HA oral: History, Induction (some) Flashcards
What are the Regulatory Requirements?
- AANA Standard of Care (14 Standards)
- American Society of Anesthesiologists – mandated
- The Joint Commission on Accreditation of Healthcare Organizations – mandated
- Centers for Medicaid and Medicare – reimbursement
What are the Goals of Preoperative Evaluation*
- Reduce patient risk and morbidity associated with surgery and anesthesia
- Reduce costs
- Promote efficiency
- Prepare the patient medically and psychologically
What are the Components of Preoperative Evaluation*
- Patient medical history (chart review + history taking)
- Physical exam
- Medications/Allergies
- Laboratory testing/Diagnostic testing
- Medical consultation (if indicated)
- ASA-Physical Status assignment
- NPO status (fasting status and aspiration risk)
- Formulation of anesthetic plan
- Discussion of plan (educate and decrease anxiety)
- Informed consent
- Documentation
Where is the pre-operative assessment performed?
- Presurgical testing centers (early testing)
- Hospitals (OR settings, Critical care units, or Specialty departments)
- Outpatient centers
When is the Preop Eval performed?
Optimal Situation = Preoperative Clinic Visit ~ 1 week preop
Patient interview
Physical examination
Develop anesthetic plan
Promotes patient teaching & anxiety reduction
Allows time to schedule appointments with medical consultants and complete required pre-operative diagnostic testing
Obtain informed consent prior to operative day
Who Requires EARLY Preoperative Assessment?
Examples:
Angina, CHF, MI, CAD, poorly controlled HTN
COPD/severe asthma, airway abnormalities, home O2 or ventilation
IDDM, adrenal disease, active thyroid disease
Liver disease, end-stage renal disease
Morbid obesity, symptomatic GERD
Severe kyphosis, spinal cord injury
Bringing these patients in early, gives ample time for testing, may need to see consult services, and prevents surgery being cancelled day of.
How do we collect this info? OR SCHEDULE
Demographics (name, age, gender) Diagnosis/Procedure Length of procedure + position Surgeon(s) Type of anesthesia (double check)
How do we collect this info? CHART REVIEW
Chart Review Demographics (name, age, gender) Diagnosis/Procedure Prior H&P (from surgeon or internist) Nursing notes Patient questionnaire Results of Laboratory Tests EKG, PFTS, X-Ray, Etc. Vital Signs Medication List Allergies Surgical consent
How do we collect this info? IF INPATIENT MAY ALSO LOOK AT:
If inpatient, may also look at: Progress notes Medication administration records Nursing notes & Consult notes Test results Old anesthesia records – complications noted?
Are there additional benefits of preop assessments?
Preoperative Interview
Introduction: title (SRNA, CRNA, MDA) & role
Reason for interview & Handshakes
Eye contact, speak at eye level, having a calming voice, make the patient feel comfortable as much as you can = decrease patient’s anxiety
Confirmation: pt. ID, dx, procedure (surgical site)
Education: type of anesthetic, IV insertion, urinary cath, airway instrumentation, monitors, postop care
Establishment: trusting relationship
Make sure it is okay to speak in front of their family members
Assessment of a patient’s HISTORY?
Review of Systems (subjective)
CNS/NM
Cardiac/Vascular/HTN (“heart problems?” what happen, did you have a heart attack?)
Pulmonary (“lungs”)/ENT
Endocrine
GI/Liver/Renal
Hematologic
Medications
Prescription meds (*dc’ed, Taken this AM?)
OTC (ASA, NSAIDS, ibuprofen, etc.)
Herbals – stop these meds 2 weeks prior
Allergies (what was it and what happened) *including latex type of reactions
DC MEDS PRE-OP (Box 31.15)
ACEIs (-prils), ARBs (-sartan) for HTN
Aspirin 3 days prior
Exception: continue w/prior PCI, High grade IHD, and significant CVD
P2Y12 Inhibitors
Clopidogrel: 5-7 days prior
Ticagrelor: 5-7 days prior
Prasugrel: 7-10 days prior
Ticlopidine: 10 days prior
Exception: Do not DC w/drug eluting stents until they completed 6 mo of dual anti-plt therapy, Metal stents until they have completed 1 mo of dual anti-plt therapy, or cataract surgery w/topical or GA
NSAIDs (ibuprofen – Motrin, Advil, Celebrex, Ketorolac) DC48 hrs before Sx
Warfarin (Coumadin) 5 Days prior
Exception: Continue if pt having cataract Sx w/o a Bulbar block
Short Acting Insulin (Regular) unless insulin is administered by continuous pump
Type 1 DM: take a small amount (~1/3) of usual AM long-acting insulin dose on day of Sx
Type 2 DM: take none or up to ½ of their dose of long-acting or combination (70/30) insulin on day of Sx
Non-insulin anti-diabetic meds DC day of Sx.
