Download - Preop. CB 2013
Cindy E. BoomRS. Pusat JantungDan PembuluhDarah Harapan KitaJakarta
PREOPERATIVE
PREPARATION
PERSIAPAN PRA BEDAH
Semua pemeriksaan, persiapan, sistem skoring dll diperlukan untuk menentukan rencana tindakan bedah maupun anestesi, waktu pelaksanaan, jenis anestesi yang dipergunakan, persiapan obat-obatan, darah, cairan IV, penyulit anestesi, perawatan pascabedah (ICU/ rg. Rawat), biaya, inform consent dll
GCS PCS
Eye opening
SpontaneousTo verbal stimuliTo painNone
4321
Ditto
Verbal Oriented ConfusedInappropriate wordsNon specific soundsNone
54321
Oriented Words Vocal soundsCriesNone
54321
Motor Follows commandsLocalises painWithdraws in response to painFlexion in response to painExtension in response to painNone
654321
Ditto
Trauma Score
16 13 10 7 4 1
% Survival
99 93 60 15 2 0
TRAUMA SCORE
0 1 2 3 4 5 6 7 8 9 10 Mild Moderate Severe
Pain threshold
Pain tolerance
Pain Rating Scales
CHOOSING PAIN KILLER AND ITS COMBINATIONS
10 Pain Intensity Scale
0 1 2 3 4 5 6 7 8 9 10 Mild Moderat
eSevere
Strong opioid ±
NSAID ±
adjuvant analgesic
paracetamolor/+
NSAIDNSAID ±
adjuvant analgesic
NSAIDNSAID ±
weak opioid ±
adjuvant analgesic
Pasien dengan kelainan jantung yang menjalani operasi non jantung meningkat
Komplikasi Perioperatif yang sering terjadi berhubungan dengan :Myocardial infarction (MI)ArrhythmiasPulmonary Insufficiency
PERSIAPAN PREOPERATIF PASIEN DGN KELAINAN JANTUNG UNTUK
OPERASI NON JANTUNG
Manifestasi dapat berupa:Infark miokardAngina tidak stabilGagal jantung (akut) kongestifDisritmiaKematian
MORBIDITAS JANTUNG PERIOPERATIF
① Akut/ recent MI 7-30 hari② Dekompensasi Kordis Akut/ Tidak Stabil :
lakukan terapi terlebih dahulu (optimalisasi)
③ Severe Aritmia.④ Penyakit Jantung Iskemik yang tidak stabil⑤ Total AV block transient pacemaker⑥ Penyakit katup jantung berat (severe valve
disease, misal AS severe) Yang lain adalah kontraindikasi RELATIF
KONTRAINDIKASI ABSOLUT UNTUK ANESTESIA
Perioperative Myocard Infarction (PMI) and Ischemia Priebe.Br J Anaesth 2005;95:3-19, Gombar S et al. IJA 2007;51(4):287-302
Major cause of short and long term morbidity and mortality associated with non-cardiac surgery.
More than one half of postoperative deaths are caused by cardiac events, most of which are ischemic in origin.
Incidence in patients with at risk of CAD, PMI was reported 20-63%.
Early mortality after PMI 3,5%-25% Postoperative MI: Preoperative MI: 3:1 Postoperative MI: Intraoperative MI: 5:1 Postoperative MI increased the odds for
long term cardiac events 20-fold.
Myocardial Ischemia
① CAD② Left Ventricular
Hyperthrophy (LVH)③ Reduced oxygen
supply④ Low flow ischemia
(coronary vasoconstriction, intracoronary thrombus/ plaque)
Myocardial Infarction
① Significant preexisting CAD
② Hypertensive③ Left Ventricle
Hyperthrophy④ Coronary plaque
disruption⑤ Subsequent
thrombosis
UNDERSTOOD THE PATHOPHYSIOLOGYGOMBAR S ET AL. IJA 2007;52(4):287-302, LANDESBERG G ET AL. CIRULATION 2009;119:2936-
2944
Landesberg G et al. Circulation 2009;119:2936-44
Kaul TK et al. IJA 2007;51(4):280-86
① Hemodynamic and Clinical Presentation
② ECG③ Functional (echocardiogram)④ Metabolic (coronary lactate
production)⑤ Biochemical (Troponin T, Troponin I,
Creatinekinase-MB)
MAKING A DIAGNOSISPRIEBE H.J BR J ANAESTH 2005;95:3-19,
Penyakit jantung yang membutuhkan terapi surgikal untuk penyakit jantungnya, pertimbangkan urgensinya.
