Nagelhout-chapter 20-preop assessment Flashcards
What are the goals of preoperative assessment and preparation?
- Optimize patient care, satisfaction, comfort, and convenience
- Minimize perioperative morbidity and mortality
- Prevent surgical delays and cancellations
- Determine appropriate postoperative disposition
- Evaluate overall health status
- Optimize medical conditions through lifestyle changes
- Formulate a plan for perianesthetic and postoperative care
- Ensure effective communication among care providers
- Provide specific preoperative instructions
- Educate patients on surgery and postoperative care
- Ensure efficient and cost-effective patient evaluation
None
What is the first step in the preoperative evaluation process?
Medical Record Review
Guides further assessments such as diagnostic tests and specialist consultations.
What are the benefits of a Preanesthesia Assessment Clinic?
- Reduced patient anxiety and costs
- Fewer last-minute surgical cancellations
- Shortened post-surgical hospital stays
- Decreased diagnostic testing
- Shift from inpatient to outpatient surgeries
Services include patient registration, medical history review, and scheduling consultations.
When should patient assessments ideally be conducted before surgery?
At least 1 week prior, especially for complex cases
Day-of-surgery assessments may lead to unexpected issues.
What types of conditions require early preoperative evaluation?
- Medical conditions impairing daily activities
- Need for continuous assistance or monitoring
- Recent hospital admissions due to acute conditions
- Use of medications requiring perioperative adjustments
- Cardiac history including angina or MI
- Respiratory conditions like asthma or COPD
- Endocrinologic issues such as diabetes
- Active hepatobiliary disease
- Oncologic conditions causing physiological compromise
- Gastrointestinal issues like obesity or GERD
These conditions are critical to assess for potential surgical risks.
What is the purpose of the patient interview in preoperative assessment?
- Establish trusting relationship
- Enhance patient confidence in anesthesia care
- Introduce anesthesia provider’s role
Conducted in person or via telephone.
What are effective communication strategies during the patient interview?
- Conduct in a caring and unhurried manner
- Providers should sit during the interview
- Use patient’s surname unless instructed otherwise
Professional appearance and attitude create a positive impression.
What objectives should be met during the preoperative interview?
- Ensure assessment goals are met
- Provide preoperative education
- Obtain written informed consent
- Familiarize patient/family with surgical process
- Evaluate patient’s social support system
- Encourage compliance with preventive care strategies
This helps to ensure a comprehensive understanding of the patient’s needs.
What should be included in the medical history during preoperative assessment?
- Detailed health history if unavailable
- Organized and systematic questioning
- Focus on major findings if documented by surgeon
Use open-ended and direct questions for better responses.
What are the common adverse reactions to previous anesthesia that should be investigated?
- Prolonged vomiting
- Difficult airway
- Malignant hyperthermia
- Postoperative delirium
- Anaphylaxis
- Cardiopulmonary collapse
Preoperative knowledge of complications prevents recurrence.
What factors should be considered in the drug history during preoperative assessment?
- Dosages, schedules, and treatment duration
- Purpose and effectiveness of medications
- Focused inquiry based on medication type
Patients on β-blockers may require detailed cardiovascular assessment.
What are the most common causes of hypersensitivity reactions during anesthesia?
- Neuromuscular blocking agents
- Antibiotics
True allergies are absolute contraindications.
What are the symptoms to assess for latex sensitivity?
- Rash
- Swelling
- Wheezing upon latex exposure
High-risk patients include those with chronic latex exposure or multiple surgeries.
Fill in the blank: The preoperative evaluation aims to reduce risks and enhance _______.
surgical outcomes
None
How does substance use impact perioperative risk?
Substance use (tobacco, alcohol, illicit drugs) impacts perioperative risk.
What percentage of Americans were illicit drug users in 2021?
31.9 million Americans (11.7%) were illicit drug users in 2021.
How many deaths annually in the U.S. are linked to addiction?
75,000 deaths annually in the U.S. are linked to addiction.
What is the economic burden of substance abuse in the U.S.?
The economic burden exceeds $400 billion per year.
What is an effective approach for preoperative evaluation regarding substance use?
Open-ended, nonjudgmental questioning encourages honest disclosure.
What should patients be educated about regarding substance use?
Educate patients on anesthesia-related risks of substance use.
How does smoking affect perioperative complications?
Smoking increases perioperative complications.
What is the annual death toll linked to smoking in the U.S.?
1 in 5 deaths linked to smoking (~480,000 annually).
What percentage of lung cancer deaths are caused by smoking?
90% of lung cancer deaths are caused by smoking.
What is the mortality rate for smokers compared to non-smokers?
Smokers have a 12-13× higher mortality rate than non-smokers.
What are the annual deaths caused by secondhand smoke?
Secondhand smoke causes 7,300 lung cancer deaths and 34,000 coronary heart disease deaths annually.
What has been the trend in e-cigarette use?
