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Of general interest

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interesgeneral MEDICAL CONDITIONS OF GENERAL INTEREST

ALLERGY AND ANAESTHESIA

Allergic reactions in anaesthesia pose a serious potential problem due to potentially life-threatening complications, since they are associated with a mortality rate of between 3% and 5% and an incidence of side effects of around 35%. The frequency of occurrence is highly variable, between 1:3000 and 1:13000 anaesthetic interventions, and is linked mainly to the use of general anaesthesia, particularly during induction.

Substances involved are, in descending order:

  • Muscle relaxants (50%-70%)
  • Latex (12%-17%)
  • Antibiotics (8%)
  • Barbiturates (4%-10%)
  • Plasma substitutes (3%)
  • Non-narcotic analgesics (2%)
  • Neuroleptics (1%)

The high incidence observed with muscle relaxants is due to the presence of a molecule they contain, ammonium ion, also used in cosmetics, dyes and certain food products. Although every patient may have an allergic reaction to any pharmacological substance, there are certain predisposing factors:

  1. A history of allergic reaction to a given substance, especially if it is an anaesthetic agent, documented by a specialist in Allergology
  2. A history of clinical symptoms pointing to an allergic reaction to an anaesthetic agent and/or latex
  3. Children with a history of multiple operations, particularly spina bifida, myelomeningocele or genitourinary malformations (increased risk of allergy to latex)
  4. Clinical symptoms suggesting allergy following the intake of avocados, kiwi, banana, chestnut, apricot, grape, pineapple and/or after exposure to rubber, plastic objects (risk of latex allergy)

Should you present or have ever presented any of these symptoms, please inform the surgeon and the anaesthesiologist before the proposed surgery in order to prevent the onset of complications related to an allergic reaction.

Prevention of allergic reactions is based on the following points:

  1. Identification of the allergenic product by means of targeted clinical questioning and the performance of specific laboratory tests, such as skin tests, with a sensitivity and specificity of almost 100%
  2. Avoid contact with or exposure to the allergenic agent
  3. Establish suitable preoperative medication
  4. Minimise the number of drugs to be given

Performing preoperative specific tests (skin tests) has no utility in the general population or in atopical patients and should be reserved for patients with documented risk factors. The test results should be delivered in writing to the patient and be recorded in the Medical History and in the Informed Consent Document (ICD), to be signed before the operation. The risk-benefit ratio should be assessed, although it is not advisable to delay emergency surgery to have such tests performed.

ASTHMA AND ANAESTHESIA

Asthma is an inflammatory disease of the airways involving a reversible air-flow obstruction, which gives rise to a variable degree of respiratory difficulty (dyspnoea) depending on the severity of the obstruction.

Extrinsic and intrinsic asthma

This obstruction may occur as a result of an identifiable stimulus (pollen, grass, exercise, emotional stress, food, aspirin...), in which case we are dealing with extrinsic asthma, or one that has no apparent trigger, intrinsic asthma.

Incidence of asthma in the population

The incidence of asthma in the adult population is around 5%, while in children this figure rises to approximately 10%.

How is it diagnosed?

The clinical diagnosis of asthma (breathing difficulty, accelerated breathing, wheezing, or "whistles" on auscultation...) must be confirmed by respiratory function tests (RFT) by a Pneumology Department. The RFT for asthma include essentially spirometry or the determination of mobilizable pulmonary volumes with normal and/or forced breathing and a bronchodilatory test to measure resistance to air flow and assess response to medical treatment.

Asthma and anaesthesia

The problem of asthma in relation to anaesthesia depends essentially on its severity, which is determined by the presence of the following factors:

  1. High frequency of asthma attacks
  2. Nocturnal crises
  3. Frequent need for medical care, with or without hospitalisation
  4. Important and documented involvement of the RFT

If you present any of the above, inform your surgeon and the anaesthesiologist before surgery to assess your condition and prevent the onset of complications related to the asthma process. If you are a smoker, stop smoking 1-2 weeks before surgery.

If you are already on a bronchodilatory and anti-inflammatory treatment that you are doing well with, in principle you should stay on it until the operation.

