PREOPERATIVE

PREPARATION

Department Anesthesiology &

Reanimation Medical Faculty
Lampung University
 Preoperative preparation
• Preoperative visit
• Assess the risk of anesthesia and surgery
• Informed consent
• Fasting
• Premedication
 Preoperative visit

Inadequate pre op. preparation may be a

major contributory factor to the
perioperative morbidity & mortality. It is
essensial that anesthetist visits every
patient before surgery.
 The purpose of it :
• Establish rapport with the patient
– Meet the doctor with the patient
– Discuss possible causes of anxiety regarding
anesthetic and surgical manner
– Explain how the patient will be cared for during and
after anesthesia and about pain relief
– Establish a doctor-patient relationship that reduces
patient anxiety by building trust & respect
• Assessment of physical status
• Order special investigations
 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
 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)
 Successful approach (Buskirk)
• Treat all patients as human being
• Be friendly, explain your visit & your plan
• Be patient & sympathetic
• Listen to his concern, answer all questions
in understanding and warm manner
• Allay patient’s fears
 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 and
Preoperative Visit 38 38 71
Source : Data from Egbert LD et al : The value of the
preoperative visit by the anesthetist JAMA 185:553, 1963
 History and physical
examination
Personal and family history
Hereditary conditions associated with
anesthesia : porphyria, malignant hyperthermia,
haemophilia
Previous operations & anesthetics
Allergies
Medications  drug interaction
Habits : alcohol and smoking
Diseases of CVS and respiratory systems
 Alcoholism
• Impairment of liver function
• Heart  cardiac arrhythmia
– Cardiac contractility decrease
– Cardiomyopathy
• Kidney  diuretic effect by inhibiting ADH
• Plasma catecholamine increase
• Metabolic & respiratory acidosis from alcohol
intoxication
• Increases the anesthetic requirement
 Smoking
Ciliary function reduce, disturbing
tracheobronchial clearance
Increase production and thicken of sputum
Strong risk factor for coronary heart disease
and occlusive peripheral arterial disease
Systolic hypertension is potentiated
Decrease cerebral blood flow and increase risk
of stroke
Increase gastric volume & acidity
Increase COHb level, decrease blood O2
content & O2 delivery to tissue
Increase catecholamine : CVS responses & O2
requirement increase
Respiratory complication increase 5-7 times
 Recomendations
COHb fall to normal level  stop smoking 48
hours preoperatively
Reduction of sputum volume & post op
complications  stop smoking 4 weeks pre
operatively
 Physical examination
General condition : name, age, weight.
B.P. pulse rate & temperature.
Cardiopulmonary examination including
- Cyanosis in finger tips
- V. jugularis engorgement
 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
• Difficult estimate circulatory volume by V.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 gastic volume, acidity & pressure
 Physical examination
General condition : name, age, weight.
B.P. pulse rate & temperature.
Cardiopulmonary examination including
- Cyanosis in finger tips
- V. jugularis engorgement
 Airway :
- Neck : stout, short, sunker cheeks, distance
from mentum to hyoid (  5 cm)
- Mouth : mouth opening, loose or damage
teeth, protruding upper incissors

 Vertebral column : anatomical deformities may

render some blocks in practical
 Simple Bedside cardiopulmonary function
 Sebarase’s test : 2-3 deep breaths – hold as
long as possible
Time :  40 seconds  normal
30-40 seconds  diminished reserve
< 20 seconds  severely compromised

 Match test : The ability to blow out a standard

match held 6 inches from the open mouth
negative  max breathing cap low

 Tilt test
 Laboratory testing
Routine lab.test in pts who are apparently healthy
(history & clinical exam) are invariably 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
 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
 Assess the risk of anesthesia and
surgery
ASA (American Society of Anesthesiologist)
grading system
 Class I : A normally healthy individual, the
pathology which surgery is needed only
localized
 Class II : A patient with mild or moderate
systemic disease
 Class III : A patient with severe systemic
disease that is not incapacitating (limits the pt
activity)
 Class IV : A patient with incapacitating
systemic disease that is a constant threat to life
 Class V : A moribund patient who is not
expected to survive 24 hour with or without
operation
 Class E : Added as a support for emergency
operation. All pts induced in ASA I-V that need
emergency operation get a higher ASA grade
 CARDIAC RISK

CRITERIA POINTS

Hystory
- Age > 70 years 5
- MI in previous 6 mo 10

Physical examination
- S3 gallop or jugular vein distension 11
- Important VAS 3
 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
 CRITERIA POINTS

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 3
Operation
- Intraperitoneal, intrathoracic, or aortic
operation 3
- Emergency operation 4
TOTAL POSSIBLE POINTS 53
RISK CLASSIFICATION AND OUTCOME BY
THE CARDIAC RISK INDEX (CRI) AND
AMERICAN SOCIETY OF
ANESTHESIOLOGISTS (ASA) CRITERIA
No or Minor Life-Treatening
Complication Complication Cardiac Deaths
CRI
Class 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%
 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 the

patient has sufficient information about the
procedures, their risks, and benefits.

Obtaining informed consent honors a patient’s

right to self determination whether GA, regional
anesthesia, or i.v sedation.
Without the patient’s consent, the physicion may
liable for assault and battery.

When the patient is a minor or otherwise 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 chart and is signed by the
patient or their representative.
 Fasting

To prevent aspiration of gastric content

NPO 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 4 hours
Gastric emptying is delayed by : anxiety, pain, trauma,
and pregnancy.
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
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 2hours before surgery
 Premedication
Objectives 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
 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
 Sedative
Sedative in appropiate dose can reduce anxiety
and stress, in higher dose become hypnotic.

