Preoperatif Preparation Icha
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Transcript of Preoperatif Preparation Icha
PREOPERATIVE PREPARATION
Riza CintyandyRS. Jantung & Pembuluh darah Harapan Kita Jakarta
PREOPERATIVE EVALUATION
Aim : To reduce the risk associated with
surgery & anesthesia To increase the quality of perioperative
care To restore the patient to the desired
level of function To obtain the patients inform consent
Semua pemeriksaan, persiapan, sistem
skoring rencana tindakan bedah maupun anestesi
waktu pelaksanaan
jenis anestesi yang dipergunakan
penyulit anestesi
persiapan obat-obatan, darah, cairan IV
perawatan pascabedah (ICU/ rg. Rawat)
biaya, inform consent
dll
PERSIAPAN PRA BEDAH
Anamnesa•Riwyt peny, terapi obat2an, pola hidup, keluarga, genetik, dll•Terapi saat ini, alergi, pemasangan stent, riwyt pemeriksaan, dll•Riwayat fungsi organ, (otak, jantung, ginjal, hepar )
Pemeriksaan Fisik•Airway, Breathing, Circulation, Dissability, Environment ( A,B,C,D,E)•Tandai dan tentukan tindakan yang dapat dilakukan untuk mengoptimalkan kondisi fisik pasien pra bedah
Pemeriksaan Lain•Laboratorium standar dan tambahan ( AGD, T3-T4-TSH) dll•Thorax foto, EKG, Echocardiographi, ( TTE maupun TEE), CT scan, MRI, USG abdomen , BNO/IVP dll
PHYSICAL STATUS
P1. A normal healthy patient
P2. A patient with mild systemic disease
P3. A patient with severe systemic disease
P4. A patient with severe systemic disease that is a constant threat to life
P5. A moribund patient who is not expected to survive without the operation
P6. A declared brain-dead patient whose organs are being removed for donor purposes
American Society of Anesthesiologists
Pemeriksaan Airway
GCS (Glasgow Coma Scale) and PCS (Paediatric Coma Scale)
GCS PCS
Eye opening
SpontaneousTo verbal stimuliTo painNone
4321
Ditto
Verbal Oriented ConfusedInappropriate wordsNon specific soundsNone
54321
Oriented Words Vocal soundsCriesNone
54321
Motor Follows commandsLocalises painWithdraws in response to painFlexion in response to painExtension in response to painNone
654321
Ditto
TRAUMA SCORE
% Survival9993601520
Trauma Score 161310741
0 1 2 3 4 5 6 7 8 9 10 Mild Moderate Severe
Pain threshold
Pain tolerance
Pain Rating Scales
CHOOSING PAIN KILLER AND ITS COMBINATIONS
10 Pain Intensity Scale
0 1 2 3 4 5 6 7 8 9 10 Mild Moderat
eSevere
Strong opioid ±
NSAID ±
adjuvant analgesic
paracetamolor/+
NSAID ±
adjuvant analgesic
NSAID ±
weak opioid ±
adjuvant analgesic
FASTING GUIDELINES
Adult Food : 6 hour Clear fluid: 2 hour
Infant & pediatric Formula milk & food : 6 hour Breast milk : 4 hour Clear fluid: 2 hour
PERSIAPAN PREOPERATIF PASIEN DGN KELAINAN JANTUNG UNTUK
OPERASI NON JANTUNG
Pasien dengan kelainan jantung yang menjalani operasi non jantung meningkat
Komplikasi Perioperatif yang sering terjadi berhubungan dengan : Myocardial infarction (MI) Arrhythmias Pulmonary insufficiency
KONTRAINDIKASI ABSOLUT UNTUK ANESTESIA
Akut/ recent MI 7-30 hari Dekompensasi kordis akut/ tidak stabil
lakukan terapi terlebih dahulu (optimalisasi)
Penyakit jantung iskemik yang tidak stabil Severe aritmia Total AV block transient pacemaker Penyakit katup jantung berat (severe valve
disease, misal AS severe) Yang lain adalah kontraindikasi RELATIF
PRINSIP
Pembedahan elektif atau “less urgent” Penyakit jantung yg membutuhkan terapi
surgikal untuk penyakit jantungnya, pertimbangkan urgensinya
Pembedahan Emergensi►Pembedahan dengan resiko sedang atau tinggi
OPTIMALKAN kondisi jantung dan penderita:
