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Ch 07 Pre-Operative Care(2)

Ch 07 Pre-Operative Care(2)

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Published by Christian Leepo
Anaesthesia in Developing Countries
Anaesthesia in Developing Countries

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Categories:Business/Law, Finance
Published by: Christian Leepo on Sep 15, 2009
Copyright:Attribution Non-commercial

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05/11/2014

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CHAPTER 7PRE-OPERATIVE CARE
Outline:Pre–operative assessment
HistoryExaminationInvestigationsASA Classification
Pre–operative preparation
PrinciplesEmergency surgery – special problemsFasting Guidelines
Premedication
PurposesDrugs used for premedicationRoutes of administrationChoice of drugs
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PRE-OPERATIVE ASSESSMENT
The role of the anaesthetist begins not in the operating theatre but in theward. The pre-operative assessment is designed to present the patient for surgery in the best possible condition.
HISTORYAnaesthetic
Any problems encountered during past anaesthetics must be fullyinvestigated. Records of previous occasions yield a wealth of information onresponse to various drugs, intubation difficulties, allergic responses and post–operative problems.Family anaesthetic history is also important because certain abnormal and possibly dangerous responses to drugs (e.g. malignant hyperpyrexia,suxamethonium apnoea) tend to run in families.Further, several diseases which can give rise to "anaesthetic problems" for instance sickle cell disease, dystrophia myotonica and blood dyscrasias,have a familial incidence.
Medical
Respiratory problems: cough, sputum, smoking, asthma, breathlessnessand exercise tolerance. History of previous chest disease (TB, bronchitis etc)
Cardiovascular disease:Difficulty in breathing, palpitation, chest pain, ankle oedemaPrevious heart attacksExercise toleranceHypertension
Other illnesses, e.g. diabetes, renal disease, hiatus hernia, epilepsy
Alcohol and drug intake
Allergies
Smoking habits
Surgical
Past surgical procedures as well as that for which the patient is beingassessed are important.Some operations, such as those on the heart, lungs, kidneys and CNS maytend to interfere with vital functions under anaesthesia.
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Drug history
The following drugs, previously or currently being taken may influence present anaesthesia.
 Steroids
Prolonged steroid therapy (> 10mg prednisolone/day) results in atrophy of the adrenal glands so that they cannot secrete extra hormones in time of stress. Collapse, with a fall of blood pressure, may ensue. Many differentregimes have been described to provide perioperative steroid cover. The principles are as follows:
Hydrocortisone sodium succinate (rapidly acting) is the drug mostfrequently used.
Steroid cover is provided if the patient has had steroids in the threemonths before surgery unless the surgery is very minor and imposesvery little stress on the patient.
Hydrocortisone is administered at induction.Dose: 25mg IV (adult)
Any unexplained fall in blood pressure either during or after surgery istreated with steroids. However hypotension from more common causesi.e. blood loss or hypoxia must be excluded.
The steroid cover is maintained until the stress of the operative and post-operative period is over and then gradually reduced.
For a more detailed description of this regime see Chapter 40 Antihypertensive drugs
These drugs produce their effect by a reduction in peripheral vascular tone.This tends to interfere with circulatory homeostasis under anaesthesia. Most patients are left on these tablets until the day of operation. The anaesthetistmust bear in mind that these patients cannot compensate for such stresses as blood loss, changes in posture, intermittent positive pressure ventilation(IPPV), etc. in the same way as normal patients can. Further, they may react badly to drugs such as thiopentone which can cause a fall in blood pressure.
 Monoamine oxidase inhibitors (MAOI)
The actions of these drugs are imperfectly understood. They interact withnarcotic analgesics, e.g. pethidine and morphine and result in various bizarrereactions - severe hypo or hypertension, coma, convulsions, Cheyne Stokesrespiration and death. They also react abnormally with pressor drugs and potentiate the side effects of barbiturates. The effects of MAOI last from 1 to2 weeks depending on the drugs. Suspension of MAOI will be necessary for major surgery requiring post-operative analgesia. This must be done 10 to14 days pre-operatively.
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