The preoperative evaluation consists of gathering patient information and formulating an anesthetic plan to reduce perioperative risks. Inadequate planning and errors in preparation are common causes of anesthetic complications. The evaluation includes reviewing medical history and test results, performing a physical exam, consulting specialists, and optimizing the patient's medical condition prior to elective surgery. The goal is to ensure the patient is in the best possible state before undergoing anesthesia and procedures.
Pre anaesthetic assessment and preoperative fasting guidelinesAnor Abidin
The document outlines the key steps and objectives of pre-anaesthetic consultation:
- Evaluate the patient's medical condition and optimise any risk factors.
- Determine the anaesthetic technique and perioperative care plan.
- Obtain informed consent from the patient after discussing anaesthesia and the procedure.
- The assessment may involve medical history, physical exam, and targeted lab/imaging tests to evaluate risk.
- The goals are to ensure patient safety and provide preoperative counselling and risk assessment.
The document outlines the objectives and components of an anesthesia and CPR course for medical students. It covers pre-anesthesia assessment, orientation to anesthesia equipment, post-operative care, ICU rounds, and the role of anesthesiologists in the pre-operative period. Key topics include pre-anesthesia evaluation, anesthesia principles, medical history taking, risk stratification, airway evaluation, preoperative testing, informed consent, and documenting the preoperative visit.
This document discusses the goals and process of a pre-anaesthetic clinic. It defines a pre-anaesthetic clinic as the clinical assessment that precedes anaesthesia care. The goals are to reduce anxiety, optimize patient health, facilitate early recovery, improve outcomes, provide efficient care, obtain consent, discuss pain control options, determine appropriate tests, and discuss risks. The process involves problem identification, risk assessment, preoperative preparation, and planning the anaesthetic technique. Key aspects are evaluating the patient's medical history and condition, the surgical procedure, and anaesthetic risks to determine if the patient's condition is optimal and any precautions are needed.
1) Preoperative hypertension is common and increases the risk of perioperative complications, however well-controlled hypertension may not need surgery postponement.
2) Isolated systolic hypertension over 180 mmHg and high pulse pressure over 80 mmHg are associated with increased risk and reasonable to postpone surgery.
3) Left ventricular hypertrophy and diastolic dysfunction from long-standing hypertension increase perioperative risk and require careful fluid management during surgery.
This document provides an overview of the classification, pathophysiology, preoperative evaluation, and anesthetic management considerations for patients undergoing surgery with congenital heart defects such as atrial septal defects (ASD) and ventricular septal defects (VSD). It discusses the pathophysiology of left-to-right and right-to-left shunting, preoperative assessment including history, examination, investigations, and risk factors. It also outlines goals and techniques for anesthesia including bubble avoidance, optimizing oxygen delivery and ventilation, and avoiding hypovolemia and increases in left-to-right shunting. Specific considerations for inhalational and intravenous induction agents, central neuraxial blockade, pregnancy, and Eisenmenger
The document discusses the importance of preoperative evaluation in ensuring patient safety and optimal outcomes. A thorough evaluation includes obtaining medical history, conducting a physical exam, and ordering appropriate tests. Key areas of focus include assessing cardiovascular, pulmonary, coagulation, and gastrointestinal status. Airway evaluation helps predict potential difficulties. The goals are to identify and address any issues that could impact anesthesia or surgery, provide informed consent, and reduce risk through optimization when possible.
Perioperative Management of Hypertensionmagdy elmasry
This document discusses peri-operative hypertension and provides recommendations for its management. It defines peri-operative as referring to the pre-operative, intra-operative, and post-operative periods of surgery. While stage 1 or 2 hypertension alone may not increase perioperative risk, the presence of target organ damage from hypertension can affect outcomes. The guidelines recommend continuing most antihypertensive medications during surgery, with the exception of ACE inhibitors and ARBs. For patients with grade 1 or 2 hypertension, there is no evidence delaying surgery to optimize therapy provides benefits. Acute postoperative hypertension is a frequent complication that should be treated to avoid adverse events.
Pre anaesthetic assessment and preoperative fasting guidelinesAnor Abidin
The document outlines the key steps and objectives of pre-anaesthetic consultation:
- Evaluate the patient's medical condition and optimise any risk factors.
- Determine the anaesthetic technique and perioperative care plan.
- Obtain informed consent from the patient after discussing anaesthesia and the procedure.
- The assessment may involve medical history, physical exam, and targeted lab/imaging tests to evaluate risk.
- The goals are to ensure patient safety and provide preoperative counselling and risk assessment.
The document outlines the objectives and components of an anesthesia and CPR course for medical students. It covers pre-anesthesia assessment, orientation to anesthesia equipment, post-operative care, ICU rounds, and the role of anesthesiologists in the pre-operative period. Key topics include pre-anesthesia evaluation, anesthesia principles, medical history taking, risk stratification, airway evaluation, preoperative testing, informed consent, and documenting the preoperative visit.
This document discusses the goals and process of a pre-anaesthetic clinic. It defines a pre-anaesthetic clinic as the clinical assessment that precedes anaesthesia care. The goals are to reduce anxiety, optimize patient health, facilitate early recovery, improve outcomes, provide efficient care, obtain consent, discuss pain control options, determine appropriate tests, and discuss risks. The process involves problem identification, risk assessment, preoperative preparation, and planning the anaesthetic technique. Key aspects are evaluating the patient's medical history and condition, the surgical procedure, and anaesthetic risks to determine if the patient's condition is optimal and any precautions are needed.
1) Preoperative hypertension is common and increases the risk of perioperative complications, however well-controlled hypertension may not need surgery postponement.
2) Isolated systolic hypertension over 180 mmHg and high pulse pressure over 80 mmHg are associated with increased risk and reasonable to postpone surgery.
3) Left ventricular hypertrophy and diastolic dysfunction from long-standing hypertension increase perioperative risk and require careful fluid management during surgery.
This document provides an overview of the classification, pathophysiology, preoperative evaluation, and anesthetic management considerations for patients undergoing surgery with congenital heart defects such as atrial septal defects (ASD) and ventricular septal defects (VSD). It discusses the pathophysiology of left-to-right and right-to-left shunting, preoperative assessment including history, examination, investigations, and risk factors. It also outlines goals and techniques for anesthesia including bubble avoidance, optimizing oxygen delivery and ventilation, and avoiding hypovolemia and increases in left-to-right shunting. Specific considerations for inhalational and intravenous induction agents, central neuraxial blockade, pregnancy, and Eisenmenger
The document discusses the importance of preoperative evaluation in ensuring patient safety and optimal outcomes. A thorough evaluation includes obtaining medical history, conducting a physical exam, and ordering appropriate tests. Key areas of focus include assessing cardiovascular, pulmonary, coagulation, and gastrointestinal status. Airway evaluation helps predict potential difficulties. The goals are to identify and address any issues that could impact anesthesia or surgery, provide informed consent, and reduce risk through optimization when possible.
Perioperative Management of Hypertensionmagdy elmasry
This document discusses peri-operative hypertension and provides recommendations for its management. It defines peri-operative as referring to the pre-operative, intra-operative, and post-operative periods of surgery. While stage 1 or 2 hypertension alone may not increase perioperative risk, the presence of target organ damage from hypertension can affect outcomes. The guidelines recommend continuing most antihypertensive medications during surgery, with the exception of ACE inhibitors and ARBs. For patients with grade 1 or 2 hypertension, there is no evidence delaying surgery to optimize therapy provides benefits. Acute postoperative hypertension is a frequent complication that should be treated to avoid adverse events.
1. Perioperative hypertension is commonly encountered and can increase morbidity and mortality. It occurs during induction of anesthesia, intraoperatively due to pain or other factors, and in the first few postoperative days.
2. Treatment involves first identifying and addressing reversible causes while also preventing sharp drops in blood pressure. Several intravenous antihypertensive medications can be used including clevidipine, enalaprilat, esmolol, labetalol, fenoldopam, and nicardipine. The goal is to lower blood pressure by 10-15% or to 110 mmHg over 30-60 minutes to reduce risk.
