Intro Flashcards
Preoperative Assessment Goals
-Optimize care, satisfaction and comfort
(important for quality of care; adverse effects are associated with inadequate evaluation)
-Minimize morbidity and mortality
-Minimize surgical delays or cancellations (by detecting problems early)
-Determine appropriate post-operative disposition (will they go to the ICU or go home?)
-Evaluate health status and determine if any further consultative, diagnostic investigations are needed
-Formulate most appropriate anesthetic plan
-optimize communication among members of the surgical and anesthetic teams
-evaluation should be efficient and cost-effective
Components of Preoperative Evaluation
mandated by joint commision – all patients requiring anesthesia for surgery undergo a preoperative evaluation by an anesthesia provider to be completed within 30 days prior to surgery and a reassessment 48 hours after surgery.
AANA and ASA publish standards of conduct for our practices and within that it is required we do an evaluation
- Patient Hx (Chart review + Hx taking)
- comorbidities, past meds, past surgeries..
- Physical Exam
- Laboratory Testing
- interpret lab results already done or may need to order a new lab test and interpret it-anesthesia providers responsibility
- Medical Consultation
- ASA Physical Status Class
- NPO status
- Formulation Plan
- Discussion of plan (educate and decrease anxiety)
- Informed Consent
- Documentation
3 main questions answered by the preoperative assessment
- Is the patient in optimal health?
- Could health problems or medications unexpectedly influence perioperative events?
- Can, or should, the patients physical or mental condition be improved before surgery?
Where do we get the data?
- Patients medical history (medical record and patient interview)
- Physical examination
- Diagnostic Test (labs, etc.)
- Specialist Consultation/reports
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 preoperative diagnostic testing
- obtain informed consent prior to operative day
Who requires Early Pre-Operative Assessment?
Angina, CHF, MI, CAD, poorly controlled HTN
COPD, severe asthma, airway abnormaltities, home o2 or vent
diabetes, adrenal dz, active thyroid dz
liver dz, end-stage renal dz
massive obesity, symptomatic GERD
severe kyphosis, spinal cord injury
OR Schedule
- Demographics- name, age, sex
- Procedure + diagnosis
- Length of procedure + position
- Surgeon
- Type of Anesthesia
Chart Review
- Demographics- name, age, sex
- Diagnosis/Procedure
- Surgical Consent
- Prior H&P (from surgeon or internist)
- Nursing notes
- Patient questionnaire
- Results of Laboratory Tests
- EKG, PFTS, X-RAY, etc
- Vital signs, pain score
- medication list
- allergies
If inpatient, may also look at:
- progress notes
- medication sheets
- nursing notes
- old anesthetic records
- complications? look for malignant hyperthermia, airway difficulties, previous n/v
Preoperative Interview: 6 purposes
1) obtain pertinent medical hx
2) formulate plan of anesthetic care
3) obtain informed consent
4) patient education
5) improve efficiency, reduce cost of perioperative care
6) utilize operative experience to motivate patient to more optimal health status
Preoperative Interview
- Introduce anesthesia provider to patient and/or family
- Confirm pt ID, diagnosis, and procedure (surgical site)
- open-ended questions
- general to specific
- organized and systematic
- layperson terminology
- individualized
- control environment (+/- family members present, interpreters, good lighting, respectful, “unrushed”)
-look for co-exisiting dz
- medications
- allergies including latex, including type of rxn
- prescriptive-d/c for surgery? taken this am?
- OTC (ASA, NSAIDS)
- herbals
The preoperative history:
- previous anesthetics + surgeries
- complications, family hx complications, OB deliveries
- exercise tolerance
- sleep apnea hx
- ETOH abuse
- drug abuse
- tobacco use
- females- last menstrual period
Physical Exam: General Impression
GENERAL IMPRESSION:
- height
- weight
- physical features
- mental status
- vital signs
Physical Exam: Airway
- Mallampati Classification
- Thyromental distance
- Head and neck movement
- Neck circumference
- Interincisor distance
- Dentition
- Relevant craniofacial deformities
- *LOOKING FOR PREDICTORS OF A DIFFICULT AIRWAY
Physical Exam: Heart
Ausculatation
- rate
- rhythm
- murmurs
- bruits (carotid)
- extremity pulses
- extremity edema
Physical Exam: Lungs
Inspection
Auscultation
Percussion
Palpation
Physical Exam: Neurologic System
Extent of neuro exam depends on baseline deficits, dz or procedure
motor- gait, grip strength, ability to hold arms forward
sensory- distinction of vibration, pain, light touch along dermatomes
muscle reflexes- deep, superficial, and pathologic
cranial nerve abnormalities
mental status
speech
Physical Exam: Musculoskeletal System and Obesity
Gait, ROM, and deficits
Obesity: 20% over ideal body weight
IBW (M)= 105 lb +6lb for each inch > 5 ft.
IBW (F)= 100 lb + 5lb for each inch > 5 ft.
Body mass index of 30- 39.9 kg/m2
Physical Exam: Other
Surgical site (confirm!)
IV
Position
Monitoring
Goals of preoperative/preprocedure lab testing:
reduce anesthetic morbidity
increase quality of periooperative care
decrease cost of perioperative care
return patient to desirable functioning
lab tests
- lab tests are NOT good dz screening tools
- follow up of “abnormal” results is costly
- nonindicated test increase risks for patients
- batteries of tests present medicolegal risk to providers
- excessive testing decreases facility efficiency and reduces resources available to care for others
The Litmus Test
Will the results of this “test” change my management of this anesthetic?
Will the results of this “test” improve this patient’s outcome?
Questions to ask about labs/tests
Is the test needed to confirm a suspicion?
Is the suspected abnormality linked to morbidity?
Is there a higher than average likelihood of an abnormality?
Will a positive or negative result affect the case management in any way?
Predictive Value
Sensitivity vs Specificity
Sensitivity : if a lab test test is sensitive than it will make the lab result positive in a patient that has the disease
Specificity: it will be negative in a patient without the disease
