Nagelhout Chapter 20 Flashcards
What are the main goals of preoperative assessment?
Identify anesthesia-related risks, optimize patient condition before surgery, and predict and reduce surgical complications.
What is the Preanesthesia Assessment Clinic (PAC)?
The most effective way to provide comprehensive preoperative evaluation in a single visit.
What are the benefits of the PAC?
Reduces patient anxiety & direct costs, lowers last-minute surgery cancellations, shortens hospitalization, decreases unnecessary testing, and improves patient education.
What key services are provided at the PAC?
Patient registration & medical history collection, physical examination & patient education, scheduling consultations & preoperative testing, and ensuring compliance with surgical and anesthesia guidelines.
What is a goal related to perioperative risks?
Minimize perioperative risks by assessing and mitigating anesthesia-related factors.
What should be determined to prevent surgical delays?
The appropriate setting for surgery (ambulatory, inpatient, ICU).
What should be assessed regarding medical conditions?
The need for further investigations & specialty consultations and optimizing preexisting medical conditions (e.g., smoking cessation, weight management).
What preoperative preparation instructions should be provided?
Instructions on fasting, glucose management, and medication guidelines.
How can patient anxiety be reduced?
Educate patients on anesthesia, surgery, and postoperative expectations.
What general medical conditions benefit from early preoperative evaluation?
Medical conditions inhibiting ability to engage in normal daily activity; conditions necessitating continual assistance or monitoring at home within the past 6 months; admission within the past 2 months for acute episodes or exacerbation of chronic condition; use of medications (e.g., anticoagulants or monoamine oxidase inhibitors) for which modification of schedule or dosage might be required.
What cardiocirculatory conditions should be evaluated preoperatively?
History of angina, coronary artery disease, myocardial infarction, symptomatic arrhythmias; history of cardiac rhythm device requiring interrogation or reprogramming; poorly controlled hypertension (diastolic >110 mm Hg, systolic >160 mm Hg); history of congestive heart failure.
What respiratory conditions warrant early preoperative evaluation?
Asthma or chronic obstructive pulmonary disease requiring chronic medication; acute exacerbation and progression of these diseases within the past 6 months; history of major airway surgery, unusual airway anatomy, or upper or lower airway tumor or obstruction; history of chronic respiratory distress requiring home ventilatory assistance or monitoring.
What endocrinologic conditions should be considered for preoperative evaluation?
Diabetes treated with insulin or oral hypoglycemic agents (unable to control with diet alone); adrenal disorders; active thyroid disease.
What hepatic condition is relevant for early preoperative evaluation?
Active hepatobiliary disease or compromise.
What musculoskeletal conditions should be evaluated preoperatively?
Kyphosis or scoliosis causing functional compromise; temporomandibular joint disorder with restricted mobility; cervical or thoracic spine injury.
What oncologic conditions warrant early preoperative evaluation?
Patients receiving chemotherapy; other oncological processes with significant physiologic compromise.
What gastrointestinal conditions benefit from early preoperative evaluation?
Obesity (BMI of 35 or greater); hiatal hernia; symptomatic gastroesophageal reflux.
What is the first step in the process of preoperative assessment?
The process begins with reviewing medical records followed by patient interview & physical exam.
What guides additional tests or specialist referrals during preoperative assessment?
Findings from the initial assessment guide additional tests or specialist referrals if needed.
What factors determine the extent of the preoperative assessment?
The extent of the assessment depends on the patient’s medical condition & surgical complexity.
Does the timing of the preoperative assessment impact surgical outcomes?
No, the timing of the assessment does not significantly impact surgical outcomes.
Who must conduct the preoperative assessment?
The assessment must be conducted by a qualified anesthesia provider.
Why is reviewing past medical records essential for preoperative assessment?
It is essential for patients with prior anesthesia exposure to retrieve previous anesthesia records, especially if complications occurred.
What should be done if past anesthesia records are unavailable?
If records are unavailable, patient history should provide details of prior anesthetic experiences.
What precautions should be taken for rare conditions before surgery?
For rare conditions, records should be reviewed before surgery or appropriate precautions taken (e.g., avoiding succinylcholine).
What should be verified in current medical records during preoperative assessment?
Verify surgical & anesthesia consents for accuracy, ensuring patient name, surgeon, date, and procedure match OR schedule.
What baseline data should be obtained from the admission record?
Baseline data such as age, height, weight, vitals, and fluid balance should be obtained.
What do progress notes & consultation reports provide?
They provide a comprehensive health history and help guide anesthesia planning.
What additional insights can nursing notes provide?
Nursing notes may provide insights such as cultural background, coping mechanisms, or physical limitations (e.g., hearing impairment).
What is the objective of promoting interactive communication between patient and care provider?
To encourage patient participation in making decisions about perioperative care.
How can patient self-care skills be maximized during the postoperative phase?
By enhancing patient participation in continuing care.
What is one goal related to the patient’s ability to cope?
To increase the patient’s ability to cope with their own health status.
What should individualized preoperative instructions include?
Details on laboratory tests, consultations, and diagnostic procedures.
What is an important instruction regarding food and drink before surgery?
The appropriate time at which the patient should cease ingestion of food and drink.
What personal considerations should be communicated to the patient?
Comfortable clothes to wear, no jewelry or makeup, personal items to bring, and leaving valuables at home.
What postoperative considerations should be included in preoperative instructions?
Anticipated recovery course, discharge instructions, and how to deal with complications.
Who should the patient contact if their physical condition changes?
A designated person for issues like upper respiratory tract infection or cancellation.
What should be detailed regarding arrival at the surgical facility?
The process of arrival and registration, including time and location.
What legal information should be reviewed with the patient?
Advance directive information as required by law in some states.
What should be explained to the patient and family regarding the surgical facility?
The surgical facility policies.
What are the objectives of the patient interview?
Confirm patient’s medical history and identify risk factors. Determine the most appropriate anesthesia plan.
How can patient education enhance compliance and reduce anxiety?
Education should be verbal & written for better patient understanding. Preoperative fasting & medication instructions, expected intraoperative & postoperative care, and what to expect in the recovery process should be included.
What are the benefits of a well-executed interview and education process?
Reduces patient anxiety & increases satisfaction, improves compliance with perioperative instructions, decreases surgical delays & cancellations, reduces hospital length of stay & overall costs, and enhances clinical outcomes.
Why is a thorough medical history important?
Structured, systematic questioning helps ensure no critical information is omitted. Open-ended and direct questions allow detailed responses.
What should be assessed in a patient’s surgical history?
Key details to assess include complications (e.g., uncontrolled bleeding, peripheral nerve injury) and unusual surgical events that may require further investigation.
What is important about anesthetic history?
Key anesthetic reactions to assess include prolonged vomiting, difficult airway, malignant hyperthermia, postoperative delirium, and anaphylaxis.
What familial conditions should be assessed regarding anesthetic history?
Malignant hyperthermia, atypical plasma cholinesterase deficiency, porphyria, and glycogen storage diseases (e.g., G6PD deficiency).
What should be reviewed in a patient’s drug history?
All prescribed and over-the-counter drugs, including dosages, schedules, duration of use, purpose, effectiveness, side effects, and potential interactions with anesthesia.
What considerations are there for discontinuing medications before surgery?
Not all medications should be stopped; weigh benefits vs. risks of discontinuation and allow 3–5 half-lives for clearance if discontinuing.
How should drug allergies be differentiated?
Differentiate between allergies and adverse reactions. A true allergy is an absolute contraindication to drug use.
What is the significance of latex sensitivity in surgery?
Up to 20% of intraoperative anaphylaxis cases are linked to latex, especially in high-risk patients.
What precautions should be taken for latex-allergic patients?
Schedule as the first case of the day, ensure a no-latex environment in the OR, and perform preoperative skin-prick or in-vitro testing if necessary.
What are the effects of smoking on perioperative complications?
Smoking increases perioperative complications such as wound healing and pulmonary risks.
How does chronic alcohol use affect anesthetic requirements?
Chronic alcohol use increases anesthetic requirements due to tolerance and enzyme induction.
What is the average lifespan reduction associated with alcohol abuse?
Alcohol abuse shortens lifespan by an average of 29 years.
What is the increased risk of postoperative complications for heavy alcohol users?
Heavy alcohol users have a 2-5x increased risk of postoperative complications such as arrhythmias, infections, and withdrawal syndromes.
What is a life-threatening complication of alcohol withdrawal?
Alcohol withdrawal (delirium tremens) is a life-threatening complication.
How does acute alcohol intoxication affect anesthetic requirements?
Acute intoxication reduces anesthetic requirements due to CNS depression.
What are some increased risks of postoperative complications due to alcohol use?
Increased risks include poor wound healing, infections, pneumonia, bleeding due to liver dysfunction, and further hepatic deterioration in patients with liver disease.
What tools can be used to assess alcohol use risk?
Use AUDIT (Alcohol Use Disorders Identification Test) or CAGE questionnaire to assess risk.
What are the CAGE criteria for assessing alcohol dependence?
CAGE Criteria: Cut down, Annoyed, Guilty, Eye-opener. ≥2 positive responses indicate high risk for alcohol dependence and withdrawal.
What symptoms are associated with alcohol withdrawal?
Symptoms include tremors, tachycardia, hypertension, insomnia, anxiety, nausea, restlessness, hallucinations, agitation, and seizures.
What preoperative medication may be needed to prevent alcohol withdrawal?
