Preoperative evaluation and preparation

Mahendratama P. AdhiSMF Anestesiologi RS Ulin Banjarmasin

The preoperative evaluation consists of gathering information about the

patient and formulating an anesthetic plan. The overall objective is

reduction of perioperative morbidity and mortality.

Inadequate preoperative planning and errors in patient preparation are the most common

causes of anesthetic complications.

Anesthesia and elective surgery should not proceed until the patient is in optimal medical

condition.

Patient dataDoctor – patient relationshipAnesthetic planPatient consent

Preoperative evaluation and preparation

Review of Patient Data

Medical record Interview History : history of underlying disease, medication, functional capacitance, previous anesthetic history, family history, smoking & alcoholic use, review of system, psycological support Surgical condition :

- condition & symptom of disease- surgical procedure- position of procedure

Physical Examination Vital signs General appearance Respiratory system CVS system Abdomen Extremities and spine Neurologic system Airway evaluation anticipate difficult intubation & its management

Laboratory Data

Value of testing Risk and costs benefits Preoperative testing: base on indication Hematological studies : Hct/Hb, Plt , coagulation factor Serum chemistry studies : BUN, Creatinin, SGOT-SGPT, Albumin, Electrolite, Glucose ECG, Chest radiography, pulmonary function tes

Hematological & serum chemistry studies are routine while ECG & chest x-ray for patient over than 40 y.o. or indicatedHb 7 gr/dl for young & healthy patient undergoing minimal risk surgery, Hb > 10 gr/dl over than 40’s, children, CAD, undergoing high risk surgery

Platelet count within normal limit (150.000-400.000) but for urgent or emergency procedure > 70.000 without any clinical spontaneus bleeding

Coagulation factor ; PT & APTT within normal limit or if the value lengthened, not over than 1.5 times than control valueCan be corrected with given of Vit K and FFPLiver function test not over 5 times than normal valueCreatinin not over than 5If over than 5 should be corrected (given of medication or/and RRT)

Electrolyte disturbance with any clinical signs must be corrected

Specific test: Cardiac evaluation:

exercise stress testthallium scanechocardiogram

Pulmonary evaluation: lung function test

spirometry arterial blood gas

Medical consultation To define patient’s condition To optimize patient’s medical condition and future management before surgery

Consent formInformed consent involves : discussing anesthetic management plan, alternatives

potential complication

Record Preoperative formASA physical Classification Class1 normal healthy patient Class 2 A patient with mild systemic disease and

no functional limitations Class 3 A patient with moderate or severe systemic

disease that results in some function limitation Class 4 A patient with severe systemic disease

that is threat to life and functionally incapicitating Class 5 A moribund patient who is not expected to

survive 24 hours with or without surgery (Class 6 A brain-dead patient whose organs are being

harvested) E for Emergency case

ASA Classification & preoperative mortality rates

Class Mortality Rate

1 0.06 – 0.08 %

2 0.27 – 0.4 %

3 1.8 – 4.3 %

4 7.8 – 23 %

5 9.4 – 51 %

NPO Guideline

NPO 6-8 hr. before surgery Clear liquid diet for 2 hr.

Children Clear liquid 2 hr Breast milk 4 hr Infant formula 6 hr solid diet 8 hr.Guideline used for patient with no problemwith gastric emptying time

Perioperative Cardiovascular Evaluation for Noncardiac Surgery

History – angina, recent or past MI, HF, symptomatic arrhythmias, presence of pacemaker or ICD

Physical Examination – general appearance, rales, elevated JVP, carotid and other arterial pulses, S3 gallop, murmurs

Comorbid Diseases Pulmonary Diabetes Mellitus Renal Impairment Hematologic Disorders

Ancillary Studies - ECG almost always indicated, blood chemistries and chest X-ray based on history and physical findings

General approach to the patient

Clinical of chest pain,heart failure and arrhythmia should be treated before elective surgery Interval between MI time and surgery less than 6 month is more likely with reinfarction Perioperative cardiovascular risk :

clinical predictorssurgical procedureexercise tolerance

Major Unstable coronary

syndromes Decompensated CHF Significant Arrhythmias

Intermediate Mild angina pectoris Prior MI Compensated or prior HF Diabetes Mellitus

(particularly taking insulin) Renal insufficiency

Minor Advanced Age. Abnormal ECG. Rhythm other than

sinus. Low functional

capacity. History of stroke. Uncontrolled

systemic hypertension

Clinical Predictors of Increased Perioperative Cardiovascular Risk

Surgical Procedures of Increased Perioperative Cardiovascular Risk

High: Emergency major (particularly in elderly patient), vascular surgery, prolong operation with large fluid shifts and/or blood loss

Intermediate: carotid endarterectomy,head and neck surgery, intraperitoneal & intrathoracic surgery, orthopedic surgery, prostate surgery

Low: endoscopic procedure, breast surgery, superficial procedure, cataract surgery

4 METs: walk at 6 km/hr, run short distance, heavy work around house, golf, bowling, dancing

Exercise Tolerance

The metabolic equivalent, or MET, is defined as the ratio of a person's working metabolic rate relative to the resting metabolic rate.

