Preoperative

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By Donald E. Martin, M.D., Teresa O’Flynn, M.D., and Stephen R. Strelec, M.D.

The section contains summaries of recommendations regarding aspects of the pre-anesthetic preparation of patients and the anesthesia machine, with links to complete standards, guidelines, and references.

Elements of Preoperative Evaluation (ASA Practice Parameter on Preoperative Evaluation)
Cardiovascular
MH Management
Anticoagulation and Anti-Thrombosis
Diabetes Mellitus
Perioperative NPO Recommendations (ASA Practice Advisory)
Preoperative Anesthesia Machine Checklist Recommendations (ASA Recommendations)
Pacemakers and Implantable Cardioverter Defibrillators (ASA Recommendations)

 

Elements of Preoperative Evaluation

This practice advisory presents recommendations regarding the timing and content of the anesthesiologist’s pre-anesthetic evaluation, including the medical history, physical examination, selection of preoperative testing, and medical consultation.

Reference

Practice Advisory for Preanesthesia Evaluation: A Report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology 2002; 96:485-496.

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Cardiovascular

This section contains cardiovascular summaries and recommendations regarding aspects on preparation for patients in Preoperative Cardiovascular Evaluation for Non-cardiac Surgery, Patients with Indwelling Coronary Stents, Beta Blockade (ACC/AHA)

Endocarditis Prophylaxis (ACC/AHA), Hypertension, Perioperative Pacemaker and AICD, Management,and Statins.

MH Management

The section contains summaries and recommendations regarding aspects on treating patients who suffer from Malignant Hyperthermia (MH), a genetically transmissible, predisposition to an acute, life-threatening hypermetabolic muscle activity.

Anticoagulation and Anti-Thrombosis

Neuraxial anesthesia presents a greater potential for serious sequella from bleeding and hematoma formation than any other commonly employed regional anesthetic procedure. Guidelines established for the safe practice of neuraxial anesthesia in the anticoagulated patient therefore represent the most conservative practice recommendations.

The ASRA (American Society of Regional Anesthesia ) Consensus Statements is predicated upon evidence-based reviews, and represents the collective experience and knowledge of experts in the fields of anticoagulation and regional. An understanding of the complexity of the issue is paramount, and “cookbook” management of patients is never appropriate; moreover, the practitioner must continually monitor the medical literature for new developments and revisions to published Guidelines and Consensus Statements.

The decision to perform a regional anesthetic—neuraxial or peripheral—should only be made after considering variables such as the alternative anesthetic techniques available to the patient, the overall medical condition of the patient, and the ability to assess the patient for the possibility of bleeding and hematoma formation at the procedural site.

Post-operative decisions such as when to initiate venous thromboembolus (VTE) prophylaxis, and the timing of removal of epidural or deep tissue catheters requirement intimate knowledge of the pharmacology and pharmacokinetics of the anti-VTE agents used. Administration of multiple medications having effects on coagulation may complicate such decision-making. Vigilance in monitoring and early intervention is especially crucial for those patients who are at risk for the development of spinal hematoma, in order to ensure early intervention and optimize neurologic outcome.

Specific recommendations:

  • Thrombolytic/Fibrinolytic therapy—e.g. Alteplase/TPA
    • No definitive recommendations in literature
    • Most conservative approach—avoid neuraxial procedure for 10 days after full dose therapy
    • If catheter-based techniques used, minimize drugs causing sensory or motor blockade to permit observation of neurologic function
  • Unfractionated heparin
    • Mini-dose s.q. use is not a contraindication for neuraxial anesthesia and no time restriction exists
  • Low molecular weight heparin (LMWH)
    • Delay needle placement for 10 - 12 hours after low dose therapy
    • Delay needle placement 24 hours after full dose therapy
    • Single daily dose anti-VTE therapy begin 8 hours post spinal puncture with second dose 24 hours after first dose
    • Catheter removal 10 - 12 hours after last dose
    • Twice daily dose anti-VTE therapy begin 24 hours post spinal puncture
    • Indwelling catheters should be removed prior to initiating therapy, and first dose should wait until 2 hours post catheter removal
  • Oral anticoagulants (warfarin/Coumadin)
    • Delay needle placement until INR < 1.5
    • Patients given warfarin pre-op must have PT/INR before needle placement
    • Low dose warfarin therapy patients with indwelling catheters should have daily PT/INR
    • Remove catheter when INR < 1.5
  • Oral anti-platelet therapy
    • Aspirin/NSAIDs
      • No restrictions on needle placement
    • Plavix/clopidogrel
      • Delay needle placement until 7 days after last dose
    • Ticlid/ticlopidine
      • Delay needle placement until 14 days after last dose
    • Pletal/cilostazol
      • Delay needle placement until 48 hours after last dose
    • GP IIb/IIIa inhibitors
      • Avoid neuraxial techniques until platelet function recovers
      • Reopro/abxicimab—delay needle placement until 48 hours after last dose
      • Integrillin/ebtifibatide—delay needle placement until 8 hours after last dose
      • Aggrastat/tirofiban—delay needle placement until 8 hours after last dose
  • Direct thrombin inhibitors
    • Argatroban, lepirudin/Refludan, bivalrudin/Angiomax
    • No current recommendations from ASRA
    • Wait until aPTT < 40 sec before needle placement
    • Avoid these agents while catheter in place
  • Aggrenox/ aspirin-dipyridamole combo
    • No specific recommendations for this drug
    • Dipyridamole does not affect bleeding time, PTT, or INR
    • Aspirin is an irreversible platelet inhibitor
    • Recommendation is to stop 7 days prior to surgery
  • Arixtra/fondapariux
    • Delay needle placement until 24 - 48 hours after last dose
    • Catheter removal at least 24 hours after last dose
    • Delay next dose at least 12 hours after catheter removal
  • Xigris/drotrecogin alfa
    • No current recommendations from ASRA
    • Delay needle placement until 24 hours after last dose
  • Herbals
    • Risk insufficient to interfere with neuraxial blocks

References

Regional Anesthesia in the Anticoagulated Patient: Defining the Risks (The Second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation) Regional Anesthesia and Pain Medicine, Vol 28, No 3 (May–June), 2003: pp 172–197

The Safety and Efficacy of Extended Thromboprophylaxis With Fondaparinux After Major Orthopedic Surgery of the Lower Limb With or Without a Neuraxial or Deep Peripheral Nerve Catheter: The EXPERT Study, Anesth Analg 2007; 105:1540-1547

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Diabetes Mellitus

Most recent literature recommends maintenance of perioperative blood glucose within the range of 120-200, usually about 150 mg/dl, using either preoperative subcutaneous insulin or insulin infusions. The protocol below presents an example of a detailed preoperative evaluation and management protocol. The paper by Vora et al. and the “Preoperative Instructions for the Management of Your Diabetes” present examples and the rationale for the Penn State University approach to preoperative glucose management. The more recent “Nice Sugar” study group presents the most recent evidence for optimum blood sugar control in the critical care settings.

References

Teresa O’Flynn: Management of Diabetes 

Vora AC, et al.: Improved perioperative glycemic control by continuous insulin infusion under supervision of an Endocrinologist does not increase costs in patients with diabetes. Endocrine Practice 2004; 10:112-118

The Nice-Sugar Study Investigators: Intensive vs. conventional glucose control in critically ill patients. NEJM 2009; 360:1283-1297

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Perioperative NPO Recommendations

The ASA Practice Guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration, which was first published in 1999, has been updated in 2010 as part of an effort to reduce the complications associated with aspiration of gastric contents. The revised guideline recommends no routine use of either gastrointestinal stimulants such as metoclopramide; gastric acid secretion blockers such as ranitidine; or omeprazole, antacids, antiemetics or anticholinergics.