Preoperative benzodiazepines may be needed to prevent withdrawal.
What should be optimized in perioperative nutrition for alcohol users?
Optimize perioperative nutrition to address deficiencies such as thiamine, magnesium, and folate.
What are the health risks associated with smoking?
Smoking causes 90% of lung cancer deaths, 80% of COPD-related deaths, and increases the risk of coronary heart disease and stroke by 2-4x.
How does carbon monoxide affect oxygenation in smokers?
Carbon monoxide (CO) binds to hemoglobin 250-300x more than oxygen, reducing tissue oxygenation.
What is the impact of smoking on postoperative pulmonary complications?
Smoking increases postoperative pulmonary complications (pneumonia, atelectasis) nearly 6-fold.
What is the risk of perioperative complications for heavy smokers?
> 20 pack-years of smoking increases the risk of perioperative complications.
What are the benefits of short-term smoking cessation before surgery?
Short-term cessation (12-48 hours pre-op) improves CO levels, BP, and HR but does not reduce pulmonary risks.
What are the benefits of long-term smoking cessation before surgery?
Cessation >8 weeks pre-op results in improved pulmonary function, ciliary function, and immune response.
What advice should be given to patients regarding smoking cessation?
Patients should be advised to quit smoking at any time preoperatively without fear of worsening pulmonary outcomes.
What are the risks of secondhand smoke exposure in children during surgery?
Children exposed to secondhand smoke have increased risks of laryngospasm, coughing during induction/emergence, postoperative desaturation, hypersecretion, and reactive airway disease.
What complications does illicit drug use cause in anesthesia?
Illicit drug use complicates anesthesia due to drug interactions, tolerance, and withdrawal risks.
When may urine drug screening be necessary?
Urine drug screening may be necessary for suspected recent use.
What are the high-risk substances related to cocaine and methamphetamines?
Cocaine and methamphetamines are high-risk due to cardiovascular effects.
What cardiovascular issues can cocaine and methamphetamines cause?
They can cause severe hypertension, arrhythmias, and myocardial ischemia.
What is the risk associated with cocaine and methamphetamines regarding catecholamines?
They sensitize the heart to catecholamines, increasing the risk of hypertensive crisis.
Which medications should be avoided in patients using cocaine and methamphetamines?
Avoid ephedrine and ketamine, which exacerbate cardiovascular instability.
When should elective surgery be delayed for patients with recent cocaine or methamphetamine use?
Elective surgery should be delayed if recent use was within 24-72 hours.
What effects does marijuana (Cannabis, THC, CBD) have on anesthesia?
Marijuana increases anesthetic and sedative requirements.
What cardiovascular effects can marijuana cause?
It may cause tachycardia, anxiety, and hypotension.
What are the potential long-term effects of chronic marijuana use?
Chronic use may lead to airway hyperreactivity and bronchospasm.
What is the impact of chronic opioid use on pain management?
Chronic opioid users have higher pain thresholds and require increased postoperative analgesia.
What risk is associated with chronic opioid use?
There is a high risk of opioid-induced hyperalgesia.
What is recommended for pain management in chronic opioid users?
Multimodal analgesia (NSAIDs, ketamine, regional anesthesia) is recommended.
What should be discussed if opioid substitution therapy is used?
Discuss withdrawal risk and pain management strategies.
What risks are associated with hallucinogens?
Hallucinogens can cause unpredictable cardiovascular and psychological effects.
What complications can arise from hallucinogen use?
There is a risk of hypertensive crisis, serotonin syndrome, and postoperative delirium.
What risks are associated with inhalants?
Inhalants pose a risk of sudden cardiac arrest due to myocardial sensitization.
What long-term effects can result from inhalant use?
Long-term use can cause neuropathy and cognitive impairment.
What physical exam findings suggest substance abuse?
Track marks, skin abscesses, and venous thrombosis indicate IV drug use.
What does constricted pupils indicate?
Constricted pupils suggest opioid use.
What does dilated pupils indicate?
Dilated pupils suggest cocaine or amphetamine use.
What does nystagmus indicate?
Nystagmus is indicative of PCP use.
What does nasal perforation suggest?
Nasal perforation indicates cocaine abuse.
What does poor dental health indicate?
Poor dental health is associated with methamphetamine use.
What does malnutrition suggest in the context of drug use?
Malnutrition may indicate chronic amphetamine use.
What are common medications for opioid abstinence?
Common medications include Methadone, Buprenorphine, and Naltrexone.
What is Methadone?
Methadone is a full opioid agonist. for opioid abstinence
What is Buprenorphine?
Buprenorphine is a partial agonist (e.g., Suboxone). for opioid abstinence
What is Naltrexone used for?
Naltrexone is an opioid antagonist used for both opioid and alcohol dependence.
Signs and symptoms of cannabis (marijuana or hashish) abuse?
Tachycardia, labile blood pressure, headache, euphoria, dysphoria, depression, occasional anxiety and panic reactions, psychosis (rare). Poor memory and decreased motivation with chronic use.
Signs and symptoms of cocaine and amphetamines abuse?
Tachycardia, labile blood pressure, hypertension, myocardial ischemia, arrhythmias, pulmonary edema, excitement, delirium, hallucinations to psychosis. Euphoria: feeling of excitation, well-being, and enhanced physical strength and mental capacity. Hyperreflexia, tremors, convulsions, mydriasis, sweating, hyperpyrexia, exhaustion, coma with overdose.
Signs and symptoms of hallucinogens (LSD, PCP) abuse?
Sympathomimetic and weak analgesic effects, altered perception and judgment; high doses may progress to toxic psychosis. PCP produces dissociative anesthesia with increasing doses.
Signs and symptoms of opioid abuse?
Respiratory depression, hypotension, bradycardia, constipation, euphoria (most marked with heroin). Pinpoint pupils with overdose; decreased level of consciousness to coma.
What is required for opioid-tolerant patients for pain control?
Higher doses of opioids are required for pain control.
What should be considered for multimodal pain management?
Regional anesthesia, NSAIDs, ketamine, IV lidocaine, clonidine, COX-2 inhibitors, and management of methadone & buprenorphine in collaboration with addiction specialists.
Why is a thorough social history important in MAT patients?
It allows for early intervention and risk reduction.
How should patients be approached about substance use?
Patients may not disclose substance use unless specifically asked in a professional, nonjudgmental manner.
What is the purpose of assessment in MAT patients?
Assessment helps in tailoring anesthesia plans and educating patients on the risks of substance use in the surgical setting.
What approach should be used to encourage honest disclosure from patients?
Use open-ended, nonjudgmental questions.
What are anabolic steroids self-administered for?
To increase muscle mass, strength, and athletic performance.
What are the hepatic risks associated with long-term anabolic steroid use?
Impaired liver function, cholestatic jaundice, hepatic adenocarcinoma, and peliosis hepatis.
What cardiovascular risks are associated with anabolic steroid use?
Increased risk of myocardial infarction, atherosclerosis, stroke, hypertension, dyslipidemia, and hypercoagulopathy.
What endocrine and psychiatric risks are associated with anabolic steroid use?
Testicular atrophy, gynecomastia in males, menstrual irregularities in females, aggressive behavior, mood swings, psychosis, and depression.
What preoperative tests should be obtained for chronic steroid users?
Preoperative liver function tests (LFTs) should be obtained due to hepatic impairment.
What cardiovascular status should be monitored in chronic steroid users?
Monitor for risk of myocardial infarction, hypertension, and stroke.
What should be assessed regarding coagulation status in chronic steroid users?
Assess for hypercoagulability which increases the risk of thrombosis.
What potential issue should be considered for chronic steroid users?
Potential adrenal insufficiency due to long-term steroid suppression of the hypothalamic-pituitary-adrenal (HPA) axis.
What may be required perioperatively for chronic steroid users?
Stress-dose steroids may be required for adrenal suppression.
What risks do certain herbal dietary supplements pose perioperatively?
They can affect blood clotting, glucose control, CNS function, and interact with anesthesia.
What should patients do with their herbal products before surgery?
Patients should bring their herbal products to preoperative assessment if unsure.
Which herbs increase bleeding risk?
Garlic, ginkgo, ginger, ginseng, vitamin E, feverfew.
What effect does St. John’s Wort have on warfarin?
It reduces warfarin effect and increases clotting risk.
Which herbs can cause hypoglycemia?
Aloe vera, ginseng, fenugreek, cinnamon.
What CNS effects do kava and valerian root have?
They increase sedation and potentiate anesthetic agents.
What risks are associated with ephedra (Ma Huang)?
Increases blood pressure, heart rate, arrhythmia risk, and may cause hypertensive crisis.
What effect does St. John’s Wort have on medications?
Induces CYP enzymes, reducing efficacy of anesthesia and other medications.
How long before surgery should patients discontinue herbal supplements?
2–3 weeks before surgery to avoid interactions.
What should be monitored if anticoagulant herbal use is suspected?
Monitor for excessive bleeding.
What risk should be assessed in diabetic patients using herbal glucose modulators?
Assess for hypoglycemia risk.
What caution should be taken with herbal supplements that enhance sedation?
Be cautious with supplements like kava and valerian.
Why is airway assessment important?
Every patient must undergo a preoperative airway evaluation to identify risks for difficult mask ventilation or endotracheal intubation.
What does the airway assessment include?
The assessment includes inspection of teeth, mouth, mandibular space, and neck to determine airway management challenges.
