Day 7: Triage, Systemic Disease, and Optimisation Flashcards
the challenge of triage
-TRIAGE—deciding on URGENCY of surgery
-ASA GRADING—taking into account patients baseline status
-OPTIMIZATION—Is it feasible? Is it necessary? Is it achievable? To what degree?
triage: red
Absolute emergency—requires theatre immediately
triage: orange
Surgery within 2 hours
triage: yellow
Surgery within 6 hours
triage: green
Surgery within 24 hours
triage: blue
Elective surgery
ASA grade: I
a normal healthy patient
ASA grade II
A patient with mild systemic disease and no functional limitations
ASA grade III
A patient with moderate to severe systemic disease that results in some functional limitation, but not incapacitating
ASA grade IV
A patient with severe systemic disease that is constant threat to life and incapacitating
ASA grade V
A moribund patient that is not expected to live for more than 24 hours with or without the surgery
ASA grade VI
A brain dead patient whose organs are being harvested
ASA grade E
If the procedure is an EMERGENCY, the physical status is followed by and “E”
24 yr old booked for emergency exploratory laparotomy for abdominal gunshot wound. No known medical history
ASA score
ASA score is 1 E
Triage code is RED
Safest decision begin resuscitation, proceed ASAP with surgery
74 yr old patient booked for removal of cataracts under GA
Longstanding hypertensive, ran out of medication 2 weeks ago
BP on examination ranges between 170/100 –210/110 mmHg
ASA score is II or III
Triage code is BLUE (elective)
Safest decision cancel surgery, optimise treatment, rebook
33 yr old patient has an acute asthma attack and trips trying to find their asthma pump
Booked for open reduction and fixation of an open ankle fracture
Asthma is usually well controlled, but patient recently developed an URTI
On examination the patient is still clearly wheezing
ASA is II (E)
Triage code is YELLOW (open fracture, risk of infection)
Safest decision?
Delay (but do not cancel) surgery resolve acute bronchospasm
Schedule surgery as soon as patient is stable
A previously well-controlled Type 1 diabetic develops appendicitis
Acute abdomen, unwell, hypotensive, becoming unresponsive
Blood sugar is 24 mmol/L in DKA (why?)
ASA score is II E
Triage score is probably ORANGE
Can one delay surgery and treat the DKA?
NO.
Must start resuscitation, and continue this intraoperatively
High risk situation
A patient with poorly-controlled, longstanding cardiac failure and angina is diagnosed with a dissecting aortic aneurysm
They require emergent surgery
ASA score is IV E (very high risk!)
Triage score is RED
No time to optimize
Balance of risk favours proceeding with surgery
Elderly patient with ischaemic heart disease and some functional limitation slips while getting out of bed and sustains a closed neck of femur fracture
They are scheduled for operative fixation of the fracture
They are stable in the ward, in some pain, and blood pressure is high (177/97)
ASA score is III E
Triage score? Probably GREEN fracture needs fixing, but not immediately life-threatening to patient
Enough time to optimise patient in 24 hours (analgesia, restart medication, get special investigations etc)
major comorbidities in anaesthesia
-cardiovascular
-respiratory
-renal
-endocrine
major cardiovascular diseases affecting anaesthesia
hypertension
ischemic heart disease
valvular heart disease
cardiac failure
dysrhythmias
hypertension
-common
-Associated with significant morbidity & mortality (CNS, CVS)
-End-organ damage may lead to the need for surgery and anaesthesia
-Anaesthesia may aggravate or precipitate hypertensive complications
How does anaesthesia typically affect hypertension?
Anaesthesia often induces hypotension, but in some cases, it can lead to hypertensive crises.
What are some potent stimuli during anesthesia that can induce hypertensive crises?
Potent stimuli such as laryngoscopy and intubation, as well as surgical stimulation, can trigger hypertensive crises during anesthesia.
What are common procedures during anesthesia that may trigger hypertensive crises?
Laryngoscopy, intubation, and surgical stimulation are common procedures during anesthesia that may trigger hypertensive crises
What is the term used to describe increased sensitivity to vasodilatation of anaesthetic agents leading to hypotension?
The increased sensitivity to vasodilatation of anaesthetic agents leading to hypotension is referred to as “alpine anaesthesia.”
What is characteristic of patients undergoing “alpine anaesthesia”?
Patients undergoing “alpine anaesthesia” are often volume depleted and may tolerate fluid or blood loss poorly.
