History & Physical (some induction) 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
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
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
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!!!!
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
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
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