What is the Mallampati Classification?
Assesses tongue size relative to oral cavity.
How is the Mallampati Classification performed?
Patient sits upright, mouth wide open, tongue fully extended, and no phonation to prevent palate elevation.
What does Class I of the Mallampati Classification indicate?
Full visibility of soft palate, fauces, uvula, tonsillar pillars → Easy intubation.
What does Class II of the Mallampati Classification indicate?
Uvula partly visible → Moderate ease of intubation.
What does Class III of the Mallampati Classification indicate?
Only base of uvula visible → Potential difficulty.
What does Class IV of the Mallampati Classification indicate?
No uvula or soft palate visible → High risk of difficult intubation.
What is a limitation of the Mallampati classification?
It has a high false-positive and false-negative rate and should not be used alone.
What is Thyromental Distance (TMD)?
Measures the distance from thyroid cartilage to mandibular border with neck fully extended, mouth closed.
What TMD measurement is associated with difficult intubation?
<6-7 cm (~3 fingerbreadths) is associated with difficult intubation due to misalignment of pharyngeal and laryngeal axes.
What does Interincisor Distance measure?
Measures mouth opening capability, which depends on temporomandibular joint (TMJ) mobility.
What is considered a normal Interincisor Distance?
≥4 cm (2-3 fingers width) = normal.
What Interincisor Distance indicates a risk for difficult intubation?
<2 fingers width = risk for difficult intubation.
What can affect mouth opening after anesthesia?
Some patients may have adequate mouth opening while awake but reduced TMJ mobility after anesthesia.
How can jaw protrusion help with intubation?
Forward protrusion of the mandible may help compensate for restricted mouth opening.
What does Head & Neck Mobility assess?
Moderate flexion of the neck + full extension of the atlantooccipital joint (‘sniffing position’) optimizes alignment of the oral, pharyngeal, and laryngeal axes.
What conditions can limit neck extension?
Limited extension (e.g., cervical arthritis, prior neck surgery, small C1 gap) pushes the larynx anteriorly, making intubation difficult.
What is the Jaw Protrusion Test?
Patients should attempt to protrude the lower jaw forward and bite the upper lip.
What does inability to move the jaw forward indicate?
Inability to move the jaw forward may indicate difficult laryngoscopy due to reduced maneuverability.
What is the formula for Ideal Body Weight (IBW) for males?
IBW (male) = 105 lb + 6 lb for each inch >5 ft
What is the formula for Ideal Body Weight (IBW) for females?
IBW (female) = 100 lb + 5 lb for each inch >5 ft
How do you calculate Body Mass Index (BMI)?
BMI = Weight in kg/(height in meters)
What are the most common anesthesia-related medicolegal claims?
Dental injuries are the most common anesthesia-related medicolegal claims, accounting for one-third of all claims in the U.S.
What are the risk factors for perioperative dental injury?
Risk factors include preexisting poor dentition, limited neck motion, history of craniofacial abnormalities or previous difficult intubation, and prior head and neck surgery.
What should be done during preoperative dental assessment?
Inspect and document the condition of teeth before airway management to prevent false attribution of preexisting damage to anesthesia.
What is the risk associated with loose or protuberant maxillary incisors?
Loose or protuberant maxillary incisors pose a high risk of tooth injury or loss during laryngoscopy.
What should patients with fragile dentition be informed about?
Patients with fragile dentition must be informed of the risk of tooth damage, and this discussion should be documented in the anesthesia consent.
What should be noted regarding crowns, braces, dentures, and prosthetic devices?
Crowns, braces, dentures, and prosthetic devices should be noted and removed unless necessary for mask fit.
What may need to be done with extremely loose teeth before laryngoscopy?
Extremely loose teeth may need extraction before laryngoscopy to prevent aspiration.
What is a comorbid condition associated with obesity related to sleep?
Known sleep apnea in which the patient is noncompliant with continuous positive airway pressure (CPAP)
What HbA1c level indicates a comorbid condition associated with obesity?
HbA1c (glycosylated hemoglobin) >8% (average blood sugar >200 mg/dL)
What diabetic complications are comorbid conditions associated with obesity?
Diabetic nephropathy, retinopathy, or neuropathy
What liver condition is a comorbidity associated with obesity?
Cirrhosis
What cardiovascular condition is associated with obesity?
Pulmonary hypertension
What neurological condition can be a comorbidity of obesity?
Pseudotumor cerebri (with severe headaches or impending vision loss)
What bleeding condition is associated with obesity?
Significant coagulopathy (including history of pulmonary embolus, bleeding diathesis, hypercoagulable syndrome, excessive bleeding, more than one deep venous thrombosis, taking Coumadin or clopidogrel medication)
What therapy is considered a comorbidity associated with obesity?
Chronic steroid therapy
What oxygen requirement is a comorbidity associated with obesity?
Oxygen dependent (does not necessarily have to be constant)
What mobility condition is associated with obesity?
Wheelchair-bound most of the time
What systemic diseases indicate poor functional capacity associated with obesity?
Systemic disease and poor functional capacity (including multiple sclerosis, inflammatory bowel disease, scleroderma, lupus, cancer)
What skin condition is a comorbidity associated with obesity?
Severe venous stasis ulcers
What recent symptom may indicate a comorbidity associated with obesity?
Recent complaint of chest pain (undiagnosed)
What is the classification of obesity based on body weight?
Body weight >20% over ideal body weight = obesity.
Body weight >100% over ideal weight = morbid obesity.
What are the BMI classifications for obesity?
Overweight: 25–29.9 kg/m²
Class 1 Obesity: 30–34.9 kg/m²
Class 2 Obesity: 35–39.9 kg/m²
Class 3 Obesity (Severe): ≥40 kg/m²
What percentage of U.S. adults are overweight or obese?
Two-thirds of U.S. adults are overweight or obese.
What are the health risks associated with obesity?
Increased risk for:
- Cardiovascular disease
- Sleep-disordered breathing
- Difficult airway management
- Metabolic disorders (diabetes, dyslipidemia)
- Increased perioperative complications
What preoperative considerations should be made for the obese patient?
Assess cardiovascular health per American Heart Association guidelines.
Screen for coronary disease if:
- Abnormal ECG
- History of coronary/valvular disease
- Age >50 years with two or more risk factors (diabetes, hypertension, smoking, dyslipidemia, family history).
Do obese patients with no comorbidities require extensive preoperative testing?
Obese patients with no comorbidities may not require extensive preoperative testing.
What percentage of bariatric surgery patients have OSA?
More than 70% of bariatric surgery patients have OSA.
What symptoms should be screened for OSA?
Screen for OSA symptoms:
- Snoring
- Apneic episodes
- Frequent arousals during sleep
- Morning headaches
- Daytime somnolence
What does the physical exam for OSA focus on?
Physical exam focuses on:
- Airway evaluation
- Neck circumference
- Tonsil size
- Tongue volume
What is the STOP-Bang Questionnaire used for?
STOP-Bang Questionnaire for OSA Screening: High sensitivity for identifying OSA risk.
What is the gold standard for diagnosing OSA?
Polysomnography (sleep study) is the gold standard for diagnosis.
What should be done if OSA is diagnosed?
If OSA is diagnosed, optimize CPAP settings preoperatively.
What is the incidence of difficult intubation in obese patients with OSA?
Obese patients with short, thick necks or OSA have a higher incidence (8%) of difficult intubation compared to the general population (0.045%).
What should be prepared for if difficulty in intubation is anticipated?
Prepare for possible awake tracheal intubation if difficulty is anticipated.
What does the ‘S’ in STOP stand for?
Snoring: Do you snore loudly (loud enough to be heard through closed doors)?
What does the ‘T’ in STOP stand for?
Tired: Do you often feel tired, fatigued, or sleepy during daytime?
What does the ‘O’ in STOP stand for?
Observed: Has anyone observed you stop breathing during your sleep?
What does the ‘P’ in STOP stand for?
Blood Pressure: Do you have or are you being treated for high blood pressure?
What does ‘Bang’ refer to in the STOP-Bang Questionnaire?
BMI: BMI >35 kg/m²?
What is the age criterion in the Bang section?
Age: Age >50 years?
What is the neck circumference criterion in the Bang section?
Neck circumference: Neck circumference >40 cm?
What is the gender criterion in the Bang section?
Gender: Male?
What indicates a high risk of OSA?
High risk of OSA: Yes to ≥3 questions.
What indicates a low risk of OSA?
Low risk of OSA: Yes to <3 questions.
What are some preoperative medication considerations?
Antiobesity drugs (amphetamines, Schedule IV appetite suppressants) and antidepressants (fluoxetine, sertraline), which may interact with anesthesia.
What are common musculoskeletal disorders relevant to anesthesia?
Osteoarthritis (degenerative disk disease), ankylosing spondylitis (AS), and rheumatoid arthritis (RA).
What should be considered preoperatively for AS & RA patients?
Chronic pain and inflammation can limit mobility and surgical positioning. Patients may require perioperative corticosteroid supplementation if on chronic steroid therapy.
Who is at risk for adrenal insufficiency?
Patients receiving >20 mg hydrocortisone daily for >3 weeks in the past year and those on chronic corticosteroid replacement therapy.
What is a strategy for perioperative steroid management?
Minimize steroid dosage to reduce risk of surgical site infection and wound healing.
What increases the risk of difficult intubation in patients with AS and RA?
Limited TMJ and cervical spine mobility increases risk of difficult intubation.
