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8/11/2019 Persiapan Anestesi.ppt
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PREOPERATIVE
PREPARATION
Department Anesthesiology &Reanimation Medical Faculty
Malahayati University
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Preoperative preparation
Preoperative visit
Assess the risk of anesthesia and surgery
Informed consentFasting
Premedication
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Preoperative visitInadequate pre op.preparation
may be a major contributory factor
to the perioperative morbidity &mortality. It is essensial that
anesthetist visits every patient
before surgery.
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The purpose of it :Establish rapport with the patient
Meet the doctor with the patient
Discuss possible causes of anxietyregarding anesthetic and surgical manner
Explain how the patient will be cared forduring and after anesthesia and about painrelief
Establish a doctor-patient relationship that
reduces patient anxiety by building trust &respect
Assessment of physical status
Order special investigations
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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)
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Successful approach (Buskirk)
Treat all patients as human being
Be friendly, explain your visit & your plan
Be patient & sympatheticListen to his concern, answer all questions
in understanding and warm manner
Allay patients fears
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Comparison of Preoperative Visit and
Pentobarbital (2mg/kg i.m) (% of
Patients)
Felt Drowsy Felt Nervous Adequate
Preparation
Control Group 18 58 35
Pentobarbital Only 30 61 48
Preoperative Visit 26 40 65
Pentobarbital andPreoperative Visit 38 38 71
Source : Data from Egbert LD et al : The value of the
preoperative visit by the anesthetist JAMA 185:553, 1963
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History and physical
examinationPersonal and family historyHereditary conditions associated with
anesthesia : porphyria, malignant
hyperthermia, haemophiliaPrevious operations & anesthetics
Allergies
Medications drug interaction
Habits : alcohol and smoking
Diseases of CVS and respiratory
systems
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AlcoholismImpairment of liver function
Heart cardiac arrhythmia
Cardiac contractility decrease
Cardiomyopathy
Kidney diuretic effect by inhibitingADH
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 ofsputum
Strong risk factor for coronary heart
disease and occlusive peripheral arterialdisease
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
O2content & O2delivery to tissueIncrease catecholamine : CVS
responses & O2requirement increase
Respiratory complication increase 5-7times
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Recomendations
COHb fall to normal level stop smoking48 hours preoperatively
Reduction of sputum volume & post op
complications stop smoking 4 weekspre 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/H2more than 30)
oAirway problems
o Mechanical ventilation is impaired
tendency to hypoventilation e.c. fixthorax & 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 invenipuncture
CVS disorders :
Hypertension 3X more
Ischemic H.D 2X more
CVD/CVA 3X more
DM 3-4 X more
Increase gastic volume, acidity &pressure
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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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Airway :
- Neck : stout, short, sunker cheeks,distance from mentum to hyoid ( 5cm)
- Mouth : mouth opening, loose ordamage teeth, protruding upperincissors
Vertebral column : anatomicaldeformities may render some blocks inpractical
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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, abnormalnutritional 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
A th i k f th i d
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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 (limitsthe pt activity)
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Class IV : A patient with incapacitatingsystemic disease that is a constantthreat to life
Class V : A moribund patient who is not
expected to survive 24 hour with orwithout operation
Class E : Added as a support for
emergency operation. All pts induced inASA I-V that need emergency operationget a higher ASA grade
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CARDIAC RISK
CRITERIA
POINTS
Hystory
- Age > 70 years
5
- MI in previous 6 mo 10Physical examination
- S3 gallop or jugular vein distension
11
- Im ortant VAS 3
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CRITERIA
POINTS
Electrocardiogram- Rhythm other than sinus or
premature atrial contraction on
last preoperative ECG 7
- > 5 premature ventricular
contractions/m in documented at
anytime before operation 7
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CRITERIAPOINTS
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 3Operation
- Intraperitoneal, intrathoracic, or aortic
operation 3
- Emergency operation 4
TOTAL POSSIBLE POINTS 53
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RISK CLASSIFICATION AND OUTCOME BY
THE CARDIAC RISK INDEX (CRI) ANDAMERICAN SOCIETY OF
ANESTHESIOLOGISTS (ASA) CRITERIA
No or Minor Life-Treatening
Complication Complication Cardiac Deaths
Class
CRI
Ponts CRI ASA CRI ASA CRI ASA
1. 0-5 99% 100% 0,7% 0% 0,2% 0%
2. 6-12 93% 97% 5% 2% 2% 1%3. 13-25 86% 93% 11% 4% 2% 2%
4. 25 22% 78% 22% 17% 56% 5%
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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,regional anesthesia, or i.v sedation.
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Without the patients consent, the
physicion may liable for assault and
battery. When the patient is a minor orotherwise 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 chartand is signed by the patient or their
representative.
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To prevent 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 thethreshold to epinephrine induced arrhythmia.
Recommendation : NPO 4 hours
Gastric emptying is delayed by : anxiety, pain,
trauma, and pregnancy.
Fasting
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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. agentReduces post op nausea and vomitting
Produce amnesia
Reduction in vagal reflexLimit sympathoadrenal responses
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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
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Sedative
Sedative in appropiate dose can reduceanxiety and stress, in higher dose
become hypnotic.
