ANTICHOLINERGICS
Antisialagpgue effect (not necessary when regional anesthesia . ' planned)
:, •;
Sedation and amnesia (decrease doses in elderly patients;
scopolamine most effective) Vagolytic action (intramuscular
administration not as effective
as intravenous injection just before the anticipated vagal
stimulus)
TABLE 18-18
SIDE EFFECTS OF ANTICHOLINERGIC DRUGS
Central nervous system toxicity (restlessness and confusion
especially in elderly patients; unlikely with glycopyrrolate :because,it
crosses the brain barrier .muuiiRally):,, ,; ' Relaxation of the lower
esophageal sphincter (inay not be .'
clinically significant) : : , Mydriasis and cycloplegia
(continue miotic eye drops in
patients with glaucoma) 'i Increased physiologic dead
space Drying of airway secretions Interference with sweating (an
important consideration in
febrile patients, especially children) , ... . Increased heart rate
(unlikely after intramuscular .. i
administration) ;, -, -:,
292 Preparing for Anesthesia
TABLE 18-16
COMPARATIVE EFFECTS OF ANTICHOLINERGICS"
: • ' - " ''.'^^•'^•.^'^'"•ty' e-:
••••'• Atropine Scopolamme ^Glycopyirolate
Antisialagogue effect ++ + ++ •. v'W'•• ^y
Sedative and amnesic + ++ .- -~y•:
' effects •.<•„. x^.^;-'"
Central nervous + + + .. ^.^..^.^
system toxicity
Relaxation of ++ + + • :.^':++ '
gastroesophageal
sphincter :
Mydriasis and + + + 6'
cycloplegia
Increased heart rate ++ + + + 4
"Inrravenous administration. 0 = none; + =; mild; + + = moderate; + + 4- = marked.
TABLE 18-17
INDICATIONS FOR ANTICHOLINERGICS
Antisialagogue effect (not necessary when regional anesthesia 'planned)
: , Sedation and amnesia (decrease doses in elderly patients;
scopolamine most effective) Vagolytic action (intramuscular
administration not as effective
as intravenous injection just before the anticipated vagal
stimulus)
TABLE 18-1S
SIDE EFFECTS OF ANTICHOLINERGIC DRUGS
Central nervous system toxicity (restlessness and confusion
especially in elderly patients; unlikely with glycopyrrolate ,,; because
jtxrosses the brain barrier .minimally) .^ • ' Relaxation of the lower
esophageal sphincter (may riot 6e ^
clinically significant) Mydriasis and cycloplegia (continue miotic eye
drops in
patients with glaucoma) ;
Increased physiologic dead space . .
Drying of airway secretions
Interference with sweating (an important consideration in
febrile patients, especially children) , , Increased heart rate
(unlikely after intramuscular :... '
administration) ., '
294 Preparing for Anesthesia
I. MUSCULAR DYSTROPHY
A. The muscular dystrophies are characterized by a progressive but
variable race of loss of skeletal muscle function. Cardiac and smooth
muscle function are also affected.
B. Duchenne's Muscular Dystrophy
1. This is the most severe form of muscular dystrophy and is produced
by a genetic abnormality resulting in lack of production.of muscle
protein, dystrophin, an important component of the skeleton of the
muscle n-.embrane.
2. The genetic defect is sex linked (manifests opiy in males),
symptoms manifest between 2 and 5 years of age (creatine kinase
may be increased before symptoms appear). Death is usually
secondary to congestive heart failure or pneumonia. a. Axial
skeletal muscle imbalance produces kyphoscoliosis, which often
requires surgical correction.
b. Involvement of cardiac muscle is reflected by a progressive loss
of the R-wave amplitude on the lateral precordial leads of the
electrocardiogram. Routine echocardiography can provide
important information about cardiac function. Progressive