4928104-pre-and-postoperative-monitoring-of-patients, revised.ppt
TRANSCRIPT
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Pre-operative Preparation andPeri-, Post-operative Monitoring
of the
Surgical Patient
DR. KAMEL IBRAHIM HADYDR. SAMY AB ALREHMAN
CONSULTANT ANAESTHESIA/ICU
K.K.M.H
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SURGERY
“ One of the most challenging aspect of surgical
practice is not just making the decision to
perform a surgical procedure on a patient, butdeciding on the proper timing when a surgicalprocedure can be done.”
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Surgical Management Decision
Surgery
Management
Disease
Patient
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SURGERY
Disease Factor: Natural History
Prognosis
Management Factor: Classical and Advances in Surgical and Medical Techniques (Management
Options)
Anesthesia Methods and Medications
Patient Factor: General Health (Optimization)
Co-morbid Conditions (Identify and Manage)
Psychological Preparation
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SURGERY
“ Thus, appropriate pre-operative preparation
and post-operative monitoring is absolutely
mandatory and essential to minimize the risks,lessen complications and optimize outcome of apatient even with the best technically performedoperative procedure.”
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Pre-operative Care
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Optimize efficiency and bed utilization
preoperatively
Avoid delays and cancellations resulting in lostoperating room time
Proactively coordinate patient care with otherspecialties
Provide high-quality and safe patient care
Improve patient satisfaction and set foundation
for optimum outcomes
OBJECTIVES
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General Aspects of Pre-op Care
History and Physical Examination
Surgical Consent
Patient Preparation:
Psychological preparation Physical preparation
Physiological preparation
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History and Physical Examination
Diagnosis of current condition
Identifies associated risk factors: Age of the patient (Extremes of age)
Co-morbid conditions Previous surgery
Determines current medications
Reviews past medical history
Determines physical status: American Society of Anesthesiologists’ (ASA) Physical Status
Assessment
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Pre-operative Medical Care
Elective/Emergency
Cardiac disease
Pulmonary disease
Renal dysfunction
Liver dysfunction
Diabetics
Bleeding disorders Malnourished
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Surgical Emergency
AMPLE History:
A llergies
M edications P ast Medical History
L last meal
E vents Preceding Surgery
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Pre-operative Medical Care
Elective/Emergency
Cardiac disease
Pulmonary disease
Renal dysfunction
Liver dysfunction
Diabetics
Bleeding disorders Malnourished
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Coronary Artery Disease Definition of CAD....
Physiology of Surgery: myocardial oxygen demand catecholamines: HR, contractility, PVR HR also causes decreased diastolic filling
Coronary arteries fill in diastole Less blood flowing in coronaries: less myocardial O2 supply
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Myocardial Infarction
Pt without risks: 0.5% chance of MI Pt with risks: 5% chance of perioperative MI
Perioperative MI has 17-41% mortality
CAD causes MI
Risk stratifications:
MI w/in 3 months of OR 27% reinfarction rate
MI 3-6 months before OR 10% reinfarction rate
MI >6 months of OR 5-8% reinfarction rate*
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Criteria: Points A. Historical:
Age >70 yr. 5Myocardial infarction previous 6 months 10
B. Examination:S3 gallop or jugular venous distention 11
Significant aortic valvular stenosis 3C. Electrocardiogram:
Premature atrial contractions or other rhythm 7>5 premature ventricular contractions/min. 7
D. General status: Abnormal blood gases 3K+/HCO3 abnormalities 3
Abnormal renal function 3Liver disease or bedridden 3
E. Operation:Emergency 4Intraperitoneal, intrathoracic, aortic 3
Total possible: 53 Adapted from Goldman, L., Caldera, D. L., Nussbaum, S. R., et al.: N.Engl. J. Med., 1977; 297:845. Copyright 1977. Massachusetts Medical
Society. All rights reserved.
