1. SPHMMC
Faculty of Medicine
Department of Anesthesiology and Critical care medicine
Preoperative/Preanaesthetic Evaluation(PAC)
BY: HABTAMU ( MD,ACCPR3)
MARCH 15,2022
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3. Objectives
At the end of presentation you are expected to know ;
Components of preop evaluation
Difficult airway assasement and approach
Preop investigation needed before surgery
Preop Risk stratifications
Components of Preop orders
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4. PREOPERATIVE EVALUATION
• Defined as the process of clinical assessment that precedes the delivery of
anesthesia for surgery and for non surgical procedures.
• It is the most important part of your work!!
• It consists of the consideration of information of multiple sources that may
include the patient’s interview, medical records, physical examination and
findings from medical tests and evaluations.
• The overall goals of the preoperative assessment are to reduce
perioperative morbidity & mortality and to allay patient anxiety.
5. GOALS
• To ensure that the patient is in the best(optimal) condition.
• Patients with unstable symptoms should be postponed for optimization
prior to elective surgery.
• Anesthetic drugs and techniques have profound effects on human physiology.
• Hence, focused review of all major organ system should be done prior to
elective surgery.
• Decrease delays & cancellations on the day of op.
• 11.6% of reports identified inadequate or incorrect preoperative assessment.
(due to communication failure)
7. STEPS OF PREOPERATIVE VISIT
1. Problem identification
2. Risk assessment
3. Preoperative preparation
4. Plan of anesthetic technique.
8. Phase 1: History taking
• Demographic details; Date & time of examination, Patient’s name, Age, weight & address,
Source of referral, Source of history: patient, relative, care taker,religion
• Presenting complaint (PC),
• History of presenting complaint (HPC),
• Past medical history (PMH),
• Previous anesthetic history-any h/o difficult intubation,any h/o allergy at
that time
• Drug history (DH),smoking,chat chewing,herbal medications,and others
• Family history (FH),
• Social history (SH),
• Systemic enquiry (SE),
Previous history of difficult airway
Airway-related untoward events
Airway-related symptoms/diseases
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10. Airway
• Incidence of difficult intubation
reported to range between 0.13 –
5.9%
• It can be predicted and expert
anaesthsiologist is called for the
case.
• Evaluation is the first step in
management of difficult intubation.
11. AIRWAY CLASSIFICATION SYSTEM
MALLAMPATI SCORE
CLASS DIRECT VISULAISATION OF AIRWAY
1 Full view of Soft Palate, fauces,
uvula, tonsillar pillars
2 Soft palate, fauces ,upper portion of
uvula
3 Soft palate ,uvular base
4 Hard palate only.
LARYNGOSCOPIC VIEW
Cormack lehane
CLASS LARYNGOSCOPIC VIEW
1 Entire glottic
2 Posterior commisure
3 Tip of epiglottis
4 No glottic structure.
Upright, maximal jaw opening, tongue
protrusion without phonation
14. Def`n: If a trained Anaesthetisia professional using conventional
laryngoscope takes more than 3 attempts or more than 10 minute to
complete tracheal intubation.
1. Congenital causes
2. Acquired causes
Basic airway evaluation in all patients
BONES
The 4 D’s
Dr. Binnion’s LEMON Law
Look externally.
Evaluate the 3-3-2 rule.
Mallampati.
Obstruction
Neck mobility.
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O: Obstruction?
Blood
Vomitus
Teeth
Epiglottis
Dentures
Tumors
Impacted Objects
16. Can’t ventilate
That when sign of inadequate ventilation could not be reversed by mask ventilation or oxygen
saturation could not be maintained>90%
Defined by “BONES”
Beard
Obesity
No teeth
Elderly
Snoring
Is laryngeal visualization going to be difficult?
Defined by 4 D’s
Disproportion
Distortion
Dysmobility
Dentition
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17. Predictors in ICU ?? 17
Coded from 0 to 12
Hence 0=easy ,12 very difficult
21. Airway Examination
Normal
Opens mouth normally (Adults:
greater than 2 finger widths or
3cm)
Able to visualize at least part of
the uvula and tonsillar pillars
with mouth wide open & tongue
out (patient sitting) without
phonation
Normal chin length (Adults:
length of chin is greater than 2
finger widths or 3 cm)
Normal neck flexion and
extension without pain /
paresthesias
Wilson score (<2,3-
22.
