ANESTHESIA ANESTHESIA FOR FOR

SURGEONSSURGEONSORAWAN PONGRAWEEWAN,ORAWAN PONGRAWEEWAN,

DEPARTMENT OF ANESTHESIOLOGY,DEPARTMENT OF ANESTHESIOLOGY,SIRIRAJ HOSPITALSIRIRAJ HOSPITAL

Friday Friday 1616 OctoberOctober 18461846Dr. William Thomas Green MortonDr. William Thomas Green Morton

a dentist from Harford, Connecticut a dentist from Harford, Connecticut

Type of AnesthesiaType of Anesthesiazz Monitored Anesthetic Care (MAC)Monitored Anesthetic Care (MAC)

: conscious sedation : conscious sedation -- minimally depress minimally depress level of consciousnesslevel of consciousness

: deep sedation : deep sedation controlled state of controlled state of depressed consciousnessdepressed consciousness

zz Regional Anesthesia (RA)Regional Anesthesia (RA): central neural blockade: central neural blockade: peripheral nerve blockade: peripheral nerve blockade

zz General Anesthesia (GA)General Anesthesia (GA)

General AnesthesiaGeneral Anesthesia

zz Balanced anesthesiaBalanced anesthesiazz UnconsciousnessUnconsciousnesszz Muscle relaxation Muscle relaxation zz AnalgesiaAnalgesiazz Blunting of reflexBlunting of reflex

zz Inhalation anesthesiaInhalation anesthesiazz Total intravenous anesthesia (TIVA)Total intravenous anesthesia (TIVA)

Anesthetic drugsAnesthetic drugszz Induction agentsInduction agents

((pentothal,propofol,etomidate,BZPpentothal,propofol,etomidate,BZP))

zz Inhalation agentsInhalation agents((halothane,isoflurane,sevoflurane,desfluranehalothane,isoflurane,sevoflurane,desflurane))

zz Muscle relaxantsMuscle relaxants((succinylcholine,pancuronium,vecuronium,atracuriumsuccinylcholine,pancuronium,vecuronium,atracurium,,cisatracurium,rocuroniumcisatracurium,rocuronium))

zz OpioidsOpioids((morphine,pethidine,fentanyl,remifentanylmorphine,pethidine,fentanyl,remifentanyl))

zz Reversal agentsReversal agentszz Local anestheticsLocal anesthetics

((lidocaine,bupivacaine,levobupivacaine,ropivacainlidocaine,bupivacaine,levobupivacaine,ropivacain))

PERIOPERATIVE CAREPERIOPERATIVE CARE

PREOPERATIVE

INTRAOPERATIVE

POSTOPERATIVE

Preoperative evaluationand preparationNPO,Smoking,DM,HT,IHD,Invetigations

Perioperative fliuid

Preoperative Evaluation and Preoperative Evaluation and Preparation Preparation

GOALSGOALSzz To obtain information to determine the To obtain information to determine the

test and consultationtest and consultationzz To choose the care plan guide by patient To choose the care plan guide by patient

choices and risk factorschoices and risk factorszz To educate the patient about anesthesiaTo educate the patient about anesthesiazz To make To make periopertativeperiopertative care more efficientcare more efficientzz To obtain inform consentTo obtain inform consent

QuestionsQuestions

zz Is the patient in optimal health? Is the patient in optimal health? zz Can, or should, the patient's physical or Can, or should, the patient's physical or

mental condition be improved before mental condition be improved before surgery? surgery?

zz Does the patient have any health Does the patient have any health problems or use any medications that problems or use any medications that could unexpectedly influence could unexpectedly influence perioperativeperioperativeevents? events?

ASA PS classification1 A normal healthy patient

2 A patient with mild systemic disease

3 A patient with severe systemic disease

4 A patient with severe systemic disease that isa constant threat to life

5 A moribund patient who is not expected to survive without the operation

6 A declared brain-dead patient whose organsare being removed for donor purposes

E for EmergencyE for Emergency

MortalityMortality

Anesthesia safety: Model or myth? A review of the published literatureand analysis of current original data. Anesthesiology 2002 vol .97

Nothing Per Os (NPO)Nothing Per Os (NPO)zz HalfHalf--life of clear fluids in the stomach is 10 to 20 life of clear fluids in the stomach is 10 to 20

minutes minutes zz Residual gastric volume after 2 hours is less in Residual gastric volume after 2 hours is less in

patients ingesting small amounts of clear fluids patients ingesting small amounts of clear fluids than in fasted patients than in fasted patients

zz After an overnight fast, 50% and 44% of After an overnight fast, 50% and 44% of outpatients complained of moderate to severe outpatients complained of moderate to severe hunger and thirst hunger and thirst

zz 14% of young female outpatients arriving at the 14% of young female outpatients arriving at the operating room with serum glucose < 45 mg/operating room with serum glucose < 45 mg/dLdL

Schreiner MS, Nicolson SC: Pediatric ambulatory anesthesia: NPObefore or after surgery? J Clin Anesth 7:589, 1995.

