Department Anesthesiology &

Reanimation Medical Faculty

Pattimura University

Preoperative preparation
Preoperative visit
Assess the risk of anesthesia and

surgery
Informed consent
Fasting
Premedication

Inadequate pre op.preparation

may be a major contributory
factor
to
the
perioperative
morbidity & mortality. It is
essensial that anesthetist visits
every patient before surgery.

The purpose of it :
Establish rapport with the patient
Meet the doctor with the patient
Discuss possible causes of anxiety
regarding anesthetic and surgical manner
Explain how the patient will be cared for
during and after anesthesia and about
pain relief
Establish a doctor-patient relationship
that reduces patient anxiety by building
trust & respect
Assessment of physical status
Order special investigations

Fears related to anesthesia

(Sheffer)
He may tell secrets
The operation will start too soon
He may wake up during surgery
He may not wake up after surgery
Fears of suffocation, mutilation,

vomitting & cancer

Incidence of anxiety
Type of surgery :
G.U.T

80%
Possible cancer, disabling 85%

Sex : women higher than men

Type of body build :

Asthenic > normal or over weight

(pyknic)

Successful approach
(Buskirk)
Treat all patients as human being
Be friendly, explain your visit & your

plan
Be patient & sympathetic
Listen to his concern, answer all
questions in understanding and
warm manner
Allay patients fears

Comparison of Preoperative
Visit and Pentobarbital
(2mg/kg i.m) (% of Patients)

Control Group

Felt Drowsy Felt Nervous Adequate

Preparation
18
58
35

Pentobarbital Only

30

61

48

Preoperative Visit

26

40

65

Pentobarbital and
Preoperative Visit
38
38
71
Source : Data from Egbert LD et al : The value of the
preoperative visit by the anesthetist JAMA 185:553, 1963

History and physical

examination
Personal and family history
Hereditary conditions associated with
anesthesia : porphyria, malignant
hyperthermia, haemophilia
Previous operations & anesthetics
Allergies
Medications drug interaction
Habits : alcohol and smoking
Diseases of CVS and respiratory
systems

Alcoholism
Impairment of liver function
Heart cardiac arrhythmia
Cardiac contractility decrease
Cardiomyopathy
Kidney diuretic effect by inhibiting

ADH
Plasma catecholamine increase
Metabolic & respiratory acidosis from
alcohol intoxication
Increases the anesthetic requirement

Smoking
Ciliary

function reduce, disturbing

tracheobronchial clearance
Increase production and thicken of
sputum
Strong risk factor for coronary heart
disease and occlusive peripheral arterial
disease
Systolic hypertension is potentiated

 Decrease cerebral blood flow and

increase risk of stroke

Increase gastric volume & acidity
Increase COHb level, decrease blood
O2 content & O2 delivery to tissue
Increase
catecholamine
:
CVS
responses & O2 requirement increase
Respiratory complication increase 57 times

Recomendations
COHb fall to normal level stop

smoking 48 hours preoperatively

Reduction of sputum volume & post
op complications stop smoking 4
weeks pre operatively

Physical examination
General condition : name, age, weight.
B.P. pulse rate & temperature.
Cardiopulmonary examination
including
- Cyanosis in finger tips
- V. jugularis engorgement

Obesity (W/H2 more than

30)

o Airway problems
o Mechanical ventilation is impaired

tendency to hypoventilation e.c. fix

thorax & elevated diaphragm
o Easily developed hypoxia e.c.
- FRC is reduced

- V/Q ratios are low

 Difficult estimate circulatory volume

by V.J. pressure and difficulty in

venipuncture
CVS disorders :
Hypertension 3X more
Ischemic H.D 2X more
CVD/CVA 3X more
DM 3-4 X more
Increase gastic volume, acidity &
pressure

Physical examination
General condition : name, age, weight.
B.P. pulse rate & temperature.
Cardiopulmonary examination
including
- Cyanosis in finger tips
- V. jugularis engorgement

 Airway :
- Neck :

stout, short, sunker

cheeks, distance from mentum
to hyoid ( 5 cm)
- Mouth : mouth opening, loose or
damage teeth, protruding upper
incissors