Functional capacity is defined as :poor (<4 METS),moderate (4–7METS), good (>7–10METS) , based on evaluation of the patient’s daily activity.

Suplemental Preoperative Evaluation

Noninvasive testing in preoperative patients indicated if 2 or more of following present:

Intermediate clinical predictors (Canadian Class I or II angina, prior MI based on history or pathological Q waves, compensated or prior HF, or diabetes)

Poor functional capacity (<4 METs) High surgical risk procedure (emergency major surgery*,

aortic repair or peripheral vascular, prolonged surgical procedures with large fluid shifts or blood loss)

* Emergency major operations may require immediately proceeding to surgery without sufficient time for noninvasive testing or preoperative interventions.

No further preoperative testing recommended

Preoperative angiography

ECG ETT

Exercise echo or perfusion imaging‡**

Pharmacologic stress imaging (nuclear or echo)

Dipyridamole or adenosine perfusion

Dobutamine stress echo or nuclear imaging

Other (eg, Holter monitor, angiography)

Yes

Prior symptomatic arrhythmia(particularly ventricular tachycardia)?

Borderline or low blood pressure?Marked hypertension?

Poor echo window?

No

Yes

Prior symptomatic arrhythmia

(particularly ventricular tachycardia)?

Marked hypertension?

Bronchospasm?II AV Block?

Theophylline dependent?Valvular dysfunction?

No

No

Resting ECG normal?

Patient ambulatory and able to exercise?‡

Yes

No

YesYes

Indications for angiography? (eg, unstable angina?)

Yes

Yes

No

No

*Testing is only indicated if the results will impact care.

†See Table 1 for the list of intermediate clinical predictors, Table 2 for thermetabolic equivalents, and Table 3 for the definition of high-risk surgical procedure.

‡Able to achieve more than or equal to 85% MPHR

** In the presence of LBBB, vasodilator perfusion imaging is preferred.

2 or more of the following?†*1. Intermediate clinical predictors2. Poor functional capacity (less than 4

METS)3. High surgical risk

Supplemental Preoperative Evaluation: When and Which Test*

Patient risk for MI postopDMPeripheral vascular diseaseHTTobacco usedHypercholesterolemia

Risk associated with surgical influence decision to make further test

Perioperative morbidity may be decreased with beta blocker

Continue medication except anticoagulant or antifibrinolytic: aspirin,warfarin,ticlopidine etc.

Digitalis : discontinue except in severe arrhythmia

Perioperative of Hypertension

Category Systolic mmHg Diastolic mmHgOptimal < 120 and < 75Normal < 130 and < 85Mild HTN 140-159 or 90-99Moderate 160-179 or 100-109Severe > 180 or > 110Isolated SBP HTN > 140 and < 90Pulse Pressure > 65mmHgOrthostatic changes Hyper response > 20 mmHg Hypo response < 20 mmHG

Classification

Hypertension

History of end organ damage: cardiac ischemia, renal, neurological

Elective surgery should be delayed if DBP ≥ 110 mmHg with or without new onset of headache but if no sign of end organ damage surgery or LVH may be proceed

In DM keep DBP < 90mmHg

End Organ Damage & Perioperative Outcome

Occult CAD (Q wave on ECG) CHF (symptoms and signs) LVH (ECG voltage criteria) Renal insufficiency (creatinine>2.0) Cerebrovascular disease (hx of CVA

and TIA)

Treatment Aggressive treatment associated with

reduction in long term risk Generally, antihypertensive drug

should be continued during the perioperative peroid.