23. Types of Surgical Procedure
• Type A- Minimally invasive
Little physiological changes e.g. cataract
• Type B- Moderately invasive
Modest physiological changes e.g. TURP
• Type C- Highly invasive
Significant physiological disruption e.g. THR
27. medical status mortality
ASA I normal healthy patient without organic, biochemical, or psychiatric
disease
0.06-0.08%
ASA II mild systemic disease with no significant impact on daily activity e.g.
mild diabetes, controlled hypertension, obesity .
Unlikely to have an
impact 0.27-0.4%
ASA III severe systemic disease that limits activity e.g. angina, COPD, prior
myocardial infarction
Probable impact 1.8-
4.3%
ASA IV an incapacitating disease that is a constant threat to life e.g. CHF,
unstable angina, renal failure ,acute MI, respiratory failure requiring
mechanical ventilation
Major impact 7.8-
23%
ASA V moribund patient not expected to survive 24 hours e.g. ruptured
aneurysm
9.4-51%
ASA VI brain-dead patient whose organs are being harvested
ASA Physical Status Classification System
For emergent operations, you have to add the letter ‘E’ after the classification
Limitations; neither the type of anesthesia nor the location of op
most importantly, no attempt to quantify the risk
29. Recommended test Guidelines For
Asymptomatic Patient
• Age up to 49 yrs CBC
• Age 50-64yrs CBC,ECG
• Age > 65 yrs CBC, ECG, CXR
Urine analysis
BUN/ Cr, Electrolyte
Blood Sugar
• Type C Surg Blood Gr , ALB, Plt
32. PRE OP ORDERS……….
Informed consent
Keep NPO.
MF
Blood components
antiemetics
Sedation : Diazepam 2mg-5mg
INDUCTION,maintanance agents plan
Analgesia plan both intraop and post op
Post op pt disposition
Possible anesthesia concern
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35. Cardiovascular system
Pulse: rate, rhythm, character and volume,
Blood pressure (BP),
Jugular venous pulse (JVP): height and character,
Ankle edema: presence or absence,
Symptoms of the following problems sought in all patients.
Ischaemic heart disease
HTN
Heart failure
Conduction defect and arrythmia
Peripheral vascular disease
Dr Resham B Rana,MD 26
36. Patient with h/o of MI are greater risk of perioperative reinfarction,
the incidence of which is related to the time interval between surgery
and infarct.so 6weeks needed for elective
The presence of unstable angina has been associated with a
high perioperative risk of MI.
The presence of active congestive heart failure has been associated
with an increased incidence of perioperative cardiac morbidity.
38. Cardiac Risk Indices
Goldman cardiac risk index
Eagle cardiac risk index
Lee revised cardiac index
NHYA classification
Revised cardia risk index
40. At what HF condition do we have potentially acceptable risk for non
cardiac surgery?
Is there a difference in mortality and morbidity b/n HFpEF and HFrEF in
non cardiac surgery?
41. Heart Failure
Patients with clinical heart failure are at significant risk for perioperative complications
It is widely used indices of cardiac risk include HF as an independent prognostic
variable
In a population-based data analysis of 4 cohorts of 38,047 consecutive patients, the 30-day
postoperative mortality rate was significantly higher in patients with
Non ischemic HF (9.3%)
ischemic HF (9.2%), and
atrial fibrillation (AF) (6.4%) than in those with out CAD (2.9%)
42. In a meta-analysis……. perioperative risk
HF with preserved LVEF had a lower all-cause mortality rate than that of those with HF and
reduced LVEF (the risk of death did not increase notably until LVEF fell below 40%)
The absolute mortality rate was still high in patients with HF and preserved LVEF as compared
with patients without HF
Ischemic cardiomyopathy is of greatest concern because the patient has substantial risk for the
development of further ischemia, which can lead to myocardial necrosis and potentially a
downward spiral.
43. Hypertension
poorly controlled hypertension was associated with untoward hemodynamic responses
antihypertensive agents should be continued perioperatively
several large prospective studies were unable to establish
mild to moderate hypertension as an independent predictor of postoperative cardiac complications
such as cardiac death, postoperative MI, heart failure, or arrhythmias.