Vertebral

column
:
anatomical
deformities may render some blocks
in practical

Simple Bedside cardiopulmonary

function
Sebarases test : 2-3 deep breaths hold
as long as possible
Time : 40 seconds normal
30-40 seconds diminished
reserve
< 20 seconds severely
compromised
Match test : The ability to blow out a
standard match held 6 inches from the
open
mouth
negative

max
breathing cap low
Tilt test

Laboratory testing
Routine lab.test in pts who are
apparently healthy (history & clinical
exam) are invariably of little use and
wasting.
Blood :
Hb, leuco all female, male > 50,
major surgery, clinically indicated
Ureum, creatinine pt > 50, renal &
hepatic diseases, diabetes, abnormal
nutritional state

 Blood sugar DM, vascular disease,

corticosteroid drugs
Urinalysis every pt, very inexpensive
and
may
occasionally
reveal
an
undiagnosed diabetic or UTI
Chest X Rays :
- History of pulmonary and cardiac
disease

- Tbc endemis
- Smoking
ECG pt > 40, hypertension, history of
cardiac disease

Assess the risk of anesthesia and

surgery
ASA
(American
Society
of
Anesthesiologist) grading system
Class I : A normally healthy individual,
the pathology which surgery is needed
only localized
Class II : A patient with mild or
moderate systemic disease
Class III : A patient with severe
systemic disease that is not
incapacitating (limits the pt activity)

 Class

IV
:
A
patient
with
incapacitating systemic disease that
is a constant threat to life
Class V : A moribund patient who is
not expected to survive 24 hour with
or without operation
Class E : Added as a support for
emergency operation. All pts induced
in ASA I-V that need emergency
operation get a higher ASA grade

CARDIAC RISK
CRITERIA

POINTS

Hystory
- Age > 70 years
5
- MI in previous 6 mo
10
Physical examination
- S3 gallop or jugular vein distension
11
- Important VAS
3

CRITERIA
POINTS
Electrocardiogram
- Rhythm other than sinus or
premature atrial contraction on
last preoperative ECG
7
- > 5 premature ventricular
contractions/m in documented at
anytime before operation
7

CRITERIA
POINTS
General status : PO2 < 60 or
PCO2 > 50 mmHg, K < 3.0 or
HCO3 < 20 Meq/l, BUN > 50 or
Cr > 3.0 mg/dl, abnormal SGOT, signs of
chronic liver disease or patient bed ridden
from non cardiac causes
3
Operation
- Intraperitoneal, intrathoracic, or aortic
operation
3
- Emergency operation
4
TOTAL POSSIBLE POINTS
53

RISK CLASSIFICATION AND OUTCOME BY

THE CARDIAC RISK INDEX (CRI) AND
AMERICAN SOCIETY OF
ANESTHESIOLOGISTS (ASA) CRITERIA
No or Minor
Complication
CRI
Class Ponts CRI ASA
1.
0-5 99% 100%
2.
6-12 93% 97%
13-25 86% 93%
3.
25 22% 78%
4.

Life-Treatening
Complication Cardiac Deaths
CRI ASA
0,7% 0%
5%
2%
11% 4%
22% 17%

CRI
0,2%
2%
2%
56%

ASA
0%
1%
2%
5%

Informed consent
A patient active knowledgeable authorization
to allow a specific procedure to be provided
by an anesthesiologist.
Consent must be informed to ensure that the
patient has sufficient information about the
procedures, their risks, and benefits.
Obtaining informed consent honors a
patients right to self determination whether
GA, regional anesthesia, or i.v sedation.

Without the patients consent, the

physicion may liable for assault
and battery. When the patient is
a minor or otherwise not competent
to consent (mentally disturbed or
drugs),
the
consent
must
be
obtained
from
someone
legally
authorized to give it, such as
parent,
guardian,
or
close
relative.
Written
documentation
of
the
informed consent is included in
the patient chart
and is signed
by
the
patient
or
their

Fasting
To prevent aspiration of gastric
content
NPO after midnight has been questioned
nowadays.
Hazard fasting 12 hours :
- Hydration is compromised
- Fasting for 1 day may deplete liver
glycogen &
greater risk for hepatic toxicity
Fasting for 1 day increases FFA
lower the threshold to epinephrine
induced arrhythmia.
Recommendation : NPO 4 hours
Gastric emptying is delayed by :
anxiety, pain, trauma, and pregnancy.

