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Sp: Intro to Anes > 2. Preop Eval > Flashcards

2. Preop Eval Flashcards

1
Q

goals

A
  1. ensure pt can tolerate anesthetic
  2. mitigate risk of complications
  3. reduce pt anxiety/educate pt
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2
Q

chart review

A

age
gender
surgical dx
previous hospitalizations

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3
Q

past medical history

A

co-existing diseases

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4
Q

meds/allergies

A

current meds
vitamins
herbal supplements

allergies

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5
Q

past surgical/anesthetic Hx

A

review past anesthetic records
- difficult IV
- difficult airway
- intraoperative hemodynamic instability
- respiratory issues
- PONV

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6
Q

Patient interview

A
  • systematically question pt about each organ system
  • use clinical judgement to det necessary depth of questions related to each organ system
  • talk to pt at their education level
  • engage at eye level
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7
Q

neurologic system

A
  • current mental status
  • seizures
  • cardiovascular accident (CVA)
    • stroke
  • transient ischemic attack (TIA)
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8
Q

cardiac system

A

heart or vascular issues?

  • stiff vessels: hypertension
  • vessel blockage: CAD
  • structural changes: septal defect
  • electrical conduction: abnormal
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9
Q

coronary artery disease (CAD)

A

plaques build up in coronary arteries
resistance to flow

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10
Q

CAD evaluation

A
  • any recent episodes of chest pain?
  • do you have chest pain while performing activities?
  • MET assessment
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11
Q

Metabolic Equivalents of Physical Activities

A

> = 4 METs is high risk for cardiovascular event during surgery

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12
Q

MET 1

A

eating
working at computer
dressing

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13
Q

MET 4

A

raking leaves
gardening

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14
Q

MET 5

A

Climbing 1 flight of stairs
dancing
bicycling

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15
Q

Revised cardiac risk index
(RCRI)

A

used to estimate pt level of risk for cardiac complications

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16
Q

RCRI factors

A
  • High-risk surgery
  • Ischemic heart disease
  • H/O congestive heart failure
  • H/O cerebrovascular disease
  • diabete mellitus
  • creatine >2.0mg/dL
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17
Q

High risk surgery

A

intraperitoneal
intrathoracic
supra-inguinal vascular

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18
Q

Hypertension evaluation

A

have you been diagnosed w/high blood pressure?
are you on blood pressure meds?

47% of americans

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19
Q

normal BP

A

<120/80 mmHg

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20
Q

elevated BP

A

120/80 - 129/80 mmHg

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21
Q

high BP stage 1

A

130/80 - 139/90 mmHg

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22
Q

high BP stage 2

A

> 140/90 mmHg

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23
Q

hypertensive crisis

A

> 180/120 mmHg

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24
Q

congestive heart failure

A

less than optimal ejection of blood from heart
= less blood to oxygenate tissues

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25
Q

CHF evaluation

A

shortness of breath w/activity?
more fatigued/weaker than normal?
swelling in legs?
persistent cough w/pink phlegm?
weight gain?

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26
Q

Valvular disease evaluation

A

diagnosed w/heart valve problem?
ascultate heart for murmurs

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27
Q

common valvular disorders

A

stenosis
regurgitation

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28
Q

stenosis

A

valve area narrowing restriction to flow

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29
Q

regurgitation

A

valve area does not close properly so blood flows back through valve

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30
Q

Atrial Septal Defect /
Ventricular Septal Defect

A

septum has not formed properly and has a hole
causes pressure changes
impacts blood flow direction in heart

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31
Q

Conduction System abnormalities

A

specialized cardiac cells allow electrical conduction
change conduction = change how heart pumps

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32
Q

HR 60-100

A

normal

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33
Q

HR < 60

A

bradycardia

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34
Q

HR > 60

A

tachycardia

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35
Q

bradycardia/tachycardia

A

may not supply heart w/enough O2
leads to ischemia

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36
Q

respiratory system common diseases

A

obstructive lung disease
restrictive lung disease
cigarette smoking/cessation
obstructive sleep apnea

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37
Q

Risk of postoperative pulmonary complications in pts w/respiratory diseases

A

risk is 1-23% after major surgery
PPC includes:
respiratory infection, resp failure, pleural effusion, atelectasis, pneymothorax, bronchospasm, apsiration pneymonitis

