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Preoperative and postoperative care

Preoperative and postoperative care

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Preoperative and postoperative care

  1. 1. Preoperative and postoperative care :Edited by Dr Salem Al-Shabahi
  2. 2. PREOPERATIVE CARE
  3. 3. Pre-operative Management• Pre-operative Assessment.• Pre-operative Preparation.• Premedication.
  4. 4. Pre-operative Assessment• The purposes of pre-operative visit.• Taking history .• Physical Examination.• Risk Assessment.• Common causes for postponing Surgery.
  5. 5. The purposes of pre-operative visit• Establish report with the patient.• Taking a history .• Order special investigation.• Assess the risk of anaesthesia.• Start pre-operative management.• Discussion about pre-operative and plan the anaesthetic management.• To avoid any drug induction or not.• Introduce a treatment in early post-operative period..
  6. 6. History Taking• Chart review• Present illness• Family History: porphyria, malignant hyperpyraxia, haemophilia, Cholinesterase abnormalities and dystrophy myotonica .• Disease of C.V.S & Respiratory, dyspnoea, paroxysmal nocturnal dyspnoea, orthopnoea, angina , MI .
  7. 7. History Taking• Hematological Disease : Anemia , Clotting abnormalities , Thromboprophylaxis .• Musculoskeletal Disease : Rheumatoid Arthritis .• Renal Disease : Renal Failure , Patients on Dialysis .• CNS Disease: Seizures , TIA , Stroke, Raise ICP.• GI: Liver Disease , hepatitis, vomiting , diarrhea• Endocrine Disease: Diabetes Mellitus
  8. 8. A history of previous anaesthesia .• Allergy to drugs .• Sore throat and headache• Post-operative nausea or vomiting.• Expose to Halothane within 3 months prior to Surgery• DVT or Respiratory problems.• Difficulties with tracheal intubation.
  9. 9. History Taking• Allergy to drugs, food, antibiotics, anesthetic agent, latex allergy and atopic patient• HBV,HCV,HIV carriers have additional risk on staff.• Taking a special method with infected patient:
  10. 10. Pregnancy• If it’s elective surgery then postpone it till delivery.• Many anaesthetic are teratogenic especially in early stage.• They my induct spontaneous abortion.
  11. 11. Smoking• Smoking indicate: CVS problems , chronic bronchitis or Lung CA.• It cause tachycardia, increase peripheral resistance, decrease the availability of O2 by 25%, and the Respiratory complication will increase by 6 folds.• It must be stopped 1 month to operation Or at least 6 hours before anesthesia .
  12. 12. Alcohol• Alcohol: it cause induction of liver enzyme, hepatic & cardiac damage, delirium tremors post-operatively as result of drug withdrawal.• Drug history: many drugs interact with the anaesthesia• Drugs must be stooped before surgery and anesthesia (contraceptive tablets .warfarin and MAOI )
  13. 13. Drug History• CVS medication: ACE Inhibitors, Diuretics, B- Blockers, Calcium channel blockers• Antibiotics: Aminoglycosides,Sulphonamides.• Anticoagulant: Warfarin, Aspirin, contraceptive, hormone replacement therapy• Lithium and Insulin .
  14. 14. Physical Examination• Full examination must be done even if it’s a minor surgery.• General: color, activity, weight, dehydrated, & type of breathing.• CVS: pulse volume, rate, and pressure, heart sounds, & BP.• RS: Breathing sound, chest , airway and trachea.• Assessment of the ease of tracheal intubation.
  15. 15. Physical Examination• Mouth opening – Flexion of cervical spine & extension of Atlanto-occipital joint.• CNS : cranial nerve examination , Eye Examination , Peripheral sensory & Motor Dysfunction
  16. 16. Investigation• Routine investigation : urine analysis & CBC• Medically fit pt less than 40 yr old ( Hb & sugar in urine )• Medically fit pt more than 50 yr old ( Hb & sugar in urine + chest X-ray & ECG )• More investigation, if the pt has any medical diseases.
