5_6125448697896502769.pptx

5_6125448697896502769.pptx

• 1.
  PRINCIPLES OF PEROPERATIVE MANAGEMENTOF COMMON SURGICAL PROCEDURES
• 2.
  Introduction • After surgerymetabolic demands increases due to tissue destruction, blood loss, fluid shifts from an average of 110ml/min/m2 at rest to 170ml/min/m2 in postoperative period • Patients who are unable to meet their demands due to limited cardiorespiratory reserve are at risk of oxygen debt • Occult hypovolemia resulting from fluid shift or blood loss ,lead to sphlanchnic vasoconstriction to compensate may lead to gut ischemia • So those with coronary artery and cerebrovascular disease are at high risk for myocardial ischemia or stroke
• 3.
  Who are thehigh risk patients ? 1.Surgery specific 2.Comorbidity related 3.others
• 4.
  Surgery specific estimatesof risk HIGH RISKS > 5% INTERMEDIATE RISK 1-5% LOW RISK <1% Open aortic Major vascular Peripheral vascular Urgent body cavity Elective abdominal Carotid endovascular aneurysm Head and neck Major neurosurgery Arthroplasty Elective pulmonary Major urology Breast Dental Thyroid Ophthalmic Gynaecological Reconstructive Minor orthopaedic Minor urologic
• 5.
  Comorbidity related 1 .Cardiovascular– IHD,HF ,valvular heart disease, coronary stent placement, with pacemakers, PVD , arrythmias 2 . Respiratory system -Upper respiratory tract infection ,Asthma and COPD, Chronic smokers Restrictive lung diseases ,Obstructive sleep apnoea ,Patients scheduled for lung resection 3. Endocrine disorders -Diabetes Mellitus ,Thyroid disorders,Hypothalamic- pituitary- adrenal disorders ,Pheochromocytoma 4 .Renal disorders - CKD ,AKI 5.Hepatic disorders – Hepatitis,Alcohol liver disease ,Obstructive jaundice ,Cirrhosis 6. Hematological disorders -Anaemia ,Sickle cell disease ,G6PD deficiency ,Coagulopathies
• 6.
  7.Neurological disorders -CVD,Seizure disorders ,Multiple sclerosis.Aneurysm and AV malformation,Parkinson disease ,Neuromuscular junction disorders ,Muscular dystrophy and myopathy 8. Musculoskeletal disorders - Rheumatoid Arthritis ,Ankylosing Spondylitis ,Systemic Lupus Erythematosus ,Raynaud Phenomenon
• 7.
  Others • Age –due to less physiological reserve • Obesity • Substance abuse • Previous history of surgery
• 8.
  Factors contributing tothe risk • Previous cardiorespiratory illness • Late stage vascular disease involving aorta • Age>70 years with limited physiological reserve in one or more vital organs • Extensive surgery for carcinoma • Acute abdominal catastrophe with haemodynamic instability • Acute massive blood loss > 8units • Septicemia • Positive blood culture or septic focus • Respiratory failure pao2 <8kpa or fio2 >0.4 or mechanical ventilation > 48 hrs • Acute renal failure { urea >20mmol or creatinine >260 mmol/l}
• 9.
  A PRACTICAL APPROACHTO THE CARE OF HIGH RISK PATIENTS 1.preoperative evaluation and care a)preoperative assessment b)preoperative preparation 2.intraoperative management 3.postoperative management
• 10.
  Preoperative assessment HISTORY TAKING Donot assume that history has been adequately covered previously • Important points may have been overlooked in a busy OPD • Standard history focuses on the patient’s hopes and expectations Principles of history taking • Listen: What is the problem? (Open questions) • Clarify: What does the patient expect? (Closed questions) • Narrow: Differential diagnosis (Focused questions) • Fitness: Comorbidities (Fixed questions)
• 11.
  PAST MEDICAL HISTORY Comorbidityrelated – • cvs, rs, cns. Gut,git,endocrine disorders Previous surgery • Problems encountered • Family history of problem with anaesthesia Other • Human immunodeficiency virus • Malignancy • Allergy
• 12.
  PHYSICAL EXAMINATION General • Anaemia,Jaundice, Cyanosis, Nutritional status, Peripheral oedema • Infection source (teeth, feet, leg ulcers) CVS • Pulse, BP, heart sounds CNS • GCS Respiratory • RR and effort, chest expansion • Percussion note ,breath sounds and oxygen saturation GIT • Abdominal masses, ascites, bowel sounds • Hernia and genitalia
• 13.
  INVESTIGATIONS CBC • Major operationsin elderly and in those with anemia • Pathology with ongoing blood loss Urea and electrolytes • Major operation and >60 years old patient • Cardiovascular, renal and endocrine disease • Anticipated blood loss • Medication : NSAID, diuretics, steroids ECG • Patients aged over 60 years • Cardiovascular, renal and DM β-Human chorionic gonadotrophin • Pregnancy needs to be ruled out in all women of childbearing age.