3. Special considerations for preoperative, intraoperative, and postoperative hypertension
The document discusses preoperative assessment and premedication. It covers setting up preoperative testing based on a patient's history and physical exam, evaluating cardiovascular and respiratory disease risk, managing medications before surgery, and guidelines for preoperative fasting. The goal is to identify and minimize risks, improve outcomes, and avoid unnecessary delays or cancellations.
Preop evaluation of cardiac patient postd=ed for non cardiac surgery Rajesh Munigial
This document discusses pre-operative evaluation and preparation of cardiac patients for non-cardiac surgeries. It outlines that patients with coronary artery disease undergoing non-cardiac surgery are at increased risk of complications. A thorough pre-operative evaluation including history, physical exam, diagnostic tests, and knowledge of the planned surgery is important to assess risk factors and develop a management plan. Tests like ECG, stress testing, echocardiogram and in some cases angiography help evaluate cardiac status. Medical optimization including management of angina, heart failure, diabetes, etc. can help reduce perioperative risk. Timing of surgery depends on the clinical status and risk of delay. Intraoperative management focuses on preventing ischemia.
Perioperative myocardial infarction is a common cause of morbidity and mortality in patients undergoing noncardiac surgery. It can occur through acute coronary syndrome or prolonged myocardial ischemia in patients with stable coronary artery disease. Diagnosis is difficult as symptoms often do not present in anesthetized patients. Risk is determined by patient clinical factors, exercise capacity, and surgery risk. Management may include beta blockers, statins, aspirin, and evaluating need for revascularization based on standard criteria.
The presentation deals with the basics of pre anesthetic checkups, its only for the educations purpose!
Any kind of replication, modifications and republication is strictly prohibited.
All Rights reserved to the Author. 2016
The medical specialty of anesthesiology is founded on patient experience and patient safety. Having major surgery would be a very different experience without anesthesia. Before the advent of safe anesthesia techniques, the world of surgery was basically limited to amputations and other attempts at life-saving maneuvers. Dr. Bigelow’s publication describing the safe administration of ether changed everything, and the New England Journal of Medicine called this the most important article in its history. With this article, the science and clinical practice of anesthesiology, as well as the modern era of surgery, were born. Understanding and appreciating the rich history of anesthesiology will help guide the future direction of this specialty. Physician anesthesiologists have the skills necessary to take the quality of perioperative medicine to the next level, combat the opioid epidemic, and redesign the surgical experience,
This document discusses the importance of preanesthetic evaluation by an anesthesiologist. It aims to ensure patients can safely tolerate anesthesia and mitigate perioperative risks. Key components include documenting medical history, performing examinations, optimizing conditions, ordering tests selectively, and discussing care. History taking and physical exams detect most issues. Tests are only needed based on history, procedure, and anticipated blood loss. The evaluation helps determine a patient's fitness and perioperative risk level. Medication management and fasting guidelines are also reviewed.
1) The document discusses preoperative evaluation and anesthetic considerations for thoracic surgery patients, with a focus on patients undergoing one-lung ventilation.
2) Key points of preoperative evaluation include assessing pulmonary function, cardiac status, investigating the extent of lung involvement, and optimizing patients with respiratory conditions like COPD.
3) Anesthetic management focuses on techniques for one-lung ventilation using devices like double-lumen endotracheal tubes, as well as strategies for ventilation, induction, and analgesia tailored to patient comorbidities.
The document discusses the posterior fossa, including its boundaries, contents, blood supply, clinical presentation of lesions, and considerations for anesthesia. The posterior fossa is bounded anteriorly by the clivus and petrous bone, posteriorly by the occipital bone, and laterally by the temporal bone. It contains the cerebellar hemispheres, brainstem, and cranial nerves III-XII. Lesions can cause a variety of signs and symptoms depending on location, including ataxia, nystagmus, limb weakness, and cranial nerve deficits. Anesthesia for posterior fossa surgery requires careful monitoring and positioning to maintain stability while allowing surgical access.
This document provides an overview of preanesthesia evaluation. The key purposes are to obtain relevant medical history, assess perioperative risks, order appropriate tests, and formulate an anesthetic plan. Important components of the medical history include past and current medical problems, medications, allergies, and lifestyle factors. A physical exam focuses on vital signs, airway assessment, and systemic examination. For patients with cardiovascular or pulmonary diseases, specific evaluations and tests are recommended to optimize management and identify high-risk patients. The preanesthesia evaluation aims to detect underlying conditions, evaluate perioperative risks, and develop a customized anesthetic plan tailored to each patient's needs.
Physiological triggers for blood transfusion in the icuchandra talur
Physiological triggers for blood transfusion in critically ill patients should be based on an individual patient's volume status, evidence of shock or end-organ compromise, and cardiopulmonary parameters rather than a single hemoglobin threshold. A restrictive transfusion strategy (transfusing when Hb <7 g/dL) is as effective as a liberal strategy (Hb <10 g/dL) for hemodynamically stable patients. The decision to transfuse should take into account the patient's hemodynamic status, rate of blood loss, oxygen delivery capabilities, and risk-benefit ratio of transfusion.
This document discusses premedication before anesthesia. It defines premedication as the administration of drugs before anesthesia induction. The goals of premedication are to provide anxiolysis, analgesia, amnesia and facilitate induction and recovery from anesthesia. Common drugs used for premedication include benzodiazepines for anxiolysis and sedation, opioids for analgesia, anticholinergics to reduce saliva production, antihistamines for their anticholinergic effects, and antiemetics to prevent nausea and vomiting. Factors like a patient's medical history, surgery type and timing must be considered when determining appropriate premedication.
The document discusses preoperative evaluation, which involves assessing a patient's medical status and anaesthetic risks before surgery through history, examinations, tests, and a multidisciplinary team to reduce morbidity and mortality. It outlines the goals, steps, assessments including airway and exercise tolerance, role of physicians and nurses, and concludes that a combined effort can significantly reduce surgical risks.
The document discusses pre-anesthetic evaluation. It defines pre-anesthetic evaluation as the clinical foundation that guides preoperative patient management to reduce perioperative morbidity and enhance outcomes. It outlines the focused steps of pre-anesthetic evaluation which include taking a proper history and physical exam, documenting comorbidities, addressing patient anxiety, ordering investigations, discussing perioperative care plans, arranging postoperative care, and suggesting delaying or cancelling surgery if needed. The benefits outlined are more selective test ordering, reduced patient anxiety, improved acceptance of regional anesthesia, fewer cancellations, shorter hospital stays, and lower costs.
1) The document discusses anesthesia considerations for spinal surgery, including pre-operative assessment of airway, respiratory, cardiovascular, and neurological systems, as well as unique challenges like patient positioning and intra-operative monitoring.
2) Key surgical procedures mentioned are laminectomy, discectomy, and instrumentation/fusion, while common spinal conditions requiring surgery include disc lesions, stenosis, tumors, and deformities.
3) Anesthesia techniques aim to maintain a stable depth and avoid sudden changes in anesthetic depth or blood pressure. Intra-operative monitoring discussed includes wake-up tests, SSEP, MEP, and EMGs to evaluate spinal functional integrity.
Perioperative myocardial infarction or injury after noncardiac surgeryVijay Yadav
1) Perioperative myocardial injury and infarction are common complications after non-cardiac surgery, occurring in up to 17% of high-risk patients, with many events going unrecognized due to a lack of symptoms.
2) Both symptomatic and asymptomatic perioperative myocardial infarctions are associated with a significant increase in short- and long-term mortality.
3) Routine screening for myocardial injury using high-sensitivity troponin measurements can help identify at-risk patients, and secondary prevention treatments with aspirin, statins, and other medications may provide mortality benefits.
The document discusses the history and importance of post-anesthesia care units (PACUs) and outlines their design, equipment, staffing needs, and standard procedures for patient care and monitoring. Key aspects of PACU care include criteria for patient transfer from the operating room to PACU, routine post-anesthesia monitoring and treatment, potential post-operative complications, discharge criteria, and scoring systems used to evaluate patient recovery status.
preoperative evaluation for residents of anesthesia part 1mansoor masjedi
The document discusses the importance of preoperative evaluation in anesthesia. It notes that anesthesiologists now perform many roles beyond just anesthesia in the operating room, including focused clinical exams, medical optimization, reducing patient anxiety, and informed consent. A thorough preoperative evaluation can reduce surgical risks, delays and cancellations. Key aspects of the evaluation include assessing medical history and physical exam findings, laboratory tests, EKG, and risk classification using the ASA system. The goals are to identify health risks, heart conditions, optimize medical issues, and modify perioperative risk.