Exception: SGLT2 Inhibitor DC 24 hrs before Sx
Topical Meds (Creams & Ointments)
Diuretics DC day of Sx
Exception: Do NOT DC Thaiazide Diuretics
Sildenafil (Viagra) DC 24 hrs before Sx
Past Surgical History (including previous anesthetics)
Complications & Family history complications “Stayed intubated for a while” = pseudocholinesterase inhibitor? “Allergic to anesthesia” = MH? Other Pain NPO status Height/weight ETOH use? Drug abuse? Tobacco use? Females – LMP? Obstetrical deliveries? Document!!!!
The Preop Interview: PHYSICAL EXAM
General Impression, Mental status (CNS/PNS Assessment)
Airway Exam** – for every patient, regardless of plan
Looking for predictors of difficult airway management
Lungs
Heart
Vital signs (the most current)
Height/weight (important in dosing)
Mallampati Classification:
PUSH “By itself, the Mallampati class has a low positive predictive value in identifying patients who are difficult to intubate. Therefore, a multifactorial approach to predicting intubation difficulty has proven to be more helpful”
Additional difficult airway predictive tests*
1. Thyromental distance Ideal: at least ~6 cm (3-4 FB), but <9 cm >9 cm is harder to intubate because the glottic opening is so far down 2. Interincisor distance Ideal: > 3 cm (~2 FB) 3. Atlanto-occipital function Located on the back of the neck/joint Max degree of extension: 35° Problematic when it’s limited to 23°
- Mandibular protrusion test (Upper Lip Bite Test)
- Hyomental distance (mandibulohyoid)
Distance from the hyoid bone from the mandible
Ideal: > 3 cm (~2 FB) - Neck circumference
Average neck size: ~15
Male = 15 - 16 inches (38-40 cm);
Women = 13-14 inches (33-35 cm)
17 inches or > 40 cm neck size = 5% chance of difficult airway
↑ 1.3% for every 1 cm ↑ in neck size (bigger neck = more problems)
COMPONENTS OF AN AIRWAY EXAMINATION
& NON-REASSURING FINDING
DIFFICULT AIRWAY
Length of upper incisors - Relatively long
Relationship of maxillary and mandibular incisors during normal jaw closure - Prominent “overbite”
Maxillary incisor ANTERIOR to mandibular incisor
Relationship of maxillary and mandibular incisors during upper lip bite test - Inability to bring mandibular incisors ANTERIOR to maxillary incisor
Interincisor distance - < 3 cm (~2 FB)
Visibility of uvula-Not visible when tongue is protruded with patient in sitting position (e.g., Mallampati Class II)
Compliance of the mandibular/oral space - Highly arched or very narrow
Radiation or surgical changes
Stiff, indurated, occupied by mass or nonresilient
Thyromental distance - < 6 cm (3 FB)
Length of neck - short
Thickness of neck - thick
Range of motion of head & neck - cannot touch tip of chin to chest or extend neck
Difficult Mask Ventilation
Age > 55 years old OSA or snoring Previous head/neck radiation, surgery, trauma Lack of teeth Beard BMI > 26 kg/m2
Difficult Direct Laryngoscopy
Reported history of difficult intubation, aspiration, pneumonia after intubation, dental or oral trauma following intubation
OSA or snoring
Previous head/neck radiation, surgery, trauma
Congenital disease: Down syndrome, Treacher-Collins syndrome, Pierre Robin syndrome
Inflammatory/Arthritic disease: Rheumatoid arthritis, Ankylosing spondylitis, Scleroderma
Obesity
Cervical spine disease or previous surgery
What is the Prayer Sign? How do we assess for it?
Should perform this during airway exam, especially on pts with Type I DM
When we see this in hands, this could also occur in airway/neck
May not have A-O extension of 35 degrees
Overtime DM causes collagen linking disorder affecting joints opening between pinkies, unable to flatten fingers together
Finger flat?
