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
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
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:
Confirm schedule with OR team on:
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
LOSTSEAL
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
Testing ventilation - if unable to ventilate?
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
“ABORT”
What are the considerations when administering NMB during induction
Apply Peripheral Nerve Stimulator (PNS) and check baseline 4 twitches
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
What do you do while the paralytic is taking effect?
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 Watch it pass the vocal cords Fogging of ETT Bilateral chest rise Bilateral breath sounds Presence of 3 ETCO2 waveforms With severe bronchospasms = you won’t see any of this Tape ETT. Depth approximately = ID x 3
“Ventilate EPIC Trachea”
Confirming placement: “Everyone Can Finally Breathe Passively”
Induction medications
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
Consider use of Lidocaine Dose: 1 mg/kg for induction
Induction Agent – Propofol/Etomidate/Ketamine/Thiopental
Intubation unsuccessful? What next?
(this is the big diagram) Call for Help Awaken patient & spontaneous ventilation (If possible/reversible) Mask patient Masking adequate (non emergent pathway: LMA, fiberoptic, diff laryngoscope blade, Masking inadequate LMA LMA adequate (non emergent pathway) LMA inadequate (Emergency pathway) Call for Help (again) Emergency non-invasive ventilation inadequate Emergency invasive airway access (cric) Try awakening the patient throughout.