The document discusses the American Society of Anesthesiologists (ASA) physical status classification system. The ASA system was developed in 1941 to assess preoperative patient health and predict surgical risk. It categorizes patients from Class I (healthy) to Class VI (brain dead donor). While the ASA score correlates with outcomes, there is disagreement on its consistency due to variability in its application and definitions that do not consider all relevant factors like age, surgery complexity, or medical care quality.
The document discusses diseases of the pancreas, including congenital anomalies, endocrine and exocrine pancreatic diseases, acute and chronic pancreatitis, and pancreatic tumors. It provides details on the causes, pathophysiology, clinical presentation, diagnosis, and treatment of each condition. Key points include the role of gallstones and alcohol as common causes of acute pancreatitis, the use of CT and lab tests to diagnose and determine severity, and supportive care along with surgical or endoscopic interventions for severe cases.
This document discusses a case of hyperthyroidism in a 39-year-old female presenting with nervousness, anxiety, palpitations, diarrhea, and weight loss. On examination, she had a heart rate of 110 bpm, tremor, increased reflexes, and an enlarged thyroid. Laboratory tests found high free T3 and T4, low TSH, and positive thyroid stimulating immunoglobulins, consistent with a diagnosis of Graves' disease. Graves' disease is an autoimmune disorder causing hyperthyroidism through thyroid stimulating antibodies. If left untreated, hyperthyroidism can progress to a thyroid storm, a life-threatening condition of severe hypermetabolism.
1. Perioperative hypertension is commonly encountered and can increase morbidity and mortality. It occurs during induction of anesthesia, intraoperatively due to pain or other factors, and in the first few postoperative days.
2. Treatment involves first identifying and addressing reversible causes while also preventing sharp drops in blood pressure. Several intravenous antihypertensive medications can be used including clevidipine, enalaprilat, esmolol, labetalol, fenoldopam, and nicardipine. The goal is to lower blood pressure by 10-15% or to 110 mmHg over 30-60 minutes to reduce risk.
3. Special considerations for preoperative, intraoperative, and postoperative hypertension
The document discusses preoperative assessment and premedication. It covers setting up preoperative testing based on a patient's history and physical exam, evaluating cardiovascular and respiratory disease risk, managing medications before surgery, and guidelines for preoperative fasting. The goal is to identify and minimize risks, improve outcomes, and avoid unnecessary delays or cancellations.
Preop evaluation of cardiac patient postd=ed for non cardiac surgery Rajesh Munigial
This document discusses pre-operative evaluation and preparation of cardiac patients for non-cardiac surgeries. It outlines that patients with coronary artery disease undergoing non-cardiac surgery are at increased risk of complications. A thorough pre-operative evaluation including history, physical exam, diagnostic tests, and knowledge of the planned surgery is important to assess risk factors and develop a management plan. Tests like ECG, stress testing, echocardiogram and in some cases angiography help evaluate cardiac status. Medical optimization including management of angina, heart failure, diabetes, etc. can help reduce perioperative risk. Timing of surgery depends on the clinical status and risk of delay. Intraoperative management focuses on preventing ischemia.
Perioperative myocardial infarction is a common cause of morbidity and mortality in patients undergoing noncardiac surgery. It can occur through acute coronary syndrome or prolonged myocardial ischemia in patients with stable coronary artery disease. Diagnosis is difficult as symptoms often do not present in anesthetized patients. Risk is determined by patient clinical factors, exercise capacity, and surgery risk. Management may include beta blockers, statins, aspirin, and evaluating need for revascularization based on standard criteria.
The presentation deals with the basics of pre anesthetic checkups, its only for the educations purpose!
Any kind of replication, modifications and republication is strictly prohibited.
All Rights reserved to the Author. 2016
The medical specialty of anesthesiology is founded on patient experience and patient safety. Having major surgery would be a very different experience without anesthesia. Before the advent of safe anesthesia techniques, the world of surgery was basically limited to amputations and other attempts at life-saving maneuvers. Dr. Bigelow’s publication describing the safe administration of ether changed everything, and the New England Journal of Medicine called this the most important article in its history. With this article, the science and clinical practice of anesthesiology, as well as the modern era of surgery, were born. Understanding and appreciating the rich history of anesthesiology will help guide the future direction of this specialty. Physician anesthesiologists have the skills necessary to take the quality of perioperative medicine to the next level, combat the opioid epidemic, and redesign the surgical experience,
This document discusses the importance of preanesthetic evaluation by an anesthesiologist. It aims to ensure patients can safely tolerate anesthesia and mitigate perioperative risks. Key components include documenting medical history, performing examinations, optimizing conditions, ordering tests selectively, and discussing care. History taking and physical exams detect most issues. Tests are only needed based on history, procedure, and anticipated blood loss. The evaluation helps determine a patient's fitness and perioperative risk level. Medication management and fasting guidelines are also reviewed.
1) The document discusses preoperative evaluation and anesthetic considerations for thoracic surgery patients, with a focus on patients undergoing one-lung ventilation.
2) Key points of preoperative evaluation include assessing pulmonary function, cardiac status, investigating the extent of lung involvement, and optimizing patients with respiratory conditions like COPD.
3) Anesthetic management focuses on techniques for one-lung ventilation using devices like double-lumen endotracheal tubes, as well as strategies for ventilation, induction, and analgesia tailored to patient comorbidities.
The document discusses the posterior fossa, including its boundaries, contents, blood supply, clinical presentation of lesions, and considerations for anesthesia. The posterior fossa is bounded anteriorly by the clivus and petrous bone, posteriorly by the occipital bone, and laterally by the temporal bone. It contains the cerebellar hemispheres, brainstem, and cranial nerves III-XII. Lesions can cause a variety of signs and symptoms depending on location, including ataxia, nystagmus, limb weakness, and cranial nerve deficits. Anesthesia for posterior fossa surgery requires careful monitoring and positioning to maintain stability while allowing surgical access.
This document provides an overview of preanesthesia evaluation. The key purposes are to obtain relevant medical history, assess perioperative risks, order appropriate tests, and formulate an anesthetic plan. Important components of the medical history include past and current medical problems, medications, allergies, and lifestyle factors. A physical exam focuses on vital signs, airway assessment, and systemic examination. For patients with cardiovascular or pulmonary diseases, specific evaluations and tests are recommended to optimize management and identify high-risk patients. The preanesthesia evaluation aims to detect underlying conditions, evaluate perioperative risks, and develop a customized anesthetic plan tailored to each patient's needs.
Physiological triggers for blood transfusion in the icuchandra talur
Physiological triggers for blood transfusion in critically ill patients should be based on an individual patient's volume status, evidence of shock or end-organ compromise, and cardiopulmonary parameters rather than a single hemoglobin threshold. A restrictive transfusion strategy (transfusing when Hb <7 g/dL) is as effective as a liberal strategy (Hb <10 g/dL) for hemodynamically stable patients. The decision to transfuse should take into account the patient's hemodynamic status, rate of blood loss, oxygen delivery capabilities, and risk-benefit ratio of transfusion.
This document discusses premedication before anesthesia. It defines premedication as the administration of drugs before anesthesia induction. The goals of premedication are to provide anxiolysis, analgesia, amnesia and facilitate induction and recovery from anesthesia. Common drugs used for premedication include benzodiazepines for anxiolysis and sedation, opioids for analgesia, anticholinergics to reduce saliva production, antihistamines for their anticholinergic effects, and antiemetics to prevent nausea and vomiting. Factors like a patient's medical history, surgery type and timing must be considered when determining appropriate premedication.
The document discusses preoperative evaluation, which involves assessing a patient's medical status and anaesthetic risks before surgery through history, examinations, tests, and a multidisciplinary team to reduce morbidity and mortality. It outlines the goals, steps, assessments including airway and exercise tolerance, role of physicians and nurses, and concludes that a combined effort can significantly reduce surgical risks.