Goldman Index
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Goldman Classification
Class Point Total
I 0-5II 6-12
III 13-25
IV > 26
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Goldman Cardiac Risk in Non-cardiac SurgeryClass III & IV patient warrant routinepre-operative cardiology consultation
Class IV – life saving procedure only
28 of the 53 points are potentiallycorrectible pre-operatively
Index correctly classified 81% of cardiacoutcomes
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Pre-operative Medical Care
Surgical emergency Cardiac disease
Pulmonary disease
Renal dysfunction Liver dysfunction
Diabetics
Bleeding disorders
Malnourished
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Pulmonary Disease
Patient History: unexplained dyspnea, cough, reduced exercise tolerance
Physical Exam:
wheeze, rales, rhonchi, exp time, BS
5.8x more likely to develop pulmonary complications*
Pre-operative CXR:
Mandatory in patients over 40 yo
ABG: no role for routine use
result should not prohibit surgery
* Lawrence et al Chest 110:744, 1996
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Pulmonary Disease
Patient-related risks:
Chronic lung dz – wheeze, productivecough
Smoking
General health
Obesity
Age?
separate from others?
Procedure related risks: Type of anesthesia
GETA alone FRC 11%
inhibited coughing peri-op
Surgical site Duration of surgery
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Modifiable Pulmonary Risks
Obesity Risks: lung capacity, FRC, VC
Hypoxemia
Tobacco Risks:
Definition of “stopped
smoking”....
“When was your last cigarette?”
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Pre-operative Medical Care
Surgical emergency Cardiac disease
Pulmonary disease
Renal dysfunction Dialysis dependent
Liver dysfunction
Diabetics
Bleeding disorders
Malnourished
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Renal Dysfunction
Not all renal failure is oliguric
Check BUN/Cr
Assume DM have CRI
Volume status
Electrolytes
Drug metabolism
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Renal Dysfunction
Dialyze preop to improveelectrolytes, volume status
No or limit K + in MIVF
Very judicious MIVF while onNPO
Consider: Altered drug metabolism
Altered platelet fxn
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Pre-operative Medical Care
Surgical emergency Cardiac disease
Pulmonary disease
Renal dysfunction Liver dysfunction
Diabetics
Bleeding disorders
Malnourished
Why does hepatic disease
cause coagulopathy?
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Child-Pugh Criteria for Hepatic Reserve
Measure A B C
Bilirubin <2.0 2-3 >3.0
Albumin >3.5 2.8-3.5 <2.8
Prothrombin
Time (PT)
increase
1-3 4-6 >6
Ascites None Slight Moderate
Neuro None Minimal “Coma”
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Child-Pugh Criteria for Hepatic Reserve
Predictor of perioperative mortality: Class A: 0 - 5%
Class B: 10 – 15%
Class C: > 25% Correct what you can vitamin K,
FFP, Albumin, etc.
Anticipate bleeding, complications
Townsend, Textbook of Surgery, 16th ed.
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Perioperative Medical Care
Surgical emergency
Cardiac disease
Pulmonary disease
Renal dysfunction
Liver dysfunction
Diabetics
Bleeding disorders
Malnourished
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Patients with Diabetes
Coronary Artery Disease
Neuropathy
Diabetic Nephropathy Infection
Others
Treatment: Control of hyperglycemia pre-operatively
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Pre-operative Medical Care
Surgical emergency Cardiac disease
Pulmonary disease
Renal dysfunction
Liver dysfunction
Diabetics
Bleeding disorders
Iatrogenic Inherited
Malnourished
Reasons patients are placed on
anticoagulants:
−Atrial fibrillation
−Prosthetic heart valve
−DVT or PE
−CVA or TIA
−Hypercoagulable state
REVIEW: Merritt J Thrombosis and Thrombolysis 13(2), 97-103, 2002
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Evaluation of Hemostatic Disorders
History :
Easy bruising, epistaxis Cut when shaving
Heavy menstrual bleeding
Family history of bleedingdisorders
ASA / NSAID’s
Renal disease
Hepatic disease (EtOH)
Physical:
Ecchymoses
Hepatosplenomegaly
Excessive mobility of joints orexcess skin laxity
Stigmata of renal or hepaticdisease
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Laboratory Tests of Bleeding Function
Prothrombin time (PT/INR): Measures factor VII and common pathway factors (factor X,
prothrombin/thrombin, fibrinogen, and fibrin)
Partial thromboplastin time (PTT):
Intrinsic pathway and common pathway
Platelet count:
quantifies platelets
Bleeding time and Clotting time: estimates qualitative platelet function
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Patients on Anticoagulants
Aspirin (ASA)
Coumadin (Warfarin)
Heparin
1Ridker et al Ann Intern Med 114:835-839, 1991.