• 14.
  Chest xray • Cardiacfailure and smokers • COPD and Acute respiratory symptoms Blood glucose and HbA1c • DM or family history • Obese or poor nutrition • Steroid use Liver function tests All patients with upper abdominal pain, jaundice, hepatic disease • Alcoholic • Screening for Hepatitis B and Hepatitis C Blood group/ cross match • Emergency preoperative case • Suspicion of blood loss, anemia, coagulation defects • Procedure on pregnant ladies
• 15.
  Coagulation studies: • h/oof bleeding disorder, liver disease or excessive alcohol use • Patients receiving anticoagulants( PT/INR done on the morning of surgery for patients instructed to discontinue warfarin
• 16.
  Additional investigations Echocardiogaraphy • Havenewly occurring dyspnoea of unknown origin • Have known heart disorder with symptoms of detoriation • Have cardiomyopathy • Have undergone preoperative chemotherapy with epirubicin Arterial blood gas analysis Carotid doppler • had experienced TIA or stroke within 3 months that occurred without proper follow up or medical assessment or diagnosis Pulmonary function tests • Elderly patients • Previous history of thoracotomies or major surgeries near diaphragm • Known case of restrictive or obstructive lung disorders • Prolonged surgery
• 17.
  Identification ofhighriskpatientsandassessment oflevelofrisk Thereare number of scoring systems have been developed for identification of high risk patients, most widely used are 1.ASA GRADING it does not account age and nature of surgery and it is operator dfependent It is simple and related to operative mortality
• 18.
  2. METABOLIC EQUIVALENT Toassess overall functional fitness 1 met ~ oxygen consumption of adult at rest (3.5ml/kg/min) If a person able to perform > 4 met then he / she is considered as suitable candidate for surgery
• 19.
  3. For cardiacevaluation { revised cardiac risk index}
• 20.
  4.Possum score (physiologicaland operative severity score for enumeration of morbidity and mortality
• 21.
  5.ACS NSQIP SCORE Comparespatient risk with average person risk , it’s a webtool used postoperatively
• 22.
  5.CPET(cardiopulmonary exercise testing) Itused to detect oxygen consumption and co2 production When subject’s delivery of oxygen to tissues becomes inadequate then anaerobic metabolism begins . AT= oxygen consumption ml/kg/min above which anaerobic metabolism occurs Vo2 = peak oxygen consumption (measured) AT CUTOFF OF 11, VO2 15ml/kg/min indicates high risk of postoperative morbidity and mortality If CPET is not available six minute walk test or incremental shuttle walk test can be used to assess the functional capacity of the patient.
• 23.
  Preoperative preperation • Informedpatient consent and motivation • Interdisciplinary risk assessment • Optimising physical condition and medication a)nutritional assessment and intervention b)review of medications and administration of antibiotics
• 24.
  Nutritional assessment andintervention • Malnutrition increases risk of major morbidity • Obesity has increased risk for cardiovascular events , DVT,PE ASSESSMENT • A - Anthropometry{ BMI} • B – Biochemical {albumin,transferrin} • C - Clinical • D - Dietary history BMI - <18.5KG Sr.Albumin-<3g Wt loss 10-15 % in 6months Has poor outcome
• 25.
  Calorie requirement: ABW (ADJUSTEDBODY WEIGHT) = IBW (IDEAL BODY WEIGHT) + 0.4 (ACTUAL WEIGHT – IBW) IBW For men =50kg +2.3 kg for each inch over 5’ in height IBW for women =45.5 kg +2.3 kg for each inch over 5’in height Normal calorie requirement : 25 kcal/kg/day Protein requirement: Minimal daily requirement is 0.8gm /kg/day Severely ill patients : 2 gm/kg/day Nutritional risk assesement (15.19x sr albumin g/dl+41.7x present wt/usual weight). • NRI < 83% indicates increased mortality
• 26.
  Preoperative fluid therapy 1.Correctionof hypovolemia 2.Correction of anemia 3.correction of other disorders Causes:vomiting,bloodloss. In elective surgery Third space losses 1.fluid overload Ex. Acute intestinal obstruction, should be corrected 2.electrolyte disturbances 48- 72 hrs prior Acute pancreatitis Mild dehydration-4%bw deficit as 2,3,dpg restoration takes 48 hrs Mod dehydration-6-8% bw packed cell better for Severe dehydration -10%bw correction 0.9%ns,RL,colloid, wholeblood Monitor achieving urine output >30 – 5oml/hr suggests correction
• 27.
