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Aishah Awatif Haziq. Pre-operative evaluation and preparation (prior to procedure under general anesthesia). Introduction . Anaesthesia = absence of all sensation Analgesia = absence of pain

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Aishah awatif haziq

Aishah

Awatif

Haziq

Pre-operative evaluation and preparation (prior to procedure under general anesthesia)


Introduction
Introduction

  • Anaesthesia = absence of all sensation

  • Analgesia = absence of pain

  • General anaesthesia = a state where all sensation is lost and the patient is rendered unconscious by drugs.

  • GA should be performed by qualified anasthetists in a hospital setting with access to appropriate medical support.


Assessment of risk
Assessment of risk

  • Patient should be made as fit as possible for the operation.

  • The anticipated benefit should outweigh the anesthetic and surgical risks involved.


Pre operative evaluation and preparation prior to procedure under general anesthesia

  • Overall mortality rate ≈ 1 in 100 000

  • Surgical mortality ≈ 1 in 1000

  • Factors contribute to this mortality:

    • Poor preoperative assessment

    • Inadequate supervision and monitoring in the intraoperative period

    • Inadequate postoperative care


Aims of pre operative evaluation and preparation
Aims of Pre-operative evaluation and preparation

  • To provide diagnostic & prognostic information.

  • To ensure the patient understands the nature, aim, and expected outcome of surgery.

  • To relieve anxiety and pain.

  • Ensure that the right patient gets the right surgery.

  • Get informed consent.

  • Assess/balance risks of anaesthesiaans maximize fitness.

  • Check anaesthesia/analgesia type with anesthesia.



History
History

  • Past medical history:

    • Asthma

    • Diabetes

    • Tuberculosis

    • Seizures

    • Chronic organ dysfunction

    • HIV infection

    • Drug allergy

    • DVT

    • Post-operative nausea and vomiting


Drug history
Drug history

  • Drug interactions

    • Anticoagulant might be contraindicated to spinal, epidural or other regional techniques

    • Anticonvulsants might increase the requirements for anasthetic agents, enflurane should be avoided as it might precipitate seizures

    • Beta-blockers – negative ionotropic effect – hypotension


Pre operative evaluation and preparation prior to procedure under general anesthesia


Social history
Social history

  • Ceasing smoking 12h before surgery can improve the oxygen carrying capacity of the blood.

  • Excessive alcohol – hepatic and cardiac damage


Family history
Family history

  • Hereditary traits:

    • Haemophilia

    • Porphyria

    • Cholinesterase abnormalities – prolongation of muscle relaxants such as suxamethonium


Physical examination
Physical examination

  • Assess cardiorespiratory system, exercise tolerance, existing illness, drugs, and allergies.

  • Is the neck unstable (eg; arthritis complicating intubation?)

  • Assess past history of; MI, diabetes, asthma, hypertension, rheumatic fever, epilepsy, jaundice.

  • Assess any specific risk, eg is the patient pregnant? Is the neck/jaw immobile and teeth stable (intubation risk)?


Pre operative evaluation and preparation prior to procedure under general anesthesia



Pre operative evaluation and preparation prior to procedure under general anesthesia

Indications of preoperative investigations

  • Full blood count

    • anaemia

    • females post menarche

    • cardiopulmonary disease

    • possible haematological pathology, e.g.

    • haemoglobinopathies

    • likelihood of significant intraoperative blood loss

    • history of anticoagulants

    • chronic diseases such as rheumatoid disease


Pre operative evaluation and preparation prior to procedure under general anesthesia

  • Clotting screen

    • liver disease

    • anticoagulant drugs or a history of bleeding or

    • bruising

    • kidney disease

    • major surgery

  • Urea and electrolyte concentrations

    • major surgery >40 years

    • kidney disease

    • diabetes mellitis

    • digoxin, diuretics, corticosteroids, lithium

    • history of diarrhoea and vomiting


Pre operative evaluation and preparation prior to procedure under general anesthesia

  • Liver function tests: these will be carried out when there

    • is any suspicion of liver disease

  • ECG

    • >40 years asymptomatic male or >50 years asymptomatic female

    • history of myocardial infarction or other heart or vascular disease

    • <40 years with risk factors e.g. hyperlipidaemia, diabetes mellitus, smoking, obesity, hypertension and cardiac medication

  • Chest radiography

    • breathlessness on mild exertion

    • suspected malignancy, tuberculosis or chest infection

    • thoracic surgery



Pre op therapy
Pre-op therapy

  • Pt with respiratory disease – physiotherapy or bronchodilator therapy

  • Infective endocarditis – prophylactic antibiotic

  • Hypertension – adjustment of drug therapy to obtain optimal control (diastolic pressure below 110 mmHg)


Postponement of surgery
Postponement of surgery

  • Pt with acute upper resp tract infection

  • Cardiac/endocrine diseases that are not yet under optimal control

  • Elective surgery should not be undertaken unless:

    • Pt has fasted for 6h for solid food, Infant formula or other milk

    • 4h for breast milk

    • 2h for clear non-particulate and non-carbonated fluids


Pre medication
Pre-medication

  • benzodiazepines – anxiolysis, anterograde amnesia

  • Anticholinergic drug – reduce excessive secretions in the airway

  • Antiemetic

  • Antihistamine

  • Metoclopramide - enhance gastric emptying

  • Sodium citrate, H2 blockers, proton pump inhibitor – reduce gastric acidity


Preparation for anesthesia
Preparation for anesthesia

  • Fast patient.

    • Nil by mouth ≥ 2h pre-op for clear fluid and ≥ 6h for solids

  • Is there any bowel or skin preparation needed, or prophylactic antibiotic?

  • Start DVT prophylaxis as indicated, eg: graduated compression stockings + heparin 5000U sc 2h pre-op, then every 8-12h sc for 7d or until ambulant.


Pre operative evaluation and preparation prior to procedure under general anesthesia

  • Write up the pre-meds; book any pre-, intra-, or post-operative x-rays or frozen sections. Book post-op physiotherapy.

  • If needed, catheterize and insert Ryle’s tube before induction. These can reduce organ bulk, making it easier to operate in the abdomen.