PHYSICAL EXAM: Heart & CV
Heart Auscultation Rate & Rhythm Murmurs Bruits (carotid) Extremity pulses CV Bruits (carotid) Extremity pulses Extremity edema
Physical Exam: Lungs
Lungs (front and back; skin to skin w/stethoscope) Inspection Auscultation Percussion Palpation
Physical Exam Neurologic/Musculoskeletal
Neurologic/Musculoskeletal System: Extent of neuro exam really depends on baseline deficits, disease or surgical procedure (important that you document baseline deficits!)
Motor – gait, grip strength, ROM, ability to hold arms forward, etc.
Sensory – distinction of vibration, pain, light touch along dermatomes
Muscle reflexes – deep, superficial, and pathologic
Cranial nerve abnormalities
Mental status & Speech
End Target Organ Damage
usually with chronic complications e.g., DM, hypertension target organ damage like heart, kidney, eyes have been affected may require an ECHO before we put them to sleep)
ROS: review of systems
Do you have heart issues? Heart attack, angina = TARGET ORGAN DAMAGE
Have you had a stroke = TARGET ORGAN DAMAGE
PE: physical assessment
Hear a bruit (stenosis, ~70% occlusion) = TARGET ORGAN DAMGE may require a doppler before we put them to sleep
Cotton wool exudate Damage eye sight = TARGET ORGAN DAMAGE
CXR/EKG:
Cardiomegaly (Big heart) = TARGET ORGAN DAMAGE
Wide QRS, L axis deviation Inverted T waves = TARGET ORGAN DAMAGE
Labs:
High BUN & Creatinine = TARGET ORGAN DAMAGE
GFR < 60 = TARGET ORGAN DAMAGE
Protein in urine = TARGET ORGAN DAMAGE
Pre-procedure Laboratory Testing. Who needs what?
“2012 ASA Practice Advisory for Pre-anesthesia Evaluation states that routine preoperative tests do not make an important contribution to preanesthetic evaluation of an asymptomatic patient”
Preop testing should be SELECTIVELY ordered based on:
Patient’s medical history and physical exam
Planned surgery
Expected intraoperative blood loss
SELECTIVE testing:
Expedites patient care
Reduces healthcare cost
Improves delivery of perioperative meds
Will the results change the INTRAOPERATIVE management of this patient? If yes, then order the test. If we aren’t going to do anything different to our plan of care than don’t order more tests.
Defining Normal Values
We must understand the interpretation
Ideally, tests would confirm or exclude presence of disease
Most tests only increase or decrease probability of disease
Performing a test in a pt with no risk for a specific disease high level of false-positive results
Ex. A K+ level of 3.0mg/dL in a healthy individual is most likely a normal result. Interpreting as abn and initiating tx could lead to harm without benefit.
Predictive Value of Test
Sensitivity: a sensitive test is very good at identifying those who have the disease; TRUE POSITIVE
A Sensitive test with a Negative result rules OUT disease SnNOUT
Specificity: a specific test is very good at identifying those without the disease; TRUE NEGATIVE
A Specific test with a Positive result usually rules IN disease SpPIN
Factors that contribute to nonselective ordering
Surgeons and PCPs – often no diagnostic focus
Anesthesia providers “require them”
Routine screening for disease states
Diagnostic baseline
Personal habit
Medicolegal necessity “not to miss anything”
The more things you get, the more you are responsible for following up on
For an ASA 1 patient, the more you are increasing their changes for being sued more/increasing medical liability
Pre-testing is partially based on invasiveness of Sx
Minimally Invasive (skin lesion excision):
Little tissue trauma
Minimal blood loss (<500 mL)
Moderately Invasive (inguinal hernia, tonsillectomy, knee arthro)
Modest disruption of normal physiology
Anticipate some blood loss (500-1500 mL)
May need invasive monitors and/or ICU
Highly Invasive (vascular surgery, TURP, TJR, radical neck dissection, lung)
Significant disruption of normal physiology.
Blood loss >1500 mL
Commonly require transfusion and ICU care
Labs/Tests: Will a positive or negative result affect the case management in any way?
What labs/tests and when? Table 31.18
Institutional policy
Current expert organization guidelines i.e. ACC/AHA guidelines
Anesthesia provider judgment
CXR? When to order, indications? Smokers?
