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Spring Clinical Methods (final exam) > Anesthesia Consultation > Flashcards

Anesthesia Consultation Flashcards

1
Q

What is the purpose of the preoperative consultation?

A

To reduce the patient’s surgical and anesthetic perioperative morbidity or mortality, and to return the patient to desirable level functioning as quickly as possible.

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2
Q

“Perioperative risk” is multifactorial and a function of: (3)

A
  • the preoperative medical condition of the patient
  • the invasiveness of the surgical procedure
  • the type of anesthetic administered
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3
Q

Surgical procedures and administration of anesthesia are associated with a complex stress response that is proportional to: (4)

A
  1. the magnitude of injury
  2. total operating time
  3. amount of intraoperative blood loss
  4. degree of postoperative pain
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4
Q

What is the key factor in improving outcome and lowering the length of hospital stay as well as the total costs of patients care?

A

Decreasing the stress response to surgery and trauma

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5
Q

What are the goals of preoperative evaluation?

A
  • Documentation of the condition(s) for which surgery is needed.
  • Assessment of the patient’s overall health status.
  • Uncovering of hidden conditions that could cause problems both during and after surgery.
  • Perioperative risk determination.
  • Optimization of the patient’s medical condition in order to reduce the patient’s surgical and anesthetic perioperative morbidity or mortality.
  • Development of an appropriate perioperative care plan.
  • Education of the patient about surgery, anesthesia, intraoperative care and postoperative pain treatments in the hope of reducing anxiety and facilitating recovery.
  • Reduction of costs, shortening of hospital stay, reduction of cancellations and increase of patient satisfaction.
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6
Q

What is the most important component of the preoperative evaluation?

A

patient history

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7
Q

What should the patient history include? (8)

A
  • a past and current medical history
  • a surgical history
  • a family history
  • a social history (use of tobacco, alcohol and illegal drugs)
  • a history of allergies
  • current and recent drug therapy
  • unusual reactions or responses to drugs and any problems or complications associated with previous anesthetics.
  • family history of adverse reactions associated with anesthesia should also be obtained.
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8
Q

A focused pre-anesthesia physical examination includes: (2)

A
  • an assessment of the airway
  • lungs and heart, with documentation of vital signs
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9
Q

When is a complete blood count needed? (4)

A
  • major surgery
  • chronic cardiovascular, pulmonary, renal, or hepatic disease, or malignancy
  • known or suspected anemia, hemorrhage, or myelosuppression
  • less than 1 y/o
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10
Q

When is an PTT/INR indicated? (3)

A

anticoagulant therapy

bleeding diathesis (hemorrhage)

liver disease

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11
Q

When are electrolytes and creatinine labs indicated? (5)

A

HTN

renal disease

diabetes

pituitary or adrenal disease

digoxin or diuretic therapy

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12
Q

An EKG is indicated prior to surgery for these patients:

A
  • heart disease, HTN, diabetes
  • other risk factors for cardiac disease (including age, which alone is reason to get an ECG)
  • subarachnoid or intracranial hemorrhage, CVA, head trauma
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13
Q

When is a CXR indicated preoperatively?

A

cardiac or pulmonary disease

malignancy

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14
Q

When should MAO be withdrawn prior to surgery?

Why?

A

2-3 weeks

risk of interactions with anesthetics

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15
Q

When should oral contraceptives be discontinues before elective surgery?

Why?

A

6 weeks

increased risk of venous thrombosis

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16
Q

When should patients discontinue their herbal supplements?

A

2 weeks prior

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17
Q

When should aspirin be discontinued prior to surgery?

A

7-10 days

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18
Q

When should thienopyridines (such as clopidogrel) be discontinued prior to surgery?

Why?

A

2 weeks before

Affects platelets

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19
Q

When should oral anticoagulants be discontinued prior to surgery?

What should INR level be?