What complications may RA patients experience related to airway management?
RA patients may have cricoarytenoid arthritis, causing stridor, hoarseness, painful speech, and dysphagia.
What airway evaluation may be required for RA patients?
RA patients may have tracheal stenosis, requiring airway evaluation before intubation.
What physical limitations do AS patients face that affect intubation?
AS patients may have a rigid spine and kyphosis, limiting head extension.
What respiratory issues are associated with AS patients?
AS patients may have restrictive lung disease and pleural effusions.
What is papilledema?
Swelling of the optic disc due to increased intracranial pressure.
What are the signs of mydriasis?
Unilateral or bilateral dilation of the pupils.
What types of headaches are associated with increased intracranial pressure?
Headaches that are postural, worse in the morning, and made worse by coughing.
What gastrointestinal symptoms may occur with increased intracranial pressure?
Nausea and vomiting.
What speech changes may indicate increased intracranial pressure?
Slurred speech.
What cognitive changes may occur with increased intracranial pressure?
Disorientation and altered levels of consciousness.
What motor symptoms can result from increased intracranial pressure?
Flaccid hemiplegia or hemiparesis.
What cranial nerve palsies may be present?
Abducens or oculomotor palsy.
What physical sign indicates neck stiffness?
Neck rigidity.
What respiratory symptoms may occur?
Respiratory disturbances.
What cardiovascular changes may occur with increased intracranial pressure?
Arterial hypertension with corresponding decreases in heart rate.
What ECG changes may indicate hypothalamic ischemia?
The appearance of Q waves, deep and inverted T waves, prolonged QT intervals, and ST segment elevations.
What systemic effects may AS and RA present with?
Restrictive lung disease, pleural and pericardial effusions, cardiac conduction abnormalities, and increased risk of difficult venous access.
What are pharmacologic considerations in RA patients?
DMARDs and biologic agents cause immunosuppression, increasing the risk of delayed wound healing, wound dehiscence, and surgical site infections.
What should be monitored in RA patients during anesthesia?
Monitor progression of neurologic dysfunction, including coma, obtundation, and decerebrate rigidity.
What Glasgow Coma Scale (GCS) score indicates coma?
A GCS score of <8 indicates coma and need for intubation.
What diagnostic tests are used for neurologic disorders?
Electromyography (EMG), electroencephalography (EEG), CT or MRI scans, and cerebral arteriography.
What are indicators of intracranial hypertension?
CT or MRI showing ≥0.5 cm midline shift of the brain, hydrocephalus, cerebral edema, or obliteration of CSF cisterns.
What considerations are there for cerebrovascular disease?
Carotid endarterectomy patients require a full cardiac workup, and patients with vertebral artery disease should avoid extreme head flexion, extension, or rotation.
What is the anesthetic management for patients with intracranial hypertension?
Avoid CNS depressants (opioids, benzodiazepines) in patients with ICP and altered consciousness.
What should be assessed in a preoperative neurologic assessment?
Observe gait, ability to toe-and-heel walk, arm extension, grip strength, sensory perception, muscle reflexes, cranial nerve abnormalities, and mental status.
Why is it important to recognize neurologic disease?
To identify signs of increased intracranial pressure (ICP) or cerebral ischemia and monitor progression of neurologic dysfunction.
What should be done with anticonvulsants perioperatively?
Continue anticonvulsants (phenytoin, phenobarbital) perioperatively.
When is routine serum drug level monitoring necessary for anticonvulsants?
Routine serum drug level monitoring is unnecessary unless withdrawal or major dose change is expected.
What should be monitored in long-term phenytoin users?
Monitor CBC in long-term phenytoin users due to the risk of agranulocytosis.
What corticosteroids should be continued perioperatively in CNS tumors?
Dexamethasone or methylprednisolone therapy should be continued perioperatively.
How do steroids affect cerebral edema?
Steroids reduce cerebral edema via capillary membrane stabilization.
What should be monitored closely due to steroid therapy?
Monitor blood glucose closely due to steroid-induced hyperglycemia.
What are the risks associated with long-term steroid use?
Increased risk of pulmonary infection and gastrointestinal irritation in long-term steroid users.
What conditions are included in preexisting cardiac disease?
Hypertension, ischemic heart disease, valvular dysfunction, cardiac arrhythmias, cardiac conduction abnormalities, and ventricular failure.
What factors should be assessed in disease severity and stability?
Assess current management and medication use, and determine stability of condition and history of decompensation.
What are the high-risk surgeries according to the Revised Cardiac Risk Index?
Aortic, major vascular, and peripheral vascular surgeries.
What constitutes ischemic heart disease in the Revised Cardiac Risk Index?
Previous myocardial infarction, positive stress test, use of nitroglycerin, typical angina, ECG Q waves, previous PCI or CABG.
What indicates a history of compensated previous congestive heart failure?
History of heart failure, previous pulmonary edema, third heart sound, bilateral rales, evidence of heart failure on chest radiograph.
What defines a history of cerebrovascular disease in the Revised Cardiac Risk Index?
Previous TIA or previous stroke.
What is considered diabetes mellitus in the context of the Revised Cardiac Risk Index?
Diabetes mellitus with or without preoperative insulin.
What level of creatinine indicates renal insufficiency in the Revised Cardiac Risk Index?
Creatinine >2.0 mg/dL.
What is the estimated rate for postoperative major cardiac complications with 0 risk factors?
0.4%.
What is the estimated rate for postoperative major cardiac complications with 1 risk factor?
0.9%.
What is the estimated rate for postoperative major cardiac complications with 2 risk factors?
7%.
What is the estimated rate for postoperative major cardiac complications with more than 3 risk factors?
11%.
What are unstable coronary syndromes that require evaluation before noncardiac surgery?
Unstable or severe angina and recent myocardial infarction (MI) within 30 days.
What condition is classified as decompensated heart failure?
Decompensated heart failure requires evaluation before noncardiac surgery.
What are significant arrhythmias that necessitate evaluation before noncardiac surgery?
High-grade atrioventricular block, symptomatic ventricular arrhythmias, supraventricular arrhythmias (>100 beats/min at rest), symptomatic bradycardia, and newly recognized uncontrolled ventricular tachycardia.
What constitutes severe valvular disease requiring evaluation before noncardiac surgery?
Severe aortic stenosis (mean pressure gradient >40 mm Hg, area <1 cm² or symptomatic) and symptomatic mitral stenosis.
What are the clinical risk factors for evaluation before noncardiac surgery?
History of ischemic myocardial disease, currently stable but history of heart disease, history of cerebrovascular disease, diabetes (insulin dependent), and renal failure (serum creatinine (SCr) >2 mg/dL).
What are the cardiac high-risk surgical procedures?
Aortic surgery, major vascular surgery, peripheral vascular surgery.
Cardiac risk >5%.
What are the cardiac intermediate-risk surgical procedures?
Intraperitoneal, transplant (e.g., renal, liver, pulmonary), carotid, peripheral arterial angioplasty, endovascular aneurysm repair, head and neck surgery, major neurologic/orthopedic (e.g., spine, hip), intrathoracic, major urologic.
Cardiac risk 1%-5%.
What are the cardiac low-risk surgical procedures?
Breast, dental, endoscopic, superficial, endocrine, cataract, gynecologic, reconstructive, minor orthopedic (e.g., knee surgery), minor urologic.
Cardiac risk <1%.
What is 1 MET?
1 MET represents poor functional capacity, including activities like self-care, eating, dressing, or using the toilet, and walking indoors or around the house.
Example activities include walking 1-2 blocks on level ground at 2-3 mph.
What is 4 METs?
4 METs indicate good functional capacity, involving light housework, climbing stairs without stopping, or walking on level ground at 4 mph.
Example activities include running a short distance, heavy housework, and moderate recreational activities like golf or dancing.
What are activities greater than 10 METs?
Activities greater than 10 METs signify excellent functional capacity, including strenuous sports and high-intensity exercises.
Example activities include basketball, cross-country skiing (>8 km/hr), rope skipping, running, soccer, swimming (>3.5 km/hr), and weight training.
What is perioperative cardiac risk stratification?
It involves assessing major cardiac conditions associated with increased perioperative risk, warranting referral to a cardiologist for further assessment.
What tool is used for predicting major postoperative cardiac complications?
The Revised Cardiac Risk Index (RCRI) is used for predicting major postoperative cardiac complications.
What is the significance of Metabolic Equivalent (MET) assessment?
Functional capacity is a key predictor of perioperative cardiac complications.
What MET level indicates good functional capacity?
Patients with good functional capacity are those with >4 METs.
What questions can assess functional capacity?
- Can you walk four blocks without stopping, regardless of symptoms? 2. Can you climb two flights of stairs without stopping, regardless of symptoms?
Inability to do so indicates poor functional capacity (<4 METs) and higher perioperative cardiac risk.
What should patients with <4 METs undergo?
They should undergo further cardiac risk stratification.
What is the New York Heart Association (NYHA) Classification used for?
It is used to categorize the severity of heart failure and functional impairment based on symptoms.
What are the classifications of hypertension according to updated guidelines?
- Normal BP: <120/80 mmHg 2. Elevated BP: 120–129/<80 mmHg 3. Stage 1 Hypertension: 130–139/80–89 mmHg 4. Stage 2 Hypertension: ≥140/≥90 mmHg 5. Stage 3 (Severe) Hypertension: ≥180/≥110 mmHg.