How do patients undergoing “alpine anaesthesia” typically respond to fluid or blood loss?
Patients undergoing “alpine anaesthesia” may respond poorly to fluid or blood loss due to volume depletion.
How might low cardiac output during hypertensive crises compromise organ perfusion?
Low cardiac output during hypertensive crises may compromise organ perfusion, leading to organ dysfunction or failure.
How do anti-hypertensive drugs interact with anaesthesia?
Anti-hypertensive drugs may affect the depth and duration of anesthesia, as well as the hemodynamic stability of the patient during surgery. Their effects should be carefully considered and managed by anesthesia providers.
Interactions of hypertensive medication: diuretics
-fluid depletion
-electrolytes disturbances (esp K)
Interactions of hypertensive medication: B blockers
-bradycardia
-negatively inotropic
Interactions of hypertensive medication: Ca channel blockers
hypotension
Interactions of hypertensive medication: ACE inhibitors
-exaggerated hypotension (particularly under anaesthesia)
Hypertension risk evaluation: Treated and well- controlled hypertensives
normal anaesthetic risk
Hypertension risk evaluation: treat, uncontrolled patients
higher risk
Hypertension risk evaluation: untreated, uncontrolled patients
have the highest risk
Hypertension risk evaluation: diastolic BP > 120 for elective surgery
-BP control
-postpone for 2-6 weeks
assessing the hypertensive patient
-BP chart with regular BP recordings (trend0
-effort tolerance
-end organ function
-ECG and CXR to assess cardiac hypertrophy
principles of management
- optimise BP control if time allows
-continue anti- hypertensive therapy - good premed to minimise anxiety
-blunt the intubation response
-avoid >25% decrease in systolic/ mean BP
-adequate post op analgesia
How common is Ischemic Heart Disease (IHD)?
Ischemic Heart Disease (IHD) is a common condition.
What is a major cause of peri-operative deaths?
IHD is a major cause of peri-operative deaths.
How can anesthesia impact Ischemic Heart Disease (IHD)?
Anesthesia may aggravate or precipitate acute coronary syndrome in patients with Ischemic Heart Disease (IHD).
What is the mortality rate associated with peri-operative myocardial infarction?
Peri-operative myocardial infarction has a mortality rate of approximately 50%.
IHD risk evaluation: Acute coronary syndrome
unstable angina+ myocardial infarction
extremely high risk anaesthetic risk
IHD risk evaluation: Recent myocardial infarction
(<6 months)
a high risk for re-infarction
IHDD risk evaluation: Patients with “stable angina” and poor effort tolerance
elevated risk
IHD risk evaluation: Patients with “stable angina” and poor effort tolerance
normal risk
IHD patient assessment
-ECG
-50% of patients with IHD present for the first time with an MI!!
-Effort tolerance is reliable, but not diagnostic
-BEWARE the diabetic
perioperative management of IHD
- good premed
-maintain cardiovascular stability
-appropriate agent selection
**Etomidate for induction (propofol: give very slowly and cautiously)
Acceptable volatiles: isoflurane, sevoflurane,
All currently used muscle relaxants are safe
-good analgesia
**Fentanyl gold standard; morphine acceptable
Consider: LA or regional techniques
IV paracetamol
Careful with NSAIDs
IHD: post operative placement
Most peri-operative myocardial infarcts occur in the first 48-72 hours following surgery
Need good monitoring and analgesia post-operatively, and supplemental oxygen if needed
What is the incidence of Valvular Heart Disease (VHD) in South Africa (SA)?
Valvular Heart Disease (VHD) has a high incidence in South Africa (SA).
What type of valve disease is commonly observed in VHD?
Mixed valve disease, involving both stenosis and incompetence, is the norm in VHD cases.
How do clinicians determine the dominant lesion in mixed valve disease?
Clinicians must decide which lesion, either stenosis or incompetence, is dominant in cases of mixed valve disease.
What are some common combinations of valve disease observed in VHD?
Combined Aortic/Mitral disease is also common in VHD.
What complications may arise from Valvular Heart Disease (VHD)?
Complications of VHD may include
atrial fibrillation,
pulmonary hypertension,
cardiac failure,
bacterial endocarditis, and
myocardial ischemia
What preventative measure may be necessary in cases of VHD to mitigate the risk of bacterial endocarditis?