The document discusses pre-anesthetic evaluation. It defines pre-anesthetic evaluation as the clinical foundation that guides preoperative patient management to reduce perioperative morbidity and enhance outcomes. It outlines the focused steps of pre-anesthetic evaluation which include taking a proper history and physical exam, documenting comorbidities, addressing patient anxiety, ordering investigations, discussing perioperative care plans, arranging postoperative care, and suggesting delaying or cancelling surgery if needed. The benefits outlined are more selective test ordering, reduced patient anxiety, improved acceptance of regional anesthesia, fewer cancellations, shorter hospital stays, and lower costs.
1) The document discusses anesthesia considerations for spinal surgery, including pre-operative assessment of airway, respiratory, cardiovascular, and neurological systems, as well as unique challenges like patient positioning and intra-operative monitoring.
2) Key surgical procedures mentioned are laminectomy, discectomy, and instrumentation/fusion, while common spinal conditions requiring surgery include disc lesions, stenosis, tumors, and deformities.
3) Anesthesia techniques aim to maintain a stable depth and avoid sudden changes in anesthetic depth or blood pressure. Intra-operative monitoring discussed includes wake-up tests, SSEP, MEP, and EMGs to evaluate spinal functional integrity.
Perioperative myocardial infarction or injury after noncardiac surgeryVijay Yadav
1) Perioperative myocardial injury and infarction are common complications after non-cardiac surgery, occurring in up to 17% of high-risk patients, with many events going unrecognized due to a lack of symptoms.
2) Both symptomatic and asymptomatic perioperative myocardial infarctions are associated with a significant increase in short- and long-term mortality.
3) Routine screening for myocardial injury using high-sensitivity troponin measurements can help identify at-risk patients, and secondary prevention treatments with aspirin, statins, and other medications may provide mortality benefits.
The document discusses the history and importance of post-anesthesia care units (PACUs) and outlines their design, equipment, staffing needs, and standard procedures for patient care and monitoring. Key aspects of PACU care include criteria for patient transfer from the operating room to PACU, routine post-anesthesia monitoring and treatment, potential post-operative complications, discharge criteria, and scoring systems used to evaluate patient recovery status.
preoperative evaluation for residents of anesthesia part 1mansoor masjedi
The document discusses the importance of preoperative evaluation in anesthesia. It notes that anesthesiologists now perform many roles beyond just anesthesia in the operating room, including focused clinical exams, medical optimization, reducing patient anxiety, and informed consent. A thorough preoperative evaluation can reduce surgical risks, delays and cancellations. Key aspects of the evaluation include assessing medical history and physical exam findings, laboratory tests, EKG, and risk classification using the ASA system. The goals are to identify health risks, heart conditions, optimize medical issues, and modify perioperative risk.
The document discusses the American Society of Anesthesiologists (ASA) physical status classification system. The ASA system was developed in 1941 to assess preoperative patient health and predict surgical risk. It categorizes patients from Class I (healthy) to Class VI (brain dead donor). While the ASA score correlates with outcomes, there is disagreement on its consistency due to variability in its application and definitions that do not consider all relevant factors like age, surgery complexity, or medical care quality.
The document discusses diseases of the pancreas, including congenital anomalies, endocrine and exocrine pancreatic diseases, acute and chronic pancreatitis, and pancreatic tumors. It provides details on the causes, pathophysiology, clinical presentation, diagnosis, and treatment of each condition. Key points include the role of gallstones and alcohol as common causes of acute pancreatitis, the use of CT and lab tests to diagnose and determine severity, and supportive care along with surgical or endoscopic interventions for severe cases.
This document discusses a case of hyperthyroidism in a 39-year-old female presenting with nervousness, anxiety, palpitations, diarrhea, and weight loss. On examination, she had a heart rate of 110 bpm, tremor, increased reflexes, and an enlarged thyroid. Laboratory tests found high free T3 and T4, low TSH, and positive thyroid stimulating immunoglobulins, consistent with a diagnosis of Graves' disease. Graves' disease is an autoimmune disorder causing hyperthyroidism through thyroid stimulating antibodies. If left untreated, hyperthyroidism can progress to a thyroid storm, a life-threatening condition of severe hypermetabolism.
2012 Clinical Practice guidelines for hypothyroidism in adults: American Asso...Jibran Mohsin
This is presentation format of 2012 Clinical Practice guidelines for hypothyroidism in adults: American Association of Clinical Endocrinologists (AACE) / American Thyroid Association (ATA)
This document discusses types of shock, including hypovolemic, cardiogenic, obstructive, distributive, septic, anaphylactic, and neurogenic shock. It covers the pathophysiology, signs and symptoms, treatment principles of fluid resuscitation, and choices of intravenous fluids for each type of shock. The key aspects of fluid management in shock include initially restoring intravascular volume with crystalloids before considering colloids or blood transfusion to achieve hemodynamic goals.
Damage control surgery (DCS) is an approach used for severely injured trauma patients that focuses on rapidly addressing life-threatening issues like hemorrhage rather than fully repairing anatomy. It aims to prevent the lethal triad of hypothermia, acidosis, and coagulopathy that can result from long operations and blood loss. Key aspects of DCS include temporary measures like packing bleeding liver injuries; stapling but not repairing some intestinal injuries; leaving unrepaired vascular injuries clamped; and rapidly closing the abdomen with clips rather than drains to allow reoperation once the patient is stabilized. The goal is definitive repair within 24 hours once the patient's physiology is corrected.
This document provides information on preoperative assessments for anesthesia. It discusses performing a clinical assessment of patients including medical history, physical exam, and necessary investigations. Patients are categorized based on medical complexity, with low-risk patients able to schedule surgery and higher-risk patients requiring further testing or specialist consultation. The goals of preoperative assessment are to optimize patient health and identify risks so surgeries are not cancelled due to medical issues. Post-anesthesia care and potential complications are also outlined.
Thyroid disorders result from issues with thyroid hormone production or secretion, altering metabolism. Hyperthyroidism occurs when excessive thyroid hormones are produced, often due to Graves' disease, an autoimmune disorder. Hypothyroidism results from decreased thyroid hormone production, commonly caused by Hashimoto's thyroiditis or thyroid surgery/radiation treatment. Both conditions are managed through pharmacological interventions like antithyroid drugs or levothyroxine replacement therapy.
Hyperthyroidism, Reference: Hyperthyroid, Harrison's Principles of Internal Medicine, Soheil Elahi, Islamic Azad University of Medicine- International Branch (IAUM-int)
Damage control surgery involves rapidly controlling hemorrhaging and contamination through temporary closure of injuries to stabilize critically injured patients, followed by resuscitation and definitive repair once physiology is restored. It aims to prevent the lethal triad of hypothermia, acidosis, and coagulopathy. The approach has three stages - initial laparotomy and packing, ICU resuscitation, and planned reoperation once metabolic conditions improve. It has been shown to improve survival rates for severely injured trauma patients compared to traditional surgery.
Thyroid and its pathology (Hypothyroidism).Vikas Reddy
GREEK :- THYREOS – SHIELD ; EIDOS – FORM
1.LOCATION:- Anterior to trachea in between the cricoid cartilage and the suprasternal notch.
2.SHAPE:- It has 2 lobes connected with an isthmus, each lobe in turn has two poles.
3.Weighs around 10-20 gm, highly vascular and soft in consistency.
4. 4 Parathyroid glands which secrete PTH are located posterior to each pole of thyroid
The RLN traverse the lateral border of thyroid gland and must be identified during thyroid surgery to avoid injury and vocal cord paralysis.
Develops from the floor of primitive pharynx during the 3rd week of gestation.
Fetal cells in which developmental transcription factors TTF-1,TTF-2 & PAX-8 are expressed selectively form the thyroid gland ,secondly they result in induction of thyroid specific genes
Tg,TPO,NIS,TSH-R.
Mutations-THYROID AGENESIS & DYSHORMONOGENESIS(CONG. HYPOTHYROIDISM).
The developing gland migrates along the thyroglossal duct to reach its final location in the neck.
LINGUAL THYROID AND THYROGLOSSAL DUCT CYST.
Thyroid hormone synthesis begins at about 11 weeks of gestation.
Until 11 week of gestation and even later, it is the maternal thyroid hormones which cross the placenta to reach the fetus and aid its development.