A
study
to
unpremedicated
patients
oral intake 150 ml water 2-3
hours pre operatively R.G.V
low, pH more alkaline (72%)
150 ml water + ranitidine 150
mg only 2% had RGV > 25 ml
pH < 2,5

To
avoid
hypoglycemia
and
thirsty and in order pediatric
pts calm & cooperative :
Milk 10 ml/kg 4 hours
before
surgery
- Dextrose 5% 10 ml/kg 2
hours before
surgery

Premedication
Objectives are :
Allay anxiety & fear
Reduce secretions
Analgesia
Enhance the hypnotic effect of G.A.
agent
Reduces post op nausea and vomitting
Produce amnesia
Reduction in vagal reflex
Limit sympathoadrenal responses

Drugs for premedication

Sedativa, tranquilizer
Narcotics-analgetics
Alkaloid belladona as antisecretion

and reduce vagal reflex to the heart

from :
drugs
impuls afferent abdomen, thorax,

and eyes

Antiemetic

Sedative
Sedative in appropiate dose can
reduce anxiety and stress, in higher
dose become hypnotic.
Barbiturate :
Ultra short acting
Thiopentone / penthotal
Methohexitone, hexobarbitone
Especially detoxification in liver

 Medium acting :
Pentobarbitone
Quinalbarbitone
Butobarbitone
A part of them are detoxificated in liver,

small part are excreted by kidney

Long acting :
Phenobarbitone (Luminal)
All of them are excreted by kidney

Barbiturate cerebral protection

Because : cerebral metabolism ,
cerebral oxigen consumption , C.B.F.
, & I.C.P.

Medium Acting
Medium acting that most suitable for
premedication
depress CNS, start from cortex, RAS,
medulla spinalis, use for anti convulsant
depress myocard bradycardi, cardiac
output hypotension
BMR
depress liver and kidney function
crossing placental barrier

 Interfere other drugs link and

metabolism (enzyme induction)

No analgetic effect

Premedication Sedativa
Pentobarbitone sodium / nembutal

and quinal barbitone sodium /

seconal less depress respiration
and circulation, non teratogenic, and
because it is detoxificated in liver,
suite for kidney function disturbance.
Inject 60 mg/cc, i.m, 2 hour pre

op.
Capsule 50 and 100 mg

 Adults dose 1,5-2 mg/kg BW oral, rectal

Children 3-4 mg/kg BW oral, rectal
Duration of action : 3-4 hours

Phenobarbitone / luminal
Because the excretion through

kidney,
function

barbiturate suite for

liver
disturbance
Sedative dose 30 50 mg
Hypnotic dose 100 mg for adult, 3-5
mg/kg BW for children

Tranquilizer :
Benzodiazepines

Benzodiazepines : anxiolysis sedation

amnesia
Preferable to the barbiturate
- Produce amnesia
- Greater therapeutic index
- Less cardiovascular and respiratory
deppression
- Longer duration of action

Tranquilizer :
Phenothiazine
Phenothiazine : sedative-antiemetic,
antihistamine (Phenergan),
antipiretic (central vasodilatation),
central sympatic depression, and
minimize the effect of adrenalin in
perifer => less tension (Largactil),
dose : 25-50 mg oral/i.m

- Diazepam
- Lorazepam
- Midazolam
Diazepam : insoluble in water but
lipid soluble - Injection painful
(venous irritation)
- Absorption from i.m unreliable
but rapidly
absorbed from GI tract
Metabolism principally in the liver
produces active metabolites : methyl
diazepam, oxazepam, 3-hydroxy
diazepam prolonged CNS depression

 Minimal cardiovasculer effect

Ventilatory response to CO2 depressed

increase PaCO2 especially in

association with other respiratory
depressant
Anticonvulsant in tetanus and epilepsy
Mild muscle relaxant property at spinal
cord level and potentiate non
depolarizing muscle relaxant
Retrogade amnesia especially when
combine with meperidine or hyoscine
Rapidly passes the placental barrier

Doses
oral
: 0,2 0,5
mg/kg
i.v
: 0,1 0,2
mg/kg
induction : 0,3 0,5
mg/kg

MIDAZOLAM
The efect are faster and shorter, duration

approximately 60 minutes
Anterograde amnesia, has no anticonvulsant
effect
Dose : 0,150,1 mg/kg BW, i.m/i.v adult
0,5 mg/kg BW, oral children
No pain when injected because of water
soluble
Possibility become phlebitis is small

