6Th Year Anaes Lect%5b1%5d (1)

7/25/2019 6Th Year Anaes Lect%5b1%5d (1)

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2/11

PREOPERATIVE

ASSESS M E

NT

Two

main

goals

are:

1)

Evaluate and

optimize

patient's

medical conditions

2) Anticipate,

minimize,

and

plan

for

possible

complications

The Anaesthetic History

and Examination

Anaesthesia

is a compromise between

patient

medical

problems,

drug

interactions, surgical

disease

and

procedure,

the

hospital system, and social

factors. A thorough knowledge of each

of

these components

is required

to

offer

a

safe

perioperative

course.

History and

examination

are used to identify

disease

processes

that

need

to

be explored,

defined

and

optimized.

Newly

discovered

signs

and

symptoms

should not merely be documented and then

ignored.

The

pursuit

of

patient optimization takes

time,

and may need to delay

surgery.

Occasionally, optimization is compromised

by need

for

surgery,

social and

hospital

system

pressures.

Previous Exposure to

Anaesthesia

Check

date,

place

and

reason

for

previous

anaesthetics.

Specifically enquire

and

review

charts,

looking

for adverse

reactions

or events

-

E.g. Difficult

intubation,

response

to anaesthesia,

pain

requirements,

adverse

reactions,

and

awareness.

Be aware

that side effects such as

nausea and vomiting are

frequently

wrongly

reported as allergies.

A

family

history of anaesthetic

problems

should

also

be obtained,

since some

disorders

are

inherited

E.g.

Plasma cholinesterase

deficiency

(don't

metabolise suxamethonium),

malignant

hyperthermia, coagulation

abnormalities.

Fasting

Gastric

contents

are

more

likely to be

aspirated under

anaesthesia.

Patients

should consume

no

solids

after

6

hours,

and

no clear

fluids

after

2

hours

before

the

start of any

sedative or anaesthetic

procedure.

These times

for

gastric

emptying

will be

prolonged

by

pain

and

opioid

use.

Emergency situations

may require

an

unfasted

patient

to

undergo

anaesthesia.

ln

this circumstance,

a

Rapid

Sequence lntubation

is

used to

occlude

the

oesophagus

until

the

airway is

protected

by a

cuffed tube.

Medication

Some medications

interact with

those

used

in

anaesthesia.

Over-the-counter

and alternative

drugs,

tobacco,

alcohol,

and illicit drugs all

can

have serious

implications.

Medications

can also

expose

illnesses that

the

patient may have neglected to

reveal.


3/11

Allergies

A

history

of

known

allergies,

and the actual drug

effect,

is

essential

before

prescribing

or

administering

any drug.

The

difference

between an allergy and

a side

effect

is

important,

othenvise

a

best choice

drug

may

be

unnecessarily

avoided.

Dentition

The

teeth

are

at

risk of

damage during ainruay

instrumentation.

Pre-existing

damage should be

noted

for medico-legal

reasons.

The

presence

of caps,

crowns,

and

loose

or

unhealthy

teeth

(especially

in

front)

should be

noted,

and

the

risk of

damaged

discussed

with

the

patient.

Loose

teeth can

be

dislodged

into

the

lungs,

and

may need

preoperative

dental

review.

Gastro-oesophageal

Refl ux

The

extent

of

reflux should be determined.

Reflux

of

gastric

contents

(usually

acid

secretions

in the

fasted)

is

worse

under anaesthesia, and

a

Rapid

Sequence

lnduction

may

be

required.

(This

type of

induction is not

used

for

all

anaesthetics,

mainly because

of

the

side

effects of suxamethonium.)

Concurrent lllness

Many

medical illnesses

may complicate

the

course of anaesthesia and

surgery.

All systems should

be

considered

in

the

patient

assessment.

Most

consideration goes

to cardiac

and respiratory diseases, as

they

play

the

major

role

in

contributing

to

perioperative

morbidity

and

mortality.