44. BLOOD PRESSURE
CATEGORY SBP(MM HG) DBP(MM HG)
Optimal <120 and <80
Normal <130 and <85
High Normal 130-139 or 85-89
Hypertension
Stage 1 140-159 or 90-99
Stage 2 160-179 or 100-109
Stage 3 ≥180 or ≥110
45.
46. Perioperative Therapy
Perioperative Beta-Blocker Therapy
Recommendations COR LOE
Beta blockers should be continued in patients undergoing surgery who have been
on beta blockers chronically.
I BSR
It is reasonable for the management of beta blockers after surgery to be guided by
clinical circumstances, independent of when the agent was started. IIa BSR
In patients with intermediate- or high-risk myocardial ischemia noted in preoperative
risk stratification tests, it may be reasonable to begin perioperative beta blockers. IIb CSR
In patients with 3 or more RCRI risk factors (e.g., diabetes mellitus, HF, CAD, renal
insufficiency, cerebrovascular accident), it may be reasonable to begin beta
blockers before surgery.
IIb BSR
These recommendations have been designated with a SR to emphasize the rigor of support from the ERC’s systematic review. See the ERC systematic
review report, “Perioperative beta blockade in noncardiac surgery: a systematic review for the 2014 ACC/AHA guideline on perioperative cardiovascular
evaluation and management of patients undergoing noncardiac surgery” for the complete evidence review on perioperative beta-blocker therapy.
47. Perioperative Statin Therapy
Recommendations COR LOE
Statins should be continued in patients currently taking statins and scheduled
for noncardiac surgery.
I B
Perioperative initiation of statin use is reasonable in patients undergoing
vascular surgery.
IIa B
Perioperative initiation of statins may be considered in patients with clinical
indications according to GDMT who are undergoing elevated-risk procedures.
IIb C
Alpha-2 Agonists
Recommendation COR LOE
Alpha-2 agonists for prevention of cardiac events are not recommended in
patients who are undergoing noncardiac surgery.
III: No
Benefit
B
Perioperative Therapy
48. Angiotensin-Converting Enzyme Inhibitors
Recommendations COR LOE
Continuation of ACE inhibitors or angiotensin-receptor ARBs perioperatively is
reasonable.
IIa B
If ACE inhibitors or ARBs are held before surgery, it is reasonable to restart as
soon as clinically feasible postoperatively. IIa C
Perioperative Therapy
49. Impact of asthma on anesthesia – General considerations
Most well-controlled asthmatics tolerate anesthesia and surgery well.
Poorly controlled asthmatics are at risk of perioperative respiratory problems :
bronchospasm
sputum retention
atelectasis
infection
respiratory failure
Elective surgery should take place when the patient’s asthma is optimally controlled.
With major abdominal or thoracic surgery start chest physiotherapy preoperatively
Asthmatic medications should be continued up to the time of surgery except for
theophylline
Midazolam is a safe anxiolytic in this patient population and does not alter bronchial tone.
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50. Preoperative assessment
History:
Very important as asthmatic pts can be asymptomatic at time of evaluation so focus on:
Severity of disease, frequency of exacerbations, hospital or ER visit / admissions
Prior intubation or ventilation in severe attack
Recent URTI
Should be seen in PAClinic at least 1 week in advance of scheduled surgery for optimization
exercise tolerance and general activity levels.
any allergies or drug sensitivities, especially the effect of aspirin or other NSAIDs
.
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51. Investigations
o Serial measurements of peak flow are more informative than a single
reading.
o Spirometry gives a more accurate assessment. Results of peak flow and
spirometry are compared with predicted values based on age, sex, and
height.
o Blood gases are only necessary in assessing patients with severe asthma
(poorly controlled, frequent hospital admissions, previous ICU admission),
particularly prior to major surgery.
o Normal PFT in this pts population do not promise an uncomplicated
intra/post op course
o CXR and EKG
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56. Preparation For Anesthesia
• Continuing Current Medications/ Treatment of Coexisting Diseases
It is the RESPONSIBILITY of the anesthesiologist to instruct patients regarding
which medications to take and which to hold preoperatively.
Instruct Patients to take the medications with small sips of water, even if fasting!
Medications to be Continued on the day of Surgery
1.Antihypertensives except ACE Is and ARBs
2. Cardiac medications e.g ᵦ- blockers, digoxin
3. Antidepressants, anxiolytics and other
psychiatric medications
4. Thyroid medications
5.Birth control pills, eye drops, heartburn or reflux medications, narcotics,
anticonvulsants, asthma medications, Steroids, Statins,
57.