What is hypertension’s significance in health?
Hypertension is the most common circulatory disorder affecting humans and is a major risk factor for coronary artery disease and increased perioperative mortality.
What comorbid conditions increase cardiac risk?
- Diabetes mellitus 2. Peripheral vascular disease 3. Chronic pulmonary disease 4. Obesity.
How does the type of surgery influence cardiac risk?
The type of surgery influences perioperative cardiac risk, with major cardiac events (MI, cardiac death) being more likely in high-risk procedures.
What is Class I in the New York Heart Association Functional Classification?
Patients with cardiac disease have no functional limitations to physical activity. Ordinary physical activity is not associated with undue fatigue, palpitations, dyspnea, or anginal pain.
What is Class II in the New York Heart Association Functional Classification?
Patients with cardiac disease are comfortable at rest but have slight functional limitations to physical activity. Activities such as walking or climbing stairs rapidly, or during emotional stress, may cause fatigue, palpitations, dyspnea, or anginal pain.
What is Class III in the New York Heart Association Functional Classification?
Patients with cardiac disease have marked limitations to physical activity. They are comfortable at rest, but less than ordinary physical activity causes fatigue, palpitations, dyspnea, or anginal pain.
What is Class IV in the New York Heart Association Functional Classification?
Patients with cardiac disease are unable to carry on any physical activity without discomfort. Symptoms of cardiac insufficiency or anginal syndrome may be present even at rest, and any physical activity increases discomfort.
What is the effect of hypertension on perioperative risk?
Hypertension increases the risk of myocardial ischemia and perioperative hemodynamic instability.
What blood pressure level indicates significantly higher risk of complications?
Uncontrolled hypertension is defined as BP >180/110 mmHg.
What conditions increase perioperative risk in hypertensive patients?
Target-organ damage such as ischemic heart disease, heart failure, renal disease, and cerebrovascular disease increases perioperative risk.
When should elective surgery be postponed in hypertensive patients?
Elective surgery should be postponed if BP >180/110 mmHg or there is evidence of uncontrolled target-organ damage.
Is delaying surgery beneficial for mild to moderate hypertension?
Delaying surgery for mild to moderate hypertension (systolic <180 mmHg, diastolic <110 mmHg) is generally not beneficial.
What should be included in the preoperative hypertension evaluation?
History and medication review to identify coexisting diseases and review all antihypertensive medications.
What symptoms should be evaluated in hypertensive patients?
Evaluate for symptoms of cerebrovascular insufficiency (syncope, dizziness) and orthostatic hypotension (drop in BP upon standing).
What physical examination findings suggest Cushing’s disease?
Truncal obesity, purpura, and striae.
What vital sign measurement is important in hypertensive patients?
Measure BP in both arms to check for discrepancies.
What should be assessed in the neck during a physical examination?
Check for carotid bruits, distended veins, and thyroid enlargement.
What cardiac assessments are important in hypertensive patients?
Assess for abnormal rhythm, murmur, and cardiomegaly.
What lung conditions should be checked in hypertensive patients?
Look for rales or bronchospasm.
What abdominal findings should be assessed in hypertensive patients?
Check for bruits, masses, enlarged kidneys, or abnormal aortic pulsations.
What extremity findings may indicate aortic coarctation?
Delayed or absent femoral pulses.
What is a key anesthesia consideration for hypertensive patients?
Combination of antihypertensive drugs and anesthetics can cause excessive hypotension.
What is the risk for patients with uncontrolled hypertension during surgery?
They are more prone to intraoperative BP fluctuations.
What is ischemic heart disease (IHD)?
IHD occurs due to an imbalance between myocardial oxygen demand and supply.
What are common risk factors for ischemic heart disease?
Advanced age, smoking, diabetes mellitus, hypertension, pulmonary disease, history of myocardial infarction, left ventricular dysfunction, and peripheral vascular disease.
What percentage of surgical patients in the U.S. are at high risk for cardiovascular disease?
One-third of surgical patients are at high risk.
What symptoms should be investigated in the preoperative assessment for ischemic heart disease?
Undue fatigue, angina pectoris, palpitations, syncope, and dyspnea.
When is a 12-lead ECG recommended in preoperative assessment?
For known coronary artery disease, significant structural heart disease, or symptoms suggestive of ischemia or arrhythmia.
Is routine ECG recommended for low-risk surgeries?
No, routine ECG is NOT recommended for low-risk surgeries.
What characterizes stable angina?
Substernal discomfort with exertion, relieved by rest or nitroglycerin within 15 minutes.
What are the surgical considerations for stable angina?
Stable angina does not significantly increase MI risk perioperatively.
What defines unstable angina?
New-onset angina within the past 2 months, progressively worsening angina, angina occurring at rest, or lasting >30 minutes.
What are the surgical considerations for unstable angina?
Elective surgery must be postponed until cardiac status is optimized, and advanced cardiac evaluation is required.
What is the risk of perioperative reinfarction post-myocardial infarction?
Post-MI reinfarction rates are 33% <30 days, 19% 1–2 months, 6% 3–6 months, and lowest >6 months.
What is the mortality risk if reinfarction occurs post-MI?
Post-MI mortality if reinfarction occurs is 50%.
What is the recommended delay for elective surgery after a myocardial infarction (MI)?
Elective surgery should be delayed at least 60 days post-MI.
What is the risk for patients with prior coronary revascularization and no symptoms?
Patients with prior coronary revascularization and no symptoms have lower risk.
What is the restenosis rate for Bare Metal Stents (BMS)?
BMS reduce restenosis but still have a 20% restenosis rate.
What is the restenosis rate for Drug-Eluting Stents (DES) after 2 years?
DES reduce restenosis further to 5% after 2 years.
What does Dual Antiplatelet Therapy (DAPT) include?
DAPT includes aspirin (continued indefinitely) and a P2Y12 inhibitor (clopidogrel, prasugrel, ticagrelor) for at least 6 months.
What percentage of patients with stents will require non-cardiac surgery within a year?
5% of patients with stents will require non-cardiac surgery within a year.
What risks are associated with early surgery post-stent placement?
Early surgery post-stent placement increases the risk of stent thrombosis, perioperative MI, hemorrhagic complications, and death.
What should be considered for preoperative management of stent patients?
Timing of elective surgery should be coordinated with a cardiologist, and bridging strategies and continuation of antiplatelet therapy must be evaluated.
What is a significant cardiovascular risk factor for patients undergoing noncardiac surgery?
Active left ventricular failure is a significant cardiovascular risk factor.
What are the two categories of heart failure?
Heart failure can be classified into Preserved Ejection Fraction (EF ≥ 50%) (HFpEF) and Reduced Ejection Fraction (EF < 49%) (HFrEF).
How does heart failure affect perioperative mortality risk?
A diagnosis of heart failure increases perioperative mortality risk significantly.
What is the perioperative sudden death risk associated with severe aortic stenosis?
Severe aortic stenosis (valve area <1 cm²) is linked to a 14 times higher perioperative sudden death risk.
What is required for patients with moderate/severe valvular disease before noncardiac surgery?
Echocardiography is required for patients with moderate/severe valvular disease.
What should be done for symptomatic aortic stenosis before elective surgery?
Symptomatic aortic stenosis requires cardiology consultation before elective surgery.
What are prominent signs of heart failure?
Prominent signs include moist rales, tachypnea, jugular vein distention, peripheral edema, and resting tachycardia.
What diagnostic tests are used for heart failure?
Diagnostic tests include cardiac MRI, radionuclide angiography, echocardiography, and ventriculography.
What is the risk for patients with left ventricular ejection fraction (EF) < 35%?
Patients with EF < 35% have higher rates of postoperative heart failure and mortality.
What should be done for patients with confirmed congestive heart failure before elective surgery?
Elective surgery should be postponed until optimal ventricular performance is achieved.
What are the most common lesions in Valvular Heart Disease?
The most common lesions involve the aortic and mitral valves.
**Footnote rheumatic heart disease remains a major cause
What is the risk associated with severe aortic stenosis?
Severe aortic stenosis (valve area <1 cm²) is linked to a 14 times higher perioperative sudden death risk.
What is required for patients with moderate/severe valvular disease before noncardiac surgery?
Echocardiography is required.
What is necessary for symptomatic aortic stenosis before elective surgery?
Cardiology consultation is required.
What does valvular stenosis lead to?
Valvular stenosis leads to hypertrophy due to increased workload.
What should preoperative evaluation assess regarding cardiac arrhythmias?
Preoperative evaluation should assess arrhythmia type, severity, and associated heart disease.
What symptoms may indicate worsening cardiac conditions?
Symptoms like palpitations, dizziness, dyspnea, and angina may indicate worsening cardiac conditions.
What diagnostic tests are included for arrhythmias?
Diagnostic tests include ECG, electrolyte levels (potassium/magnesium), and drug level monitoring.
How are arrhythmias classified?
Arrhythmias are classified into benign, potentially malignant, and malignant.
What increases perioperative risk in patients?
Increased perioperative risk is seen in patients with severe coronary artery disease, recent MI, or peripheral vascular disease.
What minimizes risk to patients with Cardiovascular Implantable Electronic Devices?
Proper preprocedural assessment minimizes risk.
What are essential considerations for CIEDs?
Essential considerations include device type, indication for use, and functional status.
What is required to assess a CIED?
Direct interrogation by a qualified CIED team is required to assess battery status, lead performance, and adequacy of current settings.
What can pacemakers mask?
