PREOPERATIVE PREPARATION AND INTRAOPERATIVE MANAGEMENT OF HIGH RISK CASES

Aim of Preoperative Planning Issues that should be discussed with patient preoperatively Important coexisting medical diseases that increases the morbidity and mortality of surgery Non-specific factors that may increase the operative risk for patients undergoing surgery

MAJOR CARDIAC RISK FACTORS

MI within previous 3 or 6 months
Unstable angina

Untreated cardiac failure

Significant aortic valve stenosis

Untreated hypertension

RELATIVE CARDIAC RISK FACTORS

Prior MI Jugular vein distension Non-sinus rhythm Ventricular ectopic beats / min

Age > 70 years

Surgery > 3 hours Emergency surgery PaO2 < 60 mm Hg, PaCO2 > 50 mm Hg Chronic liver impairment

PREOPERATIVE ASSESSMENT FOR CARDIOVASCULAR SYSTEM

Chest X-ray
ECG Stress ECG Isotopic scanning Echocardiography Coronary angiography

ASSOCIATED RISK WITH PREVIOUS PATHOLOGY

PREVIOUS PATHOLOGY ASSOCIATED RISK OF MI 5% 6%

No previous pathology Acute MI > 6 months previously

MI 3-6 months ago

Infarction < 3 months ago

10-15%
30%

GRADING SYSTEM FOR ASSESSMENT OF ANGINA

CLASS Class 1 ASSESSMENT OF ANGINA Angina with strenuous exercise Angina with moderate exercise Angina after climbing one flight of stairs or walking one block Angina with any exercise INVESTIGATION Exercise ECG RISK OF SURGERY None

Class 2

Exercise ECG
Coronary angiography and coronary artery surgery

None

Class 3

High incidence of MI High incidence of mI

Class 4

Prior to elective surgery

MANAGEMENT IN PATIENTS WITH KNOWN OR SUSPECTED ISCHEMIC HEART DISEASE

Preoperative preparation and medication
Optimal preoperative anti-ischemia and antihypertension therapy

Pharmacological
decrease anxiety

and

psychological

attempt

to

Drugs used for medical management of patients with ischemic heart disease are continued throughout the perioperative periods

Intraoperative Management
The goal to prevent myocardial ischemia is achieved by maintaining the balance between myocardial oxygen delivery and myocardial oxygen

requirement.

INTRAOPERATIVE EVENTS THAT INFLUENCE THIS BALANCE

Decreased oxygen delivery
Decreased coronary blood flow

Decreased oxygen content

Increased preload (wall tension)

Increased oxygen requirement

Sympathetic nervous system stimulation

INDUCTION OF ANESTHESIA
Ketamine should be avoided

Fast intubation
Continuous Infusion of nitroglycerine

0.25 to 1.0 g/kg/min I/V

MAINTENANCE OF ANESTHESIA
Choice of Muscle Relaxant
Monitoring
ECG Pulmonary artery catheter Transesophageal echocardiography Intraoperative treatment of myocardial ischemia

HYPERTENSION - PREOPERATIVE AND INTRAOPERATIVE AIM

Assessment and optimization of blood pressure control Assessment of associated pathology Anesthetic management

Postoperative management

HYPERTENSION
Intraoperative management
Volatile anesthetics are useful Infusion of nitroprusside Labetalol

JAUNDICE (HEPATIC FAILURE)

Complications that jaundiced patient associated
with are
Renal dysfunction Sepsis Coagulation disturbance Poor wound healing

PREOPERATIVE MEASURE TO REDUCE THESE COMPLICATIONS

Strict perioperative control of fluid and
electrolyte balance Preoperative volume expansion Antibiotic prophylaxis Assessment of coagulation status

Assessment of nutritional status

Perform baseline investigation

ANAESTHESIA
Induction of Anesthesia

Muscle Relaxant
Monitoring

RENAL SYSTEM
Perform routine urinalysis Urea / electrolytes Serum creatinine, albumin, serum & urinary osmolality Perform USG of renal tract

