Intro to pre-operative assessment Flashcards
What are the components of the preoperative evaluation?
- Patient history
- Physical exam
- Laboratory testing
- Medical consultation
- ASA physical status class
- NPO status
- Formulation plan
- Discussion of plan
- Informed consent
- Documentation
What are the goals of the preoperative assessment?
- Optimize care, satisfaction and comfort
- Minimize morbidity and mortality
- Minimize surgical delays or cancellations
- Determine appropriate post-operative disposition
- 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
What are the 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 patient’s physical or mental condition be improved before surgery.
Where do you get the data for the pre-operative assessment?
- Patient’s medical record and patient interview
- Physical examination
- Diagnostic tests
- Specialist consultation/reports
What should be done during the preoperative clinic visit and what are the benefits of this visit?
- Patient interview
- Physical examination
- Develop anesthetic plan
- Promotes patient teaching and anxiety reduction
- Allows time to schedule appointments with medical consultants and complete required pre-operative diagnostic testing
- Obtain informed consent prior to operative day
What are some examples of patients that would require early pre-operative assessment?
Patients with:
- Angina, CHF, MI, CAD, poorly controlled HTN
- COPD/severe asthma, airway abnormalities, home O2 or ventilation
- IDDM, adrenal disease, active thyroid disease
- Liver disease, ESRD
- Massive obesity, symptomatic GERD
- Severe kyphosis, spinal cord injury
What information can you find in the OR schedule?
- Patient demographics
- Procedure and diagnosis
- Length of procedure and position
- Surgeon (s)
- Type of anesthesia
What information should be reviewed from the patient’s chart?
- Demographics
- Diagnosis/procedure
- Surgical consent
- Prior H&P
- Nursing notes
- Patient questionnaire
- Results of laboratory tests
- EKG, PFTs, x-ray, etc
- Vital signs
- Medication list
- Allergies
What additional information should you look at for inpatients?
- Progress notes
- Medication sheets
- Nursing notes
- Old anesthetic records
What are the 6 purposes of the preoperative interview?
- Obtain pertinent medical history
- Formulate plan of anesthetic care
- Obtain informed consent
- Patient education
- Improve efficiency, reduce cost of perioperative care
- Utilize operative experience to motivate patient to more optimal health status
What are some things you should do/ask in the preoperative interview?
- Introduce anesthesia provider(s) to patient and/or family
- Confirm patient ID, diagnosis and procedure
- Look for co-existing diseases: review of systems
- Medications: allergies including latex (including type of reaction), presctiptive medications, taken this AM?, over the counter (ASA, NSAIDS), herbals
- Previous anesthetics and surgeries
- Exercise tolerance
- Sleep apnea history
- ETOH abuse?
- Drug abuse?
- Tobacco use?
- Females- LMP?
What are the components of the review of systems?
- CNS/NM
- Cardiac
- ENT
- Pulmonary
- Vascular/HTN
- Endocrine
- GI
- Hepatic
- Renal
- Hematologic
What are some things to look at in the physical exam?
- General impression
- Airway
- Heart
- Lungs
- CNS/PNS
- Vital signs
- Surgical site
- Height
- Weight
- Physical features
- Mental status
- Vital signs
What are the components of the airway physical exam?
- Mallampati classification
- Thyromental distance
- Head and neck movement
- Neck circumference
- Interincisor distance
- Dentition
- Relevant craniofacial deformities
- Any predictors of difficult airway management
What do you assess when listening to the heart?
- Rate
- Rhythm
- Murmurs
- Bruits (carotid)
- Extremity pulses
What are the components of the CV assessment?
- Bruits(carotid)
- Extremity pulses
- Extremity edema
What is involved in the physical assessment of the lungs?
- Inspection
- Auscultation
- Percussion
- Palpation
What are the components of the CNS physical exam?
- Motor-gait, grip strength, 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
What are the components of the musculoskeletal physical exam?
- Gait
- ROM
- Deficits
What is considered obesity?
20% over ideal body weight or BMI of 30-39.9
What are the goals of preoperative/preprocedure laboratory testing?
- Reduce anesthetic morbidity
- Increase quality of perioperative care
- Decrease cost of perioperative care
- Return patient to desirable functioning
What are some disadvantages of preoperative laboratory testing?
- Lab tests NOT good disease screening tools
- Follow up of abnormal results is costly
- Nonindicated tests 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
Describe Minimally invasive, moderately invasive and highly invasive procedures.
Minimally invasive: little tissue trauma, minimal blood loss
Moderately invasive: modest disruption of normal physiology, anticipate some blood loss, may need invasive monitors and/or ICU
Highly invasive: significant disruption of normal physiology, commonly require transfusion and ICU care
Describe the ASA classifications
I- normal, healthy patient; no systemic disease
II- mild to moderate systemic disease, well controlled, no functional limitation
III- severe systemic disease, functional limitation
IV- severe systemic disease that is a constant threat to life
V- moribund patient, not expected to survive with or without the surgical procedure
VI- patient declared brain dead whose organs are being harvested for donation
E- emergency operation required
What are the NPO status times based on current ASA guidelines?
- 2 hours for clear liquids all patients
- 4 hours for breast milk
- 6 hours for formula or solids/light meal
- 8 hours for a heavy meal, fried or fatty food, gum and candy
What are some factors that put patients at an increased risk for aspiration?
- Age extremes (younger than 1 or older than 70)
- Ascites
- Collagen vascular disease, metabolic disorders (DM, obesity, ESRD, hypothryroid)
- Hiatal hernia/GERD/esophageal surgery
- Mechanical obstruction (pyloric stenosis)
- Prematurity
- Pregnancy
- Neurologic diseases
What are the parts of the anesthetic plan?
- Types of anesthesia
- Drugs
- Monitors
- Airway
- Positioning
- Intraoperative monitoring
- Postoperative care
Who should you discuss the anesthetic plan with?
- Supervising staff
- Patient
- Surgeon
- OR team
What information does the patient require from the anesthesia professional?
- Discuss choices of anesthetic technique, verbal and 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
- Explain process of transport to OR
- Postoperative-PACU, pain relief, airway
- Possible outcomes-sore throat, blood transfusion, facial swelling, nasal packing, etc.
What is required for informed consent?
- Explanation of the planned anesthetic
- Explanation of options available
- Risks and benefits
- Patient understanding and cooperation
- Without consent-assault and battery
- Minors- consent from parents or guardian
- Signature of patient and witness
What are the components of the final pre-operative check list?
- IV/Fluid status
- Pre-medication
- Anesthetic plan
- Labwork- results, labwork needed?
- EKG, CXR needed?
- Blood products- availability and need
- Need for inhaler, steroid coverage, antibiotics, aspiration prophylaxis
What should be documented from the preoperative evaluation?
- H&P
- Informed consent
- NPO status
- Medications
- Allergies
- ASA physical status class
- Pre-operative vital signs
- Labs, tests, and consults
