4. anesthesiologist shall be responsible for
determining the medical status of the patient
developing a plan of anesthesia care
acquainting the patient with the proposed plan
ASA
7/15/2014 4
5. study evaluating methods of reducing preoperative
anxiety
thorough preoperative evaluation can be as effective as
an anxiolytic premedication
7/15/2014 5
6. Review available medical records
Interview and perform focused examination of the patient
Discuss medical hx, including previous anesthetic experiences and
medical therapy
Assess those aspects of the patient’s physical condition that might
affect decisions regarding perioperative risk and management.
Order/ review pertinent available tests and consultations as
necessary for the delivery of anesthesia care
Order appropriate preoperative medications
Ensure that consent has been obtained for the anesthesia
care- BRAN (benefit, risks, alternatives, if Not done then..)
Document in the chart that the above has been performed
7/15/2014 6
7. Current Problem- History of present illness
The proposed surgery – affects type of anaesthesia/ position
Other known problems- Any comorbidities (DM, HTN,
psychiatric illness)
Drug history- Present therapy (prescription/ over-the-
counter), alcohol, tobacco
Allergy history- drugs, food, latex, etc.
Anesthetic history- Previous anesthetics, operations,
complications, h/o malignant hyperthermia (“allergy to
anesthesia”)
System review- Screening of any undiagnosed systemic
illnesses
Miscellaneous- Last oral intake (ER) 7/15/2014 7
8. General appearance- Comfortable, in distress, sick
looking, physique, wt, ht, BMI
Vital signs- Temp, pulse, BP, RR
Head to toe examination- Pallor, icterus, clubbing,
cyanosis, edema, dehydration, peripheral veins,
pre-existing iv cannulae
7/15/2014 8
9. dentition- loose or chipped teeth, caps, bridges, or
dentures
poor anesthesia mask fit expected in edentulous patients and
significant facial abnormalities
prominent upper incisors, large tongue, short neck suggest
difficulty may be encountered during tracheal intubation
nostrils
thyromental distance: 5cms
Sternomental distance: 12.5 cms
mandibular protrusion test
flexon and Extension of the neck
Cervical spine- Important in trauma, RA, cervical
spondylosis 7/15/2014 9
11. A screening evaluation regarding history of tobacco use,
shortness of breath, cough, wheezing, stridor, snoring or
sleep apnea
recent history of an upper respiratory tract infection
Patient's ability to carry on a conversation or to walk
without dyspnea
Physical exam- assess the respiratory rate as well as the
chest excursion, use of accessory muscles
Auscultation to detect decreased breath sounds, wheezing,
stridor
7/15/2014 11
12. Site of surgery
thoracic, aortic or upper abdominal surgery has highest risk
Type of surgery
abdominal aortic aneurysm repair, thoracic, upper abdominal have
highest risks followed by neck, peripheral vascular, and
neurosurgery
Neurosurgery and neck surgery associated with perioperative
aspiration pneumonia
Laparoscopic surgery have lesser risk than open surgery
Duration of surgery
longer the duration, longer the time exposure to anesthesia
7/15/2014 12
13. tobacco/ smoking
increase carboxy-hemoglobin
decrease ciliary function
increase sputum production
stimulates cardiovascular system secondary to nicotine
asthma/COPD
increased airway responsiveness
drugs may have adverse reactions with anesthetics
chronic CO2 retention in COPD
obstructive sleep apnea
susceptible to the respiratory depressant and airway effects of
sedatives, narcotics, and inhaled anesthetics
7/15/2014 13
14. General appearance including weight, BMI
Vital signs
Pulse and its characteristics( rate, rhythm, character, volume, delay,
all peripheral pulses)
BP (if needed in both arms)
Temperature, RR
Head to toe examination
JVP, anemia, cyanosis, clubbing, edema
Precordial examination
Inspection/Palpation- apical impulse, heave, thrills
Auscultation- heart sounds, murmurs
Auscultation of basal lung fields
Assessment of liver size and position
7/15/2014 14
15. Age
associated with multisystem disease,
Previous MI
5-8% risk of periop reinfarction
Mortality rate of reinfarction 36-70%
Risk of reinfarction decreases with time
30% <3 mnths
6% >6mnths
CHF
symptomatic CHF- predictor of perioperative pulmonary
edema
Hypertension
Leading cause of concern
Not a significant risk factor alone (esp. if <180/110), but due
its end-organ damage like LVF, renal failure and stroke
7/15/2014 15
16. DM
risk of CAD, silent MI, renal insufficiency
Equal risk as nondiabetics with previous MI
VHD
AS- 14 fold greater risk as compared with those without AS
risk of IE
Arrhythmias
Frequent PVCs and nonsinus rhythms
CHB, LBBB, 2 heart block (Mobitz type II)
Others
Smoking, hyperlipidemia, renal failure, anemia, depression,
hypoalbuminemia
Inflammatory markers: CRP, b-type natriuretic peptide
7/15/2014 16
17. Renal disease- important implications for fluid
management and metabolism of drugs.