Pacemakers can mask toxicity from antiarrhythmic drugs, electrolyte disorders, and myocardial ischemia.
What are ECG findings of pacemaker malfunction?
ECG findings include unexpected pauses or pacing spikes without myocardial contraction.
What should be done if symptoms of pacemaker failure return?
Cardiology consultation is needed.
What can chest radiography confirm regarding pacemakers?
Chest radiography can confirm electrode placement, lead integrity, and battery depletion.
What can the Valsalva maneuver do in relation to pacemakers?
The Valsalva maneuver can slow the heart rate, making pacing impulses more visible on an ECG.
What are indications for temporary preoperative pacing?
Indications include persistent bradycardia unresponsive to atropine, history of syncope with bifascicular block, and exercise-induced dizziness near the device site.
What anesthetic considerations should be taken for pacemakers?
Avoid muscle fasciculations and shivering, which can inhibit pacemaker function.
What is the purpose of preoperative cardiac testing?
Preoperative cardiac testing should only be done if the results will influence patient management.
Who are noninvasive tests primarily used for?
Noninvasive tests are primarily used for high-risk patients with three or more risk factors and poor functional capacity.
What is the role of a 12-lead ECG in preoperative testing?
The 12-lead ECG is not a strong predictor of perioperative cardiac events and is often used as an adjunct to other testing methods.
What does the Exercise Stress ECG help detect?
The Exercise Stress ECG helps detect myocardial ischemia by increasing heart workload and documents cardiovascular function and tolerance.
What findings indicate ischemia during an Exercise Stress ECG?
Findings that indicate ischemia include ST-segment depression > 0.2 mV, early ST-segment depression, and a hypotensive response during the test.
What is pharmacologic stress testing used for?
Pharmacologic stress testing is used for patients unable to perform exercise testing.
What agents are used in pharmacologic stress testing?
Dipyridamole or adenosine causes coronary blood flow redistribution, while dobutamine increases heart rate and contraction strength.
What are advanced imaging techniques used for?
Advanced imaging techniques help identify ischemic heart disease and cardiac risk, but there is insufficient evidence to support routine testing before all surgeries.
When is cardiac catheterization recommended?
Cardiac catheterization is recommended for high-risk surgical patients or those with NYHA Class III or IV heart failure.
What does cardiac catheterization identify?
It identifies significant arterial narrowing, such as 70% blockage in major coronary arteries and 50% blockage in the left main coronary artery.
What are key imaging findings that indicate poor ventricular function?
Key findings include cardiac index < 2.2 L/m², left ventricular end-diastolic pressure > 18 mmHg, ejection fraction < 40%, and akinesis or hypokinesis.
Who should receive prophylactic pharmacotherapy before surgery?
High-risk patients (history of angina, prior MI, heart failure, stroke, diabetes, or moderate-to-poor functional capacity) should receive prophylactic pharmacotherapy before surgery.
What are the benefits of Statins?
Statins improve endothelial function, reduce oxidative stress and inflammation, and increase plaque stability, lowering the risk of rupture.
What are common Statins used?
Common Statins include Atorvastatin, Fluvastatin, Lovastatin, Pravastatin, Rosuvastatin, and Simvastatin.
When should Statin therapy be started before surgery?
Statin therapy should be started at least 30 days before surgery for maximal effect and continued perioperatively.
What are the benefits of β-Blockers?
β-Blockers reduce oxygen demand mismatch, lower myocardial oxygen consumption, stabilize heart rate, and reduce perioperative myocardial infarction (MI) and death in high-risk surgical patients.
Who should receive β-Blockers?
Patients already on β-blockers for ischemic heart disease, arrhythmias, or hypertension, and high-risk cardiovascular patients (those with stress-induced myocardial ischemia) should receive β-Blockers.
What caution should be taken with β-Blockers?
DO NOT start β-blockers perioperatively in low-risk patients as it may increase the risk of mortality, stroke, bradycardia, and hypotension if initiated too close to surgery.
What are the benefits of ACE Inhibitors?
ACE Inhibitors are used to reduce heart failure symptoms and improve long-term outcomes.
In which patients are ACE Inhibitors beneficial?
ACE Inhibitors are beneficial in patients with heart failure with reduced ejection fraction (HFrEF), a history of MI, and moderate-to-severe cardiovascular disease.
What should be managed when using ACE Inhibitors perioperatively?
Perioperative use of ACE Inhibitors should be carefully managed to avoid hypotension.
What are commonly used ACE Inhibitors?
Commonly used ACE Inhibitors include Captopril, Enalapril, Lisinopril, Benazepril, and Ramipril.
When are ACE Inhibitors recommended?
ACE Inhibitors are recommended for intermediate- to high-risk surgeries and considered for low-risk surgery if appropriate.
What is Dual Antiplatelet Therapy (DAPT)?
Includes Aspirin and P2Y12 inhibitors (Clopidogrel, Prasugrel, Ticagrelor, Cangrelor).
Used to prevent stent thrombosis after percutaneous coronary intervention (PCI) with stent placement.
When should elective non-cardiac surgery be delayed after Bare Metal Stent (BMS) placement?
30 days after BMS placement.
Elective surgery should also be delayed 6 months after Drug-Eluting Stent (DES) placement.
When should elective surgery not be performed after BMS implantation?
Within 30 days of BMS implantation.
Also, within 3 months of DES implantation if DAPT discontinuation is necessary.
What should be done for patients undergoing surgery that requires stopping P2Y12 inhibitors?
Continue aspirin if possible. Restart P2Y12 inhibitor as soon as feasible after surgery.
What are Novel Oral Anticoagulants (NOACs) used for?
Used for Atrial fibrillation (AF), deep venous thrombosis (DVT), pulmonary embolism (PE), and sometimes prosthetic heart valves.
What are the types of NOACs?
Factor Xa Inhibitors: Rivaroxaban, Apixaban. Thrombin Inhibitors: Dabigatran.
What is the reversal agent available for Thrombin Inhibitors?
Idarucizumab (Praxbind) for emergency reversal.
What are preoperative therapeutic maneuvers to decrease the risk of pulmonary complications?
Instruction in and application of respiratory maneuvers, smoking cessation, antibiotic treatment of pulmonary infection, antibiotic treatment of chronic bronchitis, expectorants, psychologic preparation, bronchodilator therapy for asthmatics, maintenance of good nutrition, chest physiotherapy, weight reduction.
What are postoperative therapeutic maneuvers to decrease the risk of pulmonary complications?
Adequate pain control with minimization of postoperative opioid analgesia, avoiding nasogastric intubation when possible, maximal inspiration maneuvers, incentive spirometry, chest physiotherapy, mobilization of secretions, early mobilization of elderly patients, cough encouragement, heparin prophylaxis in selected cases.
What is the role of adequate pain control in postoperative care?
Minimization of postoperative opioid analgesia with epidural analgesia when appropriate, and PCA administration of opioids rather than intravenous boluses as needed, using opioid sparing techniques with ERAS pathways.
What are some techniques for maximizing respiratory function postoperatively?
Maximal inspiration maneuvers, incentive spirometry, chest physiotherapy.
What is the importance of early mobilization in postoperative patients?
Early mobilization of elderly patients is crucial to decrease the risk of pulmonary complications.
What is the frequency of asthmatic attacks?
Frequency of asthmatic attacks, wheezing at exercise, or wheezing >3 times in last 12 months?
What is the time interval since the last asthma attack?
Time interval since the last attack?
Has there been a recent asthma exacerbation?
Recent asthma exacerbation? How long since the patient was last hospitalized or treated in the emergency department for an asthmatic attack?
What is the increased use of inhaled short-acting ß-agonists?
Increased use of inhaled short-acting ß-agonists? Use per week?
What is the current or past use of inhaled corticosteroids?
Current or past use of inhaled corticosteroids?
What was the most recent course of oral corticosteroids?
Most recent course of oral corticosteroids?
What works best for treating an acute asthmatic event?
What works best for treating an acute asthmatic event?
Has there been a recent upper respiratory tract infection?
Recent upper respiratory tract infection (<2 weeks) or sinus infection?
Has there been a recent pneumonia?
Recent pneumonia? Was this documented on chest radiograph?
What was the severity of the asthma attacks?
The severity of attacks: Was endotracheal intubation or intensive care unit admission required?
Is there a history of pulmonary complications with prior surgical procedures?
History of pulmonary complications with prior surgical procedures?
Is there a history of long-term corticosteroid use?
History of long-term corticosteroid use or corticosteroid-dependent asthma?
Is there a nocturnal dry cough?
Nocturnal dry cough
Is there a history of hay fever?
Hay fever
Has there been exposure to passive smoke?
Exposure to passive smoke
Is there a concern about obesity?
Obesity
Is there a history of obstructive sleep apnea?
Obstructive sleep apnea
What is the CHADS₂ scoring system used for?
It is used to assess the risk of stroke in patients with atrial fibrillation.
What are the components of the CHADS₂ score?
1 point for congestive heart failure, hypertension, age >75, diabetes; 2 points for stroke/TIA.
What does a CHADS₂ score >4 indicate?
High risk.
What does a CHADS₂ score of 3-4 indicate?
Intermediate risk.
What does a CHADS₂ score <3 indicate?
Low risk.
When should NOACs be stopped before surgery?
3 elimination half-lives before surgery.
When can NOACs be restarted after surgery?
24-48 hours post-surgery if bleeding is controlled.