Assessment of perioperative risk is questionable. Therefore, should not be ordered routinely
Decision: based on abnormalities identified during the preop assessment (i.e., rales, SOB, intercostal retractions, deviated trachea)
INDICATIONS:
Severe COPD
Suspected pulmonary edema
Pneumonia
Suspected mediastinal masses or PE
What about CXR in smokers? Significant smoking history ~ 20 pack years
___ packs a day x __ year = __ pack year smoker
2 packs a day x 20 years = 40 pack year smoker
RECOMMENDATIONS for PREOP 12-LEAD ECG
CLASS IIA RECOMMENDATION: It is Reasonable to Perform the Procedure for patients with IHD (ischemic heart disease), significant arrhythmia, PAD, CVD, or significant structural heart disease (except if undergoing low-risk surgical procedures)
Class IIB: The Procedure may be Considered for asymptomatic pats w/o known coronary heart disease, except for those undergoing low-risk surgical procedures
Class III: The Procedure Should Not Be Performed Because it is Not Helpful for asymptomatic patients undergoing low-risk surgical procedures
What are the ASA liberal fasting guidelines?*
Based on CURRENT ASA guidelines that balance risk factors of fasting with pulmonary aspiration risk
2 hours for clear liquids all patients
Clear, juice without pulp, coffee without cream/sugar, gadorate, propel
4 hours breast milk
6 hours formula or solids; light meal
8 hours heavy meal fried or fatty food
1 hour sip of water or liquid pre-med up to 1 hr.
Follow your institutions policy however!
Note: Some clinicians remain skeptical and use more conservative guidelines NPO 6-8 hours etc.
Conditions Classifications That Would Make the Possibility of Aspiration More Prominent RSI***
Age extremes <1 yr or >70 yr
Ascites (ESLD)
Collagen vascular disease, metabolic disorders (DM, obesity, ESRD, hypothyroid)
Hiatal Hernia/GERD/Esophageal surgery
Mechanical obstruction (pyloric stenosis)
Prematurity
Pregnancy
Neurologic diseases
Having eaten food or non-clear drinks
HIV with a lot of lipodystrophy, cranial nerve palsy
ASA or PS (Physical Status) Classification
“To classify the physical condition of the patient requiring anesthesia and surgery.”
Reflection of Preoperative status
ASA is independent of the operative procedure and surgical risk
Subjective communication tool used between anesthesia providers
I: normal, healthy patient; no systemic disease
II: mild systemic disease, well controlled, no functional limitation
III: severe systemic disease, functional limitations
IV: severe systemic disease that is a constant threat to life
V: moribund patient, not expected to survive with or without the surgical procedure (e.g., ruptured aortic aneurysms)
VI: patient declared brain dead whose organs are being harvested for donation
E: emergency operation required (e.g., can added to anything classification IE, 2E)
Formulate Anesthetic Plan:
Preoperative care Intraoperative care: Type of Anesthesia/Drugs Monitors Airway Positioning Postoperative care Pain management – regional working 18 hrs post-surgery or PCA, etc.
Anesthesia Plan Components
Drug plan/Anesthetic technique Airway plan/Ventilation plan Fluid plan/IV access plan Monitoring plan Positioning plan Other considerations
Anesthesia plan influenced by:
Current physical status History and physical assessment Co-existing diseases Airway assessment/Diff. airway Previous anesthesia complications/Family Hx of anesthesia complications Planned surgery
Choices of Anesthetic Technique
Initiation of the anesthetic technique may include General Regional Combined General/Regional MAC Local Anesthetics
Proposed Airway Plan
Airway Plan:
ETT, LMA, NC, Face Mask
ETT: Size (Woman: 6 – 6.5; Male: 7.5 – 8.0 mm OD)
Armored, oral RAE, nasal RAE, double-lumen, etc
Blade: Miller #, Mac #,Glidescope, bougie, etc.
LMA: Size (based on body weight), gastric port, ability to insert ETT
Vent Settings:
TV: RR: FiO2: I:E:Spontaneous RR, assisted RR, volume controlled vs pressure controlled
Other
Difficult airway cart, airway blocks
Knowledge of the difficult airway algorithm
Other monitors
Invasive arterial line CVP/ PA catheter TEE PNS BIS Glucometer EEG/SSEP EMG
Intraoperative Fluid Requirements know how to calculate fluids
Maintenance Fluid deficit Estimated Blood Volume Allowable Blood loss Evaporative loss (3rd space loss)
Goal-direct fluid management
Updated: ERAS procedures (specific end points, stroke monitor endpoints, cardiac outputs, etc.)
Discuss anesthesia plan with:
Supervising staff
Patient
Surgeon
OR team
Confirm Schedule with OR team Procedure(s), Time, Length Anatomical location OR table position Patient position X-ray needed? Additional medications needed?