Antibiotic prophylaxis may be necessary in VHD cases to prevent bacterial endocarditis.
stenotic valve lesions: cardiac output is limited by degree of stenosis
-fixed cardiac output states
-Atrium or ventricle hypertrophies
-needs a long time to expel blood through stenosis
stenotic valve lesions: optimal conditions
-SLOW
-Preferably sinus rhythm
-Good PRE-LOAD
-Good INOTROPY
-Maintain AFTERLOAD
stenotic valve lesions: unable to tolerate
–Sudden drops in blood pressure
–Sudden changes of blood volume (increased or descreased)
incompetent (regurgitatant) valve lesions
- C.O. is limited by degree of regurgitation
-Ventricle is volume loaded and dilates
-Optimal conditions
**faster rate and sinus rhythm
**good preload
**afterload reduction
-full, fast and forward
cardiac failure: multiple aetilogies
Hypertension
Ischaemic heart disease
Valvular heart disease
Endocrine disease (thyroid, phaeo)
Nutritional
Cardiomyopathies
Treat the cause and principles of management apply to all types of CCF
ndependent major risk factor for anaesthesia morbidity + mortality
CF: intraoperative management
-optimise medical therapy
-invasive monitoring indicated for surgery
**A- line
**central line if inotropic support required
-maintain
**optimal preload and inotropy
**afterload reduction
-regional anesthesia
**may be beneficial, but not if patient is still in uncontrolled failure
How common is dysrhythmia?
Dysrhythmia is a common occurrence.
What is the typical nature of dysrhythmias in terms of duration and severity?
Dysrhythmias are usually benign and short-lived.
What is the recommended approach when encountering dysrhythmias?
It is essential to identify a cause and treat dysrhythmias if indicated.
What is the importance of assessing dysrhythmias in terms of their effect on hemodynamics?
It’s crucial to assess the effect of dysrhythmias on hemodynamics to determine their clinical significance.
How can anesthesia impact dysrhythmias?
Anesthesia may aggravate, precipitate, or even cure dysrhythmias depending on the individual patient’s condition and the specific circumstances of anesthesia administration.
Management of the acute dysrhythmia
-Exclude HYPOXIA, hypercarbia, acidosis
-If haemodynamically significant
**Fluid and vasopressor support
**Look for a cause and treat e.g. acidosis
-If not haemodynamically significant
**Leave alone
**Find and treat the cause
What is the significance of respiratory disease in the context of anesthesia?
Respiratory disease is a common cause of anaesthesia-related morbidity.
How does anesthesia generally impact respiratory function?
Anesthesia can adversely affect respiratory function, particularly in patients with pre-existing respiratory conditions.
What are some life-threatening complications that anesthesia may precipitate in patients with respiratory disease?
Anesthesia may precipitate life-threatening complications such as aspiration pneumonitis and bronchospasm in patients with respiratory disease.
How can pre-existing lung disease affect the administration of anesthesia?
Pre-existing lung disease can significantly impact the administration of anesthesia, requiring careful consideration and adjustment of anesthetic techniques to minimize risks and optimize outcomes.
What does Functional Residual Capacity (FRC) represent in the context of anesthesia?
Functional Residual Capacity (FRC) plays a crucial role in anesthesia as it represents the volume of air left in the lungs at the end of a normal expiration, which serves as a pool of gas for sustaining life.
How is Functional Residual Capacity (FRC) defined?
Functional Residual Capacity (FRC) is defined as the sum of residual volume (the volume of air remaining in the lungs after maximal expiration) and expiratory reserve volume (the volume of air that can be exhaled forcefully after a normal expiration).
What is the composition of the gas typically found in the Functional Residual Capacity (FRC)?
The gas typically found in the Functional Residual Capacity (FRC) is composed of approximately 21% oxygen (O2), which is the same as the ambient air composition.
decreases in FRC of relevance in anaesthesia
-supine position
-intubation
-all anesthetic agents
-muscle relaxants, immobility
-surgical retractors
-oxygen and nitrous oxide
-abdominal masses: obesity, tumors, pregnancy, ascites
common respiratory diseases of relevance
- obstructive lung disease
-restrictive lung disease
-infections
**Pneumonia
**TB
**Bronciectasis
asthma: If poorly controlled
anaesthesia can trigger fatal bronchospasm
**Airway manoeuvres / intubation / suction etc
Assess patient thoroughly
Lung function testing
*Pre and post bronchodilator FEV1/FVC ratio
*If there is > 12% / 200 ml improvement suboptimally treated
anesthetic management of the asthmatic
-preoperative optimization
**B2 agonist, steroid, continue regular therapy
-avoid histamine- releasing drugs and NSAIDS
-minimise airway irritation
**LMA vs ETT if possible
Volatiles produce bronchodilatation
Extubate deep
What is the typical presentation of acute bronchospasm under anesthesia?