What is bridging therapy?
It may be needed for high-risk patients during the perioperative period.
What percentage of adults have respiratory diseases?
Approximately 25%.
What is a major risk factor for post-operative pulmonary complications?
COPD (chronic bronchitis, emphysema).
What are risk factors for increased postoperative pulmonary complications?
Preoperative sepsis, emergency surgeries, age >50, smoking, cardiovascular disease, diabetes, kidney disease, obesity, upper abdominal/thoracic surgery, prolonged anesthesia, pulmonary hypertension, ASA status III or higher.
Which surgical sites pose the highest risk for pulmonary complications?
Thoracic and upper abdominal surgeries.
When should elective surgery be postponed for COPD patients?
If there is severe dyspnea, wheezing, pulmonary congestion, or hypercarbia (PaCO₂ > 50 mmHg).
What is the role of antibiotics in preoperative management?
Indicated for thick, purulent sputum with pulmonary infiltrates; routine prophylactic antibiotics are NOT recommended.
What is the benefit of incentive spirometry?
It reduces post-operative pulmonary complications after upper abdominal surgery.
How long should smoking cessation occur before surgery to reduce risks?
8 weeks.
When are routine preoperative chest X-rays (CXR) indicated?
If undergoing major thoracic, esophageal, or upper abdominal surgery.
When are pulmonary function tests (PFTs) necessary?
Only if severe COPD or myasthenia gravis is suspected.
What does FEV₁/FVC < 80% suggest?
An obstructive disease.
What is associated with increased post-operative pulmonary risk?
PaO₂ < 60 mmHg or PaCO₂ > 45 mmHg.
What are key characteristics of asthma?
Reversible airflow obstruction, airway inflammation, hyperreactivity to stimuli.
What are common triggers for asthma?
Allergens, exercise, infections, stress, unidentified factors.
What indicates a severe asthma history?
Frequent nocturnal awakenings, prior hospitalizations, high corticosteroid use, coexisting cardiovascular disease.
What should be done if active asthma symptoms are present on surgery day?
Postpone surgery.
What preoperative evaluations are recommended for asthma patients?
ECG if right ventricular hypertrophy is suspected, CXR if pneumonia or worsening condition is suspected, ABG for chronic respiratory insufficiency.
What are key preoperative interventions for respiratory management?
Respiratory exercises, smoking cessation, antibiotics (if indicated), bronchodilators for asthma/COPD patients, nutritional support, chest physiotherapy (select cases only).
What are key postoperative strategies to reduce pulmonary complications?
Adequate pain control, avoid nasogastric tubes, encourage deep breathing & incentive spirometry, mobilization of secretions, early ambulation, encourage coughing, use heparin prophylaxis in selected cases.
What is the normal Peak Expiratory Flow Rate (PEFR)?
80-100% of baseline.
What indicates a moderate exacerbation in PEFR?
50-80% of baseline.
What should be done in case of severe exacerbation (PEFR <50%)?
Delay surgery and intensify treatment.
What medications should be continued for perioperative asthma management?
All medications, including corticosteroids and bronchodilators.
What should be used on the morning of surgery for asthma management?
β-agonist inhalers.
What should be confirmed if the patient is on theophylline?
Therapeutic theophylline levels.
Why is it important to minimize fasting time before surgery?
Ensures hydration and prevents airway desiccation.
What is a key aspect of preoperative anxiety management?
Avoids psychologic triggers.
What is the risk of airway complications for children <1 year old with a URI?
2 to 7 times higher risk.
How long does the risk of complications from a URI persist?
Up to 6 weeks due to heightened airway reactivity.
What are some complications of URI in surgery?
Bronchospasm, laryngospasm, atelectasis, mucous plugging, impaired oxygenation.
What are common symptoms of URI?
Sore throat, nasal congestion, rhinorrhea, malaise, fever (37.5°C-38.5°C), wheezing, stridor.
What should be considered for elective surgery in children with URI?
If the child always has a runny nose but is otherwise well, surgery may proceed.
What should be done if a child has a productive cough and lower respiratory tract involvement?
Delay surgery for at least 2 weeks.
What is the recommendation if a child has a fever (>38°C) and lower respiratory tract signs?
Delay surgery for 4-6 weeks.
What should be discussed with parents and the surgical team regarding a child with a URI?
Increased perioperative risks.
What is recommended to avoid during intubation for a child with a URI?
Avoid intubation if possible; use LMA or mask anesthesia instead.
What should be used preoperatively for bronchospasm prophylaxis?
Albuterol.
What should be used to prevent airway dryness during surgery?
Humidified gases.
What should be done for febrile children or those with abnormal lung sounds?
Reschedule their surgery.
What gastrointestinal symptoms should be looked for in preoperative evaluation?
Nausea, vomiting, diarrhea, bleeding, pain, distension, dysphagia, reflux.
What should be checked for fluid and electrolyte imbalances?
Associated with weight loss or malabsorption.
What should be checked in case of active gastrointestinal bleeding?
Hemoglobin & hematocrit.
What imaging should be considered to check for obstruction or masses?
CT scan/X-ray.
What should be considered for patients with GERD or Peptic Ulcer Disease?
Use prophylactic measures to reduce aspiration risk.
What types of liver disease should be considered preoperatively?
Acute & chronic liver disease (e.g., hepatitis, cirrhosis).
What is a common issue in cholestatic liver disease?
Biliary obstruction.
What is a limitation of laboratory tests in liver disease detection?
They often fail to detect early liver disease.
What are symptoms of mild hepatic dysfunction?
Malaise, weight loss, mild jaundice.
What may indicate early cirrhosis or hepatitis?
Mildly elevated bilirubin & transaminases.
What should be done for unexplained jaundice or liver enzyme elevation?
Further testing is required.
What are symptoms of severe hepatic dysfunction and failure?
Coagulopathy, extreme jaundice, ascites, encephalopathy, hepatorenal failure.
What should be done for patients with severe hepatic dysfunction?
Emergency or palliative procedures only; elective surgery postponed.
What is the risk for patients with liver failure undergoing surgery?
High morbidity & mortality risk.
What should be done for high-risk patients with liver disease?
Consultation with a gastroenterologist.
What should be corrected in patients with coagulopathy?
Vitamin K, fresh frozen plasma, cryoprecipitate.
What should be monitored due to the risk of hypoglycemia?
Blood glucose.
What should be avoided in hepatic encephalopathy?
Sedatives.
What should be assessed for fluid/electrolyte balance?
ABG, liver function tests.
What are the limitations of liver function tests (LFTs)?
AST/ALT are not liver-specific.
What does alkaline phosphatase elevation suggest?
Cholestasis (bile duct obstruction).
What does direct bilirubin elevation indicate?
Hepatobiliary obstruction.
What is the most reliable indicator of acute liver dysfunction?
Prolonged prothrombin time (PT).
What does the Child-Pugh Score predict?
Surgical mortality in cirrhosis.
What are the scoring criteria for the Child-Pugh Score?
Bilirubin, albumin, INR, ascites, encephalopathy.
What is the surgical mortality risk for Class A in Child-Pugh Score?
10% surgical mortality (low risk).
What is the surgical mortality risk for Class B in Child-Pugh Score?
30% surgical mortality (moderate risk, requires pre-op optimization).
What is the surgical mortality risk for Class C in Child-Pugh Score?
80% surgical mortality (surgery should be delayed if possible).
What are some considerations for renal system preoperative evaluation?
Acute kidney injury (AKI), chronic kidney disease (CKD) or renal failure.
What are signs of dehydration to assess fluid status?
Dry mucosa, postural hypotension, tachycardia.
What can polyuria indicate?
Diabetes insipidus or uncontrolled diabetes.
What is urinary retention commonly associated with?
Chronic prostate enlargement or neurogenic bladder.
What should be ruled out for recurrent infections?
Cystitis, pyelonephritis, or glomerulonephritis.
What are the diagnostic criteria for acute kidney injury (AKI)?
Serum creatinine >26.4 µmol/L within 48 hours.
What is another criterion for diagnosing AKI?
Serum creatinine >1.5 times baseline in 7 days.
What urine output indicates AKI?
Urine output <0.5 mL/kg for 6 hours.
Why is Blood Urea Nitrogen (BUN) not a reliable indicator of kidney function?
Due to dietary & metabolic influences.
What is more accurate than BUN for assessing kidney function?
Serum creatinine.
What may serum creatinine appear in elderly patients despite declining renal function?
Normal.
What is a more reliable estimation of kidney function than serum creatinine?
Creatinine Clearance (GFR estimation).
What GFR indicates mild renal dysfunction?
GFR 50-80 mL/min.
What GFR indicates end-stage renal failure?
GFR <10 mL/min.
What is the formula for GFR calculation?
GFR = (U x V)/ P
What is the preoperative consideration for renal disease patients regarding urinalysis?
Preoperative urinalysis & culture → Treat infections before surgery.
What should be monitored in renal disease patients before surgery?
Monitor electrolyte imbalances (K+, Na+, Ca2+).
What medications should be avoided in renal disease patients preoperatively?
Avoid nephrotoxic medications (NSAIDs, contrast dyes).
What is the goal for chronic renal failure patients preoperatively?
Optimize hydration & correct metabolic abnormalities.
What are key concerns for dialysis patients preoperatively?
Maintain homeostasis despite abnormal BUN & creatinine levels.
What is crucial to monitor in dialysis patients regarding fluid balance?
