Introduction to history taking, Pre-operative assessment, laboratory testing & chart review. Flashcards
What are some preoperative assessment goals?
1) Optimize care, satisfaction and comfort.
2) Minimize morbidity and mortality.
3) Minimize surgical delays or cancellations.
4) Determine appropriate post-operative disposition.
5) Evaluate health status and determine if any further consultative, diagnostic investigations are needed.
6) Formulate most appropriate anesthetic plan.
7) Optimize communication among members of the surgical and anesthetic teams.
8) Evaluation should be efficient and cost-effective.
What the 10 components of Preoperative Evaluation?
1) Patient History (chart review + history taking)
2) Physical Exam
3) Laboratory Testing
4) Medical Consultation
5) ASA Physical Status Class
6) NPO status
7) Formulation Plan
8) Discussion of Plan (educate and decrease anxiety)
9) Informed Consent
10) Documentation
What are the 3 main questions answered by the preoperative assessment?
1) Is the patient in optimal health?
2) Could health problems or medications unexpectedly influence perioperative events?
3) Can, or should, the patients physical or mental condition be improved before surgery?
Where do you get your pre-op evaluation data?
- Patient’s medical history (medical record and patient interview)
- Physical examination
- Diagnostic tests (labs, etc.)
- Specialist consultation/reports
What is the optimal situation for pre-op clinic visit?
1) Optimal Situation = Preoperative Clinic Visit ~ 1 week pre-op
➢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 Pre-operative Assessment?
1) Angina, CHF, MI, CAD, poorly controlled HTN
2) COPD/severe asthma, airway abnormalities, home O2 or ventilation
3) IDDM, adrenal disease, active thyroid disease
4) Liver disease, end-stage renal disease
5) Massive obesity, symptomatic GERD
6) Severe kyphosis, spinal cord injury
Where should you start gathering data for pre-op evaluation?
From the OR schedule because it can tell you lot about what to expect with the patient.
1) Demographics- name, age, sex
2) Procedure + diagnosis
3) Length of procedure + position
4) Surgeon (s)
5) Type of Anesthesia
What items are included in the chart review?
1) Demographics- name, age, sex
2) Diagnosis/ Procedure
3) Surgical Consent
4) Prior H&P (from surgeon or internist)
5) Nursing notes
6) Patient questionnaire
7) Results of Laboratory Tests
8) EKG, PFTS, X-Ray, Etc.
9) Vital Signs
10) Medication List
11) Allergies
12) tobacco and pain score
If inpatient, what may be some items to look at in the chart review?
1) Progress Notes
2) Medication Sheets
3) Nursing Notes
4) Old Anesthetic Records
●Complications noted?
What are the 6 purposes of the preoperative interview?
1) Obtain pertinent medical history
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
What are some consideration when doing the pre-op interview?
1) Introduce anesthesia provider(s) to patient and/or family
2) 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”)
What are some factors included in the pre-op interview?
1) Look for co-existing diseases: with a review of systems (CNS/NM, Cardiac, ENT, Pulmonary, Vascular/HTN, Endocrine, GI, Hepatic, Renal, Hematologic)
2) Medications:
●Allergies including Latex, including type of reaction
●Prescriptive – Discontinued for surgery? Taken this AM?
●OTC (ASA, NSAIDS)
●Herbals
What are the seven components of the physical exam?
1) General Impression
2) Airway
3) Heart
4) Lungs
5) CNS/PNS
6) Vital signs
7) Surgical site
What are the components of the general impression in physical exam?
1) height
2) weight
3) physical features
4) mental status
5) vital signs
What are the components of airway assessment in physical exam?
1) Mallampati classification
2) Thyromental distance
3) Head and neck movement
4) Neck circumference
5) Interincisor distance
6) Dentition
7) Relevant craniofacial deformities
➢Looking for predictors of difficult airway management
What are some components of Heart/CV assessment included in the physical assessment?
1) Heart- ●Auscultation •Rate •Rhythm •Murmurs •Bruits (carotid) •Extremity pulses 2) CV Bruits (carotid) Extremity pulses Extremity edema
What are some neurological system components included in the physical exam?
Extent of neuro exam really depends on baseline deficits, disease or surgical procedure
1) Motor – gait, grip strength, ability to hold arms forward, etc.
2) Sensory – distinction of vibration, pain, light touch along dermatomes
3) Muscle reflexes – deep, superficial, and pathologic
4) Cranial nerve abnormalities
5) Mental status
6) Speech
What are the musculoskeletal system components including in the physical exam?
Gait, ROM, deficits
➢Obesity
•20% over Ideal Body Weigh
●IBW (m) = 105 lb + 6 lb for each inch > 5 ft.
●IBW (f) = 100 lb + 5 lb for each inch > 5 ft.
•Body Mass Index of 30 – 39.9 kg/m2
➢Vital signs
What are goals of preoperative/preprocedure laboratory testing?
1) Reduce anesthetic morbidity.
2) Increase quality of perioperative care
3) Decrease cost of perioperative care
4) Return patient to desirable functioning
More Tests the Better, Right? True or false and Why?
Explain.
1) Lab tests NOT good disease screening tools
2) Follow up of “abnormal” results is costly
3) Nonindicated tests increase risks for patients
4) Batteries of tests present medicolegal risk to providers
5) Excessive testing decreases facility efficiency and reduces resources available to care for others
What is the litmus test?
1) Will the results of this “test” change my management of this anesthetic?
2) Will the results of this “test” improve this patient’s outcome?
How is the type of surgery been done relates to lab test?
1) Minimally Invasive: no need of lab test and EKG
little tissue trauma, minimal blood loss
2) Moderately Invasive: may need lab test because it may change the anesthetic plan
modest disruption of normal physiology
anticipate some blood loss
may need invasive monitors and/or ICU
3) Highly Invasive
significant disruption of normal physiology
commonly require transfusion and ICU care
What labs/tests and When?
1) Institutional policy
2) Current expert organization guidelines i.e. ACC/AHA guidelines
3) Anesthesia Provider Judgment
4) Consider – H&H, Chemistry, Coags, LFTS, Renal Function tests, UA, Pregnancy Test, EKG, Chest XRay, Pulmonary Function Tests
When should you seek consults?
1) diagnosis, evaluation, and improvement of a new or poorly controlled condition.
2) creation of a clinical risk profile that patient, anesthesiologist, and surgeon use to make management decisions.
3) Controversial
4) Avoid the terms “cleared for surgery” or “cardiac clearance”
5) Ask yourself: Does peri-op management of a patient’s disease process go beyond your comfort level?
●i.e. do you need advice from an expert consultant (endocrine, cardiac, specialist etc.) on the patient’s care that could change or guide your management?