Plain abdominal X-ray

IVU (intravenous urogram) DTPA / DMSA

In critically ill patients, measure urinary output hourly

Insert urinary catheter preoperatively

ASSOCIATED MEDICAL PROBLEMS OF PATIENT WITH CHRONIC RENAL FAILURE

Cardiovascular Acid base and metabolic Immune system Coagulation Miscellaneous

INTRAOPERATIVE MANAGEMENT
Neuromuscular blocking drugs like

mivacurium, atracurium, lisatracurium Blood loss may be alarming Ventilation

FLUID MANAGEMENT
If patient is anuric ringer lactate solution or other K+ containing fluids should not be administered Administration of balanced salt solution 3-5 ml/kg/hr IV is often recommended Without adequate intravascular fluid replacement,

mannitol or furesemide are discouraged If fluid replacement does not restore urine output a

diagnosis of congestive heart failure may be considered.

Dopamine 0.5 to 3.0 g/kg/min IV increases renal blood flow, the GFR and urine output

RESPIRATORY SYSTEM
Risk factors which increase the incidence of
postoperative pulmonary complications
History
Examination Surgery and Anesthesia

PREOPERATIVE MEASURES TO REDUCE POSTOPERATIVE PULMONARY COMPLICATION

Preoperative bronchodilator therapy Preoperative chest physiotherapy

Cessation of smoking 68 weeks prior to major

surgery Use of an incentive spirometer and instruction in

techniques

of

deep

breathing

and

coughing

improves pulmonary function

PREOPERATIVE MEASURES TO REDUCE POSTOPERATIVE PULMONARY COMPLICATION

Regular assessment of pulmonary function Pain, insert an epidural catheter at the time of surgery Regional anesthetic techniques such as local nerve block, brachial block or spinal anesthetic If an acute upper or lower respiratory tract infection

is there then postpone elective procedure for at least

2 weeks following resolution Prophylactic antibiotics

PREOPERATIVE ASSESSMENT OF COMPROMISED PULMONARY FUNCTION

Proper history and examination Chest X-ray ECG

Blood gas analysis

Spirometric test
Forced Vital Capacity (FVC)

Forced Expiratory Volume in Liters (FEV1)

Peak Flow Rate (PFR) FEV1 / FVC ratio

ASTHMA
Asthma is a syndrome of heightened bronchial reactivity resulting in airflow obstruction of

variable severity

PREOPERATIVE AIM
TYPE Mild asthma (no previous hospitalization) TREATMENT Maintain routine therapy and administer selective 2 agonist (salbutamol) via aerosol or nebulizer prior to surgery

Moderate asthma (some functional impairment routine use of bronchodilator) Severe asthma (significant impairment, current brochoconstriction)

Maintain routine therapy and administer selective 2 agonist (salbutamol) prior to surgery
Corticosteroids should be used (e.g. hydrocortisone 13 mg/kg/2 hour prior to surgery in addition to inhaled 2 agonist therapy)

INTRAOPERATIVE MEASURE TO REDUCE INCIDENCE OF POSTOPERATIVE PULMONARY COMPLICATIONS

Use minimally invasive surgery (laparoscopic)

techniques when possible

Consider use of regional anesthesia Avoid use of long-acting neuromuscular blocking drugs Avoid surgical procedures likely to require more

than 3 hours

ENDOCRINE SYSTEM
Diabetes
Incidence: ~2.5% of the population have diabetes >90% have non-insulin dependent diabetes mellitus (NIDDM or type II diabetes)

ASSESSMENT OF COEXISTENT PROBLEM

Cardiovascular system Hypertension Peripheral vascular disease Renal disease

MANAGEMENT OF DM
MINOR IMMEDIATE / MAJOR Measure blood glucose 4 hourly, if >12 mmol/lt start dextrose insulin infusion. Avoid IV dextrose Omit medications and monitor blood glucose 1-2 hourly, if >12 mmol/lt start dextrose insulin infusion