Pembedahan Emergensi Pembedahan dengan resiko sedang atau tinggi
OPTIMALKAN kondisi jantung dan penderita:
- Tatalaksana Medikamentosa (diuretik, Inotropik, dll)- Tatalaksana Topangan Mekanik ( IABP,
pacemaker)
PRINSIP
PERCUTANEOUS CORONARY INTERVENTION (PCI) AND SURGERY
BARASH P, AKHTAR S. BR J ANAESTHESIA 2010; 105(S1):I3-I15
Percutaneous Coronary Intervention
Ballon Angioplasty
Bare MetalStent
Drug ElutingStent
Delay for elective /Non urgent
Proceed to OT+ Aspirin
Delay for elective /Non urgent
Proceed to OT+ Aspirin
< 14 d > 14 d > 30 – 45 d <30 – 45 d < 365 d > 365 d
Stepwise Approach to Preoperative Cardiac Assessment
Need for emergencynoncardiac
surgeryOperating room
Evaluate and treatper ACC/AHA
Guidelines
Vigilant perioperative and postoperative
management
Consider Operating Room
Low RiskSurgery
Active cardiac
conditions
No
Yes
Yes
No
Proceed withplanned surgery
Asymptomatic andgood functional
capacity
Yes
Proceed withplanned surgery
No
Yes
Manage based onclinical risk factors
No
Functional Capacity
1. Correlates with maximum oxygen uptake on treadmill testing
2. Demonstrated predictor of future cardiac events
3. Poor functional capacity may hide low threshold cardiac symptoms
ESTIMATED ENERGY REQUIREMENTS FOR VARIOUS ACTIVITIES
1 MET Can you take care of yourself ?
Eat, dress, or use the toilet ?
Walk indoors around the house ?
Walk a block or two on level ground at 2 to 3 mph or 3.2 to 4.8 km per h ?
4 METs Do light work around the house like dusting or washing dishes ?
Climb a flight of stairs or walk up a hill ?
Run a short distance ?
Do heavy work around the house like scrubbing floors or lifting or moving heavy furniture ?
Participate in moderate recreational activities like golf, bowling, dancing, doubles tennis, or throwing a baseball or football ?
Greater than 10 METs
Participate in strenuous sports like swimming, single tennis, football, basketball, or skiing?
THE RISKS PRIEBE HJ. BR J ANAESTH 2004;93:9-20, SAMBOLA A. CIRCULATION 2003;107:973-77
Clinical Predictors of Perioperative Cardiac Risks
Major Intermediate Minor
Acute or recent MI
Mild angina Advanced age
Unstable angina
Prior MI Abnormal ECG
Decompensated CHF
Compensated CHF
Rhythm other than sinus
Significant arrhythmias
DM History of stroke
Severe valvular disease
Renal insufficiency
Uncontrolled hypertension
Surgery Specific Cardiac Risks
High (5%)
Intermediate (<5%)
Low (1%)
Emergent surgery
Carotid endarterectomy
Endoscopic procedures
Aortic or major vascular surgery
Head and neck surgery
Superficial procedures
Peripheral vascular surgery
Intraperitoneal intrathorasic procedures
Cataract surgery
Large fluid shifts and blood loss
Orthopedic surgery
Breast surgery
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Attempts to Increase CARDIAC OUTPUT :
①Good oxygenation②Volume therapy③Drugs- vasoactive-
inotropic therapy④Correct metabolic
acidosis⑤Correct electrolyte
imbalance (hypokalemia)⑥Treat arrhythmias⑦Mechanical support
(Intraaortic baloon pum/IABP)
RESTORE THE CARDIAC OUTPUTHOWELL SJ, SEAR JW, FOEX P. BR J ANAESTHESIA 1004;92(4):57-83
① Avoiding extremes of hemodynamic disturbances (blood pressure (BP), tachycardia, hipercarbia, hypertermia, aritmia)
② Monitoring of cardiac ischemia (ECG, direct arterial pressure monitoring along with pulmonary artery (PA) catheter, TEE)
③ Hemodynamic control (anesthetic technique and pharmacological agents)
④ Beta blockers preventing perioperative cardiac morbidity
⑤ Adequate doses of analgesics (morphine 5-10 mg or sufentanyl or fentanyl 5-10 µg/kg)
⑥ Cardiac support ( inotrope or mechanical devices)
ANESTHETIC GOALS
INTRAOPERATIVE EVENTS THAT INFLUENCES THE OXYGEN BALANCE
STOELTING RK, DIERDORF SF. ANESTHESIA AND CO-EXISTING DISEASE 6TH EDITION, CHURCHIL LIVINGSTONE, PHIADELPHIA, 2012.