SMOKINGSMOKING

z Tobacco smoke contains > 3800 identified substances

z Nicotine ; principal vasoactive componentz inducing endothelial wall injuryz inhibiting capillary blood flowz releasing catecholaminesz decreases epithelializationz stimulates thromboxane A2z increase platelet adhesiveness

z Carbon monoxidez causes tissue hypoxia by decreasing the

oxygen carrying capacity z increase platelet adhesiveness

z Delayed perioperative wound healingz Increased pulmonary complications

SMOKINGSMOKING

Postoperative pulmpnarycomplications (PPCs) in patients who underwent coronary artery bypass graft surgery ; a smoke-free period of 8 weeks was needed to reduce the incidence of PPCs.

Warner MA, Divertie MB, Tinker JH. Preoperative cessationof smoking and pulmonary complications in coronary arterybypass patients. Anesthesiology 1984; 60:380383

RecommendationsRecommendationsz A `smoke-free' interval of 6 months would

be idealz A non-smoking interval of less than 8

weeks before surgery probably reduce pulmonary morbidity

z cessation of smoking within 24 h of surgery reducing COHb levels will decrease ST segment depression, myocardial ischema and perioperativecardiac morbidity

The importance of The importance of hypertensionhypertension

zz association between elevated arterial association between elevated arterial pressure and cardiovascular diseasepressure and cardiovascular disease

zz risk of cardiovascular events in the risk of cardiovascular events in the general population increases steadily general population increases steadily with increases in arterial pressurewith increases in arterial pressure

TARGET ORGAN DAMAGETARGET ORGAN DAMAGE

zz HeartHeartzz Left ventricular hypertrophy,angina or Left ventricular hypertrophy,angina or

prior myocardial infarction,heart failureprior myocardial infarction,heart failure

zz BrainBrainzz Stroke or transient ischemic attackStroke or transient ischemic attack

zz Chronic kidney diseaseChronic kidney diseasezz Peripheral arterial diseasePeripheral arterial diseasezz RetinopathyRetinopathy

Preoperative preparationPreoperative preparation

zz Cardiovascular risk evaluationCardiovascular risk evaluationzz MedicationMedicationzz continue esp. beta blocker,alpha 2 continue esp. beta blocker,alpha 2

agonistagonistzz stop diuretics stop diuretics

((hypovolemia,hypokalemiahypovolemia,hypokalemia))

z For stage 3 hypertension (systolic blood pressure > 180 mm Hg and diastolic blood pressure > 110 mm Hg)

z the potential benefits of delaying surgery to optimize the effects of antihypertensivemedications should be weighed against the risk of delaying the surgical procedure

zz significant significant intraoperativeintraoperative hypotensionhypotensionzzmyocardial depressionmyocardial depressionzz hypovolemiahypovolemiazz pronounced loss of blood or fluidspronounced loss of blood or fluidszz vasodilation vasodilation associated with general,associated with general, spinal, or spinal, or

epidural anesthesia epidural anesthesia zz Respond inadequately to ephedrine and Respond inadequately to ephedrine and

phenylephrinephenylephrine

Bertrand M, Godet G, Meersschaert K, et al:Should the angiotensin II antagonists be discontinuedbefore surgery? Anesth Analg 2001; 92:2630

Angiotensin converting enzyme inhibitor and angiotensin receptor

blockers

Diabetes MellitusDiabetes Mellitus

zz BLOOD GLUCOSE AND PERIOPERATIVE BLOOD GLUCOSE AND PERIOPERATIVE OUTCOMESOUTCOMESzz rate of infection is higher in subjects with diabetes rate of infection is higher in subjects with diabetes

when compared to when compared to nondiabeticnondiabetic subjects 10subjects 10--foldfoldzz blood glucose level blood glucose level >>220 mg/220 mg/dLdL on postoperative on postoperative

day 1 was associated with higher rates of wound day 1 was associated with higher rates of wound infectioninfection

zz Maintaining strict Maintaining strict glycemicglycemic controlcontrolby IV infusion resulted in similar mortalityby IV infusion resulted in similar mortalityrates in diabetic and rates in diabetic and nondiabeticnondiabetic subjectssubjects

zz retrospective studyretrospective studyzz IV insulin and subcutaneous insulinIV insulin and subcutaneous insulinzz continuous intravenous insulin infusion continuous intravenous insulin infusion

protocol resulted in a significant decrease in protocol resulted in a significant decrease in the incidence of deep the incidence of deep sternalsternal wound wound infections to 0.8%, comparedinfections to 0.8%, comparedwith the rate of 1.9% in the subcutaneous with the rate of 1.9% in the subcutaneous insulin therapy groupinsulin therapy group