 CBF is decrease ICP decrease cerebral

protection
Relaxation effect
Not interfere coronary circulation safe
for ischemic heart disease, in other way
diazepam interfere CVR unsafe

DROPERIDOL/ INAPSINE
Tranquilizer butyrophenone, phenothiazine like

effect
Forced antiemetic, ICP can be decrease because
of mild cerebral vasoconstriction
Alpha adenergic receptor blockade hypotensi,
it can prevent catecholamine induced arrhythmia
Apathis
Dose : 2,5-5 mg; duration 6-8 hours
Side effect : dyskinetic involuntary movement
(extrapyramidal disturbance)
Occasionally dysphoric reaction

Morphine
Narcotic-analgetic standard for

strong pain, euphoria

Sedativa-postural hypotension
because of vasodilatation and
myocard depression (depression of
vasomotor center)
Constrict the sphincter of gut,
peristaltic constipation
BMR , addiction-hystamine release
positif

 Depression of cough reflex post op

secret accumulation atelectasis

ICP rise in intracranial injury
Respiratory center depression CO2
CBF

 Parasympatic tone:

- Bronchus bronchoconstriction
- Eyes myosis
Through placental blood barrier
Dose : 10-15 mg i.m/s.c, duration until 6
hours
Children : 0,1 mg/kg bodyweight
Disadvantages:
Nausea and vomittus not be used in
intraocular operation
COPD or asthma worsening

PETHIDINE/ MEPERIDINE
Depression of RC, emetic effect, euphoria

and dizziness are less than morphine

Less histamine release fine for asthma
Through placental blood barrier not be
given before umbilical cord is cut
Atropine like effect : saliva dry mouth
eyes mydriasis
Dose : 50-100 mg
Child : 0,5-1 mg/kg BW; duration 2-4 hours

FENTANYL SUBLIMATE
Stronged analgetic, 100 x morphine
CVS effect are minimal so the histamine

release
Duration : 45-60
Dose : 0,05-0,1 g I.m, 1 hour pre.op.
Disadvantages:
-Respiratory depression
-Bradycardi, miosis
-Bronchoconstriction
-somatic muscle spasm

ANTAGONIST OF NARCOTIC
If RC depression, antagonist of narcotic can
be given:

Nallorphine 5mg iv Lorvan 1 mg

iv
Naloxone/ narcane is better for
respiratory depression
Dose: 0,2-0,4 mg iv

Anticholinergic drugs
Perthidin & Phenergan have
effect
anticholinergic
Sulfas atropin / alkaloid
belladona
anti secretion of salivatory, respiratory tract

and sweat glands be aware of patient with

fever
Glycopyrolat is an antisecretion 2x and more
longer than SA , no central effect
vagal block, needs a high dose until 1 - 2 mg
CNS : Tendency to stimulate CNS, hyoscine
sedation

 Light bronchodilator
CVS : tachycardi be aware to

thyrotoxicosis and ischemic HD,

cardiomyopathy
GI : intestine and urinary tracts
peristaltic constipation and urine
retension
BMR be aware to thyrotoxicosis
dose : 0,005 - 0,01 mg/kgWB
duration of action : im until 90 ; iv 3045

 Combination of those drugs

patient comes to the operation

room still aware but sleepy,
calm, cooperative, there are no
complications during and after
the operation
Doses and drugs combination
are decided by patient
condition and anesthetis
experience and skills

OPERATION CANCELLED
Anemia: Hb < 10gr%

In Research Hb < 10gr% its not increase

morbiditas/ mortalitas.
If circulating volume is enough, Hb 8 gr% its not
necessary to get tranfusion
Syok: Anesthesia depression of vital organs
syok is worsening. Volume replacement until
blood pressure > 80mmHg, good peripheral
condition, diuresis is enough
Temperatur: 380C antipyretica, find focal infection
especially respiratory tract

Respiratory Infection
Influenza, pharyngitis, bronchitis

elective operation is delayed

Airways instrument :
- trauma of infection mucosa resp.
obstruction, spasm, hypersecretion Post
operative respiratory complication.
- infection spread