58. Aspirin
Consider selectively continuing aspirin in patients where the risk of cardiac events
is felt to exceed the risk of major bleeding.
if reversal of platelet inhibition is necessary, stop aspirin at least 3 days before
surgery.
Do not discontinue aspirin if patients who have drug eluting coronary stents
until they have completed 12 months of dual anti platelet therapy.
Thienopyridines (Clopidogrel and Ticlopidine)
• Patients having Cataract Surgery – Do not need to stop.
• If reversal of platelet inhibition is necessary, then clopidogrel must be
stopped 7 days before surgery (Ticlopidine – 14 days)
• Do not discontinue Thienopyridines in Pt. who have drug eluting stents before
1 year.
59. Medications to be discontinued
• Topical medications e.g creams and ointments
• Oral hypoglycemic agents ( on the day of Sx)
• Diuretics (on the day of Sx except Thiazide)
• Sildenafil ( Viagra) of similar drugs –
discontinue 24 hrs before Sx.
• NSAIDS – discontinue 48 hrs before Sx.
• Warfarin ( Coumadin) discontinue 4 days
before Sx
NPO Guidelines
Substance Maximum Hours of Fasting
Solid 6
Formula 6
Cow’s Milk 6
Citrus Juice 6
Breast milk 4
Clear liquids 2
60. Pharmacological Agents to Reduce the risk of
Pulmonary Aspiration
• Histamine – 2 Receptor Antagonist : block the ability of histamine to induce
secretion of gastric fluid with high hydrogen concentrations e.g. Cimetidine,
Ranitidine, Famotidine
• Antacids – neutralize the acid in gastric contents
• Proton pump inhibitors: supress gastric acid secretion by binding proton pump of
the parietal cell
• Gastrokinetic Agents : Metoclopramide- Dopamine antagonist.
61. Psychological Preparation
• Preoperative visit and interview with the patient and family members,
• The anesthesiologist should explain anticipated events and the proposed
anesthetic management in an effort to reduce anxiety and diminish
apprehension.
• Pharmacological preparation
• To relief anxiety and production of sedation
• Prophylaxis against allergic reactions e.g. to latex
• Prevention of Autonomic reflexes mediated
through the vagus nerve.
• Prevention of nausea and vomiting.
62. Benzodiazepines
Produces anxiolysis, amnesia and sedations e.g. Diazepam, Midazolam,
Lorazepam
Diphenhydramine : histamine-1 receptor antagonist, blocks the
peripheral effects of histamine, it has sedative, anticholinergic and
antiemetic activity.
Anticholinergics : (Atropine, glycopyrolate, scopolamine)
1. Antisialogogue effect
2.sedation and amnesia
3. Vagolytic effect
63. Antibiotic Prophylaxis
• Cephalosporins are the most popular antibiotics because they cover skin
microbes,
• For intestinal Sx, anaerobic and Gram negative coverage is needed.
• Antibiotics must be administered within 1 hr
prior to incision except :
Vancomycin should be given 2hr prior to incision
when tourniquet is used, the antibiotics should
be adminstered prior to its inflation.
64. Tyroid D/rs
History of onset, duration, rate of growth
History suggestive of primary or secondary thyroid toxicity
History of pain
History of palpitation, precordial pain, exhaustion
History of pressure effects- like dyspnoea,
dysphagia, hoarseness of voice.
PHYSICAL EXAMINATION
Built, nourishment
Fullness of thyroid region, pallor, icterus, cyanosis, clubbing, oedema
Temperature, Sleeping pulse rate, blood pressure
Skin- hot and moist palm
Tremors
Mental status-anxiety, nervousness.
Airway assessment
65. CVS :
Enlarged heart
Atrial fibrillation
Signs of CCF.
Systolic murmurs
CNS :
Myopathy and tremors
Reflexes- hyperreflexia
TSH Assay : single best test of ThyroidHormone
Normal level : 0.4-5.0 mU/L.
Subclinical hyperthyroidism : TSH level is0.1- 0.4mU/L with normal FT3 &
FT4.
Overt hyperthyroidism : TSH level is <0.03mU/Lwith increased T3 & T4.
Thyroid Storm : TSH level is<0.01mU/L.
