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Obesity is an independent risk factor for heart disease. Hypertension, stroke, hyperlipidemia, diabetes mellitus, and OSA are more common in obese people. Morbidly obese patients require special operating room tables and gurneys to support excessive weight. Venous access and invasive and noninvasive monitoring may be difficult, and airways may require specialized equipment, techniques, and personnel. Preoperative identification and planning for these anestezikoeri will avoid delays on the day of surgery.
Preoperative evaluation should be directed anestszikleri identifying significant co-existing diseases such as OSA, pulmonary hypertension, and heart failure. Many of these patients will not be able to lie flat and will require general anesthesia.
The usefulness of routine laboratory testing as a part of anestezkkleri assessment, however, has recently been scrutinized because of the escalation of health care costs. The practice of routine preoperative laboratory testing in healthy elderly surgical inhalasyo is costly, especially because evidence jnhalasyon lacking that such testing may aneatezikleri or improve perioperative outcomes Even though ECG abnormalities are increasingly more common with advanced age, abnormalities alone have not been shown to predict postoperative cardiac complications in the elderly [13,15].
Although abnormal ECG findings are common in the elderly, significant abnormalities inhalasyoh impact care are low in the absence of a history or symptoms anesteziileri cardiac disease .
A practitioner must provide a supporting diagnosis with an acceptable ICD-9 code . ECGs are acceptable if performed within 6 months and the patient has had no change in symptoms.
Our results, along with those from Schein et al. Our results also suggest that the present guidelines for routine preoperative laboratory testing in elderly patients should be reevaluated. Inhalaxyon, routine preoperative laboratory testing for hemoglobin, creatinine, glucose, platelet, and electrolytes based on age alone may not be indicated.
Healthy patients of any age who undergo ibhalasyon or intermediate risk procedures without expected significant blood loss are unlikely to benefit from any tests.
Patients who have stable, well-controlled, mild to moderate severity co-existing diseases, and who follow up regularly with primary care or specialist physicians are unlikely inhalassyon benefit from additional diagnostic testing before surgery.
The investigators recommended that preoperative testing in geriatric patients undergoing cataract surgery or procedures with similar surgical risk should be anesteziklrei only when clinically indicated by history or physical examination. The surgical risk associated with cataract surgery is small, and therefore the results of this study may not be directly generalized to all geriatric surgical patients.
Prevalence and prognostic value of abnormal laboratory tests in elderly surgical patients. Anesth Analg ; Whereas the list of ocular surgical interventions is lengthy, these procedures may, in general, be classified as extraocular or intraocular.
This distinction is critical because anesthetic considerations are different for these two major surgical categories. For example, with intraocular procedures, profound akinesia relaxation of recti muscles and meticulous control of intraocular pressure IOP are requisite.
However, with extraocular surgery, the significance of IOP fades, whereas concern about elicitation of the oculocardiac reflex assumes prominence. It is anestezkkleri that etomidate, despite its proclivity to produce pain on intravenous iv injection and skeletal muscle movement, is associated with a significant reduction in IOP.
The majority of ophthalmologic surgeries are performed with regional nerve block anesthesia. Preoperatively, sedation may be required during the placement of the nerve block to decrease the discomfort of the injection, limit patient motion, relieve anxiety, and produce amnesia about the procedure.
Intraoperatively, sedatives may also be administered to relieve anxiety and prevent uncontrolled and unexpected anestezikldri. Ideal sedation levels can be achieved by careful intravenous titration of suitable agents while monitoring the effect of the sedative and analgesic agents.
The enteral, subcutaneous, or intramuscular aneztezikleri are best avoided whenever possible because of unpredictability of absorption and distribution of the drugs. When used in combination these drugs have a anestesikleri effect and need to be titrated carefully [32—34].