Patient Preparation: Information the Patient Requires from an Anesthesia Professional:
Discuss choices of anesthetic technique (Verbal & Written Consent)
Explain IV catheter
Describe use of local anesthetics, medications, fluids
Discuss airway management plan
Explain monitors (placement, purpose)
Discuss postoperative recovery
Discuss pain management plan
Informed Consent
Explanation of the planned anesthetic. Explanation of options available. Risks vs. Benefits Pt. understanding & cooperation Without consent – Assault and Battery Minors – consent from parents or guardian Signature of pt. & witness
MSMAIDS
- Monitors on, alarms set
- Suction on and at HOB
- Means of PPV, machine check,
- Airway (ETT, LMA)
- IV and fluids
- Drugs
- Patient position
Airway Setup
- face mask, right size
- PPV
- Suction
- tongue depressor
- oral/nasal airway
- LMA
- 2 laryngoscope handles
- 2 blades (Female Mac3, Miller 2. Males Mac4, Miller3-4)
- ETT 2 sizes (F=6.5-7, M=7.5-6)
- Stylet & syringe
- Tape
Intubation position & preoxygenation
Position patient supine in the sniffing position
Align 3 axis – oral, pharyngeal, and laryngeal axis
Ask patient if “they can tilt chin up towards me?” Allow the patient to get in a good sniffing position.
Ramp up with blankets if need to.
Align external acoustic meatus with sternal notch.
Place monitors – obtain pre-induction vitals
Pre-oxygenate = safe apnea time, replace Nitrogen in the FRC with 100% FiO2
5 minutes of 100% FiO2 at >6L/minute flow = 10 minutes of safe apnea time
4 Vital Capacity breaths in 30 seconds = 5 minutes of safe apnea time
Use for emergencies or traumas
Morbidly obese patients & pregnant patients, this time is cut in half, important that pre-oxygenate these patients very well
Meds you’ll need during intubation
With any medication think about co-morbidities, dose, on-set and duration of action
Anti-anxiety premedication – Versed/Ativan/Valium
Narcotic – Fentanyl/Dilaudid/Morphine/Demerol
Fentanyl: Onset 5 min, Blunts SNS response to laryngoscopy
Narcotic + Anti-anxiety medication = Synergistic effect (1+1 = 3)
Consider use of Lidocaine Dose: 1 mg/kg for induction
Blunts of the SNS response to laryngoscopy & helps with burning of the IV
Induction Agent – Propofol/Etomidate/Ketamine/Thiopental
They are asleep – now what
Confirm loss of consciousness with eyelash reflex Test ventilate (should only take 1 breath to determine if you can ventilate or not = chest rise, fogging in the mask) If unable to ventilate … Reposition (readjust sniffing position) Use oral airway Try two hands on the mask Difficult airway algorithm Plan B airway
We can ventilate!
Apply Peripheral Nerve Stimulator (PNS) and check baseline 4 twitches
Best place to measure onset of blockade on induction: Facial nerve (orbicularis oculi muscle) = eyebrow twitch
Best place to measure recovery of blockade on emergence: Ulnar nerve (adductor pollicis muscle) = thumb adduction, flexion of 4th & 5th fingers/adduction of 5th finger = no residual blockade exists in diaphragm if adductor pollicis recovered from relaxation definitely have action on diaphragm and vocal cords
Administer Neuromuscular blocker (NMB) – Succinylcholine/Rocuronium/Vecuronium/Atracurium/Cis-atracurium/Pancuronium
Again, with any medication think about co-morbidities, dose, on-set and duration of action! Also consider the surgery, surgeon desire/need for paralysis, length of case.
Monitor effectiveness of NMB with PNS
Paralysis takes time
Continue to ventilate while NMB action takes effect
Tape eyes
Loss of twitches confirmed with PNS
Attempt laryngoscopy and tracheal intubation (scissor mouth open, laryngoscopy, place ETT)
Confirm ETT placement (look at the patient first!)
Watch it pass the vocal cords
Fogging of ETT (you will have fogging in the esophagus too but only a breath or two; )
Bilateral chest rise
Bilateral breath sounds (recommend looking L R, because if you have a right mainstem you won’t have L)
Presence of 3 ETCO2 waveforms (takes 30 seconds for this to register on the monitor)
With severe bronchospasms = you won’t see any of this
Tape ETT. Depth approximately = ID x 3 (Listen and determine if you need to pull back or not)