Liver disease -associated with altered protein binding,
volume of distribution of drugs, coagulation abnormalities
Musculoskeletal System- anatomy evaluated for procedures
such as a nerve block, regional anesthesia, invasive
monitoring
Neurological- history of prior stroke -increased risk for a
perioperative stroke
7/15/2014 17
19. CBC
Ur. / Cr.
Na/ K
PT/ INR
CXR
ECG
Urine RE/ME
Other case pertinent inv.
7/15/2014 19
20. MET, metabolic
equivalent of the
task. 1 MET =
consumption of
3.5 mL O2/min/kg of
body weight.
Patients with MET less
than 4 or 5 have
higher risk of
perioperative cardiac
morbidity
7/15/2014 20
21. NYHA: New york Heart Association
CCVSA: Canadian Cardiovascular Society
7/15/2014 21
23. administration of drugs prior to anesthesia
to allay apprehension
produce sedation
facilitate the administration of anesthesia to the patient
7/15/2014 23
24. Devoid of any side effects
Minimal depression of respiration and
cardiovascular function.
Simple and pleasant to take.
Should act over reasonable period of time.
Should be effective in all patients.
7/15/2014 24
25. Relief of anxiety
Sedation
Amnesia
Analgesia
Drying of airway secretions
Prevention of autonomic
reflex responses
Reduction of gastric fluid
volume and increased pH
Antiemetic effects
Reduction of anesthetic
requirements
Facilitation of smooth
induction of anesthesia
Prophylaxis against
allergic reactions
7/15/2014 25
26. anxiolytics
Children- syr promethazine (6.25 mg/ml)
5- 10 ml hs/ cm
Young adults- diazepam
5-10 mg hs/ cm
Elderly –lorazepam
1- 2mg hs/ cm
Antiemetics
Antacids/ ppi
7/15/2014 26
27. Hypertension
Antihypertensive drugs to be continued except Losartan &
Diuretics
• RHD
• Prophylactic antibiotics should be considered
• Patients on anticoagulant therapy- warfarin should be substituted
by heparin 3-5 days prior to surgery
• IHD-
• Anticholinergic mainly atropine to be avoided.
• Aspirin to be discontinued 7 days before surgery
7/15/2014 27
28. • Bronchodilators, steroids should be continued
• Prophylactic antibiotics in COPD patients
• Inhaled β2-agonists, cromolyn, or steroids should be
continued up to the time of surgery
7/15/2014 28
29. Objectives
• avoid hypoglycemia, excessive hyperglycemia,
ketoacidosis
• metformin should be held if there is decreased renal
function- risk for the fear of Lactic acidosis.