Exercise

tolerance is

a

good

indicator

of cardio-respiratory

reserye

(ability

to

cope

with

the

perioperative

insult).

The

ability

to

climb

stairs,

play

golf,

do the

gardening

-

all without symptoms,

are

good

indicators of

sufficient

reserve

for

fairly

major surgery.

Concurrent disease

and

patient

age

guide

the

surgical

intern

and

anaesthetist

in

the

choice

of

which

preoperative

investigations are required.

CXR,

ECG,

U&E, FBC, Group,

x-match,

coags

should

not

be done as

routine,

but as

indicated.

More

advanced investigations

(ECHO,

stress tests, spirometry,

sleep

studies,

CT,

MRI) may also

be

required.

The

end

result

of the

investigation

process

is

that

a

change

may need

to

be made to

the

patient's

medical

care

before

surgery

is

attempted.

(See

the'Pre Admission

Screening'

questionnaire

for

suggested investigations.)

Sufficient

time

must

be

allowed

preoperatively

to

undertake

and

report on

these

tests, and

institute any

therapies. lt

is

the

responsibility

of

the

surgical

team

to

identify

more complicated

patients

and commence

the

preparation

process

early,

hence

avoiding

unnecessary delays

to

surgery.

Defining

the disease

process,

its extent, and

the

impact

on

the

patient

will

help

determine

the

anaesthetic

technique

and

agents

used. For

example, a

patient

with severe

respiratory

disease

may be better served

with

a spinal

for

Iower body

surgery.

A

patient

with

a

poorly

functioning

heart

will need

invasive

monitoring and

the

least cardiac depressant

drugs

available.


4/11

Medications to

Hold

ln

general

terms,

hold

aspirin

and clopidegrel

for 1 week,

most

other

NSAIDS

24-48

hours, and

warfarin

3-4 days

to a

normal

lNR.

The

indications for these

medications

need

to

be

considered

before ceasing

vs

risk

of

bleeding during

the procedure.

Long

acting heparins

E.g. Clexane

should

not be given within

the

12

hours

before surgery

-

they

exclude

the

possibility

of spinal and

epidural

anaesthesia,

which

may be essential to

the

patient.

Diabetic medication

-

hold

oral

hypoglycaemics on the day of surgery and the

preceding

night.

The

non insulin diabetic

would

rarely need

a sliding

scale,

and

can be

kept

hydrated

with

non

dextrose containing

lW. The fasting

insulin

dependent should

have

regular

BSL

checks,

be early on the operating

list,

and

usually a

sliding

scale

with

dextrose IVT

(to

avoid

hypoglycaemia).

The anaesthetist should

be aware

of

insulin dependent diabetics

to

contribute

to

the

preoperative

management.

Antihypertensives

would

rarely

be

held. Missing a dose

will

often

lead to

unstable

blood

pressures

and

an

increased risk

of

cardiac events.

Give other

medications as

usual.

"Fasting"

does

not include medication

lf concerned

or

unsure, always contact an anaesthetist.

The Emergency

This

poses

multiple compromises

to

optimizing

for

surgery.

There

is little time

for

patient preparation,

so only

essential

tasks

are

performed

(bloods,

invasive

monitoring,

fluids).

ldeally

a

patient

is resuscitated and cardiovascularly

stabilized

before

administration

of

anaesthetic agents,

but

this

may not be possible

and

is

performed

intraoperatively

(E.g.

a

ruptured

AAA)

ln

such

situations,

anaesthetic

techniques

need

to

be dramatically altered.

Prepared

by

Dr. Anthony Fisher.


5/11

Classification

of

Patient Fitness

Patient fitness is

classified

according to their

ASA status

(American

Society

of

Anesthesiologists). This

has

some

correlation

to

risk.

