กึสู้รมาวคบังะราย้หในอ่กยว่ปู้ผมยีรตเะลแนิมเะรปราก (Preanesthesia evaluation & preparation) านฒัพชินาพมยิน ามสัก.ญพ ์คงสะรปิธทิสพรรสลาบายพงรโ ายทิวีญญัสิวนางมุ่ลก
์คงสะรปุถตัว Risk identification & assessment Risk modification or optimization Patient - doctor relationship Anesthetic plan & post-operative care Information
Timing of preanesthesia evaluation Before the day of surgery Preanesthesia or preoperative clinic High severity of disease High surgical invasiveness On the day of surgery Ambulatory & same day admission Low severity of disease undergoing medium/low surgical invasiveness
Preanesthesia evaluation Review & assessment medical records History taking Physical examination Laboratory tests
Review & assessment medical records Description of current diagnoses Treatments Medication Alternative therapies used Medical condition Anesthetic records
History taking Current diagnosis Functional capacity & dependency Underlying medical problems / co-morbid problems Medications Smoking, alcohol
History taking Allergy Previous anesthesia / surgery & problems Family history Pregnancy NPO time
Physical examination Airway examination Pulmonary examination Cardiovascular examination Vital signs BW, height, BMI Neurologic examination
น้ตงอ้ืบเะลแนาฐน้ืพบบแยากงา่รจวรตราก
Laboratory tests Diagnostic tests Preoperative tests Indicated tests : ordered for specific clinical indication or purpose Routine tests : ordered in absence of specific clinical indication or purpose
ECG (Electrocardiogram) Cardiovascular disease Respiratory disease Type & invasiveness of procedure Age > 45 years
CXR Smoking Recent URI COPD Cardiac disease
Hemoglobin / Hematocrit Type & invasiveness of procedure Liver disease Liver disease Extremes of age History of anemia, bleeding Hematologic disorder
Coagulation study Bleeding disorder Renal dysfunction Liver dysfunction Type & invasiveness of procedure Anticoagulant medications
Serum chemistry Endocrine disorder Renal dysfunction Liver dysfunction Extremes of age
Urinalysis (UA) UTI Specific procedures : prosthesis implantation, urologic procedures Pregnancy test in female patients of childbearing age
Practice advisory Should not be ordered routinely Required on a selective basic for purposes of guiding or optimizing perioperative management Test results within 6 months generally acceptable if patient’s condition not changed
(Preoperative screening test) รากิตับิฏปงอ้หจวรตง่สรากนใา นะนแอ้ข ลดิหมยัลายทิวาหม ลาบายพชาริริศ์รตสาศยทพแะณค ายทิวีญญัสิวาชิวคาภSiPAC ์ยนูศ รากิตับิฏปงอ้หจวรตง่สรากา นะนแอ้ขงาราตRef.
ASA Physical status
ASA Physical status & perioperative mortality rate ASA classification Mortality rate 1 0.06 - 0.08 % 2 0.27 -0.4% 3 1.8 – 4.3 % 4 7.8 – 23 % 5 9.4 – 51%
ASA Physical status & mortality rate Mortality rates by ASA status from Anesthesiology, V 97, No 6, Dec 2002 p1615
ASA Physical status ดมหง้ัทงย่ีสเยัจจัปมุลคบอรค่มไ กายจใยาหยว่ชอ่ท่สใรากกาจงย่ีสเมาวค (surgical risk) ดัตา่ผรากงอขนอ้ซบัซมาวคกาจงย่ีสเมาวค นักยว้ดา้ขเงา่ยอๆยาลหาหญัปอืรหงย่ีสเยัจจัปมวรรากีธิวีม่มไงัย (cumulative risk)
Perioperative cardiovascular evaluation & management of patients undergoing noncardiac surgery American College of Cardiology (ACC) American Heart Association (AHA) 2014 ACC/AHA guideline
นิมเะรปงอ้ต่ีทยัจจัป Active cardiac conditions Functional capacity Clinical risk factors Surgical procedure risks
Active cardiac conditions
Functional capacity มรรกจิกา ทรากนใถรามาสมาวค : metabolic equivalents นจเิซกอออืรหนางงัลพ้ชใรากงอขยว่นห (METS) 1 METS = resting O consumption = 3.5 ml/kg/min 2 บัดะร 4 Excellent > 10 METS Good 7-10 METS Moderate 4-7 METS Poor < 4 METS
Surgical procedures risks
Risk of surgical procedures Low risk procedure : risk of major adverse cardiac event (MACE) of death or MI < 1% Elevated risk (intermediate & high risk) : MACE ≥ 1%