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Perioperative medical care:
Surgical emergency
Cardiac disease
Pulmonary disease
Renal dysfunction
Liver dysfunction
Diabetics
Bleeding disorders Malnourished
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Patients who are malnourished
Proteins are essential for healing andregenerating tissue
Malnourished patients have
Higher wound complications (dehiscence) andgreater anastomotic leak rate
More postoperative muscle weakness
(diaphragm)
Longer time in rehabilitation
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Treating malnourishment
“If the gut works, use it.”
TPN vs. enteral feeds
Preoperative “bulking up” Gastric and esophageal cancers
Why are they malnourished?
How do you build someone up?
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American Society of Anesthesiologists’ (ASA)
Physical Status Assessment
Classification
(Elective)
Classification
(Emergency)
Description
1 1E Normally healthy
2 2E With mild systemic disease
3 3E With severe systemic disease thatis not incapacitating
4 4E With incapacitating systemic
disease that is a constant threatto life
5 5E Moribound patient not expectedto survive without operation
6 6E Comatose/Organ Donor
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Surgical Consent
Details of a particular surgical procedure:
Procedure
Preparation (bowel preparation; NPO guidelines)
Benefit from the procedure
Risks and potential complications
Answer questions of patients and relatives:
To dispel fear and alleviate anxiety
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Patient Preparation
Psychological: Acceptance and positive outlook
Physical: Skin preparation Bowel preparation
Prophylactic antibiotics
Physiological: Correcting associated co-morbid conditions
Patient optimization
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A. Blood Orders:
1. Type and screen or type and cross fornumber of units appropriate to the procedure
B. Skin Preparation:1. Hair removal best performed on day of surgery
with an electric clipper2. Pre-operative scrub or shower of the operative site witha germicidal soap.
C. Pre-operative antibiotics:1. Administer prophylactic antibiotics 30 min prior to
incision
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D. Respiratory Care:
1. Pre-operative spirometry on the evening priorto surgery when indicated
2. Bronchodilators for moderate to severe COPD
E. Decompression of GI tract:
1. NPO after midnight
F. Intravenous fluids:
1. Maintenance rate overnight (D5LR)
G. Access and Monitoring lines:
1. At least one ga.18 IV needed for initiation ofanesthesia
2. Arterial catheters and central or pulmonaryartery catheters when indicated
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H. Thromboembolic prophylaxis:1. When indicated (those predispose to deep venous
thrombosis)
I. Pre-operative sedation:1. As ordered by the anesthesiologist
J. Special Consideration:
1. Maintenance medication2. Pre-operative diabetic management3. Other prophylactic medications4. Peri-operative steroid coverage (if needed)
K. Skin Marking:1. For Plastic/Reconstructive Surgeries2. Marking of stoma sites
P. Pre-operative notes
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Peri- and Post-operative Care
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Peri- and Post-operative Monitoring
Important aspects:
Physiologic Monitoring:
Vital Signs
Hemodynamic Respiratory
Gastric Tonometry
Renal
Neurologic
Metabolic/Nutritional
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Traditional 4 Cardinal Vital Signs
Temperature: Rectally or orally
Aural (Digital): measures core temperature
Heart Rate: Cardiac rate
Pulse rate
Blood Pressure:
Standard BP apparatus Respiratory Rate:
Breaths per minute
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Monitoring Temperature
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Hemodynamic Monitoring
Purpose:
To monitor cardiovascular function/performance
Traditional tools unreliable (critically ill patients)
Methods:
Arterial Catheterization
Central Venous Catheterization
Pulmonary Artery Catheterization
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Arterial Catheterization
Indications:
Continuous monitoring of blood pressure
Frequent sampling of arterial blood
Contraindications: Severe occlusive arterial disease (distal ischemia)
Vascular prosthesis (graft)
Local infection
Caution:
Bleeding diathesis
Anticoagulant therapy
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Arterial Catheterization
Clinical Utility:
Systolic blood pressure (SBP)
Diastolic blood pressure (DBP)
Mean arterial pressure (MAP)
Pulse Rate
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Arterial Catheterization
Sites of catheterization:
Radial/Ulnar
Axillary
Femoral
Dorsalis pedis
Superficial temporal
Brachial
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Assess Circulation
Allen’s test (E.V. Allen, 1929): patient makes tight fist for 1 min.