Therefore a child born to a hypothyroid mother would suffer from features of congenital hypothyroidism.
Secondly if the mother has TSH-R blocking antibodies or has received anti thyroid therapy during pregnancy, might lead to transient congenital hypothyroidism.
This document provides an overview of hypothyroidism, including its definition, effects on different organ systems, types, causes, investigations, and treatment. Some key points are:
- Hypothyroidism is a deficiency in thyroid hormone secretion, occurring in 2-15% of the population more commonly in women. Risk increases with age.
- It affects the cardiovascular, respiratory, renal, central nervous, neuromuscular, gastrointestinal, and hematological systems, causing decreased metabolism.
- Types include primary, central, and congenital hypothyroidism. Causes include iodine deficiency, autoimmune disease, surgery, radiation, and certain drugs.
- Investigations include thyroid function tests and antibodies
Next day discharge following elective caesarean section using Enhanced Recovery Care Pathways.
Ian Wrench (Consultant Anaesthetist)
Andrea Galimberti (Consultant Obstetrician)
Jan Hall (Midwifery Sister – Postnatal ward)
Julie Humphries (Midwifery Sister – Postnatal Ward)
Sheffield Teaching Hospitals NHS Foundation Trust
Presentation from Shaping the Future Direction of Enhanced Recovery Care Pathway Seven Days a Week workshop held in London on 5 December 2013
This document provides guidelines for the management of acute heart failure. It discusses current treatment strategies including diuretics, vasodilators, and inotropes. Novel therapeutic strategies are mentioned, such as newer inotropic drugs, rollofylline, tolvaptan, ularitide, relaxin, and others. The goals of therapy for acute heart failure are to make the patient feel better by reducing dyspnea, improve quality of life, reduce mortality and rehospitalization, and do so safely. Recent large clinical trials of new agents for acute heart failure have failed to show benefits observed in smaller earlier studies.
Hashimoto's thyroiditis and subacute thyroiditis are the most common causes of primary hypothyroidism. Hashimoto's is an autoimmune disorder characterized by elevated TSH and the presence of anti-thyroid antibodies. Subacute thyroiditis causes a transient hypothyroid phase due to thyroid hormone release rather than increased synthesis, with low radioactive iodine uptake and no antibodies present. Graves' disease, the most common cause of hyperthyroidism, results from TSH receptor antibodies that mimic TSH and stimulate increased thyroid hormone production.
Acute Decompensated Heart Failure : What is New ?drucsamal
1. The document discusses drug trials for acute decompensated heart failure and their results. Many trials tested drugs like nesiritide, milrinone, tezosentan, levosimendan, tolvaptan, and rolofylline but did not show clinical benefit.
2. It proposes classifying patients based on their clinical profile into those with volume overload, reduced cardiac output, or a combination, to help determine optimal treatment which may include diuretics, vasodilators, inotropes, or renal preservation agents.
3. The management of acute heart failure is divided into initial, in-hospital, and discharge phases, with goals like establishing diagnoses, treating precip
This document defines various gallstone diseases and provides information on their risk factors, presentations, diagnoses, and treatments. It discusses the definitions of cholelithiasis, cholecystitis, choledocholithiasis, and other conditions. The risk factors include factors like female gender, obesity, and hemolytic states. Imaging studies like ultrasound and CT are used for diagnosis, and treatments involve analgesics, antibiotics, ERCP, and cholecystectomy.
This document discusses the management of pancreatic pseudocysts, which are fluid collections that can develop after acute pancreatitis. It outlines the different treatment approaches depending on the stage of the pseudocyst. For acute pseudocysts in unstable patients, conservative management is recommended to allow for stabilization. If complications occur, surgical intervention may be needed. Pseudocysts with infected pancreatic necrosis require surgical drainage and debridement. Chronic pseudocysts with thick walls seen on imaging likely will not resolve spontaneously and require surgical drainage or endoscopic drainage if technically possible.
The document discusses the history and development of the internet over the past 50 years, from its origins as a US military program called ARPANET to the commercialization of the world wide web in the 1990s. It led to an explosion of new technologies and services over the following decades that have transformed how people live and work through greater connectivity and access to information.
This document discusses different types of analgesic (pain-relieving) drugs. It categorizes analgesics into groups including NSAIDs, narcotics, adjuvants, and anesthetic nerve blockade. NSAIDs like aspirin, ibuprofen, and naproxen are over-the-counter pain relievers that reduce inflammation and pain. Narcotics like morphine and oxycodone are stronger prescription opioids that act in the central nervous system but carry addiction risks. Other drugs like amitriptyline and gabapentin are used as adjuvants to treat neuropathic pain. Nerve blocks using lidocaine can also temporarily relieve pain in localized areas.
Perioperative management of patients on corticosteroidsTerry Shaneyfelt
In these annotated PowerPoints I discuss the evaluation and perioperative management of patient taking or who have taken steroids. I discuss how to determine if the adrenal axis is suppressed and how to provide supplemental glucocorticoids if needed. Remember to download these slides to see the annotations for each slide.
This patient has a history of myocardial infarction, triple vessel coronary artery disease, and is scheduled for elective non-cardiac surgery. Based on his positive stress test results and coronary angiogram showing severe blockages, the cardiologist recommends coronary artery bypass graft surgery prior to the planned surgery to improve his long-term prognosis and reduce perioperative cardiac risks.
The document discusses the process and objectives of pre-anesthesia checkups (PACs). A PAC involves assessing a patient's medical history, conducting a physical exam, and developing an anesthesia plan. It aims to evaluate perioperative risk and ensure a patient can safely tolerate anesthesia. Key parts of the evaluation include reviewing the cardiovascular, respiratory, and other organ systems, as well as performing airway exams and risk assessments. The PAC provides important information to inform anesthesia management and optimize patient safety and outcomes.
This document discusses the important aspects of pre-operative patient preparation and assessment. It outlines the key components of taking a patient history, performing a physical exam, identifying relevant comorbidities, and ordering appropriate pre-operative tests and investigations. Special focus is given to evaluating and optimizing patients' cardiovascular and pulmonary systems to reduce perioperative risk. The goals are to identify any issues that could impact the surgical outcome and to optimize medical conditions in order to decrease complications.
Acute Decompensated Heart Failure : What is New ?drucsamal
Prof. U. C. SAMAL is an expert in cardiology who has held leadership positions in several cardiological societies. The document discusses the management of acute decompensated heart failure and summarizes recent changes to guidelines. It provides an overview of pharmacological interventions for acute heart failure such as diuretics, vasodilators, and inotropes. Non-invasive ventilation and risk stratification scores are also mentioned. The document emphasizes the importance of both short-term stabilization and long-term management through multi-disciplinary programs to prevent readmissions.
pre op evaluation of cardiac pts for non-cardiac surgeryVkas Subedi
This document discusses the preoperative evaluation of cardiac patients undergoing non-cardiac surgery. It notes that 1-5% of unselected patients experience perioperative cardiac morbidity, and outlines the goals of pre-op evaluation as defining risks, determining if further testing is beneficial, planning anesthesia appropriately, and considering peri-op beta blockade or other therapies. It discusses evaluating patients' history, symptoms, physical exam findings, and using risk indices to stratify cardiac risk. Higher risk factors include recent MI, heart failure, significant arrhythmias or valvular disease. The document provides recommendations for further testing and treatment based on a patient's functional status and cardiac conditions.
This document discusses the preoperative evaluation of cardiac patients undergoing non-cardiac surgery. It notes that 1-5% of unselected patients experience perioperative cardiac morbidity, and outlines the goals of pre-op evaluation as defining risks, determining if further testing is beneficial, planning anesthesia appropriately, and considering peri-op beta blockade or other therapies. It discusses evaluating patients based on history, physical exam, risk stratification tools like Goldman and Detsky cardiac risk indices, and determining functional capacity. Specific cardiac conditions like coronary artery disease, heart failure, valvular issues and their peri-op implications are also reviewed.
