PREOPERATIVE PREPARATION

by Deddy Koesmayadi, dr.,SpAnKIC Anesthesiology Department & Reanimasi Faculty Padjadjaran University/Hasan Sadikin General Hospital

Preoperative preparation
Preoperative visit Assess the risk of anesthesia and surgery Informed consent Fasting Premedication

Preoperative visit
Inadequate pre op.preparation may be a major contributory factor to the perioperative morbidity & mortality. It is essensial that anesthetist visits every patient before surgery.

The purpose of it :
Establish rapport with the patient Meet the doctor with the patient Discuss possible causes of anxiety regarding anesthetic and surgical manner Explain how the patient will be cared for during and after anesthesia and about pain relief Establish a doctor-patient relationship that reduces patient anxiety by building trust & respect Assessment of physical status Order special investigations

Fears related to anesthesia (Sheffer)

He may tell secrets The operation will start too soon He may wake up during surgery He may not wake up after surgery Fears of suffocation, mutilation, vomitting & cancer

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)

Successful approach (Buskirk)

Treat all patients as human being Be friendly, explain your visit & your plan Be patient & sympathetic Listen to his concern, answer all questions in understanding and warm manner Allay patients fears

Comparison of Preoperative Visit and Pentobarbital (2mg/kg i.m) (% of Patients)

Felt Drowsy Felt Nervous Adequate Preparation 18 58 35 30 26 61 40 48 65

Control Group Pentobarbital Only Preoperative Visit

Pentobarbital and Preoperative Visit 38 38 71 Source : Data from Egbert LD et al : The value of the preoperative visit by the anesthetist JAMA 185:553, 1963

History and physical examination

Personal and family history Hereditary conditions associated with anesthesia : porphyria, malignant hyperthermia, haemophilia Previous operations & anesthetics Allergies Medications drug interaction Habits : alcohol and smoking Diseases of CVS and respiratory systems

Alcoholism
Impairment of liver function Heart cardiac arrhythmia Cardiac contractility decrease Cardiomyopathy Kidney diuretic effect by inhibiting ADH Plasma catecholamine increase Metabolic & respiratory acidosis from alcohol intoxication Increases the anesthetic requirement

Smoking
Ciliary function reduce, disturbing tracheobronchial clearance Increase production and thicken of sputum Strong risk factor for coronary heart disease and occlusive peripheral arterial disease Systolic hypertension is potentiated

Decrease cerebral blood flow and increase risk of stroke Increase gastric volume & acidity Increase COHb level, decrease blood O2 content & O2 delivery to tissue Increase catecholamine : CVS responses & O2 requirement increase Respiratory complication increase 5-7 times

Recomendations
COHb fall to normal level stop smoking 48 hours preoperatively Reduction of sputum volume & post op complications stop smoking 4 weeks pre operatively

Physical examination
General condition : name, age, weight. B.P. pulse rate & temperature. Cardiopulmonary examination including - Cyanosis in finger tips - V. jugularis engorgement

Obesity (W/H2 more than 30)

o Airway problems o Mechanical ventilation is impaired tendency to hypoventilation e.c. fix thorax & elevated diaphragm o Easily developed hypoxia e.c. - FRC is reduced - V/Q ratios are low

 Difficult estimate circulatory volume by V.J. pressure and difficulty in venipuncture CVS disorders : Hypertension 3X more Ischemic H.D 2X more CVD/CVA 3X more DM 3-4 X more Increase gastic volume, acidity & pressure

Physical examination
General condition : name, age, weight. B.P. pulse rate & temperature. Cardiopulmonary examination including - Cyanosis in finger tips - V. jugularis engorgement

 Airway : - Neck : stout, short, sunker cheeks, distance from mentum to hyoid ( 5 cm) - Mouth : mouth opening, loose or damage teeth, protruding upper incissors Vertebral column : anatomical deformities may render some blocks in practical

