Preoperative assessment

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Preoperative assessment risk

• Int ???

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Basic Data Chief complaint

• 85 y/o gentleman
• With an intertrochanteric femur
  fractureScheduled to undergo surgery for the
  placement of a dynamic hip screw

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Brief history PE

• BP 190/120 mmHgUnknown antihypertensive
  medication used daily
• Resting pulse rate 140/minRadial pulse is
  irregular in tempo and volume
• Systolic murmur over apex, Gr 3
• Ankle edema
• Bilateral basal crepitation in the lungsCant
  lie flat (orthopnea)
• Hematocrit 31

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Question 1

• What is your preliminary diagnosis regarding the
  cardiovascular system of the patient?

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• BP 190/120 mmHg? history of hypertension with
  unknown antihypertensive medication used daily
• Resting pulse rate 140/minRadial pulse is
  irregular in tempo and volume?tachycardia with
  arrhythmia
• Systolic murmur over apex, Gr 3?suspect MR

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• Ankle edema ? may related to Rt heart
  failure, malnutrition, liver or renal disease
• Bilateral basal crepitation in the lungsCant
  lie flat (orthopnea)?may be pulmonary edema due
  to Lt heart failure or MR
• Hematocrit 31
• ?anemia, maybe due to chronic malnutrition,
  chronic renal impairment or bleeding

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• HTN
• Heart function
• Liver function
• Renal function
• anemia

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Question

• What preoperative management will you recommend
  to optimize the patient?

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• Pre-op evaluation
• CBC\DC, electrolyte, albumin, liver enzyme
  (GOT\GPT), BUN\Cr, PT\aPTT
• EKG
• CXR
• Cardiac echo
• Stool OB test

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Hypertension

• Determinants of risk
• Level of blood pressure.
• Duration of treatment.
• Degree of end organ damage. (LVH, CRF, CVA,
  CAD, LVF)
• Type of surgery.

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• Level of blood pressure.
• Asymptomatic patients with mild to moderate HTN
  (DBPlt110 mmHg) are not at increased risk.
• Elective surgery should be postponed in the case
  of DBPgt110 mmHg complications, DBPgt120 mmHg
  without.
• Isolated systolic HTN lt200 mmHg should not defer
  surgery unless for vascular surgery or
  craniotomies (increased risk).

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• Duration of treatment
• Continue all antihypertensives up to and
  including the day of surgery (except diuretics).
• Delay elective surgery if SBPgt200 mmHg, or if DBP
  gt120 mmHg, until BP lt190/110 mmHg, preferably
  lowered to 140/90 mmHg over several weeks.
• Acute control within hours of surgery is
  inadvisable.

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• Type of surgery associated with increased risk
• Aortic surgery,
• carotid endarterectomy,
• CABG,
• craniotomies (aneurysm clipping),
• AVM,
• posterior fossa surgery.

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Heart failure

• Preoperative evaluation
• echocardiography
• radionuclide angiography
• Brain Natriuretic Peptide (BNP)

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• An ejection fraction less than 40 predicts
  adverse cardiac outcome.
• In some patients coronary bypass surgery or
  coronary angioplasty and stenting improve left
  ventricular function to such an extent that even
  major surgery becomes considerably safer.
• An increasing number of patients with heart
  failure are now receiving beta-blockers. The
  latter improve their long-term prognosis,
  especially where carvedilol is used.

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Question

• 3. Which anesthetic technique will you use? Why?

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Antihypertensive therapy

• Use of agents to attenuate the haemodynamic
  responses to intubation, incision and extubation
• Opioids Fentanyl, Alfentanyl.
• Antihypertensives Esmolol, Labetalol, Atenolol,
  Metoprolol, clonidine, enalapril (one dose
  preop).
• Lidocaine
•  

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Hydration

• Volume load the hypertensive patient prior to
  induction.
• ?This helps to minimise the peaks and valleys
  that characterise the hypertensive patient.
•  

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Choice of agents

• Consider using agents with minimal haemodynamic
  effects
• Fentanyl with thiopentone rather than propofol
• pethidine rather than morphine,
• vecuronium or cis-atracurium rather than
  atracurium, sevoflurane induction etc.
•  

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Analgesia

• Opioid and non steroidal anti-inflammatory agents
  prevent the hypertensive response to pain, intra-
  and post- operatively