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38
Q

obstructive lung disease

A

asthma
COPD
* cant exhale as much as normal lung

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39
Q

dyspnea grade 0

A

no dyspnea while walking at normal pace

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40
Q

dyspnea grade I

A

short of breath when hurrying up hill

mild

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41
Q

dyspnea grade II

A

slower than contemporaries

moderate

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42
Q

dyspnea grade III

A

stops for breath after 100 yds

severe

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43
Q

dyspnea grade IV

A

dyspnea at rest

very severe

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44
Q

Cigarette smoking evaluation

A

always ask:
last cigarette?
how many years?
how many packs per day?id

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45
Q

ideal smoking cessation prior to surgery

A

6-8 weeks

less than 3-4 weeks doesn’t increase or decrease risk

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46
Q

ideal timeline to mx smoking cessation post surgery

A

4 weeks
reduces wound healing complications by 50%

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47
Q

obstructive sleep apnea (OSA)

A

short periods of apnea caused by blockage of air movement in upper airway

2-25% of population

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48
Q

Apnea Hypopnea Index

A

the combined average number of apneas and hypopneas that occur per hour of sleep

level of severity of OSA

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49
Q

AHI scoring system

A

Snoring
Tired
Observed apnea
Pressure (BP high)
BMI > 35
Neck > 16
Gender

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50
Q

mild OSA

51
Q

moderate OSA

52
Q

severe OSA

53
Q

pulmonary hypotension values

A

mean pulmonary artery pressure >25mmHg
systolic pulmonary artery pressure >50mmHg

54
Q

pulmonary HTN

A

increased risk for
- heart failure
- hemodynamic instability
- respiratory failure
- prolonged intubation

55
Q

Endocrine System

A
  • diabetes
  • hyperthyroidism: Graves
  • hypothyroidism: Hashimotos
  • obesity
56
Q

diabetes mellitues

A

fasting plasma glucose > 126mg/dL
or
HgA1c >= 6.5%

goal: preop sugar < 180 mg/dL

57
Q

insulin guidelines

A

facility dependent

decrease long acting day prior
no insulin day of

58
Q

obsesity

A

increases risk of coexisting disease
dosing meds can be challenging
difficult mechanical ventillation
incr risk of postoperative hypoxia

59
Q

ideal body weight male

A

50+2.3(height-60inches)

60
Q

ideal body weight female

A

45.5-2.3(height-60inches)

61
Q

BMI

A

body mass index (kg/m2)

weight / (height*height)

62
Q

obese BMI

63
Q

overweight BMI

64
Q

Gastrointestinal evaluation

A

GERD
IBD
- Cronhns
- ulcerative colitis
bowel obstructions
peptic ulcers

65
Q

Musculoskeletal

A

myopathies
- MH
- rhadbomyolosis
myasthenia gravis
hemiplegia (no succ)

66
Q

Oncology

A

cancer treatment?
avoid dexamethasone?

67
Q

Hepatic

A

liver failure
- changes drug metabolism
- risk for esophageal varices

68
Q

Kidney disease

A

end-stage renal disease
- renal excretion of meds is slowed

69
Q

Common allergies

A

antibiotics
- penicillin
- cephalosporin
foods
-seafood
- bananas/kiwi
- egg (propofol)
latex
- spina bifida/myelemeningocele
aspirin/NSAIDS

70
Q

Social history

A

alcohol use
smoking
drugs

71
Q

Family history of anesthesia

A

malignant hyperthermia
psuedocholinesterase deficiency

72
Q

malignant hyperthermia

A

ryanodine receptor mutation
- increases metabolic output
life threatening response to volatile anesthetics

73
Q

psuedocholinesterase deficiency

A

prolonged response to drugs metabolized by pseudocholinesterase

succinycholine
mivacurium

74
Q

ASA 1

75
Q

ASA2

A

pt w/mild systemic disease

76
Q

ASA 3

A

pt w/severe systemic disease

77
Q

ASA 4

A

pt w/severe systemic disease that is a constant threat to their life

78
Q

ASA 5

A

moribund pt who is not expected to survive w/o surgery

79
Q

ASA 6

A

brain dead pt for organ donation

80
Q

ASA E modifier

A

ie. ASA3E
pt when an emergency procedure is required

81
Q

Vitamin K antagonists

A

Warfarin
stop 5 days prior
briding therapy of LMW heparin for mod/high risk VTE

82
Q

Direct Oral anticoagulatnts

A

low bleeding risk - 24 hrs
mod bleeding risk - 48 hrs
high bleeding risk - 72 hrsh