Simple Bedside cardiopulmonary function Sebarases test : 2-3 deep breaths hold as long as possible Time : 40 seconds normal 30-40 seconds diminished reserve < 20 seconds severely compromised Match test : The ability to blow out a standard match held 6 inches from the open mouth negative max breathing cap low Tilt test

Laboratory testing
Routine lab.test in pts who are apparently healthy (history & clinical exam) are invariably of little use and wasting. Blood : Hb, leuco all female, male > 50, major surgery, clinically indicated Ureum, creatinine pt > 50, renal & hepatic diseases, diabetes, abnormal nutritional state

 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

Assess the risk of anesthesia and surgery ASA (American Society of Anesthesiologist) grading system Class I : A normally healthy individual, the pathology which surgery is needed only localized Class II : A patient with mild or moderate systemic disease Class III : A patient with severe systemic disease that is not incapacitating (limits the pt activity)

 Class IV : A patient with incapacitating systemic disease that is a constant threat to life Class V : A moribund patient who is not expected to survive 24 hour with or without operation Class E : Added as a support for emergency operation. All pts induced in ASA I-V that need emergency operation get a higher ASA grade

CARDIAC RISK
CRITERIA Hystory - Age > 70 years - MI in previous 6 mo Physical examination - S3 gallop or jugular vein distension - Important VAS POINTS

5 10 11 3

CRITERIA Electrocardiogram - Rhythm other than sinus or premature atrial contraction on last preoperative ECG - > 5 premature ventricular contractions/m in documented at anytime before operation

POINTS

CRITERIA POINTS 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 3 Operation - Intraperitoneal, intrathoracic, or aortic operation 3 - Emergency operation 4 TOTAL POSSIBLE POINTS 53

RISK CLASSIFICATION AND OUTCOME BY THE CARDIAC RISK INDEX (CRI) AND AMERICAN SOCIETY OF ANESTHESIOLOGISTS (ASA) CRITERIA
No or Minor Complication CRI Class Ponts CRI ASA 1. 0-5 99% 100% 2. 6-12 93% 97% 13-25 86% 93% 3. 25 22% 78% 4. Life-Treatening Complication Cardiac Deaths CRI ASA 0,7% 0% 5% 2% 11% 4% 22% 17% CRI 0,2% 2% 2% 56% ASA 0% 1% 2% 5%

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 the patient 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.

Without the patients consent, the physicion may liable for assault and battery. When the patient is a minor or otherwise 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 chart and is signed by the patient or their representative.

Fasting
To prevent aspiration of gastric content NPO 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 the threshold to epinephrine induced arrhythmia. Recommendation : NPO 4 hours Gastric emptying is delayed by : anxiety, pain, trauma, and pregnancy.

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

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

Premedication
Objectives are : Allay anxiety & fear Reduce secretions Analgesia Enhance the hypnotic effect of G.A. agent Reduces post op nausea and vomitting Produce amnesia Reduction in vagal reflex Limit sympathoadrenal responses

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

Sedative
Sedative in appropiate dose can reduce anxiety and stress, in higher dose become hypnotic. Barbiturate : Ultra short acting
Thiopentone / penthotal Methohexitone, hexobarbitone Especially detoxification in liver

 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

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

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

 Interfere other drugs link and metabolism (enzyme induction) No analgetic effect

Premedication Sedativa
Pentobarbitone sodium / nembutal and quinal barbitone sodium / seconal less depress respiration and circulation, non teratogenic, and because it is detoxificated in liver, suite for kidney function disturbance. Inject 60 mg/cc, i.m, 2 hour pre op. Capsule 50 and 100 mg

 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 30 50 mg Hypnotic dose 100 mg for adult, 3-5 mg/kg BW for children

Tranquilizer : Benzodiazepines
Benzodiazepines : anxiolysis sedation amnesia Preferable to the barbiturate - Produce amnesia - Greater therapeutic index - Less cardiovascular and respiratory deppression - Longer duration of action

