Preoperative assessment - PowerPoint PPT Presentation

Loading...

PPT – Preoperative assessment PowerPoint presentation | free to view - id: 69b59-ZDc1Z



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Preoperative assessment

Description:

With an intertrochanteric femur fracture ... posterior fossa surgery. Heart failure. Preoperative evaluation: echocardiography ... – PowerPoint PPT presentation

Number of Views:285
Avg rating:3.0/5.0
Slides: 21
Provided by: cmuh5
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Preoperative assessment


1
Preoperative assessment risk
  • Int ???

2
Basic Data Chief complaint
  • 85 y/o gentleman
  • With an intertrochanteric femur
    fractureScheduled to undergo surgery for the
    placement of a dynamic hip screw

3
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

4
Question 1
  • What is your preliminary diagnosis regarding the
    cardiovascular system of the patient?

5
  • 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

6
  • 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

7
  • HTN
  • Heart function
  • Liver function
  • Renal function
  • anemia

8
Question
  • What preoperative management will you recommend
    to optimize the patient?

9
  • Pre-op evaluation
  • CBC\DC, electrolyte, albumin, liver enzyme
    (GOT\GPT), BUN\Cr, PT\aPTT
  • EKG
  • CXR
  • Cardiac echo
  • Stool OB test

10
Hypertension
  • Determinants of risk
  • Level of blood pressure.
  • Duration of treatment.
  • Degree of end organ damage. (LVH, CRF, CVA,
    CAD, LVF)
  • Type of surgery.

11
  • 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).

12
  • 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.

13
  • Type of surgery associated with increased risk
  • Aortic surgery,
  • carotid endarterectomy,
  • CABG,
  • craniotomies (aneurysm clipping),
  • AVM,
  • posterior fossa surgery.

14
Heart failure
  • Preoperative evaluation
  • echocardiography
  • radionuclide angiography
  • Brain Natriuretic Peptide (BNP)

15
  • 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.

16
Question
  • 3. Which anesthetic technique will you use? Why?

17
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
  •  

18
Hydration
  • Volume load the hypertensive patient prior to
    induction.
  • ?This helps to minimise the peaks and valleys
    that characterise the hypertensive patient.
  •  

19
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.
  •  

20
Analgesia
  • Opioid and non steroidal anti-inflammatory agents
    prevent the hypertensive response to pain, intra-
    and post- operatively
About PowerShow.com