Page 40 - TNFlipTest

A6 Anesthesia
Monitoring Toronto Notes 2019 Fasting Guidelines
Fasting Guidelines Prior to Surgery (Canadian Anesthesiologists’ Society)
• beforeelectiveprocedures,theminimumdurationoffastingshouldbe:
■ 8hafteramealthatincludesmeat,friedorfattyfoods
■ 6hafteralightmeal(suchastoastorcrackers)orafteringestionofinfantformulaornon-humanmilk ■ 4hafteringestionofbreastmilk
■ 2 h after clear fluids (water, black coffee, tea, carbonated beverages, juice without pulp)
Hematological Disorders
• historyofcongenitaloracquiredconditions(sicklecellanemia,factorVIIIdeficiency,ITP,liverdisease)
• evaluatehemoglobin,hematocritandcoagulationprofileswhenindicated(seeTable1)
• anemia
■ pre-operative treatments to increase hemoglobin (PO or IV iron supplementation, erythropoietin or pre-admission blood collection in certain populations)
• coagulopathies
■ discontinue or modify anticoagulation therapies (warfarin, clopidogrel, ASA, apixaban, dabigatran)
in advance of elective surgeries
■ administration of reversal agents if necessary: vitamin K, FFP, prothrombin complex concentrate,
recombinant activated factor VII
Endocrine Disorders
• DiabetesMellitus(DM)
■ clarify type 1 vs. type 2
■ clarify treatment – oral anti-hyperglycemics and/or insulin
■ assess glucose control with history and HbA1c; well controlled diabetics have more stable glucose
levels intraoperatively
■ end organ damage: be aware of damage to cardiovascular, renal, and central, peripheral and
autonomic nervous systems
■ preoperative guidelines for DM:
◆ 1. verify target blood glucose concentration with frequent glucose monitoring: <10 mmol/L in critical patients, <7.8 mmol/L in stable patients)
◆ 2. use insulin therapy to maintain glycemic goals
◆ 3. hold biguanides, alpha glucosidase inhibitors, thiazolidinediones, sulfonylureas and GLP-1
agonists on the morning of surgery
◆ 4. consider cancelling nonemergency procedures if patient presents with metabolic
abnormalities (DKA, HHS, etc.) or glucose reading above 22.2-27.7 mmol/L
■ formulate intraoperative glucose management plan based on type (1 vs. 2), glucose control, and
extent of end organ damage
• HyperthyroidismandHypothyroidism
■ hyperthyroidism: can experience sudden release of thyroid hormone (thyroid storm) if not treated or well-controlled pre-operatively; treatment: B-blockers and pre-operative prophylaxis
• adrenocorticalinsufficiency(Addison’s,exogenoussteroiduse) ■ consider intraoperative steroid supplementation
Obesity and Obstructive Sleep Apnea
• assessforco-morbidconditionsinobesepatient(independentriskfactorforCVD,DM,OSA, cholelithiasis, HTN)
• previouslyundiagnosedconditionsmayrequireadditionaltestingtocharacterizeseverity
• severityofOSAmaybedeterminedfromsleepstudiesandlevelofpressureprescribedforhomeCPAP
device
• bothobesityandOSAindependentlyincreaseriskofdifficultventilation,intubationandpost-operative
respiratory complications
Monitoring
Canadian Guidelines to the Practice of Anesthesia and Patient Monitoring
• ananesthetistpresent:“theonlyindispensablemonitor”
• acompletedpre-anestheticchecklist:includingASAclass,NPOpolicy,Hxandinvestigations
• a perioperative anesthetic record: HR and BP every 5 min, O2 saturation, End Tidal CO2, dose and route
of drugs and fluids
• continuousmonitoring:seeRoutineMonitorsforAllCases,A7
Pre-Anesthetic Checklist
SAMMM
Suction: connected and working
Airways: laryngoscope and blades, ETT, syringe, stylet, oral and nasal airways, tape, bag, and mask
Machine: connected, pressures okay, all meters functioning, vaporizers full
Monitors: available, connected, and working Medications: IV fluids and kit ready, emergency medicines in correct location and accessible