83
Q

home medications

A

continue most regularly schedule meds through the morning of surgery

84
Q

home meds you might need to change prior to surgery

A

anticoagulants
oral hypoglycemics
monoamine oxidase inhibitors
ACE inhibitors
non-prescription meds

85
Q

physical exam overview

A

airway assessment
lung auscultation
cardiac auscultation
additional considerations

86
Q

difficult mask ventilation

A

Obese
Bearded
Elderly
Snorers/OSA
Edentulous

Hx of neck radiation
large neck curcumference
male
mallampati III/IV
airway mass/tumor

87
Q

airway assessment options

A

mouth opening/jaw protraction
loose/problematic dentition
neck range of motion
neck anatomy
mallampati

88
Q

mallampati class 1

A

soft palate
fauces
uvula
pillars

89
Q

class 2

A

soft pallate
fauces
uvula

90
Q

class 3

A

soft palate uvula

91
Q

class 4

A

hard palate only

92
Q

thyromental distance

A

pt fully extends neck
distance from chin to thyroid notch
3 finger breadth
(6.5cm)

  • potential space into which tongue will be displaced during DL
93
Q

mouth opening

A

<3finger width opening (3cm)

94
Q

mandibular protrusion Class A

A

lower incisor protruded anterior to upper incisors

95
Q

mandibular protrustion class B

A

lower incisor protruded edge to edge w/ upper incisors

96
Q

mandibular protrusion class C

A

lower incisor cant be protrude edge to edge

  • predictaive of difficult intubation
97
Q

Conditions associated w/difficult airway

A

pierre robin
mucopolysaccharidoses
treacher collins
trisomy 21
beckwith-weidemann
aperts
goldenhar
klippel-feil

98
Q

respiratory exam

A

auscultation of lung
work of breathing
body habitus

99
Q

physical exam

A

check for:
infection
scars
musculoskeletal deformity`

100
Q

ECG

A

5 lead std
asymptomatic pt-low risk will not get pre-op ECG
pts w/known CAD , arrythmia reasonable to get ECG

101
Q

Cardiac cath

A

procedure used to diagnose and treat certain cardiovascular conditions

long thin tube inserted into artery or vein in groin, neck, or amr and threaded through blood vessels to heart

102
Q

pulmonary function test

A

spirometry
- Forced vital capacity (80-120%)
- force expiratory vol (80-120%)

plethysmography
- ful lung function tests
- FRC (75-120%)
- RV (75-120%)
- lung CO2 diffusion capacity (60-120%

103
Q

renal kidney function

A

cr clearance
- wast from catabolism of muscle
normal male: 0.74-1.3
normal female: 0.6 - 1.1

104
Q

renal - BUN

A

6-24 mg/dL

105
Q

radiology tests

A

Chest Xray
MRI
CT
Carotid ultrasound

106
Q

BMP (Chem 7)

A

Na+
Cl-
BUN
K
CO2
Cr
Glu

107
Q

CBC

A

WBC
Hgb
Hct
PLT

108
Q

Coagulation studies

109
Q

informed consent

A

competence - ability to understand, retain, and use info
unmedicated
reasonable person std

110
Q

Na+

A

135-145 mEq/L

111
Q

K+

A

3.5-5 mmol/L

112
Q

Cl-

A

96-106 mEq/L

113
Q

CO2

A

23-29 mEq/L

114
Q

BUN

A

7-20 mg/dL

115
Q

Cr

A

male: 0.74-1.3 mg/dL
female: 0.6-1.1 mg/dL

116
Q

Glu

A

60-100 mg/dL

preDM: 100-126 mg/dL

117
Q

Hgb

A

male: 13-16 g/dL
female: 11.5-15 g/dL

118
Q

Hct

A

male: 45%
female: 39%

119
Q

WBC

A

4.5-11 x109/L

120
Q

Plt

A

150000-450000/microL

121
Q

PT

A

11-13.5sec

122
Q

PTT

123
Q

INR

Sp: Intro to Anes (12 decks)

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