In any event, your usual doses may need to be further titrated and/or you may need to have new medication prescribed to you, for example corticosteroids, theophylline and/or antibiotics, if your condition renders this advisable. Similarly, it may be necessary for you to have preoperative RFT performed that will help the doctor to make a better assessment of your current condition. Remember that it is very important that the asthma be well-controlled and/or stable before the surgery can be performed. Sometimes, this may lead to a delay in surgery, although any delay will always be conditioned by how urgent the surgery is.

In asthmatic patients, it tends to be more advisable to perform the operation under locoregional anaesthesia rather than general anaesthesia, although this will depend on the patient's condition and/or the nature of the operation.

CARDIOVASCULAR DISEASES

Cardiovascular diseases, particularly ischaemic heart disease (myocardial infarction, angina pectoris), hypertension, heart failure and valve disease (stenosis/tricuspid, pulmonary, aortal, mitral failure) are one of the most common conditions in regular anaesthetic practice and constitute a major cause of morbidity and mortality during and after surgery. In fact, cardiovascular complications are responsible for 25%-50% of the deaths that occur in surgery, with infarction, decompensated heart failure, arrhythmias and thromboembolisms being the conditions most frequently involved in this mortality.

The diagnosis of heart disease

The diagnosis of heart disease is mainly supported by a rigorous clinical history, a detailed physical examination and a number of complementary tests (electrocardiogram, echocardiogram, chest X-ray, fundus of eye, stress test...) depending on the type of condition and its severity. A clinical history with some of the diseases described below will alert us to the existence of a given cardiocirculatory condition.

  • Dyspnoea (breathing difficulty or shortness of breath) on making an effort or at rest
  • Orthopnoea (dyspnoea in the supine position that improves on sitting up)
  • Paroxysmal nocturnal dyspnoea - PND (dyspnoea crises that wake the patient up)
  • Syncope or fainting (generalised muscle weakness with the inability to stand up, coursing with a brief alteration of consciousness)
  • Oedema (swelling of the legs or ankles)
  • Palpitations (conscious and unpleasant sensation of fast or slow, regular or irregular, heart activity)
  • Chest pain, intermittent claudication (pain in the legs and functional ambulance impotence that improves at rest)
  • Murmurs (vibrations originated in the heart or large vessels)
  • Hypertension (AHT) and/or cyanosis (bluish skin discolouration)

Dyspnoea, orthopnoea, PND and oedema are the characteristic symptoms of heart failure, while retrosternal chest pain, which radiates to the neck or left arm and is relieved by rest or nitroglycerin, constitutes the basic clinical symptom of ischaemic heart disease.

Palpitations point to the presence of normal heart rhythm disorder, while cardiac murmurs indicate valve disease.

Syncopes suggest very low heart rates that are characteristic of heart blockade (cardiac conduction disorders) and often call for the placement of a pacemaker or a major reduction in cardiac output (the amount of blood pumped by the heart in one minute).

Hypertension (AHT) is defined by a systolic blood pressure ≥140 mmHg and/or a diastolic blood pressure ≥90 mm Hg. Severity is not only determined by blood pressure but also by the organic impact (cardiac, renal, neurological, ocular) and/or by the presence of associated medical conditions (diabetes, stroke, coronary heart disease).

One datum that should be considered, particularly in the presence of cardiovascular disease, is the patient's preoperative haemoglobin (Hb) value. In general, a preoperative Hb value of &amp;lt; 6 g/dl in the absence of cardiovascular disease and/or a preoperative value of Hb < 10 g/dl in the presence of associated cardiovascular pathology entail a substantial increase in perioperative morbidity and mortality.

On the other hand, the presence of venous insufficiency, varicose veins, significant obesity, advanced age or the intake of oral contraceptives are conducive to the onset of deep vein thrombosis (DVT), with the consequent risk of postoperative thromboembolism, which is why prevention with heparin is necessary a few hours before the surgery in these cases.