Abrupt discontinuation of β-blocker →perioperative tachycardia

Withdrawal of clonidine →rebound HTN ACEI and Angiotensin II inhibitor

→held in the morning of surgery

Perioperative of Pulmonary Disease

History of reactive airway Asthma Frequency, reversible of symptoms,

interval, last attack, history of steroid used Optimize good condition before elective

surgery COPD:new onset of bronchospasm,dyspnea

and reduced exercise tolerance should be indicated to delay elective surgery

Recent URI is controversial , elective surgery should be delayed several weeks

Continue medication Aerosol medication before surgery Risk reduction of pulmonary complication

Smoking cessation Education of lung expansion maneuver and

deep breath exercise(incentive spirometry) for postop Treatment of obstruction Antibiotic Hydration

Smoking cessation 24 hr: decrease carboxyhemoglobin 2-3 day: increase ciliary function but increase secretion 1-2 wk: decrease secretion 4-8 wks: decrease postop pulmonary complication

In TB patient, should be undertreatment min 2 weeks and without any clinical sign of coughing

Perioperative of Diabetes MellitusGeneral approach to the patient Current medication Progression of end organ damage

atherosclerosis : risk for silent MI Autonomic dysfunction Hyperglycemic condition Risk for joint stiffness: TM joint Discontinue medication day of surgery

Preoperative Evaluation Operative risk assessments

Routine risk factors: Cardiac, Pulmonary, Renal, Hematologic

Diabetes-related risk factors: Macrovascular, Microvascular, Neuropathic complication

Diabetes therapeutic regimen Reestablish correct diagnostic Pharmacological regimen Meal plan Activity level Hypoglycemia

Anticipated surgery Type of surgical procedure Inpatient or outpatient Type of anesthesia Start time Duration of procedure

In general, the goal for glucose control during surgery is to maintain the glucose level between: 150-200 mg/dl

Jacober and Sower. Arch Intern Med 159: 2405-2411, 1999

120-180 mgDagogo-Jack and Alberti. Diabetes Spectrum 15: 44-

48, 2002

Glycemic Goal During Surgery

Stop OAD 1-3 day Minor surgery: periopertive

hyperglycemia (BG > 200 mg/dl)RI 4-10 U

Major surgery or poorly controlled diabetes insulin infusion + glucose

T2DM treated with OAD

Minor surgery Major surgery Subcutaneous insulin regimens Intravenous insulin regimens

Insulin treated patients

Fig. Summary of perioperative management recommendation based on therapeuitic regimen and complexity and scheduling of the operative procedure. MDI=multiple doses of short acting insulin1

Jacober and Sower. Arch Intern Med 159: 2405-2411, 1999

Short procedureearly morning Delay diabetes

regimen

Oral agents Hold oral agents

Single dose insulin 2/3 total daily dose

Short procedure 2 or 3 doses of insulin ½ total morning dose

Late morningMDI 1/3 morning dose

Insulin pump basal rate only

Fig. Summary of perioperative management recommendation based on therapeuitic regimen and complexity and scheduling of the operative procedure. MDI=multiple doses of short acting insulin2Jacober and Sower. Arch Intern Med 159: 2405-2411, 1999

Oral agents Hold oral agents

Single dose insulin 2/3 total daily dose

Short procedure 2 or 3 doses of insulin ½ total morning dose

afternoonMDI 1/3 morning dose

Insulin pump basal rate only

Oral agents Hold oral agentsComplexProcedure

Insulin Continuous IV insulin

Table. Regimen for Separate Intravenous Insulin Infusion for Perioperative Diabetes management

Prepare a 0.1 unit/ml solution by adding 25 units RI to 250 ml normal saline

Flush 50 ml of insulin solution through infusion tubing to saturate nonspecific binding sites

Set initial infusion rate (generally, 0.5 unit/h [5ml/h] for thin woman; 1.0 unit/h [10ml/h] for other)

Adjust infusion rate according to bedside blood measurement as follows:

Blood glucose (mg/dl) Insulin infusion rate<80 Check glucose after 15 min*80-140 Decrease infusion by 0.4 unit/h (4 ml/h)141-180 No change181-220 Increase infusion by 0.4 unit/h (0.4 ml/h) 221-250 Increase infusion by 0.6 unit/h (0.6 ml/h) 250-300 Increase infusion by 0.8 unit/h (0.8 ml/h) >300 Increase infusion by 1 unit/h (1 ml/h)

*Regimen assume separate infusion of glucose at ~ 5-10 g/h and hourly blood glucose monitoring.Extremely high or low glucose value should be confirmed with an immediate repeat measurement.