PAview- position of trachea, deviation, retrosternal goiter, calcification
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66. 6% of tracheal intubationsfor thyroid surgery will be
difficult.
When conventional methodsof laryngoscopy and
endotracheal intubation do not provide airway
management. The best choice is
Fiberoptic intubation.
If fiberoptic bronchoscope is notavailable, mask
ventilation, laryngeal mask, combitube, nasotracheal
intubation, rigid bronchoscope intubation.
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67. MEDICAL TREATMENT
OBJECTIVES
Making the patientasymptomatic
Making a thyrotoxic patienteuthyroid before surgery
Euthyroid is clinically assessed by-
◦ Sleeping pulse rate < 90/min
Progressive weight gain
◦ Disappearance of toxic symptoms like tremors, nervousness, anxiety etc .
◦ No requirement of sedation for sleep.
◦ Normal pulse pressure, sinus rhythm, disappearance of cardiac murmurs
Anti thyroid drugs : Carbimazole vs.PTU
Start Carbimazole 10-30 mg/day based on severity of symptomsand time left
for surgery
Call back after 6 weeks andreassess
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68. Beta blockers
• Reduces myocardial oxygenconsumption, reduces heart rate, improves myocardial efficiency
• Used to prepare patients forsurgery
• Used with caution in patients with congestive heart failure, bronchialasthma
• Useful in thyrotoxiccrisis
CARBIMAZOLE: commonest drugused.
Blocks the synthesis of thyroidhormones.
Suppresses theautoimmuneprocess in Grave’sdisease.
PROPYLTHIOURACIL:
Blocks thyroid hormonesynthesis.
Blocks peripheral conversion of T4 toT3.
Decreases thyroid autoantibodylevels.
Safe to begiven in children and pregnancy.
Side Effects: agranulocytosisand aplasticanemia
For EmergencySurgery
Esmolol 100-300 mcg/kg/min IV until heartrate <100/min
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69. Why should a toxic patient be Euthyroid before surgery ?
ToPrevent
Thyrotoxiccrisis
Cardiac arrhythmias andtachycardia
Worsening of co existent medicalconditions:
Hemodynamiccompromise
Anesthetic druginteractions
Thyroid Storm
Is a life threateningemergency ,Characterized by sudden appearance of clinical signs of
hyperthyroidism due to theabrupt release of T4 and T3 into circulation.
Mortality is as highas 25% to 30%.
Commonly associated withGrave's disease.
Triggers
Trauma
Infection
Surgery
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70. PRE OP ORDERS……….
Informed consent
Keep NPO.
Absolute bed rest.
Sedation : Diazepam 2mg-5mg
Resting pulse chart
Patient must be made euthyroid or near euthyroid at operation.
Sleeping pulse rate <90/min
Progressive weightgain
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71. ScoringPerioperativeAKI--RiskPerioperativeAKIis NEVERbenign!
Age>56 years
Male gender
ActiveC
H
F
Ascites
Hypertension
Mild to moderateC
K
D
Diabetestreated with OHAorinsulin
• Emergencysurgery
Intra-peritoneal surgery
Kheterpal S,etal. Anesthesiology 2009; 110:505-515
Risk factors Hazardratio
0-2 1
3 3.1
4 8.5
5 15.4
6 46.2
74. Diabetes mellitus
Is a metabolic disorder resulting from an (absolute or
relative) insulin deficiency or resistance to insulin.
Affects about 5% of the population
50% of diabetes present for surgery in their lifetime
75. The stress of surgery/ anaesthesia results in metabolic disturbance that
alter glucose homeostasis, and persistent hyperglycemia
Result in;
- Depressed immunity
- Impaired wound healing
- Endothelial dysfunction = IHD, CVA
- Diabetic crises
Thorough systemic review with attention to the following detail
A- Autonomic neurophathy
- Present in up to 40% of type 1 diabetics
- features include gastroparesis gustatory sweating
nocturnal diarrhoea. postural hypotension
Assess heart rate variability with deep breath
Normal > 15 bpm
Neuropathy is likely if < 10 bpm
76. E- Airway
Glycosylation of collagen in the cervical and temporo-
mandibular joints can cause difficulty in intubation
stiff joint syndrome
F- Renal
Diabetes is one of the commonest causes of ESRF
Watch out for features of uraemia
G- Immune system
Diabetics are prone to all types of infection
77. 1- Blood glucose
RBS, FBS and 2hrs PG
2- Glycated Hb ( HbA1c )
<7% Good control
Aim for a blood glucose between 6 and
10mmol/l
78. Ensure good hydration
Correct electrolyte abnormality
Stop long acting OHG (eg chlorpropamide ) 48- 72hrs before surgery
Stop long-acting insulin a day before surgery
Convert to soluble insulin
Check blood glucose early in the morning of surgery
Give premedication
Fast patient overnight
Commence glucose/potassium/insulin(GKI) infusion
G & M blood accordingly
Obtain Intra-op antibiotics
Obtain informed consent
Catheterize patient going for major surgery
79. Smoking
It is associated with poorer outcomes in patients.