• glimepiride (Sulfonylureas) should be held while the pt.
is NPO
• Thiazolidinedione can be continued as they do not
predispose to hypoglycemia
• α-glucosidase inhibitor should be held
• Premedication to avoid aspiration, N/V
7/15/2014 29
30. Well-controlled type 2 diabetics do not require insulin for
minor surgery.
Poorly controlled type 2 diabetics and all type 1 diabetics
having minor surgery and all diabetics having major
surgery need insulin.
For major surgery, serum glucose > 270 mg/dL, the surgery
should be delayed while rapid control is achieved with
intravenous insulin.
If the serum glucose >400 mg/dL, surgery should be
postponed and the metabolic state restabilized.
7/15/2014 30
31. Administer 1/2 to 2/3rd of the patient's usual intermediate-
acting insulin subcutaneously on the morning of surgery
In addition to this basal insulin, a regular insulin sliding
scale (RISS) can be added and titrated to blood glucose
measurement.
Alternatively, an insulin infusion of 1 to 2 U/hr (100 U
regular insulin in 100 mL normal saline at 1 to 2 mL/hr) can
meet basal metabolic needs and be adjusted to maintain
blood glucose at the desired level.
7/15/2014 31
32. With either method, a slow glucose infusion (dextrose 5%
in water at 75 to 100 mL/hr) will prevent hypoglycemia
while the patient is fasting.
Some authorities recommend a combination glucose-
insulin or glucose-insulin-potassium infusions (GIK)
7/15/2014 32
34. 7/15/2014 34
Management of Diabetes Mellitus in Surgical Patients
http://spectrum.diabetesjournals.org/content/15/1/44.full
35. Intraoperative GIK solution given to diabetic patients with
CABG operation provides more stable CI, shorter time of
MV, more stable values of potassium which provides
normal rhythm and less AF onset, less insulin to maintain
target glycemia. All the above mentioned provides more
stable intraoperative hemodynamic and better recovery of
diabetic
Glucose-Insulin-Potassium (GIK) solution used with
diabetic patients provides better recovery after
coronary bypass operations.
Straus S, Gerc V, Kacila M, Faruk C.
7/15/2014 35
36. “Sliding scale insulin” is not recommended for the
management of hyperglycemia.
“set and forget”
Basal + pre-meal better
https://www.diabetessociety.com.au/documents/Periop
erativeDiabetesManagementGuidelinesFINALCleanJuly
2012.pdf
7/15/2014 36
37. Type II patients taking oral agents alone, RISS can be
added to control blood glucose levels.
Patients receiving chronic insulin can be treated similarly
to the type I patient by giving 1/2 the usual NPH insulin
dose the morning of surgery, supplemented by a RISS, or
an insulin infusion titrated to blood glucose.
7/15/2014 37
39. state of drug induced reversible unconsciousness
and loss of protective reflexes
consist of hypnosis, amnesia, analgesia, relaxation of
skeletal muscles, and loss of autonomic reflexes
Balanced anesthesia=
hypnotic+ amnesic + analgesics + muscle
relaxant
7/15/2014 39
40. Components of GA
Pre-anesthetic check up (PAC)
Premedication
Induction
Maintenance
Recovery
Postoperative Care
7/15/2014 40
41. Advantages
fast onset of anesthesia than inhalation, (10-20 seconds)
induce total unconsciousness
avoidance of the excitatory phase of anesthesia (Stage II)
complications related to induction of anesthesia.
