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 PREOPERATIVE PREPARATION  by Deddy Koesmayadi, dr.,SpAnKIC Anesthesiology Department & Reanimasi Faculty Padjadjaran University/Hasan Sadikin General Hospital
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Preop Anes

Apr 14, 2018

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PREOPERATIVE PREPARATION

 by

Deddy Koesmayadi, dr.,SpAnKIC

Anesthesiology Department & ReanimasiFaculty Padjadjaran University/Hasan

Sadikin General Hospital

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Preoperative preparation

• Preoperative visit

• Assess the risk of anesthesia and surgery

• Informed consent

• Fasting

• Premedication

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Preoperative visitInadequate pre op.preparation may be

a major contributory factor to the

  perioperative morbidity & mortality.

It is essensial that anesthetist visits

every patient before surgery.

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The purpose of it :• Establish rapport with the patient

 – Meet the doctor with the patient

 – Discuss possible causes of anxiety regardinganesthetic and surgical manner 

 – Explain how the patient will be cared for duringand after anesthesia and about pain relief 

 – Establish a doctor-patient relationship thatreduces patient anxiety by building trust &

respect• Assessment of physical status

• Order special investigations

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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 

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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)

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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

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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 andPreoperative Visit 38 38 71

Source : Data from Egbert LD et al : The value of the

 preoperative visit by the anesthetist JAMA 185:553, 1963

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History and physical examinationPersonal 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

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Alcoholism• Impairment of liver function

• Heart cardiac arrhythmia

 – Cardiac contractility decrease

 – Cardiomyopathy

• Kidney diuretic effect by inhibitingADH

• Plasma catecholamine increase

• Metabolic & respiratory acidosis fromalcohol intoxication

• Increases the anesthetic requirement

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Smoking

Ciliary function reduce, disturbingtracheobronchial clearance

Increase production and thicken of sputumStrong risk factor for coronary heart disease

and occlusive peripheral arterial disease

Systolic hypertension is potentiated

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Decrease cerebral blood flow and increase

risk of strokeIncrease gastric volume & acidity

Increase COHb level, decrease blood O2 

content & O2 delivery to tissueIncrease catecholamine : CVS responses &

O2 requirement increase

Respiratory complication increase 5-7 times

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Recomendations

COHb fall to normal level → stop smoking

48 hours preoperatively

Reduction of sputum volume & post op

complications → stop smoking 4 weeks pre

operatively

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Physical examination

General condition : name, age, weight.

B.P. pulse rate & temperature.

Cardiopulmonary examination including- Cyanosis in finger tips

- V. jugularis engorgement

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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

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•Difficult estimate circulatory volume byV.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

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Physical examination

General condition : name, age, weight.

B.P. pulse rate & temperature.

Cardiopulmonary examination including- Cyanosis in finger tips

- V. jugularis engorgement

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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

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Simple Bedside cardiopulmonary function

Sebarase’s test : 2-3 deep breaths – hold aslong as possible

Time : ≥ 40 seconds normal

30-40 seconds diminished

reserve< 20 seconds severelycompromised

Match test : The ability to blow out a standardmatch held 6 inches from the open mouthnegative →max breathing cap low

Tilt test

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Laboratory testing

Routine lab.test in pts who are apparentlyhealthy (history & clinical exam) areinvariably of little use and wasting.

Blood : Hb, leuco all female, male > 50, major 

surgery, clinically indicated

Ureum, creatinine

pt > 50, renal &hepatic diseases, diabetes, abnormalnutritional state

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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

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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 systemicdisease that is not incapacitating (limits the ptactivity)

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Class IV : A patient with incapacitatingsystemic disease that is a constant threat tolife

Class V : A moribund patient who is not

expected to survive 24 hour with or withoutoperation

Class E : Added as a support for emergency

operation. All pts induced in ASA I-V thatneed emergency operation get a higher ASA grade

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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

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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

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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 riddenfrom non cardiac causes 3

Operation

- Intraperitoneal, intrathoracic, or aortic

operation 3

- Emergency operation 4

TOTAL POSSIBLE POINTS 53

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RISK CLASSIFICATION AND OUTCOME BY

THE CARDIAC RISK INDEX (CRI) AND

AMERICAN SOCIETY OFANESTHESIOLOGISTS (ASA) CRITERIA 

  No or Minor Life-Treatening

Complication Complication Cardiac Deaths

Class

CRI

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%

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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 patienthas sufficient information about the procedures,

their risks, and benefits.