Another very important aspect that must be addressed in the clinical history is the estimation of the patient's functional capacity, since a reduction in the latter is associated with an increased risk of cardiac complications in the perioperative period. This estimate can be made through the application of different classifications, such as those of the New York Heart Association (NYHA), the Canadian Cardiovascular Society (CCS) or the American Heart Association (AHA)/ American College of Cardiology (ACC), which assess a patient's functional capacity for exercise. The most recent one is that which is advocated by the AHA/ACC, which expresses the degree of functional capacity through the so-called metabolic equivalents (METs); 1 MET defines the oxygen consumption at rest of a grown man aged 40 years weighing 70 kg, which is 3.5 ml/kg/min. The multiples of this value are then used to express the oxygen requirements involved in different physical activities. The correlation between both of them (METs and physical activity) is a useful tool to complement the clinical diagnosis.

Class Functional capacity Physical activity METS
I Excellent Sports (swimming) 7-10
II Good Walking fast (6.4 km/h)
Heavy household chores
Full sexual intercourse
5-7
III Moderate Walking slowly (4.8 km/h)
Light housework
2-5
IV Bad Unable to dress oneself or perform domestic chores < 2

The first two, on the other hand, relate physical activity to the absence or presence of symptoms, with the NYHA referring primarily to the onset of dyspnoea as an expression of heart failure and the CCS to the onset of angina symptoms as an expression of functional cardiac reserve. Tables no. 3 and 4 show the functional classifications of the NYHA and the Canadian Cardiovascular Society.

NYHA FUNCTIONAL CLASSIFICATION
Class I No limitation of physical activity
Class II Slight limitation of physical activity. Absence of symptoms at rest, but normal physical activity leads to shortness of breath, palpitations or angina
Class III Marked limitation of regular physical activity. Onset of symptoms following less than ordinary activity
Class IV Unable to carry on any physical activity. Onset of symptoms
CSS FUNCTIONAL CLASSIFICATION
Class I Ordinary physical activity (walking, climbing stairs) does not cause angina. Angina may occur with strenuous rapid or prolonged exertion.
Class II limitation ordinary physical activity. Symptoms of angina when walking or climbing stairs, after meals or under emotional stress.
Class III Marked limitation of ordinary physical activity. Symptoms of angina after walking one or two blocks on the level or 1 flight of stairs
Class IV Unable to carry on any physical activity without discomfort. Possible onset of angina at rest

There are several cardiac risk indices used in clinical practice to estimate the risk of cardiac complications. Particular mention should be made of those advocated by the AHA/ACC in 1996 and revised in 2002, including the so-called clinical predictors, surgery-related risk and functional capacity:

PERIOPERATIVE CARDIOVASCULAR RISK
: CLINICAL PREDICTORS
Major -Recent AMI (&gt; 7 days)
(and/or > 30 days).
-Severe or unstable angina (Class III - IV CCS
-Decompensated CHF.
-Significant arrhythmias or severe valve disease (aortic stenosis).
Intermediate -AMI
Old or moderate Angina (class II - I CCS).
-Compensated or old CHF.
-Diabetes Mellitus.
Minor -Uncontrolled hypertension
-Poor Functional Capacity.
-Abnormal ECG (FA - HVI - LBBB - ST Anomalies).
-Old age.

ACC - AHA Guidelines: Circulation 1996

The presence of major clinical predictors such as a recent heart attack or decompensated congestive heart failure (CHF) can render it necessary to delay surgery until the disease in question stabilises.

Intermediate predictors point to an increased risk of complications, and their presence calls for an exhaustive examination of the patient, while the minor predictors, albeit reflecting a cardiovascular disease, are not in themselves regarded as independent risk predictors.

PERIOPERATIVE CARDIOVASCULAR RISK:
TYPE OF SURGERY
HIGH-RISK (> 5%) -Urgent major surgery, particularly in the elderly
-Major vascular surgery (aortic)
-Peripheral vascular surgery
-Lengthy surgery (&gt; 3 h) associated with major blood loss and/or significant fluid dynamics alteration
INTERMEDIATE-RISK (< 5%) -Carotid surgery
-Head and/or neck surgery
-Intraperitoneal or intrathoracic surgery
LOW-RISK (< 1%) -Laparoscopic or superficial surgery

