Management of perioperative anticoagulant in patient with prosthetic valve & AF Require urgent reversed of vit. K antagonists FFP Vitamin K : not routinely recommended Effect not immediate Significant delay return of therapeutic level of anticoagulation
Hypertension Identified caused of HT Severity & duration of disease End organ damage Therapy
Hypertension End organ damage Heart : LVH, MI, CHF Brain : CVA, TIA Kidney : CKD Peripheral artery disease
Hypertension Elective Sx be delayed for severe HT → SBP ≥ 180 or DBP ≥ 110 mmHg Effective lowering of risk : 6-8 weeks therapy Too rapid or extreme lowering of BP→ cerebral & coronary ischemia
Hypertension Emergency or urgency : not decrease chronic HT too rapidly Differentiate poorly control HT from pain, anxiety & stress Continuation of anti HT treatment except diuretics & ACEI
Ischemic heart disease Goal of preoperative evaluation Identify risk for heart disease based on risk factors Identify presence & severity of heart disease (symptoms, physical finding or diagnostic tests) Determine need of preoperative interventions Modify risk of perioperative adverse events
Ischemic heart disease Continue statins & -blockers Continue aspirin or discontinue for shortest duration possible (if used for 2 nd prevention of vascular events)
Heart failure Systolic dysfunction ejection fraction (EF) ; abnormal contractility Diastolic dysfunction filling pressure ; abnormal relaxation, normal contractility & EF Combination
Heart failure Goal of preoperative evaluation : identify & minimize effects of HF Symptoms : weight gain, orthopnea, PND, nocturnal cough, peripheral edema rd th PE : 3 or 4 heart sounds, tachycardia, jugular vein distention, ascites, hepatomegaly
NYHA classification
Heart failure Echocardiography Normal LVEF > 50% Mildly diminished LVEF 41-49% Moderately diminished LVEF 26-40% Severely diminished LVEF ≤ 25% Medical therapy : -blockers, nitrate, digoxin, hydralazine, ACEIs, ARBs, diuretics
Heart failure Continuing or discontinuing drugs depends on Volume & hemodynamic status Degree of cardiac dysfunction Surgical procedure & volume challengers Continuing all medications : severe dysfunction scheduled for minor procedures
Heart failure Well compensated NYHA class I undergo high risk procedures : discontinue potent diuretics NYHA class III or IV undergo intermediate or high risk procedures : preop. consult cardiologist Unless truly emergency & life preserving, surgery postponed in decompensated or untreated HF
Asthma Chronic inflammatory disease Obstruction of airways (reversible) Precipitated by Irritants Allergens Infections Medications Instrumentation of airways
Asthma Classification Intermittent (mild) Persistent (mild, moderate, severe) Mild, well controlled asthma ; no greater risk than normal
Asthma History taking Severity Recent exacerbation Therapy : steroids Oxygen use Hospitalization & intubation
Asthma PE Breath sound, degree of wheezing Degree of accessory muscle use Pulse oxygen saturation ABG : severe exacerbation CXR : infection
Asthma Continued : bronchodilators, inhaled & oral steroids, antibiotics on the day of Sx Patients taking oral steroids Perioperative steroid supplementation Check blood sugar
COPD Severity : dyspnea on exertion, right heart failure Hx : smoking, cough, infection Current medication เคย admit, on ET, on ventilator? Right heart failure : engorged neck vein, hepatomegaly, pitting edema
COPD Preparation Stop smoking at least 8 wks Respiratory infection : delayed surgery & ATB Hydration : clear secretion Deep breathing exercise : tri flow Chest physical therapy Continue medication on the day of surgery, Beta- adrenergic agonists nebulizer on call to OR
Asthma & COPD Acute exacerbation, respiratory infection Elective Sx : delayed Sx, treat infection/ bronchospasm Emergency Sx : bronchodilator, theophyline, severity มาตsteroids
Diabetic mellitus (DM) Type & severity Medications Target organs damage CVS :atherosclerosis, silent MI, HT Nephropathy Peripheral neuropathy Autonomic neuropathy : orthostatic hypotension, gastroparesis Stiff joint syndrome : prayer sign
Diabetic mellitus (DM) Perioperative glucose management Perioperative stress → BS (release of cortisol & catecholamine) Better glycemic control → limit morbidity & mortality Goal : BS 100-200 mg/dl
Recommendation guideline st Scheduled of 1 case of day Hold oral hypoglycemic drugs on the day of Sx except metformin Insulin continued through evening before Sx Type I DM continued half of usual morning dose of intermediate/long acting insulin Use sliding scale control BS 100-200 mg/dl with short acting insulin
Chronic kidney disease (CKD) Preoperative evaluation Severity Medications Type of replacement therapy & schedules Comorbid conditions
Chronic kidney disease (CKD) CVS : HT, atherosclerosis, IHD, CHF, uremic cardiomyopathy RS : pulmonary edema, pleural effusion CNS : uremia, peripheral & autonomic neuropathy GI : delayed gastric emptying time Hemato : ↓erythropoietin → anemia, platelet dysfunction Renal : fluid & electrolyte imbalance, hyperkalemia
Chronic kidney disease (CKD) Elective case : dialysis performed within 24 hrs of Sx, but not immediately before (acute volume overload & electrolyte imbalance Dialysis : correct volume overload, hyperkalemia & acidosis
Premedication Anxiolysis Sedation Amnesia Analgesia Antisialagogue Reduction of gastric volume & pH Antiemetic effect Prevention of autonomic reflex responses
Time & route of premedication Oral route : 60-90 min before Sx (acceptable with up to 150 ml of water) Intravenous route : 2-3 circulation time for full effect Intramuscular route : 30-60 min before Sx
Benzodiazepines Most popular premedication drugs Produce anxiolysis, amnesia & sedation Little respiratory & cardiovascular depression Diazepam, lorazepam, midazolam
Lorazepam 5-10 times as potent as diazepam Prolonged sedation Oral dose 1-2 mg (25-50 g/kg) max. dose 4 mg Clinical effects 30-60 min, peak plasma conc. 2-4 hr Not useful in rapid awakening is necessary
Midazolam Water soluble, rapid metabolism 2-3 times as potent as diazepam Dose Oral 0.07-0.15 mg/kg 30-60 min before Sx Intravenous 1-2.5 mg Intramuscular 0.05-0.1 mg/kg Quicker onset, more rapid recovery than diazepam
Opioids Used when analgesia needed before Sx SE Orthostatic hypotension Respiratory depression Nausea & vomiting Sphincter of Oddi spasm Pruritus
Anticholinergic drug Antisialagogue effect Intraoral operation Instrumentation of airway Before use of topical anesthesia for airway Sedation & amnesia Scopolamine & atropine
SE of anticholinergic drugs Central anticholinergic syndrome Scopolamine & atropine Symptoms : delirium, restlessness, confusion, obtundation Treatment : physostigmine 1-2 mg iv. Mydriasis & cycloplegia → IOP Unwanted effect in glaucoma Atropine & scopolamine
H2 antagonists & antacids H2 antagonists Ranitidine 50-200 mg oral, 50-100 mg iv Cimetidine 200-400 mg oral/iv Non-particulate antacids 0.3 M sodium citrate 30 ml before induction 15-30 min
Metoclopramide Dopamine antagonist Stimulate upper GI motility, GE sphincter tone Antiemetic & speed gastric emptying time Dose Oral 10 mg 30-60 min before induction Intravenous 5-10 mg 15-30 min before induction
Adrenergic agonists Clonidine adrenergic agonist 2 Prevent HT & tachycardia from ET intubation & surgical stimulation Produce sedation
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