Tight controlTight control

Furnary AP, Continuous intravenous insulin infusion reducesthe incidence of deep sternal wound infection in diabetic patients after cardiac sugical procedures. Ann Thorac Surg 1999;67:35262.

zz End organ damageEnd organ damagezz CVSCVSzz CNS sensory,autonomicCNS sensory,autonomiczz renal impairmentrenal impairmentzz stiff joint syndromestiff joint syndrome

Diabetes MellitusDiabetes Mellitus

zz Goal of BS 100Goal of BS 100--180 mg/dl180 mg/dlzz Tight control of 80 to 120 mg/Tight control of 80 to 120 mg/dLdL

significantly decrease mortalitysignificantly decrease mortalityzz Stop oral hypoglycemic drugStop oral hypoglycemic drug

( ( chlorpropamidechlorpropamide 2 days)2 days)zz insulin given by sliding scale insulin given by sliding scale zz Frequent monitoring for glucose levelFrequent monitoring for glucose level

Diabetes MellitusDiabetes Mellitus

PerioperativeCardiovascular Evaluation

recent MI > 7 days but less than or equal to 1 month (within 30 days)

Clinical risk factors

z history of ischemic heart diseasez history of compensated or prior heart

failure

z history of cerebrovascular diseasez diabetes mellitusz renal insufficiency

Post coronary Post coronary revascularizationrevascularization

zz RestenosisRestenosis usually happens within 8 usually happens within 8 months after balloon angioplasty months after balloon angioplasty

zz PatencyPatency of drugof drug--eluting eluting stentstent is is comparable to CABGcomparable to CABG

Timing after Timing after revascularizationrevascularizationzz CABGCABG surgery should be delayed 4surgery should be delayed 4--6 weeks6 weeks

(preferably 3 mo)(preferably 3 mo)zz PTCAPTCA surgery should be delayed 2surgery should be delayed 2--4 weeks 4 weeks

zz Bare metallic Bare metallic stentstent surgery should be delay for 4surgery should be delay for 4--6 weeks6 weeks

zz DrugDrug--eluting eluting stentstent surgery should be delay for 12 monthssurgery should be delay for 12 months

Current Current antiplateletantiplatelet drugsdrugs

zz Stop ASA for 5Stop ASA for 5--10 days10 dayszz Stop Stop clopidogrelclopidogrel for 7for 7--10 days10 dayszz Needs Needs heparinizationheparinization and antiand anti--platelet platelet

(ASA) after early (ASA) after early stentstent insertioninsertion

zz BetaBeta--blockersblockers 65% reduction in perioperative myocardial ischemia

56% reduction in myocardial infarction

67% reduction in cardiac death

Medical treatment to reduce PMIMedical treatment to reduce PMI

Coronary Artery Disease 2006

Revised cardiac risk index criteriaRevised cardiac risk index criteria

1. High1. High--risk surgical procedurerisk surgical procedure: : intraperitonealintraperitoneal, , intrathoracicintrathoracic,,suprainguinalsuprainguinal vascularvascular

2. 2. IschemicIschemic heart disease includingheart disease including::History of myocardial History of myocardial infarction,History of angina,Use of sublingual nitroglycerine orinfarction,History of angina,Use of sublingual nitroglycerine or oral oral nitrates,Positive noninvasive cardiac testing,Q waves on nitrates,Positive noninvasive cardiac testing,Q waves on electrocardiogram,Symptomatic patients who have undergone electrocardiogram,Symptomatic patients who have undergone PTCA/CABGPTCA/CABG

3. History of congestive heart failure 3. History of congestive heart failure

4. 4. CerebrovascularCerebrovascular disease disease

5. Insulin5. Insulin--dependent diabetes mellitusdependent diabetes mellitus

6. Chronic renal insufficiency6. Chronic renal insufficiency: : ((CreatinineCreatinine >>2.0 mg/2.0 mg/dLdL) )

Recommendations for beta blockerRecommendations for beta blockerzz Initiation is best 1Initiation is best 12 weeks prior to surgery2 weeks prior to surgeryzz Goal heart rate is within 50Goal heart rate is within 50--60 60 bpmbpm range preoperativerange preoperativezz Start administration of Start administration of metoprololmetoprolol 25 to 50 mg 25 to 50 mg

oral bid (oral bid (betalocbetaloc,,cardeloccardeloc,,motololmotolol,etc),etc)zz If patient already taking beta blocker, consider increase in If patient already taking beta blocker, consider increase in

dose to achieve goal heart rate of 60dose to achieve goal heart rate of 6080 80 bpmbpmpreoperativelypreoperatively

zz Continue for at least 1 week postoperative(goal

((.... ))

zz

zz

zz

zz zz zz

zz Studies show that the history and physical Studies show that the history and physical examination are the best ways to screen for examination are the best ways to screen for disease. disease.