- Tatalaksana Medikamentosa (diuretik, Inotropik, dll)- Tatalaksana Topangan Mekanik ( IABP,
pacemaker)
CORONARY ARTERY DISEASE
Proper preoperative evaluation of these patients is crucial to identify those with either acute MI or unstable angina
The overall mortality and infarction rate after non cardiac surgery was reduced significantly soon after PTCA (within 11 days)
Elective non cardiac surgery should be postponed for 2-4 weeks after coronary stenting to permit completion of mandatory antiplatelet regimen, thereby reducing the risk of stent thrombosis and bleeding complications
AMERICAN COLLEGE OF CARDIOLOGY/ AMERICAN HEART ASSOCIATION
Revised 1996 guidelines on perioperative cardiovascular evaluation for non-cardiac surgery 2002-2007
Combining: Clinical predictors Coronary evaluation and therapy given Patient’s functional capacity Risks in various kinds of non-cardiac
surgery
CAD CLINICAL PREDICTORS
Major clinical predictorsUnstable coronary syndromesDecompensated congestive heart failure (CHF)Significant arrhythmiasSevere valvular disease
Intermediate clinical predictorsMild angina pectorisPrior myocardial infarctionCompensated or prior CHFDiabetes mellitusRenal insufficiency
Minor clinical predictorsAdvanced ageAbnormal ECGRhythm other than sinusLow functional capacityHistory of strokeUncontrolled systemic hypertension
TYPES OF SURGERY
High riskEmergency major operations, particularly in the elderlyAortic & other major vascular surgeryPeripheral vascular surgeryAnticipated prolonged surgical procedures associated with large
fluid shifts &/or blood loss
Intermediate riskCarotid endarterectomyHead and neck surgeryIntraperitoneal and intrathoracic surgeryOrthopaedic and prostate surgery
Low riskEndoscopic proceduresSuperficial proceduresCataract surgeryBreast surgery
J Am Coll Cardiol, 2007; 50:1707-1732
ACC/AHA GUIDELINES
Stepwise Approach to Preoperative Cardiac Assessment
Need for emergencynoncardiac
surgeryOperating room
Evaluate and treatper ACC/AHA
Guidelines
Vigilant perioperative and postoperative
management
Consider Operating Room
Low RiskSurgery
Active cardiac
conditions
No
Yes
Yes
No
Proceed withplanned surgery
Asymptomatic andgood functional
capacity
Yes
Proceed withplanned surgery
No
Yes
Manage based onclinical risk factors
No
Stepwise Approach to Preoperative Cardiac Assessment
Need for emergencynoncardiac
surgeryOperating room
Evaluate and treatper ACC/AHA
Guidelines
Vigilant perioperative and postoperative
management
Consider Operating Room
Low RiskSurgery
Active cardiac
conditions
No
Yes
Yes
No
Proceed withplanned surgery
Asymptomatic andgood functional
capacity
Yes
Proceed withplanned surgery
No
Yes
Manage based onclinical risk factors
No
Functional Capacity
1. Correlates with maximum oxygen uptake on treadmill testing
2. Demonstrated predictor of future cardiac events
3. Poor functional capacity may hide low threshold cardiac symptoms
ESTIMATED ENERGY REQUIREMENTS FOR VARIOUS ACTIVITIES
1 MET Can you take care of yourself ?
Eat, dress, or use the toilet ?Walk indoors around the house ?Walk a block or two on level ground at 2 to 3 mph or 3.2 to 4.8 km per h ?
4 METs Do light work around the house like dusting or washing dishes ?Climb a flight of stairs or walk up a hill ?Run a short distance ?Do heavy work around the house like scrubbing floors or lifting or moving heavy furniture ?Participate in moderate recreational activities like golf, bowling, dancing, doubles tennis, or throwing a baseball or football ?