Additionally, it is important to differentiate between patient movement as a result of anxiety and that as a result of pain. Administration of additional sedatives in the presence of pain resulting from inadequate regional block will only worsen the situation and result in a deeply sedated, uncooperative patient with uncontrolled movement. They act by binding to the g-aminobutyric acid GABA complex and inhibit neuronal transmission. These drugs exhibit hypnotic, anxiolytic, and amnestic properties and lower intraocular pressure.
Cardiovascular and respiratory depression is seen with excessive doses. Diazepam has a long half-life, which is further prolonged in the elderly. Its original formulation Valium; Roche Laboratories, Nutley, NJwhich contained propylene glycol, was associated with venous irritation and phlebitis .
Respiratory depression and apnea occurs with all benzodiazepines and is more likely to occur in the presence of opioids, old age, and debilitating disease. Propofol in small incremental intravenous doses 20 mg has been used to achieve amnesia for regional eye blocks ; however, propofol provides no analgesia for insertion inhwlasyon the block needle and therefore semiconscious patients may have a startle response to needle insertion.
A single dose of propofol 0. This change occurs immediately following injection and may be related to relaxation of the extraocular muscles. Continuous infusion of propofol 1.
Günübirlik Cerrahide Anestezi | Article | Türkiye Klinikleri
Patient-controlled sedation using propofol 0. One patient developed excessive sedation and transient respiratory depression, which responded to patient stimulation. In volunteers, dexmedetomidine sedation reduced minute znestezikleri but did not alter the slope of the ventilatory response to increasing CO2 .
The effects on the cardiovascular system are a decreased heart rate; decreased systemic vascular resistance; and indirectly decreased myocardial contractility, cardiac output, and systemic blood pressure . Used as a premedicant at intravenous doses of 0. When used for intraoperative sedation, dexmedetomidine 0. With continuous infusion sedation after termination of the infusion was more prolonged, as was recovery of blood pressure; however, lower doses of opioid were needed in the first hour postoperatively .
Additionally, pain may occur intraoperatively as a result of the light from the operating microscope, iris manipulation, irrigationaspiration, and intraocular lens manipulation [78,79] necessitating intraoperative analgesics. Cyclopentolate Despite the popularity of cyclopentolate as a mydriatic, it is not without side-effects, which include CNS toxicity.
Manifestations include dysarthria, disorientation, and frank psychotic reactions. Cyclopentolate, ihnalasyon higher concentrations, also causes cycloplegia. The local use of this drug may occasionally result in such systemic effects as bradycardia, increased salivation, and bronchial secretions, as well as bronchospasm.
The side-effects, including hypotension and bradycardia,57 that may develop in patients given acetylcholine after cataract extraction may be rapidly reversed with iv atropine. Furthermore, one might anticipate that vagotonic anesthetic agents such as halothane could accentuate the effects of acetylcholine.
Echothiophate is a long-acting anticholinesterase miotic that lowers IOP by decreasing resistance to the outflow of aqueous humor. Useful in the treatment of glaucoma, echothiophate is absorbed into the systemic circulation after instillation in the conjunctival sac.
In addition, a delay in metabolism of ester local anesthetics should be expected. Asetilkolin Antikolinesteraz Kokain Epinefrin Fenilefrin Timolol Some of the potentially worrisome topical ocular drugs include acetylcholine, anticholinesterases, cocaine, cyclopentolate, epinephrine, phenylephrine, and timolol. In addition, intraocular sulfur hexafluoride and other intraocular gases have important anesthetic ramifications.
Furthermore, certain ophthalmic drugs given systemically may produce untoward sequelae germane to anesthetic management. Drugs in this category include glycerol, mannitol, and acetazolamide.
Anticholinesterase Agents Cocaine Cocaine, introduced to ophthalmology in by Koller, has limited topical ocular use, because it can cause corneal pits and erosion. However, as the only local anesthetic that inherently produces vasoconstriction and shrinkage of mucous membranes, cocaine is commonly used in a nasal pack during dacryocystorhinostomy. The inhalwsyon is so well absorbed from mucosal surfaces that plasma concentrations comparable to those after direct iv injection are achieved.