Definition of urgency Emergency procedure < 6 hours Urgent procedure 6-24 hours Time sensitive procedure >1-6 weeks Elective procedure 1 year
Clinical risk factors CAD (coronary artery disease) Recent MI : occurred within 6 months Independent risk factor for perioperative stroke ass. with 8 folds increase in mortality rate
Heart failure Active heart failure : higher risk of postoperative death than CAD Stability of patients with heart failure : significant role Severe HF (LVEF < 30%) → independent contributor to perioperative outcome & long term risk factor for death in patient with heart failure undergoing elevated risk non cardiac surgery
Valvular heart disease (VHD) Moderate to severe valvular stenosis/regurgitation undergo preop. echocardiography No prior echocardiography within 1 year Significant change in clinical status Patients with indications for valvular interventions Valvular interventions before elective non cardiac Sx effective in reducing perioperative risk
Valvular heart disease (VHD) Emergency non cardiac Sx in uncorrected significant VHD can be minimized risk by Accurate diagnosis : type & severity of VHD Choosing anesthetic approach appropriate to VHD Consider higher level of perioperative monitoring (A-line, PAC, TEE)
Arrhythmia & conduction disorders Arrhythmia in preoperative setting should investigation Cardiopulmonary disease Ongoing myocardial ischemia / MI Drug toxicity Metabolic disorders
Arrhythmia & conduction disorders Atrial fibrillation (AF) History of AF & clinical stable : adjustment of anticoagulation Ventricular arrhythmias (single or frequent PVC, nonsustained VT) Don’t require therapy unless hemodynamic compromised Risk factors for intra & post operative arrhythmias Not increase risk of nonfatal MI or cardiac death
Arrhythmia & conduction disorders High grade cardiac conduction abnormalities ; complete AV block Increase operative risk Necessitate temporary or permanent transvenous pacing
Cardiovascular Implantable Electronic Devices (CIED) Type of CIED Pacemaker Implantable cardioverter- defibrillator (ICD)
Cardiovascular Implantable Electronic Devices (CIED)
Cardiovascular Implantable Electronic Devices (CIED) Pre-operative evaluation Patient’s specific CIED hardware & programming (pace maker vs ICD) Underlying cardiac condition : cardiac rhythm & Hx of ventricular arrhythmias
Cardiovascular Implantable Electronic Devices (CIED) Effective communication : surgical team & CIED clinician Planned procedure Type of electromagnetic interference (EMI) Perioperative CIED interrogation / reprogramming Change pacing to asynchronous mode Inactivate ICD tachytherapies Apply magnet over CIED
Cardiovascular Implantable Electronic Devices (CIED) Perioperative management Bipolar electrocautery / harmonic scalpel External defibrillator, transcutaneous pacing ready available Should have plethysmographic or arterial pressure monitoring during Sx
Patients with percutaneous coronary interventions (PCI)
Patients with percutaneous coronary interventions (PCI) Risk of stent thrombosis is highest in first 4-6 wks after stent implantation Discontinuation of DAPT (Dual Antiplatelet Therapy) in early period → strong risk factor for stent thrombosis Urgent or emergency Sx : decision to continue ASA or DAPT → risk weighed against benefit of continuing therapy
Management of perioperative anticoagulant in patient with prosthetic valve & AF Bridging therapy : vit.K antagonists → unfractionated heparin or LMWH depend on Location of prosthetic valve Risk factors for thrombolic & thromboembolic events Aortic valve & ≥ 1 additional risk factor → bridging anticoagulant
Management of perioperative anticoagulant in patient with prosthetic valve & AF Risk factors for thrombolic & thromboembolic events AF Previous thromboembolism LV dysfunction Hypercoagulable condition Older generation prosthetic aortic valve
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