Greater than 10 METs
Participate in strenuous sports like swimming, single tennis, football, basketball, or skiing?
Need for noncardiac surgery Emergency surgery
Operating room
Postoperative risk stratification and risk factor management
Urgent or elective surgery
Coronary revascularization within 5 yr
yes Recurrent symptoms or
signs?
No
Recent coronary evaluation Recent coronary angiogram or stress test ?
Favorable result and no change in symptoms
Clinical predictors
Unfavorable result or change in symptoms
Major clinical predictors
Consider delay or cancel noncardiac surgery
Consider coronary angiography
Medical management and risk factor modification
Subsequent care dictated by findings and treatment
results
Intermediate clinical predictors
Go to step 6
Minor or no clinical predictors
Go to step 7
STEP 1
Operating room
No
No
yes
yes
STEP 2
STEP 3
STEP 4 STEP 5
Clinical predictorsIntermediate clinical predictors
Poor (< 4 METs)
Moderate or excellent
( > 4 METs)
Functional capacity
High surgical risk
procedure
Intermediate surgical risk procedure
Low surgical risk
procedur
Noninvasive testing
Operating room
Postoperative risk stratification and
risk factor reduction
Consider coronary angiography
Subsequent care dictated by findings and treatment
results
Invasive testing
Surgical risk
Low RiskNoninvasive testing
High Risk
STEP 6
STEP 8
Clinical predictorsMinor or no clinical predictors
Poor (< 4 METs)
Moderate or excellent
( > 4 METs)
Functional capacity
High surgical risk
procedure
Intermediate or low
surgical risk procedure
Noninvasive testing
Operating room
Postoperative risk stratification and
risk factor reduction
Consider coronary angiography
Subsequent care dictated by findings and treatment
results
Invasive testing
Surgical risk
Low RiskNoninvasive testing
High Risk
STEP 7
STEP 8
SUGGESTION
1. If the patient has a severe cardiac disease,
irrespective of the nature of surgery (except
perhaps really minor surgery), the risk is high.
2. If the patient has a mild cardiac disease, the
patient can be treated almost like normal.
3. If the patient has a moderate cardiac disease, risk
stratification based on the nature of surgery and
functional assessment is necessary.
ANESTHETIC GOALS
1. Avoiding extremes of hemodynamic disturbances (blood pressure (BP), tachycardia, hipercarbia, hypertermia, aritmia)
2. Monitoring of cardiac ischemia (ECG, direct arterial pressure monitoring along with pulmonary artery (PA) catheter, TEE)
3. Hemodynamic control (anesthetic technique and pharmacological agents)
4. Beta blockers preventing perioperative cardiac morbidity
5. Adequate doses of analgesics (morphine 5-10 mg or sufentanyl or fentanyl 5-10 µg/kg)
6. Cardiac support ( inotrope or mechanical devices)
HYPERTENSIVE
Which hypertensive patients have increasing perioperative risks?
Will lowering preoperative blood pressure decrease the risks?
How long and how should blood pressure be controlled before elective surgery?
History of chronic hypertension with/without therapy
HYPERTENSIVE
Patients with cerebral, coronary or renovascular abnormalities
Preoperative antihypertensive therapy for a few weeks/months can reduce morbidity, especially in severe hypertension (3-4 weeks ideally)
Moderate hypertension: duration of therapy can be shorter
Antihypertensive medication continued to the time of surgery, except ACE-I
ABP be kept within 10~20% of preoperative level
GULA DARAH, ALBUMIN, SGOT/PT, UREUM, KREATININ, AKI, ARITMIA
Gula darah tinggi : pasien DM/bukan? Asidosis, pelepasan katekolamin akibat kondisi sakit/ kritis.
Albumin rendah preoperatif : cari penyebab dan optimalkan koreksi yang dibatasi oleh waktu dan urgensi operasi.
SGOT/PT , bilirubin, ureum, kreatinin tinggi preoperatif : cari penyebab, optimalkan yang dibatasi dengan urgensi operasi
Aritmia preoperatif : tipe aritmia, berapa kali/menit.
Terima Kasih