Decreased Oxygen DeliveryDecreased coronary blood flowTachycardiaDiastolic hypotensionHypocapnia ( coronary artery vasoconstriction)Coronary artery spasm
Decreased Oxygen ContentAnemiaArterial hypoxemiaShift of the oxyhemoglobin dissociation curve to the left
Increased Oxygen RequirementsIncreased preload (wall tension)Sympathetic nervous system stimulationTachycardiaSystemic hypertensionIncreased myocardial contractilityIncreased afterload
ANESTHETIC TECHNIQUEGOMBAR S ET.AL. IJA 2007;51(4):287-302, EAGLE KA ET ALL. ACC/AHA GUIDELINE2010 REV, HARRIS SH. ANESTHESIA AND PERIOPERATIVE COMPLICATIONS. MOSBY ST LOUIS, 2 ND ED;1999:293-307, FRABDORF J. HERTS SG. BR J ANAESTHESIA 2009;103(1):89-98
① Induction should be smooth, minimize pressor response to laryngoscopy and intubation.
② Various drugs can be use: lidocaine, nitroprusside, fentanyl, esmolol, nitrogycerine, captopril etc.
③ Maintain left Ventricular Function. N2O-Opioid with additional Sevoflurane, Isoflurane, Desflurane.
④ Severely impaired LV function: use narcotic base anesthesia ( Fentanyl 5-10 μg.kgBW.IV) in combination with IV sedation/
⑤ Neuroaxial anesthetic techniques. Result symphatetic blocade, decreases preload and afterload. Study found no difference in outcome in terms of cardiac morbidity.
⑥ Monitored anesthesia. Moderate-Severe anatomy and clinical-hemodynamic dysfunction, Intermediate-Major clinical cardiac risks and Intermediate-High risks surgery are recommended to use the invasive hemodynamic monitoring.
⑦ Perioperative Pain Management is mandatory during perioperative period.
⑧ Maintenance body temperature. Avoid hypothermia (air warming).
ANESTHESIA TECHNIQUE
① Which hypertensive patients have increasing perioperative risks?
② Will lowering preoperative blood pressure decrease the risks③ How long and how should blood pressure be controlled before
elective surgery?④ History of chronic hypertension with/without therapy⑤ Blood pressure ≥ 180/110 mmHg or 120/30 mmHg?⑥ Patients with cerebral, coronary or renovascular abnormalities⑦ Preoperative antihypertensive therapy for a few weeks/months
can reduce morbidity, especially in severe hypertension (3-4 weeks ideally)
⑧ Moderate hypertension: duration of therapy can be shorter⑨ Antihypertensive medication continued to the time of surgery,
except ACE-I⑩ Arterial blood pressure be kept within 10~20% of preoperative
level
HYPERTENSIVE
GULA DARAH, ALBUMIN, GOT/PT, UREUM, KREATININ, AKI, ARITMIA
Healthy vascular endothelium coated by endothelial glycocalyx – a layer of membrane-bound proteoglycans and glycoproteins.
Healthy vascular endothelium coated by endothelial glycocalyx – a layer of membrane-bound proteoglycans and glycoproteins.
THE ENDOTHELIAL GLYCOCALIXTHE ENDOTHELIAL GLYCOCALIX
Glycocalyx affect endothelial permeability.Prevent leukocyte and platelet adhesion.Decreases inflammation.Bounds plasma proteins and fluids.
700 ~ 1000 mL of “non-circulatory” plasma fixed within.
Maintains “oncotic gradient” despite intravascular and extravascular equilibration.
Glycocalyx affect endothelial permeability.Prevent leukocyte and platelet adhesion.Decreases inflammation.Bounds plasma proteins and fluids.
700 ~ 1000 mL of “non-circulatory” plasma fixed within.
Maintains “oncotic gradient” despite intravascular and extravascular equilibration.
Jacob M. et al: The endothelial glycocalix affords compatibility of starling’s principle and high cardiac interstitial albumin level.
Cardiovasc Res 2007; 73:575-86
Jacob M. et al: The endothelial glycocalix affords compatibility of starling’s principle and high cardiac interstitial albumin level.
Cardiovasc Res 2007; 73:575-86
THE ENDOTHELIAL GLYCOCALIXTHE ENDOTHELIAL GLYCOCALIX
hyperglycemiareperfusion injury
oxidized-LDL
Mechanical stress, Endotoxin exposure,Mediator SIRS, and
ANP (Atrial Natriuretic Peptide)Intact glicocalix Loss glicocalix
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