Check for weight gain, jugular vein distension, edema, and pulmonary congestion.
When should potassium levels be checked before surgery in renal patients?
Potassium levels must be checked 6-8 hours before surgery.
What should be done if potassium levels are greater than 5.5 mEq/L?
Delay elective surgery.
What interventions can be used for emergency cases with high potassium levels?
Use interventions to reduce K+ (e.g., dialysis, medications).
What is the typical hemoglobin level in chronic renal failure patients?
Hemoglobin levels often low (5-8 mg/dL).
What are some causes of anemia in chronic renal failure patients?
Decreased erythropoietin production, red blood cell fragility due to uremia, chronic GI bleeding & dialysis-related blood loss.
What may be necessary if a chronic renal failure patient has severe anemia?
Blood transfusion may be necessary before surgery.
What risks are associated with frequent blood transfusions?
Risk of infections (Hepatitis, HIV).
What coagulopathy risk is present in chronic renal failure patients?
Prolonged bleeding time due to platelet dysfunction.
What can help correct coagulopathy before surgery?
Dialysis before surgery can help correct this.
What should be continued for renal failure patients during perioperative management?
Continue most medications (antihypertensives, digitalis, corticosteroids, insulin).
What should be reduced or avoided in renal failure patients preoperatively?
Reduce or avoid long-acting sedatives (e.g., diazepam).
What should be checked regarding vascular access sites in renal failure patients?
Check vascular access sites (AV fistulas) for infection & patency.
What should be avoided in dialysis-access limbs?
Avoid IV lines and blood pressure measurements.
What gastrointestinal preparations may be considered for renal failure patients?
Consider gastrointestinal preparations (e.g., antacids, gastrokinetics) to reduce aspiration risk.
What is the most common endocrine disorder affecting preoperative considerations?
Diabetes Mellitus.
What is the perioperative risk associated with diabetes?
Diabetic patients have a 5-10x higher morbidity & mortality risk in surgery.
What are the two types of diabetes?
Type 1 (Insulin-dependent) and Type 2 (Non-insulin dependent).
What are the risks associated with Type 1 diabetes?
Higher risk of ketoacidosis & microvascular complications.
What are the management strategies for Type 2 diabetes?
Often managed with diet, exercise, oral hypoglycemics.
What cardiovascular risks are associated with diabetes?
Higher risk of macrovascular disease (hypertension, CAD, stroke, PVD).
What should be assessed in diabetic patients preoperatively?
Assess metabolic control: Type, monitoring, usual glucose levels.
What complications should be identified in diabetic patients?
Identify cardiovascular, renal, and neurological complications.
What is the significance of Hemoglobin A1c (HbA1c) in diabetes?
Measures long-term glycemic control.
What are the HbA1c levels indicating high risk for surgery?
High Risk: 5.7-6.4%. Diabetic: ≥6.5%.
What should be done for poorly controlled diabetics (HbA1c >8%)?
They have higher surgical risks.
What should be done for uncontrolled hyperglycemia (>216 mg/dL)?
Delay elective surgery.
What is the risk associated with silent MI in diabetics?
Silent MI risk is high → Consider stress test, ECG.
What should be done to manage perioperative glucose levels?
Goal: Maintain glucose <180 mg/dL while avoiding hypoglycemia.
What should be done the night before surgery for diabetic patients?
Continue usual evening dose of insulin (long-acting like Glargine/NPH).
What should be done on the morning of surgery for fasting diabetic patients?
Withhold oral hypoglycemics and adjust insulin dosing.
What should be established for diabetic patients needing insulin?
IV access must be established with D5 (5% glucose) infusion available.
What should be determined regarding insulin pumps before surgery?
Determine type of insulin, basal rate, sensitivity factor.
When should the insulin pump be discontinued?
For long surgeries or procedures requiring MRI/X-ray/defibrillation.
What is hyperthyroidism?
Excess secretion of thyroid hormones (T3 & T4).
What is the goal of preoperative management for hyperthyroid patients?
Achieve a euthyroid state before elective surgery.
What medical therapy is used for hyperthyroid patients before surgery?
Antithyroid drugs (6-8 weeks prior to surgery).
What is the purpose of iodine therapy before surgery in hyperthyroid patients?
Reduces thyroid hormone release.
What is the goal for heart rate control in hyperthyroid patients?
Maintain HR <80 bpm.
What should be done if a euthyroid state cannot be achieved before surgery?
Use continuous esmolol infusion to control HR.
What is hypothyroidism?
Deficiency of thyroid hormones (T3 & T4).
What are common causes of hypothyroidism?
Hashimoto’s thyroiditis, iodine deficiency, post-surgical removal.
What are clinical features of hypothyroidism?
Bradycardia, fatigue, cold intolerance, weight gain.
What is the goal of preoperative management for hypothyroid patients?
Restore normal thyroid hormone levels.
What therapy is used for hypothyroid patients preoperatively?
Levothyroxine (T4) therapy.
What should be done for patients with mild to moderate hypothyroidism?
Elective surgery can proceed.
What should be done for patients with severe hypothyroidism?
Delay surgery until stabilized.
What is myxedema coma?
Life-threatening emergency with bradycardia, hypothermia, altered mental status.
What is hyperadrenocorticism (Cushing Syndrome)?
Excess glucocorticoids from prolonged steroid use or adrenal overproduction.
What are clinical features of Cushing Syndrome?
Hypertension, truncal obesity, moon facies, easy bruising.
What should be monitored in patients with Cushing Syndrome perioperatively?
Monitor blood pressure & glucose levels.
What is hyperaldosteronism?
Excess aldosterone production leading to sodium and water retention.
What are clinical features of hyperaldosteronism?
Hypertension & marked hypokalemia.
What should be done preoperatively for patients with adrenal insufficiency?
Assess electrolyte imbalances and correct before surgery.
What is the timing for routine diagnostic testing?
Normal results are valid within 6 months if no changes in health status.
What is the preferred method for pregnancy testing preoperatively?
Serum hCG preferred for accuracy.
What are the preoperative fasting guidelines for clear liquids?
Allowed up to 2 hours before surgery.
What is the fasting requirement for a heavy meal before surgery?
8 hours fasting required.
What factors increase the risk of pulmonary aspiration?
GERD, gastroparesis, obesity, diabetes, emergency surgery.
What is the ASA Physical Status Classification?
Developed by the American Society of Anesthesiologists to assess preoperative patient health.
What does ASA Class I indicate?
Healthy patient, no medical conditions.
What does ASA Class II indicate?
Mild systemic disease (e.g., controlled hypertension).
What does ASA Class III indicate?
Severe systemic disease, functionally limiting (e.g., poorly controlled diabetes).
How long are normal lab results valid if there are no changes in health status?
Normal results are valid within 6 months.
What is the validity period for serum potassium results in patients on diuretics or digitalis?
Serum potassium results are valid within 7 days.
When should blood glucose be tested for diabetics?
Blood glucose should be tested on the day of surgery.
What is the validity period for ECG results in stable cardiac disease?
ECG results are valid within 30 days.
How often should a chest X-ray be performed if pulmonary disease is present?
A chest X-ray is valid within 6 months.
When should pregnancy testing be offered?
Pregnancy testing should be offered if pregnancy status is uncertain.
What type of pregnancy test is preferred for accuracy?
Serum hCG is preferred for accuracy.
When is testing required for pregnancy risk?
Testing is required if pregnancy risk is suspected based on history or physical exam.
What is the recommendation for surgery in pregnancy?
Surgery in pregnancy should ideally be delayed unless necessary.
What is the goal of preoperative fasting guidelines?
The goal is to balance aspiration risk with minimizing patient discomfort.
What has replaced the traditional ‘NPO after midnight’ guideline?
More flexible fasting intervals have replaced the traditional guideline.
How long before surgery are clear liquids allowed?
Clear liquids are allowed up to 2 hours before surgery.
How long before surgery can a light meal be consumed?
A light meal can be consumed up to 6 hours before surgery.
What is the fasting requirement for a heavy meal before surgery?
8 hours fasting is required for a heavy meal.
What factors increase the risk of pulmonary aspiration?
Factors include GERD, gastroparesis, obesity, diabetes, emergency surgery, and pregnancy.
What are some preventive strategies for pulmonary aspiration?
Preventive strategies include prokinetics (Metoclopramide), acid suppression (Famotidine, Omeprazole), and antiemetics (Ondansetron).
What is the ASA Physical Status Classification used for?
It is used to assess preoperative patient health.
What does ASA I represent?
ASA I represents a healthy patient with no medical conditions.
What does ASA II represent?
ASA II represents a patient with mild systemic disease (e.g., controlled hypertension).
What does ASA III represent?
ASA III represents a patient with severe systemic disease that is functionally limiting (e.g., poorly controlled diabetes).
What does ASA IV represent?
ASA IV represents a patient with severe disease that is a constant threat to life (e.g., unstable angina).
What does ASA V represent?
ASA V represents a moribund patient unlikely to survive without surgery.
What does ASA VI represent?
ASA VI represents a brain-dead organ donor.
What does the ‘E’ denote in ASA classification?
‘E’ denotes emergency cases.
What is the purpose of the Joint Commission Universal Protocol?
It is developed to prevent wrong-site, wrong-procedure, and wrong-patient surgeries.
What are the key steps of the Joint Commission Universal Protocol?
Key steps include preoperative verification process, marking the surgical site, and ‘Time-Out’ before incision.