Once the risk factors have been established, the preoperative assessment must also take into account the type of drug that the patient has been taking or has taken in the 6 months before the operation due to possible interactions between them and the drugs used in the anaesthesia. Generally speaking, all drugs should be maintained up until the day of surgery, except for anticoagulants (Sintrom), heparin, aspirin, antiplatelet and antihypertensive agents ACEI (angiotensin-converting enzyme inhibitors: captopril, enalapril...), and the ARA II drugs (angiotensin antagonists): Losartan, Ibesartan):

  • Sintrom: it should be discontinued 3 to 4 days in advance and be replaced with heparin
  • Heparin: it it should be maintained up to 12 h before the operation
  • Aspirin: it should be discontinued 7 to 10 days before the operation and be replaced 3 days after that by ibuprofen or flurbiprofen until 12 h before the operation
  • Antiplatelet agents: Ticlopidine should be discontinued 14 days before the operation, Clopidogrel 7 days, Abciximab 2 days before it and dipyridamole or eptifibatide 24 h before
  • ACEI/ARA II: they should be suspended between 12 to 24 h before the operation, depending on the drug. Moreover, if you have or have had a clinical predictor within the last 6 months, carry a pacemaker or have taken any of the above drugs, you should inform your surgeon and the anaesthesiologist so that they can evaluate your current state of health and adapt, as applicable, the medication you are taking and establish the most optimal moment for your surgery
DIABETES AND ANAESTHESIA

Diabetes Mellitus (DM) is one of the most frequent diseases in surgical patients and is often detected in the preoperative examination. It is characterised by an alteration in carbohydrate metabolism secondary to an insufficient activity of the insulin secreted by the pancreas, giving rise to hyperglycaemia (increased blood glucose) and glycosuria (presence of glucose in urine). According to the American Diabetes Society's criteria, at least one of the following conditions must be met for the diagnosis of this disease:

DIABETES DIAGNOSTIC CRITERIA
• Baseline fasting glucose
(at least 8 h) ≥ 126 mg/dl (7 mmol/L) confirmed on at least two occasions
• Random blood glucose ≥ 200
mg/dl (11.1 mmol/L) accompanied by clinical symptoms characteristic of
Diabetes

Determination of blood glucose is often complemented by the so-called Glycosylated haemoglobin (Hb A1c), whose values reflect the patient's mean blood glucose figures over the last 4 weeks, and is a very useful parameter for assessing the degree of diabetes compensation; values > 9% (normal: 5%-7%) are indicative of inadequate glycaemic control.

There are 2 types of Diabetes:

  • Type 1 or insulin-dependent diabetes (IDD): insulin deficit caused by the destruction of the pancreatic cells responsible for its secretion. Control inexorably requires exogenous insulin administration
  • Type 2 or non-insulin-dependent Diabetes (NIDD): alterations in insulin secretion, together with resistance to its effects. Initial control is usually achieved with a diet and/or the administration of oral antidiabetics (OAD), although if the disease progresses the administration of insulin may be required

The fundamental differences between both types are outlined in the following table:

CHARACTERISTICS
DIFFERENCES BETWEEN THE TYPES OF DIABETES
SYMPTOMS TYPE 1 DIABETES TYPE 2 DIABETES
More frequent onset Childhood or adolescence Adult age
Insulin production Very low Normal or high
Constitution Thin Obese
Treatment Insulin Diet, OAD, insulin
Response to insulin Good Resistance
Proneness to ketoacidosis High Low
Predominant complications in the
long term
Microvascular
(small vessels)
Macrovascular
(large vessels)
Hereditary influence Moderate High

However, this classification is more theoretical than real, since both types of symptoms tend to sometimes overlap in daily practice.

The clinical symptoms characteristic of Diabetes include the so-named 3 Ps, plus a fourth factor

  • Polydipsia (excessive thirst)
  • Polyphagia (excessive hunger)
  • Polyuria (excessive urination)
  • Weight loss

The morbidity and mortality of surgical patients with Diabetes is linked to the presence of the following risk factors:

  • Inadequate metabolic control (fasting blood glucose > 140 mg/dl) and HbA1c > 9%
  • Aggressive surgery
  • Presence of systemic complications linked to Diabetes
  • Existence of associated conditions (Morbid obesity...)

