Download - 6Th Year Anaes Lect%5b1%5d (1)
-
7/25/2019 6Th Year Anaes Lect%5b1%5d (1)
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7/25/2019 6Th Year Anaes Lect%5b1%5d (1)
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.
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7/25/2019 6Th Year Anaes Lect%5b1%5d (1)
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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.
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7/25/2019 6Th Year Anaes Lect%5b1%5d (1)
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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.
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7/25/2019 6Th Year Anaes Lect%5b1%5d (1)
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.
-
7/25/2019 6Th Year Anaes Lect%5b1%5d (1)
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
-
7/25/2019 6Th Year Anaes Lect%5b1%5d (1)
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
-
7/25/2019 6Th Year Anaes Lect%5b1%5d (1)
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
-
7/25/2019 6Th Year Anaes Lect%5b1%5d (1)
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
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7/25/2019 6Th Year Anaes Lect%5b1%5d (1)
10/11
THE
TOWNSVILLE
HOSPITAI
ACUTE
PAIN SERYICE
(APS)
PATIENT
CONTROLLED ANALGESIA
Intravenous
PCA
For children