General and Regional Anesthesia Flashcards
Anesthesia Types:
○ General anesthetic
■ Drug induced loss of consciousness that requires a controlled airway
○ Regional blockade
■ Spinal and epidural anesthesia, Peripheral nerve block
○ Local anesthesia
○ Conscious sedation
_____ : Reversibly blocking pain and awareness during surgical and
nonsurgical procedures. Greek origin meaning “without sensation”
Anesthesia:
______ of the preop evaluation
depends on degree of the planned
surgical invasiveness and urgency
Timing
Why is the timing of the preop evaluation important?
Time must be allowed to follow up on
conditions discovered during the
preoperative visit and to answer
questions (if possible).
When should preop evaluations be done based on surgery severity?
High surgical invasiveness ( eg. Colon
resection)
● Minimum the day before the
procedure.
Medium surgical invasiveness
● The day before or the day of the
surgery.
Low surgical invasiveness (eg. Carpal
Tunnel)
● The day of the surgery.
History of complications from surgery/anesthesia
○ Allergic reactions
○ Abnormal bleeding
○ Delayed emergence (hard to wake up, 30-60 min)
○ Prolonged paralysis
○ Difficult airway management
○ Awareness during surgery
Important Elements of Pt history in a preop assessment
■ Kidney or liver disease
■ Metabolic abnormalities (diabetes or thyroid disease)
■ Cardiac conditions
○ Adverse responses to anesthetics (malignant hyperthermia)
Physical Exam- Important Elements
○ Airway is king (one of the most common causes of adverse outcomes)
○ Heart and lung exam (include vital signs here)
○ Other components include:
■ Potential intravenous catheter sites/potential sites for regional anesthesia.
■ Range of motion of limbs must also be noted as this may affect positioning
in the operating room.
■ Any neurologic abnormalities must be noted. (Need to know their baseline
as post CVA is a potential complication).
Mallampati score
Examination and classification of the upper airway based
on the size of patient’s tongue and the pharyngeal structures visible on mouth opening with the patient
sitting looking forward
3-3-2 Rule
● Can you fit 3 fingers in the mouth
perpendicular? If so, then should
be room for insertion of tube and
laryngoscope
● Can you fit 3 fingers between the
angle of the jaw and mentum? If
so, then should be able to lift the
tongue forward
● Can you fit 2 fingers between the
top of thyroid cartilage and
bottom of jaw? If not, then
suspect high anteriorly located
cords
Mallampati Score classifications
● Grade I The soft palate, anterior and posterior tonsillar pillars, and uvula are
visible—suggests easy airway intubation. (Easy)
● Grade II Tonsillar pillars and part of the uvula obscured by the tongue. (Should
be easy)
● Grade III Only soft palate and hard palate visible. (Hard)
● Grade IV Only the hard palate is visible. (Very challenging airway)
Perioperative complication and deaths are most often a combination of:
● Comorbidities
● Surgical complexity
● Anesthesia effects
Physical status classifications:
Does not assign risk but is a common language
used to describe patients preoperative physical status. Above ASA 2 should be seen
in preoperative clinic and have preoperative labs drawn beforehand unless emergent
Pre-op guidelines for patients that have CAD with Prior Percutaneous Coronary Intervention:
● Patients are usually placed on a dual antiplatelet therapy of aspirin and
clopidogrel following angioplasty/stenting.
● The AHA guidelines recommend if the procedure is elective, then the
operation should be postponed until the case can be done with aspirin
as the only antiplatelet drug. If the operation is emergent, then
consideration must be given to the timing of the surgery and the risk of
surgical bleeding.
Pre-op guidelines for patients that have Pulmonary Disease:
● The presence of lung disease puts the patient at risk for perioperative
complications.
● Pneumonia and prolonged difficulty weaning from the ventilator are
two of the most common.
● In some instances, arterial blood gas analysis (ABG) or pulmonary
function tests (PFT) are necessary.
● Patients should stop smoking at least 8 wks prior to the surgery
Preoperative guidelines for patients with obesity
● Airway is often difficult to maintain with mask ventilation secondary to decreased
neck mobility and adipose tissue.
● Morbidly obese patients may have a higher risk of gastric aspiration and
development of aspiration pneumonia (high mortality rate).
● Medication metabolism fatty liver, pain management
● Obesity is a risk factor for OSA
Preoperative Fasting importance and rules
Fasting helps to reduce the risk of pulmonary
aspiration.
● No solid food should be eaten after the evening meal night before. NPO after midnight except for sips of water to take oral medications.
○ At the minimum, most anesthesiologists delay an
anesthetic so that the last solid food was 6-8
hours prior to non emergent surgery.
Preop guidelines on hypertension
BP should be optimized prior to surgery
Unless absolutely indicated, neuraxial anesthesia (spinal, epidural) should
not be performed for at least 12 hours and preferably 24 hours after last dose of
Heparin
Preop guidelines for DM
● The most common metabolic abnormality dealt
with by anesthesia.
● Anesthesia is responsible for glucose control
during the procedure and will monitor at least
hourly if patient is on insulin.
● Remember, the patient will be fasting
preoperatively and intraoperatively
Roles and responsibilities of the Holding Room (aka Preop)
● The nurse checks the patient in and records
vital signs, checks for a signed consent, and
starts an intravenous line if needed.
● The surgeon should confirm and mark the site
of surgery. Answer questions/consent signed.
● The anesthesiologist should confirm the
preoperative evaluation and type of anesthetic
selected. Confirm NPO status if general used.
Preoperative- Informed Consent
● Key word is “Informed”
● Risk/Benefit discussion
○ Maybe your 100th surgery, but it is likely the
patients first
● Surgical Team- Inform the patient about surgical
complications unique to the surgery
● Anesthesiologist will inform of risks of anesthesia
in general
● Both conversations must occur
● Patient must sign informed consent
July 2004, JCAHO (Joint
Commission) instituted a safety
mandate known as the
“Universal Protocol for Preventing
Wrong site, Wrong Procedure,
Wrong Person Surgery”
Wrong Site/Procedure/Person Surgery steps
Step 1: Initial verification of the intended
patient, procedure, and site of the procedure.
Step 2: Marking the operative site
● This mark should not be an “X” but rather a word or line
(representing the proposed incision).
Step 3: A “Time Out” performed immediately before starting the procedure.
○ All members of the care team—surgeon, nurses, anesthesiologists—must
actively participate/listen. (Room needs to be quiet)
This time out must take place before incision
The anesthesiologist is in charge of
the patient well being
Considerations in choosing an anesthetic technique include:
○ Planned surgical procedure
■ For example abdominal versus extremity
○ Patient and surgeon preference
■ Prior complications
○ Urgency of the operation
○ Postoperative pain management considerations
● Patient age (relative risk factor) must also be included in the decision of choice of
anesthetic technique.