A

4-5 days

1.5

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20
Q

What are major clinical predictors of increased risk for perioperative cardiac complications? (5)

A

recent MI

unstable or severe angina

decompensated CHF

significant arrhythmias

severe valvular disease

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21
Q

What are intermediate clinical predictors of increased risk for perioperative cardiac complications? (5)

A

mild angina

prior MI history

compensated CHF

diabetes

renal insufficiency

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22
Q

What are minor clinical predictors of increased risk for perioperative cardiac complications? (6)

A

advanced age

abnormal ECG

rhythm other than sinus

poor functional capacity

history of stroke

uncontrolled HTN

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23
Q

What are high risk predictors for perioperative cardiac complications? (cardiac complication rate of >5%) (4)

A

emergency surgery

aortic and major vascular surgery

prolonged surgical procedures with large fluid shifts or blood loss

unstable hemodynamic situations

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24
Q

What are intermediate risk procedures for perioperative cardiac complications? (cardiac complication rate of 1-5%) (6)

A

abdominal or thoracic surgery

neurosurgery

ENT procedures

minor vascular surgery

orthopedic surgery

prostatectomy

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25
Q

What are low risk procedures for perioperative cardiac complications? (cardiac complication rate of

A

breast surgery

superficial surgery

eye surgery

endoscopic procedures

plastic and reconstructive surgery

ambulatory surgery

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26
Q

What functional capacity, METS:

standard light home activities
walk around the house
walk 1-2 blocks on level ground at 3-5 km/hr

A

1-4 mets

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27
Q

What functional capacity, METS:

climb a flight of stairs
walk up a hill
run a short distance
moderate activities like golf, dancing, mounting walking

A

5-9 METS

28
Q

What functional capacity, METS:

strenuous sports (swimming, tennis, bicycle)
 heavy professional work
A

>= 10 METs

29
Q

What does METs stand for?

A

metabolic equivalents of oxygen consumption

30
Q

What are postoperative pulmonary complications? (7)

A

Pneumonia
Atelectasis
Bronchitis
Bronchospasm
Hypoxemia
Respiratory failure with prolonged mechanical ventilation
Exacerbation of underlying chronic lung disease

31
Q

What ASA status is a patient with mild systemic disease?

A

ASA 2

32
Q

What ASA status is a patient with severe systemic disease?

A

3

33
Q

What ASA status is a patient with severe systemic disease that is a constant threat to life?

A

ASA 4

34
Q

What ASA status is a moribund patient who is not expected to survive without the operation?

A

ASA 5

35
Q

What ASA status is an organ donor?

A

ASA 6

36
Q

What are procedure-related risk factors?

A

Primarily based on how close the surgery is to the diaphragm (ie upper abdominal and thoracic surgery are the highest risk procedures)

37
Q

What are risk factors for postoperative pulmonary complications?

A

procedure-related risk factors

length of surgery (>3 hrs)

emergency surgery

underlying chronic pulmonary disease

smoking

age >60

obesity

presence of sleep apnea

poor exercise tolerance

38
Q

What patient should be carefully assessed preoperatively for symptoms and signs of peripheral vascular, cerebrovascular and coronary disease?

A

diabetics

39
Q

Diabetics have a higher incidence of death after a ____ than non-diabetic.

A

MI

40
Q

What should be administered prior to surgery for a diabetic prior to surgery to limit perioperative ischemia?

A

beta-blockers

41
Q

When should you treat blood glucose perioperatively?

A

> 180 is a good rule of thumb

42
Q

What are perioperative hyperglycemia complications?

A

dehydration

impaired wound healing

inhibition of WBC

43
Q

For dental extractions, arthrocentesis, biopsies, ophthalmic operations and diagnostic endoscopy patients need to alter their regimen. True or false?

A

false

do not need to

44
Q

What drugs should be considered for the anticoagulated patient?

A

IV heparin

LMWH (low molecular weight heparin)

45
Q

Invasive surgery is generally safe (from major hemorrhagic complication) when the INR ~___.

A

1.5

46
Q

It takes approximately __ days for the INR to reach 1.5 once oral anticoagulant is stopped preoperatively.