Obtaining informed consent honors a patient’s right

to self determination whether GA, regionalanesthesia, or i.v sedation.

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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 issigned by the patient or their representative.

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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 hoursGastric emptying is delayed by : anxiety, pain,

trauma, and pregnancy.

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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

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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 2 hours before

surgery 

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PremedicationObjectives 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

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Drugs for premedication

Sedativa, tranquilizer 

 Narcotics-analgetics

Alkaloid belladona as antisecretion andreduce vagal reflex to the heart from :

 – drugs

 – impuls afferent abdomen, thorax, andeyes

Antiemetic

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Sedative

Sedative in appropiate dose can reduceanxiety and stress, in higher dose become

hypnotic.

Barbiturate :

• Ultra short acting

 – Thiopentone / penthotal

 – Methohexitone, hexobarbitone

 – Especially detoxification in liver 

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• 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

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Barbiturate ⇒cerebral protection

Because : cerebral metabolism ↓, cerebraloxigen consumption ↓, C.B.F. ↓, & I.C.P. ↓

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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 

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• Interfere other drugs link and metabolism

(enzyme induction)

•  No analgetic effect

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Premedication ⇒Sedativa

Pentobarbitone sodium / nembutal andquinal barbitone sodium / seconal ⇒ less

depress respiration and circulation, nonteratogenic, and because it is detoxificatedin liver, suite for kidney functiondisturbance.

 – Inject 60 mg/cc, i.m, 2 hour pre op. – Capsule 50 and 100 mg

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 – 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 BWfor children

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Tranquilizer : Phenothiazine

Phenothiazine : sedative-antiemetic,

antihistamine (Phenergan), antipiretic

(central vasodilatation), central sympaticdepression, and minimize the effect of 

adrenalin in perifer => less tension

(Largactil), dose : 25-50 mg oral/i.m

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- 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 producesactive metabolites : methyl diazepam,

oxazepam, 3-hydroxy diazepam prolonged

CNS depression

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• Minimal cardiovasculer effect

• Ventilatory response to CO2 depressedincrease PaCO2 especially in association

with other respiratory depressant

• Anticonvulsant in tetanus and epilepsy• Mild muscle relaxant property at spinal cordlevel and potentiate non depolarizingmuscle relaxant

• Retrogade amnesia especially whencombine with meperidine or hyoscine

• Rapidly passes the placental barrier 

 

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Doses

oral : 0,2 – 0,5 mg/kgi.v : 0,1 – 0,2 mg/kg

induction : 0,3 – 0,5 mg/kg

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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

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CBF is decrease → ICP decrease → cerebral

 protection Relaxation effect

  Not interfere coronary circulation → safe for 

ischemic heart disease, in other way diazepaminterfere CVR →unsafe

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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 hoursSide effect : dyskinetic involuntary movement

(extrapyramidal disturbance)

Occasionally dysphoric reaction

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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 

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Depression of cough reflex post op ⇒ secret

accumulation ⇒atelectasis

ICP rise in intracranial injury

Respiratory center depression ⇒CO2 ↑⇒ 

CBF ↑

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Parasympatic tone:

- Bronchus →bronchoconstriction- Eyes →myosis

Through placental blood barrier 

Dose : 10-15 mg i.m/s.c, duration until 6 hoursChildren : 0,1 mg/kg bodyweight

Disadvantages:

•  Nausea and vomittus →not be used in intraocular operation

• COPD or asthma →worsening

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PETHIDINE/ MEPERIDINE

• Depression of RC, emetic effect, euphoria anddizziness 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 

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FENTANYL SUBLIMATE

• Stronged analgetic, 100 x morphine

• CVS effect are minimal so the histamine release

• Duration : 45’-60’• Dose : 0,05-0,1 µg I.m, 1 hour pre.op.

• Disadvantages:

-Respiratory depression

-Bradycardi, miosis

-Bronchoconstriction

-somatic muscle spasm

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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

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Anticholinergic drugsPerthidin & 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 - 2mg

• CNS : Tendency to stimulate CNS,

hyoscine sedation

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• Light bronchodilator 

• CVS : tachycardi ⇒  be aware tothyrotoxicosis 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’

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• Combination of those drugs →patient

comes to the operation room stillaware 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

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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 notnecessary 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

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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

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