Acute bronchospasm under anesthesia typically presents as a sudden increase in airway pressures.
What initial intervention should be provided for a patient experiencing acute bronchospasm?
The initial intervention for acute bronchospasm involves administering high-concentration oxygen to the patient.
How can the depth of anesthesia be adjusted to manage acute bronchospasm?
Anesthesia can be deepened to manage acute bronchospasm, as volatile anesthetics have bronchodilatory properties.
Anesthesia can be deepened to manage acute bronchospasm, as volatile anesthetics have bronchodilatory properties.
Bronchodilator therapy options include administering salbutamol into the anesthetic circuit, intravenous beta-2 agonists, and aminophylline.
Besides bronchodilator therapy, what other medications can be considered for managing acute bronchospasm under anesthesia?
Adrenaline can be used either through inhalation or as a dilute intravenous solution. Additionally, ketamine and magnesium sulfate (MgSO4) can also be considered.
What is the importance of optimizing ventilation and identifying the cause in the management of acute bronchospasm under anesthesia?
It’s crucial to optimize ventilation and identify the underlying cause of acute bronchospasm under anesthesia to effectively manage the condition and prevent complications.
causes of COPD
-mainly smoking
-PTB
-air pollution
-alpha 1 antitrypsin deficiency
consequences of COPD
Pulmonary hypertension
Cardiac failure
Cor pulmonale
Respiratory failure
Describe the spectrum of COPD.
OPD manifests along a spectrum, ranging from obstruction with secretions, where mucus plugs obstruct the airways,
to emphysema with hypoxia, where destruction of lung tissue leads to reduced oxygen levels in the blood.
perioperative assessment of COPD: history
Effort tolerance NB
Sputum production
Recent flare-ups
perioperative assessment of COPD: examination
Clinical
Lung function tests
CXR
Arterial blood gas
anaesthetic management of COPD
-optimise preoperative if possible
-continue regular therapy
-protect airway form secretions— suction
-ETT rather than LMA if GA
-avoid bronchospasm triggers
-avoid GA if possible –regional
What characterizes restrictive lung disease?
Restrictive lung disease is characterized by a reduction in lung volume and capacity, leading to difficulty in fully expanding the lungs during inhalation.
What are some common causes of restrictive lung disease?
Various factors can cause restrictive lung disease
How does restrictive lung disease affect lung compliance?
Restrictive lung disease results in a loss of lung compliance, meaning the lungs become stiffer and less elastic, requiring more energy to inhale.
What are the typical symptoms experienced by individuals with restrictive lung disease?
Individuals with restrictive lung disease often experience dyspnea (shortness of breath) and have small tidal volumes, resulting in shallow breathing. Unfortunately, there is often limited treatment available for this condition. Additionally, caution should be exercised with regional anesthesia techniques as they may block accessory muscles of respiration, making ventilation challenging
Acute pneumonia
-Avoid anaesthesia
-Emergencies only
-Must have ICU and may need ventilation
tuberculosis
-Chronic, with wide range of morbidity
-Frequently associated with HIV
-Avoid hepatotoxic drugs
-MDR and XDR TB require contact precautions and an N95 respirator for staff
covid 19
-AIRWAY MANAGEMENT is hazardous for staff!
-Intubation, mask ventilation: aerosol generating procedure!
-FULL PPE / N95 or N99 respirator / eye protection
bronchiectasis
Chronic disease with copious production of secretions from infected airways
What is a significant danger associated with bronchiectasis?
Bronchiectasis poses a significant risk of spilling secretions into healthy lung tissue, leading to infection and further lung damage
What pre-operative interventions are commonly recommended for individuals with bronchiectasis?
Pre-operative physiotherapy, including techniques such as postural drainage, percussion, and vibration, is often recommended to help clear secretions and improve lung function before surgery.
What post-operative treatments are typically prescribed for bronchiectasis?
Post-operatively, individuals with bronchiectasis may require continued physiotherapy, along with antibiotic therapy to treat or prevent infection, and other supportive measures to manage symptoms and promote recovery.
