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