Preop.assessment Somsak aree-wattana, M.D. Phongthara Vichitvejpaisal, M.D. Department of Anesthesiology Faculty of Medicine Siriraj Hospital Mahidol University Objectives to see the patients 1. 2. 3. 4. 5. 6. Patient’s data Tests and consultations Education about anesthesia Care plans Informed consent Effective resources utilization Physical Status Classification Physical Status Modified Slightly from USA Definition 1.The patient has no systemic disease, including the pathologic process for which operation is needed, which is localized. 2.The patient suffers mild or moderate systemic disease due either to the surgical condition or to a concomitant disease. 3. Severe systemic disease limits the patient’s activity. Physical Status Classification Physical Status Modified Slightly from USA Definition (cont.) 4.Severe life-threatening disease markedly limits the patient. 5.The moribund patient has a 50 percent 24-hour mortality, regardless of the planned operation. 6.The patient is declared dead and will undergo operation for organ donation. 7.When the patient requires emergency operation, and E is appended to the PS number. Physical Status Classification American Society of Anesthesiologists (ASA) Class I ผูป ้ ่วยสุขภาพดี เข้ารับการผ่าตัด elective surgery Class II ผู้ป่วยที่มีโรคประจาตัวเล็กน้อย Class III ผู้ป่วยที่มีโรคประจาตัวรุนแรงจนจากัดการเคลื่อนไหว แต่ยังทากิจวัตรได้บ้าง Class IV ผูป ้ ่วยที่มีโรคประจาตัวที่ทาให้เกิดความพิการเป็นอันตรายต่อชีวต ิ Class V ผูป ้ ่วยหนักที่คาดว่าอาจมีชวี ิตอยู่ไม่ถึง 24 ชั่วโมง แม้จะได้หรือไม่ได้รับการผ่าตัด Objective of preanesthetic evaluation  Review database medical history consultations laboratory and diagnostic studies  Perform physical examination directed at anesthetic concerns  Develop anesthesia management plan  Obtain consent  Establish doctor-patient relationship Review of Medical Records  relevant medical history  Previous consultations  Previous diagnostic test  Prior anesthetic records History and Physical Examination  History   Present illness Past medical history - - Medical problem with brief history Medication Allergy Past surgical and anesthetic history Family history Social history Review of system General Review of Organ System Function         General Skin Head Eye and ears Nose and throat Mouth Cardiac respiratory         Gastrointestinal Urinary Female Extremities Neurologic Endocrine Psychiatric prosthetics Physical examination        Vital signs Dental examination Airway examination Pulmonary examination Cardiac examination Neurologic and musculoskeletal examination Others Preop Evaluation Laboratory Testing Strategy for Preoperative Testing Preoperative condition HGB M F Precedure with blood loss     WBC PT/ PTT PLT BT Electrol yte Creat/ BUN Bl. Glu AST/A LK Chost flim ECG Age <40  Age 40-49  Age 50-55  Age : 65    Cardiovascular disease  Pulmonary disease Malignancy Randlation therapy  T/S  Procedure without blood loss Neonates Preg          Laboratory Testing Strategy for Preoperative Testing (cont.) Preoperative condition HGB M WBC F Hepatic disease PT/ PTT PLT BT Electrol yte Creat/ BUN Bl. Glu  ECG      Diabetes          Possible pregnancy  Diuretic use   Digoxin use   Steroid use  Anticoagulant use CNS disease Preg  Blooding disorder Smoking >20 pack-yr Chost flim  Exposure to hepatitis Renal disease AST/A LK           T/S  Aspiration of gastric contents - fasting - gastric anti-secretory agents - H2 blocker - PGE1 - Omeprazole  Aspiration of gastric contents - ondansetron - metoclopramide - droperidol Anesthetic impression and Plan Components: 1. Brief summary of the patient’s history and physical findings as they pertain to anesthesia