Class

1

fit and

healthy

Class

2

mild

systemic

illness

(such

as

hypertension)

Class

3

severe

systemic

illness

which

is not

incapacitating

Class

4 incapacitating

illness/constant

threat

to

life

Class 5

moribund/not

expecting

to

live

more than

24

hours

"E"

added to above

if

operation

is an emergency

Premedication

Premedication

should only

be

prescribed

by

the

anaesthetist.

The

exception

would

be

an

'on

call'Ventolin/Atrovent

nebule

prescribed

by

the

surgical team

where indicated. Premedication

is a

separate

issue

from

the

patient's

usual

drugs.

o

Benzodiazepines

may

be

used

for

an overly

anxious

patient.

Sedatives

are avoided where

fast

awakening

from

anaesthesia

is

desired,

in the

non-consented,

where

conscious

state is altered,

and

in

the

airway/respi ratory comprom ised.

.

Children

are most

commonly

ordered

EMLA

cream

(takes

t hour

to

work)

and

sedatives

(midazolam).

.

Ventolin

+

Atrovent

nebs

are often

given

immediately

before

anaesthesia for respiratory disease. This

prevents

perioperative

bronchospasm.

.

Antacids

(ranitidine,

sodium

citrate) are used

to

reduce

gastric

acidity

in

the

patient

at

risk

of aspiration.

This

reduces respiratory

complications.

.

Any frail

patient

should

be

well

hydrated

by lW whilst

fasting.

This is

also an

idealfor

all

patients.

Diabetics

should

also

receive

dextrose

solutions

if receiving insulins whist fasting.

.

Beta blockers are some

times

commenced

in

patients

at

risk

of

myocardial

ischaemia.


6/11

,:

A-

-7

TOWNSVILLE HEALTH SERVICE DISTRICT

PRE

ADMISSION

SCREENING

Proposed Operation:

Surgeon

Sumame U.R.No.

Given

Names

Date of

Birth

(Affix

Patient Identification

Label Here)

A

D

M

I

S

s

I

o

N

s

C

R

E

E

N

I

N

G

Previous GA Problems

Lung or breathing

problems

COAD

/

SI

Angina or

regular chest

pain

Anv other heart condition

Bruising

or bleeding

easi

blood thinners

Diabetes: 1. Diet controlled

2. Take tablets

3. IIse insulin

Reflux / indisestion / heartbum / Hiatus Hernia

Ulcers

(peptic

/

duodena

Anv other stomach / intestinal disorder

failure / kidnev

disease

/

.Iaundice in the last

Anv other liver condition

Alcohol Habits / Hx Alcohol Abuse

recent blackouts or

faintin

Any Other Health Problems

eg. severe

arthritis, dental

Poor

exercise

tolerance

Any

Infectious

Diseases

Comments:

Authorised by:

Date:

Criteria for

Anaesthetic

Review

.

0ver 75

years

.

History ofAnaesthetic

problem

.

BMI

>

35

.

For major

surgery

.

Any 'Yes'

answer

to

above assessment


7/11

Medications

(including

over-the-counter medications: Aspirin,

Oral Contraceptives, Inhalers,

Topicals, Eye

Drops, Hypnotics

& Herbals)

Note if Steroids used in last 3 months.

Drug

(Name)

Dose

When

Why do

you

take

it

2.

3.

4.

.5.

6.

7.

8

9.

10.

Allergic Reactions

(please

note all

forms

of reactions

and their cause)

Substance

Reaction

2.

3.

4.

5.

Other Drugs

n

Marijuana

o

Amphetamine

n

Heroin

I

Other

Social

Risks

n

HIV

n Hepatitis

o IV

drug use

o

Other

Religious

/ Cultural issues that may impact

on this

procedure:

Physical Examination

Patient Age Height

(cm)

Weight

(Ke)

BMI Blood

Pressure

Pulse

Peak

Flow

(L/min)

Oxygen

Saturation

Urinalysis


8/11

PROPOSED

OPEMTION:

oRl

v\1./t

S

&

EXAMINATION:

A

ro

-

Na

loo

ny]'PI

ESULTS:

WEIGHTn,

IC

PLAN:

Medicotion

/

lnstructions

NBM From:

f"\,r'^'An,i


9/11

THE TOWNSVILLE

HOSPITAL

ACUTE PAIN SERVICE

TNTERMITTENT SUBCUTANEOUS

OPIOIDS

Administration

Guidelines

for

Acute Pain

Management

These

guidelines are intended

for ward

use

in

patients

with

moderate-severe

acute

pain, not warranting PCA or PCEA.