They established the following minimum fasting periods, which apply to healthy patients of all ages and without diseases associated with delayed gastric emptying:

Ingested Material Minimum Fasting Period (hours)

Clear liquids
2
Breast Milk
4
Infant Formula
6
Non-human milk
6

Ingested Material Minimum Fasting Period (hours)

Light meal
6

References

Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures: A Report by the American Society of Anesthesiologists Task Force on Preoperative Fasting. Anesthesiology 1999; 90: 896-905.

The following detailed patient preoperative instructions include a specific application of the NPO recommendations, along with recommendations for the use of preoperative oral medications.

Teresa O’Flynn: Instructions for patients on the Day of Surgery

See document

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Preoperative Anesthesia Machine Checklist Recommendations

In 2008, the ASA, along with the American Association of Nurse Anesthetists (AANA) and the American Academy of Anesthesiologists Assistants (AAAA), endorsed updated general recommendations for the daily and pre-procedural checks of the modern anesthesia machine or work station, which appear on the ASA website along with sample check lists for particular machines developed by the hospitals across the country. These general recommendations are summarized as:

TO BE COMPLETED DAILY

Item to Be Completed

Responsible Party

1
Verify Auxiliary Oxygen Cylinder and Self-inflating Manual Ventilation Device are Available & Functioning Provider and Tech
2
Verify patient suction is adequate to clear the airway Provider and Tech
3
Turn on anesthesia delivery system and confirm that ac power is available Provider or Tech
4
Verify availability of required monitors, including alarms Provider or Tech
5
Verify that pressure is adequate on the spare oxygen cylinder mounted on the anesthesia machine Provider and Tech
6
Verify that the piped gas pressures are ≥ 50 psig Provider and Tech
7
Verify that vaporizers are adequately filled and, if applicable, that the filler ports are tightly closed Provider or Tech
8
Verify that there are no leaks in the gas supply lines between the flowmeters and the common gas outlet Provider or Tech
9
Test scavenging system function Provider or Tech
10
Calibrate, or verify calibration of, the oxygen monitor and check the low oxygen alarm Provider or Tech
11
Verify carbon dioxide absorbent is not exhausted Provider or Tech
12
Breathing system pressure and leak testing Provider and Tech
13
Verify that gas flows properly through the breathing circuit during both inspiration and exhalation Provider and Tech

 

14
Document completion of checkout procedures Provider and Tech
15
Confirm ventilator settings and evaluate readiness to deliver anesthesia care (ANESTHESIA TIME OUT) Provider

TO BE COMPLETED PRIOR TO EACH PROCEDURE

 

Item to Be Completed

Responsible Party

2
Verify patient suction is adequate to clear the airway Provider and Tech
4
Verify availability of required monitors, including alarms Provider or Tech
7
Verify that vaporizers are adequately filled and if applicable that the filler ports are tightly closed. Provider
11
Verify carbon dioxide absorbent is not exhausted Provider or Tech
12
Breathing system pressure and leak testing Provider and Tech
13
Verify that gas flows properly through the breathing circuit during both inspiration and exhalation Provider and Tech

 

14
Document completion of checkout procedures Provider and Tech
15
Confirm ventilator settings and evaluate readiness to deliver anesthesia care (ANESTHESIA TIME OUT) Provider

Reference

ASA Website 

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Pacemakers and Implantable Cardioverter Defibrillators

This practice advisory provides evidence-based recommendations on the preoperative evaluation, preoperative preparation and reprogramming, intraoperative management, and necessary postoperative management for patients with pacemakers and internal cardioverter-defibrillators, as well as patients with devices designed to provide the newer cardiac resynchronization therapy.

This guideline is revised slightly from the last version published in 2005. It has useful recommendations for management of these implanted electronic devices during multiple types of specialized surgical procedures. It is based primarily on the small amount of evidence currently available, and so its recommendations are somewhat limited. Read more

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Anesthesiologists

Physicians Protecting Patients