Systemic complications of Diabetes are an important risk factor in the surgical patient whose presence must be confirmed during the preoperative examination.

These complications include:

Diabetic retinopathy: microangiopathic eye disease that courses with decreased visual acuity and may cause vitroeus bleeding or retinal detachment, in which case a vitrectomy would be indicated. The diagnosis is made through a fundus of eye by an ophthalmologist. This examination should be performed 5 years after the onset of a type 1 DM and at the beginning of all type 2 DM.

Diabetic nephropathy: microangiopathic kidney disease that courses with proteinuria or albuminuria (presence of protein in urine > 200 mg/day), hypertension and renal dysfunction. It is diagnosed by means of laboratory studies (blood and urine analysis) and renal function tests. The detection of microalbuminuria (microproteinuria) through "test strips" is especially important, since it is an early sign of diabetic neuropathy. Microalbuminuria is currently regarded as a renal and cardiovascular damage marker in diabetic and hypertensive patients.

Cardiovascular manifestations: macroangiopathic affection of the coronary arteries and the large peripheral vessels that promote myocardial infarction or angina pectoris, hypertension, cerebrovascular accident (stroke or apoplexy), intermittent claudication and trophic lesions of the extremities (ulcers, skin wounds). The presence of dyspnoea and hyperglycaemia suggests coronary artery involvement even if the other angina symptoms (pain) are absent. Diabetic neuropathy: nervous system disorder coursing with pain and sensorial disorders such as paraesthesia (tingling) or hyperaesthesia (abnormal sensitivity) in peripheral nerve territory distribution (diabetic mononeuropathy), or alterations in autonomic or neurovegetative nervous system (sympathetic/parasympathetic) functionalism. Autonomic dysfunction characterised by postural hypotension, tachycardia at rest, bladder atony with urine retention and recurrent urinary tract infections, impotence and digestive enteropathy with diarrhoea and delayed gastric emptying.

Osteoarticular manifestations: a limitation of articular mobility often affecting only the small joints initially, and subsequently any body joint. It is particularly important to explore neck and temporomandibular joint mobility in order to assess possible orotracheal intubation difficulties. In this sense, the existence of the "preacher sign", or the inability to flatten the hands together, is often predictive of difficult intubation.

Preoperative measures in surgical patients with Diabetes: In surgical patients with Diabetes, a series of pre-operative measures should be taken in order to minimise the occurrence of complications during or after surgery: surgery should be scheduled for early morning. In the case of minor surgery, oral feeding should be suspended between 8 and 12 h before, and more than 12 h before it for major surgery (adapt evening meal time on the previous day to surgery time)

If the patient is taking anti-diabetic medication, it should be duly titrated.

  • Oral antidiabetics (OAD): sulfonylureas and acarboses should be suspended on the morning of the operation, whereas biguanides (metformin) should be suspended 48 hours before surgery
  • Long-acting insulins: they should be suspended the night before surgery and be replaced with fast-acting insulin depending on blood sugar values
  • Fast-acting insulins: maintain the usual dose subcutaneously or titrate according to blood sugar levels and the Centre's protocols
  • Once the patient begins to fast, they should be given sufficient intravenous glucose (150-200 g/24 h), which will be maintained until oral feeding is resumed; this intake begins 1-2 hours before surgery begins (provided that the patient has had an evening meal)
  • Blood sugar should be checked every four hours, the objective being to maintain stable blood sugar figures of between 100 and 200 mg/dl to avoid hypoglycaemia
  • Patients with fasting blood sugar levels &amp;gt; 140 mg/dl despite treatment must be admitted 24 hours before surgery and be given fast-acting insulin according to the Centre's protocols, together with adequate glucose supplementation

If you are diabetic, you must inform your surgeon and the anaesthesiologist ahead of surgery so that they can assess your current state of health and take the necessary measures to optimise your condition before it. This is particularly important in the following cases:

  • Type 1, or insulin-dependent, diabetes
  • A history of important decompensation (diabetic ketoacidosis, diabetic coma)
  • Presence of risk factors
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