management, organized in a problem list, parallelling any existing problem list used by the primary physician 2. Planned anesthetic technique including special techniques discussed (e.g. fiberoptic intubation, invasive monitoring) 3. Planned postoperative pain management, if appropriate Anesthetic impression and Plan Components: 4. Special postoeprative issues when indicated (e.g., ICU stay) 5. Request for further medical evaluation if indicated 6. Statement of risks, informed consent, and statement the all questions were answered 7. Physical status classification and brief justification Informed Consent Inform • anesthetic options risks benefits appropriate information written documentation Premedication  Common problems amenable to treatment before anesthesia and operation Anxiety Amnesia Pain Salivation and airway secretions Vagal reflexes Hypertensive response Aspiration of gastric contents nausea and vomiting Infection Reaction to iv contrast media, latex Continuation of preoperative therapy Alleviating anxiety   Without drugs With drugs Drug Group Drug Name Drug dose Route Anticholinergics Atropine 0.2-0.6 IM/TV Glycopyrrolate 0.2-0.3 IM/TV Scopolamine 0.2-0.4 IM/TV Gastrokinetics Metoclopramide 10-20 Oral, IM/TV H2 antagonists Cimetidine 300 Oral, IM/TV Alpha-2-agonists Clonidine 0.20-0.40 Oral 5-HT antagonist Ondansetron 4.0-8.0 IM/TV Alleviating anxiety Without drugs  With drugs Drug dose Drug Group Benzodilazepines Diazepam Flurazepam Lorazepam Midazolam Triazolam Tranqullizers Droperidol Antihistamines Diphenhydramine Hydroxyzine Opioids Fentanyl Hydromorphone Mophrine Meperidine  Drug dose 5-20 15-30 2-4 2-5 0.125-0.250 0.625-2.5 25-75 50-100 0.05-0.2 1.0-2.0 5-15 50-100 Route Oral Oral Oral, IM IM/TV Oral IM/TV Oral, IM/TV IM IM/TV IM/TV IM/TV IM/TV Amnesia Anterograde amnesia - midazolam - lorazepam - scopolamine (0.4-0.6 mg iv) Analgesia - opioids Reducing salivation and bronchial secretions - Glucopyrrolate 0.2-0.4 mg iv/im  Blocking vagal reflexes - atropine - 0.2-0.4 mg iv/im - 0.01 mg/kg iv (infant)  Prevention of hypertension - continue antihypertensive drug adequate depth of anesthesia premedication - opioid - a1b sympathetic blocker - a2sympathetic blocker ; clonidine  Anticonvulsants - continue anticonvulsants premedication with benzodiazepines Continuation of preoperative therapy Antihypertensive drug nitrate drug bronchodilator diuretics antidepressants glucocorticoids insulin regimen Premedication to prevent infection Prophylaxis of Endocarditis 1. For dental, oral or upper respiratory procedures: amoxicilline 3.0 g PO 1 hour For amoxicillin – PCN allergic patients: Erythromycin 800 mg PO, 2 hours preoperatively And 400 mg 6 hours after initial dose of clindamycin 300 mg PO 1 hour preoperatively and 150 mg 6 hours after initial dose Premedication to prevent infection Prophylaxis of Endocarditis (cont.) 2. Altematives for dental, oral or upper respiratory procedures: ampcillin 2.0 g IV/IM 30 min preoperatively; then 6 hours later, ampicillin 1.0 g IV/IM or amoxicillin 1.5 g PO. A second option: clindamycin 300 mg IV 30 min preoperatively, then in 6 hours, 150 mg IV. Premedication to prevent infection Prophylaxis of Endocarditis (cont.) 3.For GVGU procedures: IV/IM ampicilin 2.0 g plus gentamicin 1.5 mg/kg (not to exceed 80 mg) 30 minutes preoperatively; then repeat parenteral ampicilin and gentamicin 8 hours later, or substitute amoxicilin 1.5 g PO 6 hours later. For ampicilin/amoxicilin/PCN allergic patients: vancomycin and gentamicin: IV vancomycin 1.0 g plus IV/IM gentamicin 1.5 mg/kg (not to exceed 80 mg) 1 hour preoperatively; may repeat 8 hours after initital dose Thank you for your attention