Barbiturate :
Ultra short acting
Thiopentone / penthotal
Methohexitone, hexobarbitone
Especially detoxification in liver
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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
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Barbituratecerebral protection
Because : cerebral metabolism ,cerebral oxigen consumption , C.B.F., & I.C.P.
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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
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Interfere other drugs link and metabolism
(enzyme induction)
No analgetic effect
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Premedication Sedativa
Pentobarbitone sodium / nembutal andquinal barbitone sodium / seconal lessdepress respiration and circulation, non
teratogenic, and because it is detoxificatedin liver, suite for kidney functiondisturbance.
Inject 60 mg/cc, i.m, 2 hour pre op.
Capsule 50 and 100 mg
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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 3050 mg Hypnotic dose 100 mg for adult, 3-5 mg/kg
BW for children
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Tranquilizer : Benzodiazepines
Benzodiazepines : anxiolysissedationamnesia
Preferable to the barbiturate
- Produce amnesia- Greater therapeutic index
- Less cardiovascular and respiratory
deppression- Longer duration of action
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Tranquilizer : Phenothiazine
Phenothiazine : sedative-antiemetic,
antihistamine (Phenergan), antipiretic
(central vasodilatation), central sympatic
depression, and minimize the effect ofadrenalin in perifer => less tension
(Largactil), dose : 25-50 mg oral/i.m
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- 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 activemetabolites : methyl diazepam, oxazepam, 3-
hydroxy diazepam prolonged CNS depression
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Minimal cardiovasculer effect
Ventilatory response to CO2depressedincrease PaCO2especially inassociation with other respiratorydepressant
Anticonvulsant in tetanus and epilepsy
Mild muscle relaxant property at spinalcord level and potentiate non
depolarizing muscle relaxantRetrogade amnesia especially whencombine with meperidine or hyoscine
Rapidly passes the placental barrier
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Doses
oral : 0,20,5 mg/kgi.v : 0,10,2 mg/kg
induction : 0,30,5 mg/kg
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MIDAZOLAM
The efect are faster and shorter, duration
approximately 60 minutes
Anterograde amnesia, has no anticonvulsanteffect
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
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CBF is decrease ICP decrease cerebral
protection Relaxation effect
Not interfere coronary circulation safe for
ischemic heart disease, in other waydiazepam interfere CVR unsafe
DROPERIDOL/ INAPSINE
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DROPERIDOL/ INAPSINE
Tranquilizer butyrophenone, phenothiazine like effect
Forced antiemetic, ICP can be decrease because of
mild cerebral vasoconstriction
Alpha adenergic receptor blockade hypotensi, itcan prevent catecholamine induced arrhythmia
Apathis
Dose : 2,5-5 mg; duration 6-8 hoursSide effect : dyskinetic involuntary movement
(extrapyramidal disturbance)
Occasionally dysphoric reaction
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Morphine
Narcotic-analgetic standard for strongpain, euphoria
Sedativa-postural hypotension because
of vasodilatation and myocard depression(depression of vasomotor center)
Constrict the sphincter of gut, peristaltic constipation
BMR , addiction-hystamine releasepositif
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Depression of cough reflex post op secret accumulation atelectasis
ICP rise in intracranial injury
Respiratory center depression CO2CBF
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PETHIDINE/ MEPERIDINE
Depression of RC, emetic effect, euphoria anddizziness are less than morphine
Less histamine release fine for asthma
Through placental blood barrier not be givenbefore umbilical cord is cutAtropine like effect : saliva dry mouth
eyes mydriasis
Dose : 50-100 mgChild : 0,5-1 mg/kg BW; duration 2-4 hours
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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
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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 depressionDose: 0,2-0,4 mg iv
Anticholinergic drugs
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Anticholinergic drugsPerthidin & 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
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Light bronchodilator
CVS : tachycardi be aware tothyrotoxicosis and ischemic HD,
cardiomyopathy
GI : intestine and urinary tractsperistaltic constipation and urineretension
BMR be aware to thyrotoxicosisdose : 0,005 - 0,01 mg/kgWB
duration of action : im until 90 ; iv 30-
45
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Combination of those drugs
patient comes to the operationroom still aware but sleepy, calm,
cooperative, there are no
complications during and after theoperation
Doses and drugs combination are
decided by patient condition and
anesthetis experience and skills
OPERATION CANCELLED
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OPERATION CANCELLED
Anemia: Hb < 10gr%
In Research Hb < 10gr% its not increasemorbiditas/ mortalitas.
If circulating volume is enough, Hb 8 gr% its notnecessary to get tranfusion
Syok: Anesthesia depression of vital organs
syok is worsening. Volume replacement untilblood pressure > 80mmHg, good peripheralcondition, diuresis is enough
Temperatur: 380C antipyretica, find focal infection
especially respiratory tract
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Influenza, pharyngitis, bronchitis electiveoperation is delayed
Airways instrument :
- trauma of infection mucosa resp.obstruction, spasm, hypersecretion Postoperative respiratory complication.- infection spread
Respiratory Infection
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