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?