The document discusses various aspects of pre-operative, operative, and post-operative surgical care including evaluating patient medical history and risk factors, optimizing medical conditions, obtaining informed consent, monitoring vital signs and drainage after surgery, and emphasizing the importance of proper preparation, timing, and follow-up to minimize risks and optimize surgical outcomes. Key factors discussed include cardiac, pulmonary, renal, hepatic, diabetic, nutritional status as well as use of prophylactic antibiotics and measures to prevent thromboembolic events.
Dr. Brijesh Savidhan discusses strategies for evaluating cardiac risk in patients undergoing non-cardiac surgery. The goals are to identify patients at risk, evaluate the severity of underlying heart disease, and stratify surgical risk. A thorough history, physical exam, electrocardiogram, and assessment of functional capacity are recommended. For higher-risk patients, stress testing and evaluation of left ventricular function may be considered to guide management and minimize perioperative complications. Overall, a multidisciplinary approach is important to optimize cardiac status, determine the safest location and timing of surgery, and develop an anesthesia plan tailored to each patient's cardiac condition.
The document discusses guidelines for pre-operative cardiac evaluation to identify patients at risk of peri-operative complications and determine the need for interventions. It outlines goals of evaluating a patient's history, physical exam, and tests to determine cardiac risk. Non-invasive tests include ECG, stress testing, and echocardiogram. Surgical risk is stratified as high, moderate, low. Guidelines provide a framework to screen patients. The evaluation involves assessing risk factors, functional capacity, surgical risk to categorize patients and guide management through anesthesia, medical optimization, or possible revascularization.
The document discusses peri-operative care, outlining the three phases: pre-operative, intra-operative, and post-operative care. It describes pre-operative care as including patient assessment, history, examinations, investigations, and preparation. Key aspects of pre-operative care are evaluating patient risk factors, medical history, and physical status to determine fitness for surgery and identify risks. The document also discusses classifications of surgery cleanliness and urgency, as well as common post-operative complications.
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This document discusses anaesthesia considerations for lower limb revascularization procedures. It begins with an introduction to peripheral artery disease and classifications. Causes, common sites, and presentations of acute and chronic limb ischemia are described. Preoperative assessment includes cardiovascular and pulmonary evaluation. Risk stratification guidelines are provided. Optimal perioperative management focuses on hemodynamic stability, temperature control, hydration and pain management. Both regional and general anesthesia techniques are reviewed. Postoperative monitoring and analgesia are also discussed.
Pre operative cardiac assessment dr sadany-1Hossam atef
This document discusses perioperative cardiac risk assessment and management. It covers pre-operative evaluation of patient risk factors and conditions, classification of surgical procedures by urgency, predictors of perioperative cardiac complications, and recommendations for testing and treatment based on patient risk profile and functional capacity. The goal is to stratify patient risk and determine optimal management to reduce complications during surgery and recovery.
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Communicating effectively and consistently with students can help them feel at ease during their learning experience and provide the instructor with a communication trail to track the course's progress. This workshop will take you through constructing an engaging course container to facilitate effective communication.
LAND USE LAND COVER AND NDVI OF MIRZAPUR DISTRICT, UPRAHUL
This Dissertation explores the particular circumstances of Mirzapur, a region located in the
core of India. Mirzapur, with its varied terrains and abundant biodiversity, offers an optimal
environment for investigating the changes in vegetation cover dynamics. Our study utilizes
advanced technologies such as GIS (Geographic Information Systems) and Remote sensing to
analyze the transformations that have taken place over the course of a decade.
The complex relationship between human activities and the environment has been the focus
of extensive research and worry. As the global community grapples with swift urbanization,
population expansion, and economic progress, the effects on natural ecosystems are becoming
more evident. A crucial element of this impact is the alteration of vegetation cover, which plays a
significant role in maintaining the ecological equilibrium of our planet.Land serves as the foundation for all human activities and provides the necessary materials for
these activities. As the most crucial natural resource, its utilization by humans results in different
'Land uses,' which are determined by both human activities and the physical characteristics of the
land.
The utilization of land is impacted by human needs and environmental factors. In countries
like India, rapid population growth and the emphasis on extensive resource exploitation can lead
to significant land degradation, adversely affecting the region's land cover.
Therefore, human intervention has significantly influenced land use patterns over many
centuries, evolving its structure over time and space. In the present era, these changes have
accelerated due to factors such as agriculture and urbanization. Information regarding land use and
cover is essential for various planning and management tasks related to the Earth's surface,
providing crucial environmental data for scientific, resource management, policy purposes, and
diverse human activities.
Accurate understanding of land use and cover is imperative for the development planning
of any area. Consequently, a wide range of professionals, including earth system scientists, land
and water managers, and urban planners, are interested in obtaining data on land use and cover
changes, conversion trends, and other related patterns. The spatial dimensions of land use and
cover support policymakers and scientists in making well-informed decisions, as alterations in
these patterns indicate shifts in economic and social conditions. Monitoring such changes with the
help of Advanced technologies like Remote Sensing and Geographic Information Systems is
crucial for coordinated efforts across different administrative levels. Advanced technologies like
Remote Sensing and Geographic Information Systems
9
Changes in vegetation cover refer to variations in the distribution, composition, and overall
structure of plant communities across different temporal and spatial scales. These changes can
occur natural.
How to Make a Field Mandatory in Odoo 17Celine George
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Philippine Edukasyong Pantahanan at Pangkabuhayan (EPP) CurriculumMJDuyan
(𝐓𝐋𝐄 𝟏𝟎𝟎) (𝐋𝐞𝐬𝐬𝐨𝐧 𝟏)-𝐏𝐫𝐞𝐥𝐢𝐦𝐬
𝐃𝐢𝐬𝐜𝐮𝐬𝐬 𝐭𝐡𝐞 𝐄𝐏𝐏 𝐂𝐮𝐫𝐫𝐢𝐜𝐮𝐥𝐮𝐦 𝐢𝐧 𝐭𝐡𝐞 𝐏𝐡𝐢𝐥𝐢𝐩𝐩𝐢𝐧𝐞𝐬:
- Understand the goals and objectives of the Edukasyong Pantahanan at Pangkabuhayan (EPP) curriculum, recognizing its importance in fostering practical life skills and values among students. Students will also be able to identify the key components and subjects covered, such as agriculture, home economics, industrial arts, and information and communication technology.
𝐄𝐱𝐩𝐥𝐚𝐢𝐧 𝐭𝐡𝐞 𝐍𝐚𝐭𝐮𝐫𝐞 𝐚𝐧𝐝 𝐒𝐜𝐨𝐩𝐞 𝐨𝐟 𝐚𝐧 𝐄𝐧𝐭𝐫𝐞𝐩𝐫𝐞𝐧𝐞𝐮𝐫:
-Define entrepreneurship, distinguishing it from general business activities by emphasizing its focus on innovation, risk-taking, and value creation. Students will describe the characteristics and traits of successful entrepreneurs, including their roles and responsibilities, and discuss the broader economic and social impacts of entrepreneurial activities on both local and global scales.
How to Setup Warehouse & Location in Odoo 17 InventoryCeline George
In this slide, we'll explore how to set up warehouses and locations in Odoo 17 Inventory. This will help us manage our stock effectively, track inventory levels, and streamline warehouse operations.
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2. The preoperative evaluation consists of
gathering information about the patient and
formulating an anesthetic plan. The overall
objective is reduction of perioperative
morbidity and mortality.
Inadequate preoperative planning and errors in patient
preparation are the most common causes of anesthetic
complications.
Anesthesia and elective surgery should not proceed until the
patient is in optimal medical condition.