radial & ulnar arteries compressed
one artery released observe color return in hand
repeat with other artery
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Allen’s Test Findings
Color return:
< 5 seconds - normal
5 - 15 seconds - delayed
> 15 seconds - abnormal
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Arterial Catheterization
Complications:
Failure
Hematoma
Bleeding
Occlusion and ischemia
Infection
Fistulas/Pseudoaneurysms
Thrombo-embolism
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Central Venous Catheterization
Indications: Secure access:
Fluid therapy Drug infusions Parenteral nutritiona
Central venous pressure (CVP) monitoring Others:
Aspirate air emboli (neurosugery) Cardiac pacemaker placement Hemodialysis
Contraindications: Vessel thrombosis Infection Bleeding diathesis/anti-coagulant therapy
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Central Venous Catheterization
Clinical Utility:
Central venous pressure (CVP)
Indirectly:
Right atrial pressure
Right ventricular end-diastolic pressure
Relationship between intravascular volume and right
ventricular function
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Central Venous Catheterization
Sites of cetheterization:
Subclavian
Internal jugular
External jugular
Femoral
Brachiocephalic
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Central Venous Pressure
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Central Venous Catheterization
Complications:
Pneumothorax (subclavian)
Arterial puncture (internal jugular and femoral)
Hematoma/bleeding
Injury (neurovascular)
Infection
Thrombo-embolism
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Pulmonary Artery Catheterization
Indications:
Critically ill patients
Extensive surgical procedure (cardiac surgery)
Contraindications:
Vessel thrombosis
Infection
Bleeding diathesis/anti-coagulant therapy
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Pulmonary Artery Pressure
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Pulmonary Artery Catheterization
Clinical Utility:
Central venous pressure (CVP)
Pulmonary artery diastolic pressure (PADP)
Pulmonary artery systolic pressure (PASP) Mean pulmonary artery pressure (MPAP)
Pulmonary artery occlusion “wedge” pressure (PAOP)
Cardiac output (CO)
Indirectly: Left atrial pressure (LAP)
Left ventricular end-diastolic pressure (LVEDP)
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Pulmonary Artery Catheterization
Sites of catheterization:
Subclavian
Internal jugular
Femoral
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Pulmonary Artery Catheterization
Complications:
Dysrhythmias (most common)
Transient right bundle branch block (RBBB)
Coiling, looping, knotting of catheter
Aberrant catheter placement
Infection
Thrombo-embolism Bleeding
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Respiratory Monitoring
Purpose: To monitor respiratory performance:
Ventilation/Perfusion
Gas exchange Oxygen transport
To anticipate mechanical ventilatory support
Methods: Ventilation monitoring Blood-Gas monitoring
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Ventilation Monitoring
Advantages: Predict and monitor ventilatory function
Methods: Lung volumes:
Tidal volume Vital capacity Minute volume Dead space
Pulmonary mechanics:
Inspiratory force/pressure Static compliance Dynamic characteristic Work of breathing
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Lung Volumes
Tidal Volume: The volume of air moved in or out of the lungs in a
single breath
Respiratory frequency (f) : Tidal volume (Vt) ratio
Vital Capacity: The volume of maximal expiration following a
maximal inspiration
65 to 75 ml/kg (Normal)
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Lung Volumes
Minute Volume: Total ventilation
The total volume of air leaving the lung each minute
A product of Respiratory frequency ( f ) and Tidal Volume
(Vt)
Dead Space: The portion of tidal volume not involved in gas exchange
2 components: Anatomic dead space (within conducting airways)
Alveolar dead space (within unperfused alveoli)
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Pulmonary Mechanics
Inspiratory Force:
Measured as the maximal pressure belowatmospheric that a patient can exert against an