IV

opioid

administration

on the

wards

is not recommended

unless via

PCA, or directly

supervised

by

a

medical officer

in

an emergency.

Standard orders

Morphine

is the standard

strong analgesic

agent used

at

TTH.

Subcutaneous

administration through

an

indwelling

'butterfly'

or

24G cannula

is the

preferred route as

this limits

the

potential

exposure

of

nursing staff to

needle-stick

injury

and

is less

uncomfortable

for

the

patient than

repeated

IM

injections. Alternatives

for

patients

with morphine

allerry

include fentanyl

or

tramadol.

Pethidine

must

NOT

be administered subcutaneously,

however,

as

it

is

painful

and

unpredictably

absorbed.

Recommended initial

prescriptions

The initial

dose requirements

vary

considerably.

With

the

exception of Paediatrics,

the best

predictor

of

morphine

dose

is

AGE*,

not

weight.

A

2-hrly interval

with

small

doses

is safer than large doses

less

frequently.

Patient

has

pain,

requests analgesia

NO

NO

NO

Seek

medical

review

Sedation Score

0

Fully alert

I Mild, occasionally

drowsy, easy

to rouse

2 Moderate, constantly

or frequently drowsy,

easy to rouse

3

Severe, somnolent,

difficult to rouse

S

Normal sleep

Oxygen

at 6

L/min via mask

Notify RNIO

if no

improvement consider IV

naloxone 80mcg

Smaller

opioid dose

next

time.

Reassess after

I

hour

Seek

advice from

Medical

Officer

Consider

higher

dose

next

time

in

yearsl if

over

2O

years

old

)

Reviewed

APS

3/O3

Initial SC orders

2

hourly

PRN

Age

(years)l

Morphine I

Fentanyl

I

Tramadol

lDose

Range

(mg)

|

Dose range

lmcg) |

Dose range

(mg)

ttt

1s-3e I z. s-

tz.s I

roo

-

lso

I

7s

- t2s

40-s9 I 5.O

-

10.O I

75- t25

I

50

-

100

6o-6s I z.s

-z.s

I so

-

roo

I

zs -

zs

t_r-o:, I z.o

-t.o

I ou-ruu I

zJ-

tJ

zo-zs I z.s

-

s.o I

zs

-zs

I

zs -

so

w-tY tz.o-ar.L, I zJ-ro I

zJ-Jv

80+

lz.o-s.o

I

so-so

I

zo-so

.

First dose

in middle of range

.

Subsequent dose

titrated to response

.

Upper

limit

can be increased by

RMO

fl..

sedation

score

(2

and

respiratory

rate

>8

and analgesia

is inadequate

Fentanyl

Dose range

(mcg)

Is t-here

an appropriate

opioid order?

e.g.

dose as

per

table, 2-hr1y

PRN

Is the sedation

score 8/min

?

Is

the

sedation

score

S/min

?

Patient stiil

in

pain?

Requesting

analgesia?

Is DOSE intewal

>

2

hours

(*Average

dailv

morphine

dose

requirement

=

l00mg

-

age


10/11

THE

TOWNSVILLE

HOSPITAI

ACUTE

PAIN SERYICE

(APS)

PATIENT

CONTROLLED ANALGESIA

Intravenous

PCA

For children

6Th Year Anaes Lect%5b1%5d (1)

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Transcript of 6Th Year Anaes Lect%5b1%5d (1)