3. Patient data
Doctor – patient relationship
Anesthetic plan
Patient consent
Preoperative evaluation and
preparation
4. Review of Patient Data
Medical record
Interview History : history of underlying
disease, medication, functional capacitance,
previous anesthetic history, family history,
smoking & alcoholic use, review of system,
psycological support
Surgical condition :
- condition & symptom of disease
- surgical procedure
- position of procedure
5. Physical Examination
Vital signs
General appearance
Respiratory system
CVS system
Abdomen
Extremities and spine
Neurologic system
Airway evaluation anticipate difficult
intubation & its management
6. Laboratory Data
Value of testing
Risk and costs benefits
Preoperative testing: base on indication
Hematological studies : Hct/Hb, Plt ,
coagulation factor
Serum chemistry studies : BUN, Creatinin,
SGOT-SGPT, Albumin, Electrolite, Glucose
ECG, Chest radiography, pulmonary
function tes
7. Hematological & serum chemistry studies
are routine while ECG & chest x-ray for
patient over than 40 y.o. or indicated
Hb 7 gr/dl for young & healthy patient
undergoing minimal risk surgery, Hb > 10 gr/dl
over than 40’s, children, CAD, undergoing high
risk surgery
Platelet count within normal limit (150.000-400.000)
but for urgent or emergency procedure > 70.000
without any clinical spontaneus bleeding
8. Coagulation factor ; PT & APTT within normal
limit or if the value lengthened, not over than 1.5
times than control value
Can be corrected with given of Vit K and FFP
Liver function test not over 5 times than normal
value
Creatinin not over than 5
If over than 5 should be corrected (given of
medication or/and RRT)
Electrolyte disturbance with any clinical signs must
be corrected
9. Specific test:
Cardiac evaluation:
exercise stress test
thallium scan
echocardiogram
Pulmonary evaluation:
lung function test
spirometry
arterial blood gas
10. Medical consultation
To define patient’s condition
To optimize patient’s medical condition and
future management before surgery
Consent form
Informed consent involves :
discussing anesthetic management plan,
alternatives
potential complication
11. Record Preoperative form
ASA physical Classification
Class1 normal healthy patient
Class 2 A patient with mild systemic disease and no
functional limitations
Class 3 A patient with moderate or severe systemic
disease that results in some function limitation
Class 4 A patient with severe systemic disease that is
threat to life and functionally incapicitating
Class 5 A moribund patient who is not expected to
survive 24 hours with or without surgery
(Class 6 A brain-dead patient whose organs are being
harvested)
E for Emergency case
13. NPO Guideline
NPO 6-8 hr. before surgery
Clear liquid diet for 2 hr.
Children
Clear liquid 2 hr
Breast milk 4 hr
Infant formula 6 hr
solid diet 8 hr.
Guideline used for patient with no problem
with gastric emptying time
14. Perioperative Cardiovascular Evaluation for
Noncardiac Surgery
History – angina, recent or past MI, HF,
symptomatic arrhythmias, presence of pacemaker or
ICD
Physical Examination – general appearance, rales,
elevated JVP, carotid and other arterial pulses, S3
gallop, murmurs
Comorbid Diseases
Pulmonary
Diabetes Mellitus
Renal Impairment
Hematologic Disorders
Ancillary Studies - ECG almost always indicated,
blood chemistries and chest X-ray based on history
and physical findings
General approach to the patient
15. Clinical of chest pain,heart failure and arrhythmia
should be treated before elective surgery
Interval between MI time and surgery less than 6
month is more likely with reinfarction
Perioperative cardiovascular risk :
clinical predictors
surgical procedure
exercise tolerance
16. Major
Unstable coronary syndromes
Decompensated CHF
Significant Arrhythmias
Intermediate
Mild angina pectoris
Prior MI
Compensated or prior HF
Diabetes Mellitus (particularly
taking insulin)
Renal insufficiency
Minor
Advanced Age.
Abnormal ECG.
Rhythm other than
sinus.
Low functional
capacity.
History of stroke.
Uncontrolled systemic
hypertension
Clinical Predictors of Increased Perioperative
Cardiovascular Risk
17. Surgical Procedures of Increased Perioperative
Cardiovascular Risk
High: Emergency major (particularly in elderly
patient), vascular surgery, prolong operation with
large fluid shifts and/or blood loss
Intermediate: carotid endarterectomy,head and neck
surgery, intraperitoneal & intrathoracic surgery,
orthopedic surgery, prostate surgery
Low: endoscopic procedure, breast surgery,
superficial procedure, cataract surgery
18. 4 METs: walk at 6 km/hr, run short distance, heavy
work around house, golf, bowling, dancing
Exercise Tolerance
The metabolic equivalent, or MET, is defined as the ratio of a
person's working metabolic rate relative to the resting
metabolic rate.
Functional capacity is defined as :
poor (<4 METS),
moderate (4–7METS),
good (>7–10METS) ,
based on evaluation of the patient’s daily activity.
19.
20. Suplemental Preoperative Evaluation
Noninvasive testing in preoperative patients indicated if 2 or more of
following present:
Intermediate clinical predictors (Canadian Class I or II angina, prior
MI based on history or pathological Q waves, compensated or prior
HF, or diabetes)
Poor functional capacity (<4 METs)
High surgical risk procedure (emergency major surgery*, aortic
repair or peripheral vascular, prolonged surgical procedures with
large fluid shifts or blood loss)
* Emergency major operations may require immediately proceeding to surgery
without sufficient time for noninvasive testing or preoperative interventions.
21. No further preoperative
testing recommended
Preoperative angiography
ECG ETT
Exercise echo or
perfusion imaging‡**
Pharmacologic
stress imaging
(nuclear or echo)
Dipyridamole or
adenosine perfusion
Dobutamine stress echo
or nuclear imaging
Other (eg, Holter
monitor, angiography)
Yes
Prior symptomatic arrhythmia
(particularly ventricular tachycardia)?
Borderline or low blood pressure?
Marked hypertension?
Poor echo window?
No
Yes
Prior symptomatic
arrhythmia
(particularly ventricular
tachycardia)?
Marked hypertension?
Bronchospasm?
II AV Block?
Theophylline dependent?
Valvular dysfunction?
No
No
Resting ECG
normal?
Patient ambulatory and
able to exercise?‡
Yes
No
YesYes
Indications for angiography?
(eg, unstable angina?)
Yes
Yes
No
No
*Testing is only indicated if the results will
impact care.
†See Table 1 for the list of intermediate
clinical predictors, Table 2 for thermetabolic
equivalents, and Table 3 for the definition of
high-risk surgical procedure.
‡Able to achieve more than or equal to
85% MPHR
** In the presence of LBBB, vasodilator
perfusion imaging is preferred.
2 or more of the following?†*
1. Intermediate clinical predictors
2. Poor functional capacity (less than 4
METS)
3. High surgical risk
22. Patient risk for MI postop
DM
Peripheral vascular disease
HT
Tobacco used
Hypercholesterolemia
Risk associated with surgical influence decision to
make further test
Perioperative morbidity may be decreased with
beta blocker
Continue medication except anticoagulant or
antifibrinolytic: aspirin,warfarin,ticlopidine etc.
Digitalis : discontinue except in severe arrhythmia
23. Perioperative of Hypertension
Category Systolic mmHg Diastolic mmHg
Optimal < 120 and < 75
Normal < 130 and < 85
Mild HTN 140-159 or 90-99
Moderate 160-179 or 100-109
Severe > 180 or > 110
Isolated SBP HTN > 140 and < 90
Pulse Pressure > 65mmHg
Orthostatic changes Hyper response > 20 mmHg
Hypo response < 20 mmHG
Classification
24. Hypertension
History of end organ damage: cardiac
ischemia, renal, neurological
Elective surgery should be delayed if DBP ≥
110 mmHg with or without new onset of
headache but if no sign of end organ damage
surgery or LVH may be proceed
In DM keep DBP < 90mmHg
25. End Organ Damage & Perioperative Outcome
Occult CAD (Q wave on ECG)
CHF (symptoms and signs)
LVH (ECG voltage criteria)
Renal insufficiency (creatinine>2.0)
Cerebrovascular disease (hx of CVA and
TIA)
26. Treatment
Aggressive treatment associated with reduction
in long term risk
Generally, antihypertensive drug should be
continued during the perioperative peroid.