  Perioperative intervention includes: •Coronary revascularization ( bypass or percutaneous transluminal angioplasty) • Modification of choice of anesthetic • Invasive intraoperative monitoring • Pts with pacemakers- should turn off to uninhibited mode,bipolar cautery to be used • Pts with defribillator – turned off during surgery • Patients with recent angioplasty stenting should defer the elective procedure for 4 – 6 weeks • In case of MI, elective surgery should be postponed for 4-6 weeks • Medical therapy with beta blockers have been recommended as per ACC/AHA guidelines: Cardiovascular system optimization
• 28.
  • Smoking cessation( within 2 months before planned surgery) • Incentive spirometry • Encouraging exercise preoperatively. • Bronchodilator therapy • Antibiotic therapy for pre existing infection • Pretreatment of asthmatic patients with steroids Respiratory system optimization
• 29.
  • Anemia istreated with erythropoietin or darbepoietin • Management of hyperkalemia • Replacement of calcium for symptomatic hypocalcaemia • Use of phosphate binding antacids for hyperphosphatemia • Correction of metabolic acidosis ( sod bicarbonate is given i/v if levels fall below 15meq/l • Hyponatremia is treated by fluid restriction • Avoid nephrotoxic drugs • Preoperative dialysis should be done 24 hrs before elective surgery Renal disorder optimization
• 30.
  • Anithyroid drugsand beta blockers/digoxin continued on the day of surgery • In case of emergency surgery in thyrotoxic patient at risk of thyroid storm, a combination of beta blocker and glucocorticoids used Patients with h/o steroid use/ Suppression of HPAA: • Patients who have taken > 5mg of prednisolone or equivalent for > 3 weeks are at risk when undergoing major surgery • Minor procedures: no additional steroid required • Moderate operation: 50-75 mg/day of hydrocotisone (or eq) for 1 -2 days • Major operation: 100-150 mg/day hydrocortisone (or eq) for 2-3 days Endocrine disorder optimization
• 31.
  Pheochromocytoma : • Requirepreoperative pharmacologic Management to prevent intraoperative hypertensive crisis or vascular collapse • A combination of alpha and beta adrenergic blockade started 1-2 weeks before surgery • Liberalisation of sodium in diet
• 32.
  • Patients withdiet-controlled diabetes require no special preoperative treatment • Morning dose of OHA should be omitted • Patient should be started on variable rate intravenous insulin infusion • Insulin infusion should be adjusted to maintain blood sugars b/w 140 to 180 mg/dl • If possible patient should be posted till glycemic first in the list • Long-acting insulin should be avoided the night before major surgery • • If the blood sugars are not controlled the elective surgery should be deferred until control is achieved Diabetes mellitus optimization
• 33.
  Prophylaxis of VenousThromboembolism • Aspirin is not supported as a single agent for thromboprophylaxis. • Low-dose unfractionated heparin <5000 units subcutaneous bid), • low-molecular weight heparin (e.g., enoxaparin 30 mg bid or 40 mg qid) or a pentasaccharide (fondaparinux 2.5 mg qid) for patients at moderate risk, • unfractionated heparin (5000 units subcutaneous tds) for patients at high risk. • Graduated compression stockings and pneumatic compression device e useful supplements to anticoagulant therapy
• 34.
  Medication to STOP •NSAIDS - discontinued before surgery 5-7 days. • Clopidogrel – stopped 7 days prior to surgery • Hypoglycaemics • Oral contraceptive pill (OCP) or Hormone Replacement Therapy (HRT) – stopped 4 weeks before surgery • Warfarin – usually stopped 5 days prior to surgery For those on LMWH last dose should be given 20 -24 hours prior to surgery and restarted approx. 12-24 hours postoperatively.
• 35.
  Prophylactic antibiotics SSI occursat or near surgical incision within 30 days of the procedure • Prophylactic antibiotics should be initiated within 1h before surgical incision or two hours if the patient is receiving vancomycin or fluoroquinolones • Patients should receive appropriate for their specific procedure • discontinued 24 hours of surgery completion
• 37.
  Intraoperative management •Atraumatic surgicaltechnique •Combined general and epidural analgesia •Optimised airway management and ventilation •Blood glucose control •Optimised fluid management •Maintanenece of normothermia
• 38.
  Rl is mostcommon fluid used as it more physiologically similar to body fluid 0.9%NS is used in case of hypovolemic shock as large volume has to be replaced 5% dextrose used as intial fluid replacement to replace insensible losses – rapid replacement – osmotic diuresis DM- 5% dextrose+6 units insulin ( or ½ of morning dose) followed by using sliding scale mechanism HTN-5% dextrose given (if needed RL in optimum amount) CHF/RF/Cirrohosis- RL is contraindicated, 0.9%ns avoided, 5 % dextrose given in least possible amount Intraoperative fluid management
• 39.