  17. 17. Risk Assessment• Overall mortality rate from surgery is 0.6% while from anaesthesia 1/1000.• The information gathered is used to predict the patient absolute mortalityGrade status absolute mortality1 a normal healthy patient 0.12 mild systemic disease 0.23 severe systemic disease 1.84 incapacitating systemic disease 7.85 a moribund patient 9.8
  18. 18. Causes of death due to anaesthesia• Inadequate preoperative assessment.• Inadequate supervision & monitoring inter- operative period.• Inadequate post-operative care.
  19. 19. Common causes for postponing surgery• Acute upper respiratory tract infection.• Untreated medical diseases.• Inadequate resuscitates pt in emergency( 1/3 of fluid lost ) in dehydrated pt & 100 BP in shock pt.• Recent ingestion of food.• Failure to obtain informed consent.• MI : wait 6 months
  20. 20. Pre-operative preparation for surgery & anaesthesia• History , physical examination & investigation• Preoperative fasting• Providing information to the patient & gaining a consent• Collect or Prepare of the blood product• Organize appropriate staff and equipment in the theater
  21. 21. Pre-operative preparation for surgery & anaesthesia• BP should not be more than 100-105 mmhg diastolic.• Control cardiac diseases,• FBS = 130-180 mg/100cc bld.• Bld preparation for major surgery.• Drugs which may be given in the day of operation: steroid, aminophyline, heparin, antibiotic, & insulin.
  22. 22. Pre-Medication The objective of pre-medication• Allay anxiety and fear.• Reduce secretions.• Enhance the hypotonic effect of anaesthetic agents.• Reduce postoperative nausea & vomiting.• Produce amnesia.• Reduce the volume & increase pH of gastric contents.• Reduce vagal reflexes.• Limitation of sympathoadrenal response
  23. 23. Anti cholinergic• They are used to :1- antisialagogue effect ( reduce secretion )2- sedative and amnesic effect3- prevention of reflex bradycardia : as prophylactic and treatment of bradycardia
  24. 24. Anti cholinergic• Atropine:• given IM in a dose 0.6 mg for adult & 0.01 mg/kg.• It reduce the oral and respiratory secretion.• It’s highly indicated in anal surgery, eye surgery, bronchoscope, suxamethonium single dose, and Ketamine.• It should not be used for pt with high tem, thyrotoxicosis, heart failure controlled by digoxin.
  25. 25. Anti cholinergic• Scopolamine:• Given IM,IV, or SC in a dose 0.4.• It produce amnesia, hallocination, and reduce salivation.• It should not be given to a pt below 6 yr and above 60 yr.
  26. 26. Anti cholinergic• Side effects : 1 - CNS toxicity : restlessness , agitation , somnolence , convulsion & coma2 - reduction in lower esophageal sphincter tone3 - tachycardia4 – visual impairment5 – pyrexia6 – excessive drying
  27. 27. Benzodiazepines• They are used to :1 – relief anxiety2 – sedation3 – anterograde amnesia4 – muscle relaxants
  28. 28. Benzodiazepines• Diazepam: 0.2 mg/kg. long acting, night before the operation.. It produce light anaesthesia.• Midazolam: 0.1 mg/kg. shorter in action. Hepatic & non-hepatic elimination and doesn’t cause thrombosis.
  29. 29. Narcotic• They are used to : 1 – production sedation2 – relieve pain 3 – when using opioids ,lower concentration of anesthetic agent is required for maintenance of anesthesia because of its synergistic effects with anesthetics .
  30. 30. Narcotic• Pethidine: 1.5 mg/kg with mild atropine like action. Moderate to sever pain.• Morphine: 0.15 mg/kg. It’s more potent with incidence of vomiting.• Omnapone: it’s extract of opiate. 50% morphine, 25% morphine like action, and 25% papaverine.
  31. 31. Narcotic• Side effect :1 – depression of ventilation and delay resumption of spontaneous ventilation at the end of anesthesia .2 – nausea and vomiting3 – Rt upper quadrant pain
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