zz no harm from omitting no harm from omitting allall laboratory testing for laboratory testing for ASA I patients ASA I patients

zz Unnecessary testing may lead physicians to Unnecessary testing may lead physicians to pursue and treat borderline and falsepursue and treat borderline and false--positive positive laboratory abnormalities laboratory abnormalities

Narr BJ, Hansen TR, Warner MA: Preoperative laboratory screening in healthy Mayo patients: Cost-effective elimination of tests and

unchanged outcomes. Mayo Clin Proc 66:155, 1991

ROUTINE LABORATORY TEST

zz Lira RPC, Lira RPC, NascimentoNascimento MA, MA, MoreiraMoreira--FilhoFilho DC, et al: Are DC, et al: Are routine preoperative medical tests needed with cataract routine preoperative medical tests needed with cataract surgery? Pan Am J Public Health 10:13, 2001. surgery? Pan Am J Public Health 10:13, 2001.

19,000 patients at nine centers scheduled to undergo cataract extraction to be tested routinely or tested only when indicated.

No difference in outcome, hospitalization rate, or any measure of morbidity, mortality, cost, or satisfaction occurred between the "test routinely" and "test only when indicated" groups

Complete blood count Complete blood count zz 1 1 60 60 zz C C (highly invasive) (highly invasive)

10 10

zz zz zz zz zz zz zz ,, zz ,,

Urine analysis Urine analysis

zz zz zz zz zz

zz 45 45 zz C C zz zz zz zz zz zz zz zz

zz 45 45 zz C C (highly invasive) (highly invasive) zz zz zz zz zz zz zz zz

zz 60 60 zz C C (highly invasive) (highly invasive) zz zz zz (BMI(BMI 35 Kg/m2)35 Kg/m2)zz zz zz zz zz zz Steroid Steroid

BUN BUN, , creatininecreatinine, electrolytes , electrolytes zz 60 60 zz C C (highly invasive) (highly invasive) zz zz zz ( (BMIBMI 35 Kg/m2)35 Kg/m2)zz zz zz zz zz zz zz Steroid Steroid

Siriraj PreanestheticSiriraj Preanesthetic Clinic (Clinic (SiPACSiPAC))

zz consultation for ASA consultation for ASA >> 33zz OPD locationOPD locationzz service for evaluation and managementservice for evaluation and managementzz Medical consultationMedical consultationzz ICU/HDU bookingICU/HDU bookingzz aim to reduce LOS,cancellation,M&Maim to reduce LOS,cancellation,M&M

Fluid managementFluid management

The restricted intravenous fluid regimen significantly reduced postoperative complications (33%VS 51%, P

0.013). cardiopulmonary complication (7% VS 24%, P

0.007) tissue-healing complication (16% VS 31%, P 0.04)

No patients died in the restricted group compared with4 deaths in the standard group (0%VS 4.7%, P 0.12)

More patients in the R-group had low urinary output (0.5 mL/kg/h) with smaller urinary volumes the day of operation

No significant differences in urinary output on days 1 to 6A l t ti f ti i b d

RESULTSRESULTSRESULTS

excessive intravascular volum increases demands on cardiac function

blood loss was statistically significantly less in the restricted period

reduced postoperative pulmonary complications shortened the recovery period in the hospital a few studies with small sample sizes evaluating the effects benefits may not be solely attributable to crystalloid restriction

but also to the use of colloids instead need for well-controlled studies in well-defined patient

populations using clear criteria or end-points

ANESTHESIA FOR SURGEONSType of AnesthesiaGeneral AnesthesiaAnesthetic drugsPERIOPERATIVE CAREPreoperative Evaluation and Preparation QuestionsASA PS classificationMortalityNothing Per Os (NPO)SMOKINGSMOKINGRecommendationsThe importance of hypertensionTARGET ORGAN DAMAGEPreoperative preparationDiabetes MellitusTight controlDiabetes MellitusDiabetes MellitusPerioperative Cardiovascular EvaluationClinical risk factorsPost coronary revascularizationTiming after revascularizationCurrent antiplatelet drugsMedical treatment to reduce PMIRevised cardiac risk index criteriaRecommendations for beta blocker(.. ) Complete blood count Urine analysis BUN, creatinine, electrolytes Siriraj Preanesthetic Clinic (SiPAC)Fluid managementRESULTS