occluded airway < -20 to -25 cmH2O (good recovery)
Compliance:
Measure of the elastic properties of the lung andchest wall
60 to 100 ml/cmH2O (normal)
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Pulmonary Mechanics
Dynamic Characteristic: Evaluates compliance as well as impedance factors
Calculated by dividing the volume delivered by the peakairway pressure minus the positive end expiratory pressure
(PEEP) 50 to 80 ml/cmH20 (normal)
Work of Breathing: A measure of the process of overcoming the elastic and
frictional forces of the lung and chest wall A product of the change in pressure and volume
0.3 to 0.6 J/L (normal)
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Blood-Gas Monitoring
Advantages: Efficiency of gas exchange
Adequacy of alveolar ventilation
Acid-base status Methods:
Arterial blood gas
Mixed-venous blood gas Capnography
Pulse oximetry
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Gastric Tonometry
Purpose:
A reliable monitor in elective cardiac and major vascular surgery
A predictor of organ dysfunction and mortality
Principle:
Noninvasive monitor of adequacy of aerobic
metabolism in organs whose superficial mucosallining is vulnerable to low flow and hypoxemiasecondary to shock and SIRS
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Gastric Tonometry
Values Derived:
Intramucosal pH
Importance:
Guides in the resuscitative management
Provide a metabolic end point to resuscitation
Patient prognostication
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Gl l F i T
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Glomerular Function Test
Blood urea nitrogen (BUN): Dependent on GFR and Urea production
Urea (increased):
Prolonged TPN GI Bleeding
Catabolic states (Trauma, Sepsis and Steroids)
Urea (decreased):
Starvation Liver Disease
Not a reliable monitor of renal function
Gl l F i T
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Glomerular Function Test
Creatinine: Not influenced by protein metabolism and rate of fluid flow
through renal tubules
Serum creatinine:
Directly proportional to creatinine production (muscle mass andmetabolism)
Inversely proportional to GFR
Takes 24 to 72 hrs before serum creatinine changes arereflected
Gl l F i T
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Glomerular Function Test
24-hour Creatinine clearance:
Most reliable method for clinically assessing GFR
Most sensitive test for predicting renal dysfunction
Traditionally uses a 24-hr collection
Currently uses 2-hr collection:
Reasonable accurate and easier to perform
T b l F i T
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Tubular Function Tests
Purpose: Measures concentrating ability of renal tubules
To differentiate causes of oliguria (pre-renal and ATN)
Methods:
Fractional sodium excretion (most reliable)
Normal: 1-2%
BUN : Creatinine ratio Urine : Plasma Creatinine ratio
N l i M i i
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Neurologic Monitoring
Purpose:
Early recognition of cerebral dysfunction
Facilitate early and prompt intervention
Methods:
Intracranial pressure monitoring
Electrophysiologic monitoring
Transcranial doppler ultrasonography
Jugular venous oximetry
I i l P M i i
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Intracranial Pressure Monitoring
Methods: Intraventricular catheter
Subarachnoid bolt
Epidural bolts
Fiberoptic catheter
Permits calculation of: Cerebral perfusion pressure (CPP) = MAP - ICP
Complications: Infection
Malfunction/Malposition Hemorrhage
Obstruction
El h i l i M i i
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Electrophysiologic Monitoring
Electroencephalogram (EEG)
Indications:
Carotid endarterectomy
Cerebrovascular surgery
Epilepsy surgery
Open heart surgery (Some)
T i l D l Ul d
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Transcranial Doppler Ultrasound
Advantages: Noninvasive
Portable
Reproducible
Disadvantage:
Operator dependent (technical familiarity)
J l V O i
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Jugular Venous Oximetry
Applications: Carotid endarterectomy
Neurosurgical procedures
Cardio-pulmonary bypass
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Thank You
Pamantasan ng Lungsod ng Maynila
College of MedicineDepartment of Surgery