Cigarette smoking causes cough, mucous hyper-secretion
and airflow obstruction.
Passive smokers also have an increased incidence of
adverse events.
Nicotine stimulates the adrenal medulla to secrete adrenaline.
It resets the aortic and carotid body receptor----- maintain a
higher blood pressure.
Stimulates the sympathetic system.
Negative ionotropic effect----- chronic tissue hypoxia.
• Carboxyhaemoglobin levels maybe up to 15% in smokers.
Carbon monoxide and oxygen both bind to the alpha chain of haemoglobin, but the
affinity of carbon monoxide is 250 times greater than oxygen.
80. Benefits of smoking
Smoking is found to reduce risk of :
PONV
Ulcerative colitis
Schizophrenia
Deep vein thrombosis
81. Anaesthetic
consideration
Patients are advised to quit smoking at least four to six
weeks prior to surgery.
Abstinence for 12 hr. is sufficient to get rid of carbon monoxide.
Ciliary function improves -- 12-24 hours.
Laryngeal and bronchial activity is better-- 5-10 days.
Return sputum volume to normal levels– 2 weeks
Improvement in small airway narrowing is seen in 4 weeks but it takes 3
months to see changes in tracheobronchial clearance.
82. Effect ofAlcoholism
Vitamin deficiencies
Alcohol abuse is the leading cause of thiamine (vitamin B1) deficiency.
Wernicke’s encephalopathy, a syndrome characterised by the classic triad of
encephalopathy,ophthalmoplegia and ataxia.
Chronic alcohol ingestion leads to alcoholic cardiomyopathy.
Increased risk of stroke and hypertension
Metabolic abnormalities
Acidosis--Up to 25% of patients with an alcohol use disorder will have metabolic
Alcoholic liver disease
Pancreatitis; is the major causative factor of acute pancreatitis in about 32% of cases.
Immune dysfunction;
83. Drug abuse
As anesthesiologists we need to be aware of the use of illicit drugs
impacts on anesthetic care.
Medical adverse effects range from pulmonary and
cardiovascular effects, to irreversible brain damage.
May manifest or worsen under anesthesia.
Injected drugs and high-risk sexual behaviors are risk factors for the
transmission of HIV/AIDS and hepatitis C.
Cocaine-abusing patients under general anesthesia may also exhibit
hypertension and cardiac arrhythmias
84. Tricyclic and tetracyclic antidepressants
●BENEFIT/RISK CYCLIC ANTIDEPRESSANTS INHIBIT THE UPTAKE OF NOREPINEPHRINE AND
SEROTONIN AT THE SYNAPTIC CLEFT.
UNLIKE MOST NEWER ANTIDEPRESSANTS, CYCLIC ANTIDEPRESSANTS LOWER THE SEIZURE
THRESHOLD AND POSSESS SIGNIFICANT ANTICHOLINERGIC, ANTIHISTAMINIC, AND ALPHA-1
BLOCKING PROPERTIES.
THESE AGENTS DELAY GASTRIC EMPTYING, PROLONG THE QTC INTERVAL, AND MAY
INCREASE THE RISK FOR ARRHYTHMIAS IN COMBINATION WITH SOME VOLATILE
ANESTHETICS OR SYMPATHOMIMETIC AGENTS, ALTHOUGH LITERATURE TO SUPPORT THIS
CONCERN IS SCANT.
