pre operasi prabedah 2013

7/27/2019 Pre Operasi Prabedah 2013

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Preoperative preparation

Preoperative visit

Assess the risk of anesthesia and surgery

Informed consent

Fasting

Premedication


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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


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Alcoholism Impairment of liver function

Heart cardiac arrhythmia

Cardiac contractility decrease

Cardiomyopathy

Kidneydiuretic effectby inhibiting ADH

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 of sputumStrong risk factor for coronary heart disease

and occlusive peripheral arterial disease

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 O2

content & O2 delivery to tissueIncrease catecholamine : CVS responses &

O2 requirement increase

Respiratory complication increase 5-7 times


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Recomendations

COHb fall to normal level stop smoking

48 hours preoperatively

Reduction of sputum volume & post op

complications stop smoking 4 weeks

pre 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/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


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Difficult estimate circulatory volume byV.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 gastric volume, acidity & pressure


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Airway :

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

- Mouth : mouth opening, loose or damage

teeth, protruding upper incisors Vertebral column : anatomical deformities

may render some blocks in practical


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Simple Bedside cardiopulmonary function

Sebarases test : 2-3 deep breaths hold aslong as possible

Time : 40 seconds normal

30-40 seconds diminished

reserve< 20 seconds severelycompromised

Match test : The ability to blow out a standardmatch held 6 inches from the open mouth negative max breathing cap low

Tilt test


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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, abnormal

nutritional 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


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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 (limits the ptactivity)


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Class IV : A patient with incapacitatingsystemic disease that is a constant threat tolife

Class V : A moribund patient who is not

expected to survive 24 hour with or withoutoperation

Class E : Added as a support for emergency

operation. All pts induced in ASA I-V thatneed emergency operation get a higher ASAgrade


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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, regionalanesthesia, or i.v sedation.


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Fasting

Toprevent 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 the

threshold to epinephrine induced arrhythmia.

Recommendation : NPO 6 hours

Gastric emptying is delayed by : anxiety, pain,

trauma, and pregnancy.


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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. agent

Reduces post op nausea and vomitting

Produce amnesia Reduction in vagal reflex

Limit sympathoadrenal responses


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Drugs for premedication

Sedativa, tranquilizer

Narcotics-analgetics

Alkaloid belladona as antisecretion andreduce vagal reflex to the heart from :

drugs

impuls afferent abdomen, thorax, andeyes

Antiemetic


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OPERATION CANCELLED

Syok: Anesthesia depression of vital organs syok is

worsening. Volume replacement until blood pressure >

80mmHg, good peripheral condition, diuresis is enough

Temperature: 380C antipyretica, find focal infection

especially respiratory tract


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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


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pre operasi prabedah 2013

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