7/15/2014 41
42. Propofol (10 mg/ml)-
<55 yr – 2- 2.5mg/ kg slow iv
>55 yr- 1-1.5 mg/kg slow iv
Onset 30- 45 s
Duration- 20-75 min
Metabolism- hepatic conjugation
Excretion- urine
s/e- injection site burning, hypotension, apnea, rash
pruritus, cardiac s/e
Most commonly used
7/15/2014 42
43. Ketamine (10mg/ml)
1-4.5 mg/kg slow iv once
1-2 mg/ kg infusion @ 0.5mg/kg/min
Produces dissociative anesthesia
Blocks NMDA receptors
Onset- 30 s
Duration- 5 -10 mins
Metabolised by liver
Excreted in urine
s/e- emergence reaction, htn, raised ICP, tachycardia,
hallucinations
7/15/2014 43
44. Sodium thiopental
ultra-short-acting barbiturate
4–6 mg/kg
Largely replaced by propofol
mainly metabolized to pentobarbital
s/e- hypotension, apnea and airway obstruction
caution with liver disease, severe heart disease,
severe hypotension, a severe breathing disorder, or a family
history of porphyria
Etomidate (2mg/ml)
0.3-.6 mg/ kg iv over a minute
Onset 60s; duration- 3-5 mins
Hepatic metabolism, excreted in urine
s/e- adrenal suppression, pain, apnea, arrythmias
Less often used
7/15/2014 44
45. Advantages:
Excellent analgesia
Minimal hemodynamic depression
Good suppression of endotracheal tube response
Problems:
Respiratory depression
Incomplete suppression of intraoperative awareness
Used mainly for cardiac anesthesia and also in smaller
doses as a part of balanced anesthesia for non-cardiac
cases
7/15/2014 45
46. Fentanyl
More lipid soluble than morphine
Rapid onset (60 sec)
Elimination half time (200 min) is longer than the
duration of clinical effect
Very highly bound to lung as a function of time. So half-
life of effect depends upon duration of administration
because of an increase in storage.
Available as IV, transdermal patch & lollipop
7/15/2014 46
47. Isoflurane
1- 3%
Rapid onset, short acting
MAC 1.3%
s/e N/V, hypotension, arrythmias
Sevoflurane
1.4- 2.6%
Onset 2-3 min
expensive
s/e hypotension, respiratory irritation, seizures
Halothane
potent anesthetic
MAC 0.74
20% metabolized in liver
s/e- liver injury 1in 10,000
Less preferred 7/15/2014 47
48. Difficult IV access
Anticipated difficult airway
Children
7/15/2014 48
49. used for
facilitate intubation of the trachea
facilitate mechanical ventilation
optimize surgical working conditions
Depolarizing muscle relaxant
Succinylcholine
Nondepolarizing muscle relaxants
Short acting
Intermediate acting
Long acting
7/15/2014 49
51. Succinylcholine
Most often used to facilitate intubation
dose- 1-1.5 mg/kg
Onset 30-60 seconds
duration 5-10 minutes
s/e- Cardiovascular, Fasciculation Muscle pain,
Increase IOP, Increase ICP, intragastric
pressure
Malignant hyperthermia
7/15/2014 51
52. Nondepolarizing Muscle Relaxants
Do not depolarized the motor endplate
Act as competitive antagonist
Excessive concentration causing channel blockade
Act at presynaptic sites, prevent movement of Ach to
release sites
Long acting
Pancuronium
Intermediate acting
Atracurium, Vecuronium, Rocuronium, Cisatracurium
Short acting
Mivacurium
7/15/2014 52
53. Vecuronium
Analogue of pancuronium
much less vagolytic effect and shorter duration than
pancuronium
Onset 3-5 minutes
duration 20-35 minutes
Intubating dose 0.08-0.12 mg/kg
Elimination 40% by kidney, 60% by liver
7/15/2014 53
54. Neostigmine
0.03-0.07 mg/kg iv
Max dose 5mg
10-20 mins
Competitive inhibitor of choliesterase
Reverses action of muscle relaxants
Administered with anticholinergics
Atropine (
Glycopyrrolate (0.2 mg per 1 mg of neostigmine)
7/15/2014 54
55. Miller’s Anaesthesia- 7th Edition
Clinical Anaesthesia – Paul G. Barash, 6th Edition
ACC/AHA guidelines on perioperative cardiovascular
assessment
Uptodate 21.2
Medscape
www.asahq.org
http://spectrum.diabetesjournals.org/content/15/1/44.
full
7/15/2014 55