ABRUPT WITHDRAWAL OF TRICYCLIC ANTIDEPRESSANTS CAN LEAD TO INSOMNIA, NAUSEA,
HEADACHE, INCREASED SALIVATION, AND SWEATING AND SHOULD BE AVOIDED IF FEASIBLE
CYCLIC ANTIDEPRESSANTS CAN AMPLIFY THE SYSTEMIC PRESSOR EFFECTS OF
NOREPINEPHRINE AND EPINEPHRINE; HOWEVER, USE WITH EPINEPHRINE-CONTAINING
LOCAL ANESTHESIA IS GENERALLY SAFE.
USE WITH ATROPINE OR SCOPOLAMINE MAY INCREASE POSTOPERATIVE CONFUSION.
DUE TO ADDITIVE SEROTONINERGIC EFFECTS, USE WITH TRAMADOL AND MEPERIDINE IS
NOT RECOMMENDED.
85. Selective serotonin reuptake inhibitors
●Benefit/risk Selective serotonin reuptake inhibitors (SSRIs) may increase bleeding risk
and the consequent need for transfusion with surgery, perhaps because of their effects on
platelet aggregation. Bleeding risk with SSRIs has been documented primarily in association
with antiplatelet or nonsteroidal antiinflammatory drug (NSAID) use
Stopping SSRIs could lead to exacerbation of mood and other disorders. The washout
period for SSRIs may be as long as three weeks, and re-initiation may not lead to clinical
benefit for several weeks. Half-life varies widely from 15 hours up to seven days (fluoxetine).
Abrupt withdrawal of short-acting SSRIs should be avoided, as it can cause a
discontinuation syndrome including dizziness, chills, muscle aches, and anxiety
Determining whether perioperative continuation or withdrawal of SSRIs produces a net clinical
benefit requires randomized controlled trials.
Antiplatelet agents should be discontinued preoperatively if at all possible in patients
taking SSRIs
86. Monoamine oxidase inhibitors
Benefit/risk Nonselective irreversible monoamine oxidase (MAO) inhibitors for use as
antidepressants (isocarboxazid, pargyline, phenelzine, and tranylcypromine) are prescribed
far less commonly than other antidepressants but are used in patients with refractory mood
disorders in whom withdrawal and recurrent depression may be problematic.
MAO inhibitors are also used for treatment of conditions other than depression
87. administration of sympathomimetic agents, like ephedrine during anesthesia, can result in massive
release of stored norepinephrine and severe hypertensive crisis.
The "Type I" reaction occurs with the administration of anticholinergics (such as dextromethorphan)
and meperidine with MAO inhibitors, leading to a serotonin syndrome (agitation, headache, fever,
and seizures, with possibility of coma and death)
The "Type II" reaction occurs when the MAO inhibitor inhibits hepatic microsomal enzymes involved
in opiate metabolism, subsequently leading to accumulation of free narcotic, sedation, respiratory
depression, and cardiovascular collapse
As the use of morphine and fentanyl are recommended to avoid a Type I reaction, patients continuing
MAO inhibitors requiring these opiates should be monitored closely for CNS depressive effects.
88. Mood stabilizing agents (lithium and valproate)
Benefit/risk – Lithium has a number of physiologic effects that may be important perioperatively.
Lithium decreases release of neurotransmitters and may prolong the effect of neuromuscular
blockers.
Lithium has a narrow therapeutic index, is highly dependent upon maintained renal function for
clearance, and is subject to drug interactions with diuretics, NSAIDs, angiotensin-converting enzyme
(ACE) inhibitors, and serotoninergic drugs (eg, meperidine, methylene blue, tramadol).
Chronic lithium use has a multitude of effects on the thyroid & nephrogenic diabetes insipidus
Continue/discontinue – Lithium and valproate are used for treatment of serious mental illness. We
therefore recommend continuation of lithium perioperatively with increased attention to fluid and
electrolyte monitoring and a low threshold to check thyroid function tests before surgery.
We recommend that valproic acid be continued.
89. Mood stabilisers and antipsychotic drugs should be continued throughout
the perioperative period to avoid the risk of relapse.
Lithium has a low therapeutic index & high incidence of toxicity
Patients taking lithium require care with fluids and electrolytes, and
avoidance of drugs which may cause renal failure.
Cardiac risk factors are increased in patients taking long term antipsychotic
drugs due to a combination of side effects and high smoking levels in
these patients
patients taking long term antipsychotic are at risk of increased
complications(including death)during and after surgery.
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