Barbiturate :
• Ultra short acting
– Thiopentone / penthotal
– Methohexitone, hexobarbitone
– Especially detoxification in liver
• 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
Barbiturate  cerebral protection

Because : cerebral metabolism , cerebral oxigen

consumption , C.B.F. , & I.C.P. 
 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
• Interfere other drugs link and metabolism
(enzyme induction)
• No analgetic effect
 Premedication  Sedativa
 Pentobarbitone sodium / nembutal and quinal
barbitone sodium / seconal  less depress
respiration and circulation, non teratogenic, and
because it is detoxificated in liver, suite for
kidney function disturbance.
– Inject 60 mg/cc, i.m, 2 hour pre op.
– Capsule 50 and 100 mg
– 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 30 – 50 mg
– Hypnotic dose 100 mg for adult, 3-5 mg/kg BW for
children
 Tranquilizer : Benzodiazepines
Benzodiazepines :anxiolysis - sedation - amnesia

Preferable to the barbiturate

- Produce amnesia
- Greater therapeutic index
- Less cardiovascular and respiratory
deppression
- Longer duration of action
 Tranquilizer : Phenothiazine
Phenothiazine : sedative-antiemetic,
antihistamine (Phenergan), antipiretic (central
vasodilatation), central sympatic depression,
and minimize the effect of adrenalin in perifer
=> less tension (Largactil), dose : 25-50 mg
oral/i.m
- 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 active
metabolites : methyl diazepam, oxazepam, 3-
hydroxy diazepam  prolonged CNS depression
• Minimal cardiovasculer effect
• Ventilatory response to CO2 depressed
increase PaCO2 especially in association with
other respiratory depressant
• Anticonvulsant in tetanus and epilepsy
• Mild muscle relaxant property at spinal cord
level and potentiate non depolarizing muscle
relaxant
• Retrogade amnesia especially when combine
with meperidine or hyoscine
• Rapidly passes the placental barrier
Doses
oral : 0,2 – 0,5 mg/kg
i.v : 0,1 – 0,2 mg/kg
induction : 0,3 – 0,5 mg/kg
 MIDAZOLAM
 The efect are faster and shorter, duration
approximately 60 minutes
 Anterograde amnesia, has no anticonvulsant
effect
 Dose : 0,15–0,1 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
 CBF is decrease  ICP decrease  cerebral
protection
 Relaxation effect
 Not interfere coronary circulation  safe for
ischemic heart disease, in other way
diazepam interfere CVR  unsafe
 DROPERIDOL/ INAPSINE

 Tranquilizer butyrophenone, phenothiazine like effect

 Forced antiemetic, ICP can be decrease because of
mild cerebral vasoconstriction
 Alpha adenergic receptor blockade  hypotensi, it
can prevent catecholamine induced arrhythmia
 Apathis
 Dose : 2,5-5 mg; duration 6-8 hours
 Side effect : dyskinetic involuntary movement
(extrapyramidal disturbance)
 Occasionally dysphoric reaction
 Morphine
Narcotic-analgetic standard for strong pain,
euphoria
Sedativa-postural hypotension  because of
vasodilatation and myocard depression
(depression of vasomotor center)
Constrict the sphincter of gut, peristaltic  
constipation
BMR , addiction-hystamine release positif
Depression of cough reflex post op  secret
accumulation  atelectasis
ICP rise in intracranial injury
Respiratory center depression CO2 CBF
Parasympatic tone:
- Bronchus  bronchoconstriction
- Eyes  myosis
Through placental blood barrier
Dose : 10-15 mg i.m/s.c, duration until 6 hours
Children : 0,1 mg/kg bodyweight

Disadvantages:
• Nausea and vomittus  not be used in
intraocular operation
• COPD or asthma  worsening
 PETHIDINE/ MEPERIDINE
• Depression of RC, emetic effect, euphoria and
dizziness are less than morphine
• Less histamine release  fine for asthma
• Through placental blood barrier  not be given before
umbilical cord is cut
• Atropine like effect : saliva  dry mouth
eyes  mydriasis
• Dose : 50-100 mg
Child : 0,5-1 mg/kg BW; duration 2-4 hours
 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
 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 depression
• Dose: 0,2-0,4 mg iv
 Anticholinergic drugs
Perthidin & 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
• Light bronchodilator
• CVS : tachycardi  be aware to thyrotoxicosis
and ischemic HD, cardiomyopathy
• GI : intestine and urinary tracts peristaltic  
constipation and urine retension
• BMR   be aware to thyrotoxicosis
• dose : 0,005 - 0,01 mg/kgWB
• duration of action : im until 90’ ; iv 30’-45’
• Combination of those drugs  patient
comes to the operation room still aware
but sleepy, calm, cooperative, there are
no complications during and after the
operation
• Doses and drugs combination are decided
by patient condition and anesthetis
experience and skills
 OPERATION CANCELLED
• Anemia: Hb < 10gr%
In Research Hb < 10gr%  it’s not increase
morbiditas/ mortalitas.
If circulating volume is enough, Hb 8 gr%  it’s not
necessary to get tranfusion
• Syok: Anesthesia  depression of vital organs 
syok is worsening. Volume replacement  until blood
pressure > 80mmHg, good peripheral condition,
diuresis is enough
• Temperatur: 380C  antipyretica, find focal infection
especially respiratory tract
 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