A

4

47
Q

It takes approximately __ days for the INR to reach 2.0 once oral anticoagulant is restarted postoperatively.

A

3

48
Q

Regional anesthesia can safely performed in in patients receiving anticoagulant or antiplatelet therapy provided that patient management is based on appropriate timing of needle placement and catheter removal relative to the timing of anticoagulant drug administration. True or false?

A

true

49
Q

Indwelling catheters should not be removed in the presence of therapeutic anticoagulation, as this appears to significantly increase the risk of _____ _______.

A

spinal hematoma

50
Q

What does this waveform indicate?

A

hyperkalemia

progressive evolution of changes in the EKG that can culminate in ventricular fibrillation and death.
The presence of EKG changes is a better measure of clinically significant potassium toxicity than serum level.

51
Q

What does this waveform indicate?

A

hypokalemia

ST segment depression
Flattening of the T wave
Appearance of a U wave

52
Q

What EKG changes occur with hyper and hypocalcemia?

A

Hypercalcemia = shortens QT interval

Hypocalcemia = prolongs the QT interval

53
Q

What arrhythmia is associated with a prolonged QT interval?

A

torsades

54
Q

What waveform is this?

What does this waveform indicate?

A

Osborne Waves

severe hypothermia

Note: The rhythm is atrial fibrillation. Bradycardia is present. The QT/QTc is prolonged.

55
Q

What does this EKG depict?

A

Digitaisl effect.

Note the downsloping ST segment.

Digitalis toxicity is commonly associated with dysrhythmias and AV nodal blocks.

56
Q

What are the following waveforms?

A

AV Node Blocks

  1. First degree AV block is normal except for a prolonged pr interval > 0.2 sec
  2. Second degree AV block (Mobitz 1 or Wenckebach) is a progressive lengthening of the pr interval until the QRS drops
  3. Second degree AV block (Mobitz 2) there is the presence of a dropped beat without progressive lengthening of the pr interval
  4. Third degree (complete heart block) no atrial impulses make it through to activate the ventricles. Ventricles respond by generating an escape rhythm.
57
Q

What can the following drugs cause to change in an EKG:

Sotalol
Quinidine
Procainamide
Disopyramide
Amiodarone
Dofetilide

A

prolonged QT interval

58
Q

What can the following drugs cause to change in an EKG:

Tricyclic Antidepressants
Phenothiazines
Erythromycin
Quinolone antibiotics
Antifungal medications
* Droperidol & Zofran

A

Can prolong QT interval

59
Q

What are the stages of pericarditis found within the EKG?

A

ST segment elevation

T wave inversion which occurs after ST segment moves back to baseline

Q waves do not occur in pericarditis and the PR interval is sometimes depressed.

60
Q

True / false

Q waves do not occur in pericarditis and the PR interval is sometimes elevated.

A

false

depressed

61
Q

What condition is indicated by:

left ventricular hypertrophy and left axis deviation
Q waves in lateral leads I, aVL, V5, and V6

A

Hypertrophic Obstructive Cardiomyopathy (HOCM)

62
Q

What does this strip indicate?

A

Hypertrophic Obstructive Cardiomyopathy (HOCM)

63
Q

What does this strip indicate?

A

myocarditis

Note: Any diffuse inflammatory process involving the myocardium can produce a number of changes on the EKG. Most common are conduction blocks especially bundle branch blocks & hemiblocks.

64
Q

What does this strip indicate?

A

COPD

Peaked p waves in leads II, III, aVF, and V1

right axis deviation

65
Q

What changes will you see in a pulmonary embolus?

A

s waves in lead I

q waves in lead III

inverted t waves in lead III

S1 Q3 T3

66
Q

True / False

Unlike an inferior infarction, in which Q waves are seen in at least two of the inferior leads, the Q waves in an acute pulmonary embolus are limited to lead III.

A

true

67
Q

What do deeply inverted, wide T waves indicate?

A

CNS bleed

Spring Clinical Methods (final exam) (2 decks)

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