Tranquilizer : Phenothiazine
Phenothiazine : sedative-antiemetic, antihistamine (Phenergan), antipiretic (central vasodilatation), central sympatic depression, and minimize the effect of adrenalin in perifer => less tension (Largactil), dose : 25-50 mg oral/i.m

- 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 active metabolites : methyl diazepam, oxazepam, 3-hydroxy diazepam prolonged CNS depression

 Minimal cardiovasculer effect Ventilatory response to CO2 depressed increase PaCO2 especially in association with other respiratory depressant Anticonvulsant in tetanus and epilepsy Mild muscle relaxant property at spinal cord level and potentiate non depolarizing muscle relaxant Retrogade amnesia especially when combine with meperidine or hyoscine Rapidly passes the placental barrier

Doses oral : 0,2 0,5 mg/kg i.v : 0,1 0,2 mg/kg induction : 0,3 0,5 mg/kg

MIDAZOLAM
The efect are faster and shorter, duration approximately 60 minutes Anterograde amnesia, has no anticonvulsant effect 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

 CBF is decrease ICP decrease cerebral protection Relaxation effect Not interfere coronary circulation safe for ischemic heart disease, in other way diazepam interfere CVR unsafe

DROPERIDOL/ INAPSINE
Tranquilizer butyrophenone, phenothiazine like effect Forced antiemetic, ICP can be decrease because of mild cerebral vasoconstriction Alpha adenergic receptor blockade hypotensi, it can prevent catecholamine induced arrhythmia Apathis Dose : 2,5-5 mg; duration 6-8 hours Side effect : dyskinetic involuntary movement (extrapyramidal disturbance) Occasionally dysphoric reaction

Morphine
Narcotic-analgetic standard for strong pain, euphoria Sedativa-postural hypotension because of vasodilatation and myocard depression (depression of vasomotor center) Constrict the sphincter of gut, peristaltic constipation BMR , addiction-hystamine release positif

Depression of cough reflex post op secret accumulation atelectasis ICP rise in intracranial injury Respiratory center depression CO2 CBF

Parasympatic tone: - Bronchus bronchoconstriction - Eyes myosis Through placental blood barrier Dose : 10-15 mg i.m/s.c, duration until 6 hours Children : 0,1 mg/kg bodyweight Disadvantages: Nausea and vomittus not be used in intraocular operation COPD or asthma worsening

PETHIDINE/ MEPERIDINE
Depression of RC, emetic effect, euphoria and dizziness are less than morphine Less histamine release fine for asthma Through placental blood barrier not be given before umbilical cord is cut Atropine like effect : saliva dry mouth eyes mydriasis Dose : 50-100 mg Child : 0,5-1 mg/kg BW; duration 2-4 hours

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

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 depression Dose: 0,2-0,4 mg iv

Anticholinergic drugs
Perthidin & 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

 Light bronchodilator CVS : tachycardi be aware to thyrotoxicosis and ischemic HD, cardiomyopathy GI : intestine and urinary tracts peristaltic constipation and urine retension BMR be aware to thyrotoxicosis dose : 0,005 - 0,01 mg/kgWB duration of action : im until 90 ; iv 30-45

 Combination of those drugs patient comes to the operation room still aware but sleepy, calm, cooperative, there are no complications during and after the operation Doses and drugs combination are decided by patient condition and anesthetis experience and skills

OPERATION CANCELLED
Anemia: Hb < 10gr% In Research Hb < 10gr% its not increase morbiditas/ mortalitas. If circulating volume is enough, Hb 8 gr% its not necessary to get tranfusion Syok: Anesthesia depression of vital organs syok is worsening. Volume replacement until blood pressure > 80mmHg, good peripheral condition, diuresis is enough Temperatur: 380C antipyretica, find focal infection especially respiratory tract

Respiratory Infection
Influenza, pharyngitis, bronchitis elective operation is delayed Airways instrument : - trauma of infection mucosa resp. obstruction, spasm, hypersecretion Post operative respiratory complication. - infection spread