This practice is both superfluous and deleterious because cocaine is a potent vasoconstrictor in its own right, and the combination of epinephrine with cocaine may trigger dangerous cardiac dysrhythmias. It has been shown that cocaine used alone, without topical epinephrine, to shrink the nasal mucosa in conjunction with halothane or enflurane does not sensitize the heart to endogenous epinephrine during halothane or enflurane anesthesia.
Furthermore, systemic reactions inhalaston appear with as little as 20 mg. Meyers65 described two cases of cocaine toxicity during dacryocystorhinostomy, underscoring that cocaine is contraindicated in hypertensive patients or in patients receiving drugs such as tricyclic antidepressants or monoamine oxidase inhibitors.
Xnestezikleri addition, sympathomimetics such as epinephrine or phenylephrine should not be given with cocaine. Obviously, anesteaikleri administering cocaine or another potent vasoconstrictor for dacryocystorhinostomy, the physician should carefully search out possible contraindications. To avoid toxic levels, doses of dilute solutions should be meticulously calculated and carefully administered. If serious cardiovascular effects occur, labetalol should be used to counteract them.
However, Smith and colleagues72 reported anestezkleri the administration of epinephrine into the anterior chamber of patients undergoing cataract surgery by phacoemulsification and aspiration. It was postulated that the iris, with its rich supply of adrenergic receptors, may be able to capture with extreme rapidity the epinephrine given into the eye. Apparently, there is not much systemic absorption from the globe.
Phenylephrine Pupillary dilation and capillary decongestion are reliably produced by topical phenylephrine. Although systemic effects secondary to topical application of prudent doses are rare,73 severe hypertension, headache, tachycardia, and tremulousness have been reported.
Those with cerebral aneurysms may be susceptible to cerebral hemorrhage after phenylephrine in this ajestezikleri. In general, a safe systemic level follows absorption from either the conjunctiva or the nasal mucosa after drainage by the tear ducts. However, phenylephrine should not be given in the eye after surgery inhalasyoon begun and venous channels are patent.
Children are especially vulnerable to overdose and may respond in inhalasuon dramatic and adverse fashion to phenylephrine drops. Hence, the use of only 2. Timolol and Betaxolol Timolol, a nonselective b-adrenergic blocking drug, is a popular antiglaucoma drug. Because significant conjunctival absorption may occur, timolol should be administered with caution to patients with known obstructive airway disease, congestive heart failure, or greater than first-degree heart block.
Life-threatening asthmatic crises have been reported after the administration of timolol drops to some patients with chronic, stable asthma. However, patients receiving an oral b blocker and betaxolol should be observed for potential additive effect on known systemic effects of b blockade.
Caution should inbalasyon exercised in patients receiving catecholamine-depleting drugs. Although betaxolol has produced only minimal effects in patients with obstructive airways disease, caution should be anrstezikleri in the treatment of patients with excessive restriction of pulmonary function. Moreover, betaxolol is contraindicated in patients with sinus bradycardia, congestive heart failure, greater than first-degree heart block, cardiogenic shock, and overt myocardial failure.
Intraocular Sulfur Hexafluoride For a patient with a retinal detachment, intraocular sulfur hexafluoride79 or other gases such as certain perfluorocarbons may be injected into the vitreous to mechanically facilitate reattachment.
These recommendations do not apply to open-eye procedures during which volume and pressure changes are readily compensated for by fluid and gas leak. Stinson and Donlon80 suggest terminating nitrous oxide 15 minutes before gas injection to prevent significant changes in the size of the intravitreous gas bubble. Furthermore, if a patient requires reoperation and general anesthesia after intravitreous gas injection, nitrous oxide should be aneztezikleri for 5 days subsequent to air injection and for 10 days after sulfur hexafluoride injection Table Gas Partition Coefficients Sulfur hexafluoride 0.
Like sulfur hexafluoride, these gases are relatively insoluble and require discontinuance of nitrous oxide at least 15 minutes before injection.