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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 .

0 µg/kg/min I/V .INDUCTION OF ANESTHESIA Ketamine should be avoided Fast intubation Continuous Infusion of nitroglycerine 0.25 to 1.

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

PREOPERATIVE AND INTRAOPERATIVE AIM Assessment and optimization of blood pressure control Assessment of associated pathology Anesthetic management Postoperative management .HYPERTENSION .

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 .

albumin.RENAL SYSTEM Perform routine urinalysis Urea / electrolytes Serum creatinine. 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 .

atracurium. lisatracurium Blood loss may be alarming Ventilation .INTRAOPERATIVE MANAGEMENT Neuromuscular blocking drugs like mivacurium.

the GFR and urine output .5 to 3. mannitol or furesemide are discouraged If fluid replacement does not restore urine output a diagnosis of congestive heart failure may be considered. Dopamine 0.0 µg/kg/min IV increases renal blood flow.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.

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 .

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 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.

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 .

hydrocortisone 13 mg/kg/2 hour prior to surgery in addition to inhaled β2 agonist therapy) . current brochoconstriction) Maintain routine therapy and administer selective β2 agonist (salbutamol) prior to surgery Corticosteroids should be used (e.PREOPERATIVE AIM TYPE Mild asthma (no previous hospitalization) TREATMENT Maintain routine therapy and administer selective β2 agonist (salbutamol) via aerosol or nebulizer prior to surgery Moderate asthma (some functional impairment routine use of bronchodilator) Severe asthma (significant impairment.g.

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 .

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

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 0.0 unit/hour Provide sufficient glucose (5-10 g/hour) and potassium (2-4 mEq/L) .5-1.

3 unit/hour Increase insulin infusion rate by 0.5 unit/hour .3 unit/hour No change in insulin infusion rate Increase insulin infusion rate by 0.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.

THYROID Hyperthyroidism – To render hyperthyroid patient euthyroid prior to surgery – Emergency surgery Esmolol 100-300 µg/kg/min IV until heart rate < 100 bpm .

ELECTIVE SURGERY Oral administration of a β adrenergic antagonist Antithyroid drugs Antithyroid drugs + potassium iodide Potassium iodide plus a β adrenergic receptor antagonist .

COMPLICATION THAT MAY OCCUR DURING INTRAOPERATIVE PERIODS WITH CONTROLLED HYPERTHYROIDISM Thyroid storm Precipitation of angina. myocardial infarction or cardiac failure Tachyarrhythmia .

such as ketamine. pancuronium and atropine Use of β blockade to control heart rate Adequate depth of anesthesia to ablate noxious stimuli Good postoperative pain control .MANAGEMENT Intravenous administration of antithyroid drug Indwelling arterial monitoring Sedating premedication to allay anxiety Avoidance of drugs that may provoke tachycardia.

HYPOTHYROIDISM Management – Render euthyroid before surgery by oral administration of T4 .

epistaxis.g. dipyridamide) – Family history of bleeding . menorrhagia.g. aspirin.COAGULATION STATUS Special assessment is necessary in patients with a history of bleeding e. Points to be noted in history are: – Alcoholism – Liver disease – Administration of corticosteroids or antiplatelet drugs (e. petechiae. purpura or ecchymosis.

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 .