Abrupt discontinuation of β-blocker
→perioperative tachycardia
Withdrawal of clonidine →rebound HTN
ACEI and Angiotensin II inhibitor →held
in the morning of surgery
27. Perioperative of Pulmonary Disease
History of reactive airway Asthma
Frequency, reversible of symptoms, interval,
last attack, history of steroid used
Optimize good condition before elective
surgery
COPD:new onset of bronchospasm,dyspnea
and reduced exercise tolerance should be
indicated to delay elective surgery
Recent URI is controversial , elective surgery
should be delayed several weeks
28. Continue medication
Aerosol medication before surgery
Risk reduction of pulmonary complication
Smoking cessation
Education of lung expansion maneuver and deep
breath exercise(incentive spirometry)
for postop
Treatment of obstruction
Antibiotic
Hydration
29. Smoking cessation
24 hr: decrease carboxyhemoglobin
2-3 day: increase ciliary function
but increase secretion
1-2 wk: decrease secretion
4-8 wks: decrease postop pulmonary complication
In TB patient, should be undertreatment min 2 weeks
and without any clinical sign of coughing
30. Perioperative of Diabetes Mellitus
General approach to the patient
Current medication
Progression of end organ damage
atherosclerosis : risk for silent MI
Autonomic dysfunction
Hyperglycemic condition
Risk for joint stiffness: TM joint
Discontinue medication day of surgery
31. Preoperative Evaluation
Operative risk assessments
Routine risk factors: Cardiac, Pulmonary, Renal,
Hematologic
Diabetes-related risk factors: Macrovascular,
Microvascular, Neuropathic complication
Diabetes therapeutic regimen
Reestablish correct diagnostic
Pharmacological regimen
Meal plan
Activity level
Hypoglycemia
Anticipated surgery
Type of surgical procedure
Inpatient or outpatient
Type of anesthesia
Start time
Duration of procedure
32. In general, the goal for glucose control
during surgery is to maintain the glucose
level between:
150-200 mg/dl
Jacober and Sower. Arch Intern Med 159: 2405-2411, 1999
120-180 mg
Dagogo-Jack and Alberti. Diabetes Spectrum 15: 44-48, 2002
Glycemic Goal During Surgery
33. Stop OAD 1-3 day
Minor surgery: periopertive hyperglycemia
(BG > 200 mg/dl)RI 4-10 U
Major surgery or poorly controlled
diabetes insulin infusion + glucose
T2DM treated with OAD
34. Minor surgery
Major surgery
Subcutaneous insulin regimens
Intravenous insulin regimens
Insulin treated patients
35. Short procedure
early morning Delay diabetes regimen
Oral agents Hold oral agents
Single dose insulin 2/3 total daily dose
Short procedure 2 or 3 doses of insulin ½ total morning dose
Late morning
MDI 1/3 morning dose
Insulin pump basal rate only
36. Fig. Summary of perioperative management recommendation
based on therapeuitic regimen and complexity and scheduling of
the operative procedure. MDI=multiple doses of short acting
insulin2
Jacober and Sower. Arch Intern Med 159: 2405-2411, 1999
Oral agents Hold oral agents
Single dose insulin 2/3 total daily dose
Short procedure 2 or 3 doses of insulin ½ total morning dose
afternoon
MDI 1/3 morning dose
Insulin pump basal rate only
Oral agents Hold oral agents
Complex
Procedure
Insulin Continuous IV insulin
37. Prepare a 0.1 unit/ml solution by adding 25 units RI to 250 ml normal saline
Flush 50 ml of insulin solution through infusion tubing to saturate nonspecific
binding sites
Set initial infusion rate (generally, 0.5 unit/h [5ml/h] for thin woman; 1.0 unit/h
[10ml/h] for other)
Adjust infusion rate according to bedside blood measurement as follows:
Blood glucose (mg/dl) Insulin infusion rate
<80 Check glucose after 15 min*
80-140 Decrease infusion by 0.4 unit/h (4 ml/h)
141-180 No change
181-220 Increase infusion by 0.4 unit/h (0.4 ml/h)
221-250 Increase infusion by 0.6 unit/h (0.6 ml/h)
250-300 Increase infusion by 0.8 unit/h (0.8 ml/h)
>300 Increase infusion by 1 unit/h (1 ml/h)
*Regimen assume separate infusion of glucose at ~ 5-10 g/h and hourly blood glucose monitoring.
Extremely high or low glucose value should be confirmed with an immediate repeat measurement. Intravenous
boluses
of dextrose (50%) or supplemental regular insulin can be used for paid correction but are rarely necessary
38. Perioperative of Thyroid Disease
Clinical manifestation of hyperthyroid or
hypothyroid
Hyperthyroid: palpitation, weight loss, heat
intolerance, moist skin thyroid strom
Hypothyroid: bradycardia, cold intolerance,
slow mental function hypothermia,
hypoventilation
39. LABORATORY TESTING STRATEGY for THYROID
DYSFUNCTION
THRYOID DISEASES
OVERT CLINICAL
MANIFESTATION
MINIMAL
CLINICAL
MANIFESTATION
TSHs TSHs + FT4
HYPOTHYROIDISMHYPERTHYROIDISM
TSHs + FT4 TSHs + FT4
HYPERTHYROIDISM HYPOTHYROIDISM
TSHs TSHs
SUBCLINICAL HYPOTHYROIDISM: normal Free-T4, high TSHs
SUBCLINICAL HYPERTHYROIDISM: normal Free-T4, low TSHs
History taking &
physical examination
41. Preoperative Management
Patients with thyrotoxicosis must be treat with PTU
(100-300 mg/day) or metimazol (10-30 mg/day) +
propanolol 10-80 mg/day, until euthyroid condition
Add potasium iodide (10-15 drops/day) 10 days before
surgery
Patient with thyrotoxicosis who going to operative
procedure for non thyroid disease can be treat with
propranolol 2-10 mg/iv or 40 mg/p.o (total dose 160-
240 mg/d orally) every 4-6 hours, until pulse rate <90.
Iodide solution 30 drops plusPTU or metimazole
42. With hyperthyroid
Surgical approach
Thyroid illness Non Thyroid illness
Without
hyperthyroid
With hyperthyroid Without
hyperthyroid
Elective
surgery
Urgent
surgery
Treat
hyperthyroidism
• β-blocker
• KI solution
• Tionamide
operative
euthyroid
43. Perioperative in Renal Disease
Kidney Failure
Kidney Disease
Kidney failure
Kidney failure occurs when the kidneys partly or
completely lose their ability to carry out normal functions.
This is dangerous because water, waste, and toxic
substances build up that normally are removed from the
body by the kidneys.
It also causes other problems such as anemia, high blood
pressure, acidosis (excessive acidity of body fluids),
disorders of cholesterol and fatty acids, and bone disease in
the body by impairing hormone production by the kidneys
44. Chronic kidney disease
when one suffers from gradual and usually
permanent loss of kidney function over time.
This happens gradually over time, usually
months to years
Chronic kidney disease is divided into five
stages of increasing severity
Mild kidney disease is often called renal
insufficiency.
Stage 5 chronic kidney failure end stage
renal disease
45.
46. History and physical examination
The comorbidities of CRF
Sign and symptom of uremia, fluid overload and
inadequate dialysis.
Laboratory :
electrolyte conc, acid-base status, urea and
creatinine levels, hematocrit, platelet count
and coagulation
Chest radiography
pulmonary edema or pleural effusion
E C G
myocardial ischemia
electrolyte imbalance.
Preoperative Evaluation and Preparation
47. Hyperkalaemia
- > 5 mmol/L
- > 5,5 mEq/L contraindication to elective
surgery because tissue trauma and cell death
increased potassium to life-threatening levels.
Therapy of hyperkalemia :
- 5 – 10 ml 10% Ca-gluconate IV over 3 min,
can repeat in 5 min
- 3 – 5 mL 10% Ca-chloride IV over 3 minute
- 10 U insulin in 500 mL 20% Dext
- 1-2 mmol/kg Na-bicarbonat iv over 5 – 10 menit
- Nebulised salbutamol 2,5 – 5 mg will assist in
moving potassium into the cells.
48. Haematological function :
- Chronic anaemia
- Unless the patient has ischemic heart dis.
Hb level may be maintained 7 – 8 g/dl.
- Th: erythropoietin or Transfusion
- Correction of anemia helps to improve
platelet dysfunction
- Platelet dysfunction :
- Desmopresin or cryoprecipitate
- Estradioleffective in the treatment of
platelet dysfunction.
50. Dialysis :
- ESRD GFR < 12 mL/min
- 12 – 24 hours before to elective surgery
(minimum heparinisation)
-normovolemic,
- to tolerate fluid loads – surgery
- normal electrolyte concentrations.
- Hypovolemia hemodynamicinstability.
- Fluid over load or life-threatening
hyperkalemia.