Intravenous bolusesof dextrose (50%) or supplemental regular insulin can be used for paid correction but are rarely

necessary

Perioperative of Thyroid Disease

Clinical manifestation of hyperthyroid or hypothyroid

Hyperthyroid: palpitation, weight loss, heat intolerance, moist skin thyroid strom

Hypothyroid: bradycardia, cold intolerance, slow mental function hypothermia, hypoventilation

LABORATORY TESTING STRATEGY for THYROID DYSFUNCTION

THRYOID DISEASES

OVERT CLINICAL MANIFESTATION

MINIMAL CLINICAL MANIFESTATION

TSHs TSHs + FT4

HYPOTHYROIDISMHYPERTHYROIDISM

TSHs + FT4 TSHs + FT4

HYPERTHYROIDISM HYPOTHYROIDISM

TSHs TSHs

SUBCLINICAL HYPOTHYROIDISM: normal Free-T4, high TSHs

SUBCLINICAL HYPERTHYROIDISM: normal Free-T4, low TSHs

History taking & physical examination

Preoperative Evaluation Sign & symptoms of hyper or

hypothyroidism Cardiovascular performance ECG Thorax radiography Free T4

Preoperative Management Patients with thyrotoxicosis must be treat with PTU

(100-300 mg/day) or metimazol (10-30 mg/day) + propanolol 10-80 mg/day, until euthyroid condition

Add potasium iodide (10-15 drops/day) 10 days before surgery

Patient with thyrotoxicosis who going to operative procedure for non thyroid disease can be treat with propranolol 2-10 mg/iv or 40 mg/p.o (total dose 160-240 mg/d orally) every 4-6 hours, until pulse rate <90. Iodide solution 30 drops plusPTU or metimazole

Surgery and thyroid

With hyperthyroid

Surgical approach

Thyroid illness Non Thyroid illness

Without hyperthyroid

With hyperthyroid

Without hyperthyroid

Elective surgery

Urgent surgery

Treat hyperthyroidis

m

• β-blocker• KI solution• Tionamide

operativeeuthyroid

Perioperative in Renal Disease

Kidney Failure Kidney DiseaseKidney failure Kidney failure occurs when the kidneys partly or completely lose their ability to carry out normal functions. This is dangerous because water, waste, and toxic substances build up that normally are removed from the body by the kidneys. It also causes other problems such as anemia, high blood pressure, acidosis (excessive acidity of body fluids), disorders of cholesterol and fatty acids, and bone disease in the body by impairing hormone production by the kidneys

Chronic kidney disease when one suffers from gradual and usually permanent loss of kidney function over time. This happens gradually over time, usually months to years Chronic kidney disease is divided into five stages of increasing severity Mild kidney disease is often called renal insufficiency. Stage 5 chronic kidney failure end stage renal disease

History and physical examination The comorbidities of CRF Sign and symptom of uremia, fluid overload and inadequate dialysis. Laboratory : electrolyte conc, acid-base status, urea and creatinine levels, hematocrit, platelet count and coagulation Chest radiography pulmonary edema or pleural effusion E C G myocardial ischemia electrolyte imbalance.

Preoperative Evaluation and Preparation

Hyperkalaemia- > 5 mmol/L- > 5,5 mEq/L contraindication to elective surgery because tissue trauma and cell death increased potassium to life-threatening levels. Therapy of hyperkalemia : - 5 – 10 ml 10% Ca-gluconate IV over 3 min,can repeat in 5 min- 3 – 5 mL 10% Ca-chloride IV over 3 minute- 10 U insulin in 500 mL 20% Dext- 1-2 mmol/kg Na-bicarbonat iv over 5 – 10 menit- Nebulised salbutamol 2,5 – 5 mg will assist in moving potassium into the cells.

Haematological function : - Chronic anaemia- Unless the patient has ischemic heart dis. Hb level may be maintained 7 – 8 g/dl. - Th: erythropoietin or Transfusion- Correction of anemia helps to improve platelet dysfunction- Platelet dysfunction : - Desmopresin or cryoprecipitate- Estradioleffective in the treatment of platelet dysfunction.

Indication for Renal Replacement Therapy. - Oliguria (urine output < 200 mL/12 hr)- Anuria (urine output < 50 mL/12 hr)- Hyperkalemia (K > 6,5 mEq/L)- Severe acidemia (pH < 7,1)- Azotemia (urea > 180 mg/dL)- Pulmonary edema- Uremic encephalopathy- Uremic pericarditis- Uremic neuropathy/myopathy- Severe dysnatremia (Na > 160 or < 115 mEq/L)- Hyperthermia

Dialysis : - ESRD GFR < 12 mL/min- 12 – 24 hours before to elective surgery (minimum heparinisation)-normovolemic, - to tolerate fluid loads – surgery - normal electrolyte concentrations. - Hypovolemia hemodynamicinstability. - Fluid over load or life-threatening hyperkalemia.

Thank You