  Postoperative management Modern fasttrack programmes 6 Major elements • 1. Modern opiod sparing analgesia • 2. Early mobilisation and prevention of VTE • 3. Extended lung expansion exercises • 4. Early removal of tubes,catheter and drains • 5. Early oral nutrition • 6. Early detection of complications
• 40.
  postoperative complications Complications relatedto: • 1) Wound • 2) Thermal regulation • 3) GI • 4) DVT and Pulmonary Embolism • 5) Infections and fever • 6) Pulmonary • 7) Renal • 8) Cardiovascular • 9) Neurological • 10)Complications of Diabetes
• 42.
  specific approach tocomorbidities
• 43.
  Cardiovascular system
• 45.
  RESPIRATORY SYSTEM predisposing riskfactors for pulmonary complications 1. Upper respiratory tract infection: cough, dyspnea 2. Age >60 years 3. COPD 4. American Society of Anesthesiologists Class 2 5. Functionally dependent 6. Congestive cardiac failure 7. Serum albumin <3.5 g/dl 8.FEV1 < 2l 9.pco2 > 45 mmHg 10. PO2 <50 mmHg
• 46.
  Risk Modification toReduce Perioperative Pulmonary Complications Preoperatively • Cessation of smoking • Training in proper breathing (incentive spirometry) • Inhalation bronchodilator therapy • Control of infection and secretion, • when indicated -Weight reduction, when appropriate Intraoperatively • Limited duration of anaesthesia • Select shorter acting neuromuscular blocking drugs when indicated • Prevention of aspiration -Maintenance of optimal broncho dilation
• 47.
  Postoperatively Continuation of preoperativemeasures, with particular attention to inspiratory spirometry mobilization of secretions early ambulation encouragement of coughing selective use of a nasogastric tube adequate pain control without excessive narcotic agents
• 48.
  Liver disorders
• 51.
  Endocrine disorders Diabetes mellitus Manypatients with diabetes mellitus have significant symptomatic or asymptomatic CAD and may have silent myocardial ischemia due to autonomic dysfunction. • Evidence supports intensive perioperative glycemic control to achieve near-normal glucose levels (90–110 mg/dL using insulin infusion. • This practice must be balanced against the risk of hypoglycemic complication • Oral hypoglycemic agonists should be held on the morning of operation. • Perioperative hyperglycemia should be treated with intravenous infusion of short-acting insulin or subcutaneous sliding-scale insulin. • Patients who are diet-controlled may proceed to surgery with close postoperative monitoring.
• 52.
  Long question 1. Perioperativefluid replacement 2. Discuss the Perioperative management of a patient having dibates Meletus as co morbidity 3. Discuss the PeriOperative management of a pertinent on thromboprophylaxis{( post CABG) STATUS} Requiring emergency eploiratory laparotormy
• 53.
  MCQ 1))Young male presentedwith dyspnea,bleeding and petechial hemorrhage in the chest after two days following fracture shaft of the femur right side stop most likely the cause is: a) air embolism b) fat emboilism c) pulmonary thromboembolism d) amniotic embolisim 2) Reactionary hemorrhage occurs: a) after 24 hours b) after 48 hours c) within 24 hours d) after 7 days 3) Secondary hemorrhage is due to a) Slipped ligature b) Occurs 7 to 16 days after surgery c) Due to disconnection of blood transfusuion line d) None of the above 4) Post-dural puncture headache is typically: a. A result of leakage of blood into the epidural space b. Worse when lying down than in sitting position c. Bifrontal or occipital d. Seen within 4 hours of dural puncture 5)Air embolism in neural surgery maximum in which position? a. Sitting b. Supine c. Trendelenberg d. Left lateral e. Right lateral 6)Most common coagulopathy noted in surgical patients is: a. Thrombocytopenia b. Afibrinogenemia c. Fibrinolysis d. Factor VIII deficiency
• 54.
  MCQ 7)Presence of trifluroaceticacid (TFA) in urine indicates that volatile anesthetic agent used was: a. Halothane b. b. Methoxyflurane c. Trichloroethylene d. None of the above 8)A patient undergoing surgery suddenly develops hypotension. The monitor shows that the end tidal CO2 has decreased abruptly by 155 mm Hg. What is the probable diagnosis? a. Hypothermia b. Pulmonary embolism c. Massive fluid deficit d. Myocardial depression due to anesthetic agent 9)A patient developed respiratory distress and hypoxemia after central venous catheterization through internal jugular vein, reason for this is: a. Pneumothorax b. b. Hypovolemia c. Septicemia d. Cardiac tamponade 10)In the immediate post operative period, the common cause of respiratory insufficiency could be because of the following except: a. Residual effect of muscle relaxant b. Overdose of narcotic analgesic c. Mild hypovolemia d. Myocardial infarction