Controlled by diet

No specific precaution

Controlled by oral agents

Omit medication on morning of operation and start when eating normally ostoperatively

Controlled by insulin

Unless very minor procedure (omit insulin when nil by mouth) give dextrose-insulin infusion during surgery and until eating normally postoperatively

CONTINUOUS INTRAVENOUS INFUSION OF REGULAR INSULIN DURING THE PERIOPERATIVE PERIOD

Mix 50 units of regular insulin in 500 ml of normal

saline (1 unit/hr = 10 ml/hr)

Initiate intravenous infusion at 0.5-1.0 unit/hour Provide sufficient glucose (5-10 g/hour) and

potassium (2-4 mEq/L)

Measure blood glucose concentration as necessary every (1-2 hours) and adjust glucose infusion rate accordingly.

Turn intravenous infusion off for 30 min

< 80 mg/dL

Administer 25 ml of 50% glucose Remeasure the blood glucose concentration in 30 min

80-120 mg/dL 120-180 mg/dL 180-220 mg/dL >220 mg/dL

Decrease insulin infusion rate by 0.3 unit/hour No change in insulin infusion rate Increase insulin infusion rate by 0.3 unit/hour Increase insulin infusion rate by 0.5 unit/hour

THYROID
Hyperthyroidism
To render hyperthyroid patient euthyroid prior to

surgery
Emergency surgery
Esmolol 100-300 g/kg/min IV until heart rate < 100 bpm

ELECTIVE SURGERY
Oral administration of a adrenergic antagonist
Antithyroid drugs

Antithyroid drugs + potassium iodide

Potassium iodide plus a adrenergic receptor

antagonist

COMPLICATION THAT MAY OCCUR DURING INTRAOPERATIVE PERIODS WITH CONTROLLED HYPERTHYROIDISM
Thyroid storm

Precipitation of angina, myocardial

infarction or cardiac failure

Tachyarrhythmia

MANAGEMENT
Intravenous administration of antithyroid drug

Indwelling arterial monitoring

Sedating premedication to allay anxiety Avoidance of drugs that may provoke tachycardia,

such as ketamine, pancuronium and atropine

Use of blockade to control heart rate Adequate depth of anesthesia to ablate noxious stimuli Good postoperative pain control

HYPOTHYROIDISM
Management
Render euthyroid before surgery by oral

administration of T4

COAGULATION STATUS
Special assessment is necessary in patients

with

history

of

bleeding

e.g.

epistaxis,

menorrhagia, petechiae, purpura or ecchymosis. Points to be noted in history are:

Alcoholism Liver disease Administration of corticosteroids or antiplatelet drugs (e.g. aspirin, dipyridamide) Family history of bleeding

SCREENING TEST
Vascular and platelet defect Clotting mechanism Fibrinolysis in DIC Elderly patient (more than 60 years)

PAEDIATRIC SURGERY
We have to take special considerations
Physiology
Respiratory system Cardiovascular system Fluid requirement Renal function

Pharmacology
Anesthetic requirement Muscle requirement Pharmacokinetic Monitoring

Hematology
Thermoregulation

PROPHYLAXIS
DVT
Prophylactic measures
Cessation of smoking Avoidance of pressure on the venous intima Adequate perioperative fluid hydration Early mobilization Use of graduated elastic compression stocking Physical method Electrical calf stimulation, pneumatic leg compression

DVT DRUG PROPHYLAXIS

Indicated in selective patients

Most frequently used drug regimen

Low molecular weight heparin single injection each day may be given 12 hourly before surgery

Low dose subcutaneous heparin 5000 IU given 2

hours before surgery Dextran 40 to 70 (500 ml IV preoperatively)

Antibiotics
Renal function