E-cigarette use has risen, especially in young adults.
What is the trend in poison control calls related to e-liquids?
Increased poison control calls from e-liquid exposure (1 per month in 2010 → 215 per month in 2014).
What physiological effect does nicotine have?
Nicotine affects the cardiovascular system (ganglionic stimulant effects).
How does carbon monoxide affect oxygen transport?
Carbon monoxide binds to hemoglobin 250-300× more than oxygen, reducing oxygen transport.
What carboxyhemoglobin levels can heavy smokers have?
Heavy smokers may have carboxyhemoglobin levels as high as 15%.
How long before surgery should patients stop smoking?
Patients should stop smoking at least 12-48 hours before surgery.
What improvements can be seen after 12-hour smoking abstinence?
Even 12-hour abstinence improves heart rate, blood pressure, circulating catecholamine levels, and carboxyhemoglobin levels.
What is the incidence of postoperative pulmonary complications in smokers?
Higher incidence of postoperative pulmonary complications in smokers: nearly 6× increase in pneumonia, atelectasis.
What is the smoking cessation timeline for reducing complications?
Short-term cessation before surgery still reduces complications.
What are the respiratory complications associated with passive smoke exposure in children?
Increased respiratory complications include reactive airway disease, abnormal pulmonary function tests, and more respiratory tract infections.
What are the perioperative risks for children exposed to smoke?
Risks include laryngospasm, coughing on induction/emergence, breath-holding, postoperative oxygen desaturation, and hypersecretion.
How many alcohol-attributable deaths occur per year?
Alcohol-attributable deaths are approximately 95,000 per year (261 per day).
What is the life expectancy reduction for those affected by alcohol?
Life expectancy reduction is approximately 29 years for those affected.
What is the increased risk of complications for chronic excessive alcohol users?
2-5× increased risk of arrhythmias, infections, and alcohol withdrawal syndrome.
How does abstinence before surgery affect postoperative complications?
Postoperative complications decrease with ≥4 weeks of abstinence before surgery.
What should be assessed regarding alcohol use?
Type, amount, and frequency of alcohol intake must be evaluated.
What self-reporting questionnaire identifies problem drinkers?
Alcohol Use Disorders Identification Test (AUDIT) identifies problem drinkers.
What does the CAGE mnemonic help screen for?
CAGE mnemonic screens for alcohol use issues.
What are the alcohol withdrawal symptoms?
Symptoms include hand tremors, autonomic hyperactivity, insomnia, anxiety, hallucinations, and grand mal seizures.
What are the effects of chronic alcohol abuse on anesthesia?
Higher anesthetic drug doses required, exaggerated response to anesthesia, and increased postoperative morbidity and mortality.
What are common illicit drugs?
Common illicit drugs include cocaine, cannabis, crack, LSD, amphetamines, heroin, hallucinogens, inhalants, and non-medical opioid use.
What are the preoperative concerns for patients using illicit drugs?
Increased risk of adverse anesthetic interactions and pain management challenges.
What are the physical signs suggesting drug use?
Signs include injection marks, skin abscesses, and ophthalmologic changes.
What management strategies should be employed for acute substance abuse?
Delay or cancel elective surgery if intoxicated, urine drug screen if recent use is suspected.
What are the long-term risks of synthetic androgens?
Risks include hepatic dysfunction, cardiovascular risks, and psychiatric disturbances.
What should patients disclose about herbal supplements?
Patients should disclose name, duration, and dose of herbal supplements.
How can herbal supplements interfere with anesthesia?
They may affect blood clotting, alter blood glucose levels, and interact with psychotropic drugs.
When should herbal supplements be discontinued before surgery?
Herbal supplements should be discontinued 2-3 weeks before surgery.
What are the signs and symptoms of cannabis use?
Signs include tachycardia, labile BP, headache, euphoria, and poor memory.
What are the effects of cocaine and amphetamines?
Effects include tachycardia, hypertension, euphoria, and possible overdose symptoms.
What are the effects of hallucinogens like LSD and PCP?
They can cause altered perception, toxic psychosis, and dissociative anesthesia.
What are the effects of opioids?
Opioids can cause respiratory depression, hypotension, and euphoria.
What is the primary goal of an airway assessment preoperatively?
Identify patients at risk for difficult airway management.
What physical examinations are included in an airway assessment?
- Teeth
- Inside of mouth
- Mandibular space
- Neck
Name three risk factors for difficult airway.
- Structural features
- Metabolic diseases
- Congenital or acquired anomalies
What preparations can be made for a difficult airway?
- Video-assisted laryngoscope
- Positioning pillows
- Difficult airway cart
Is there a single test sufficient to predict difficult intubation?
No, a combination of criteria should be used.
What does the Mallampati Classification assess?
Tongue size relative to oral cavity.
Describe the procedure for the Mallampati Classification.
- Patient sits upright, head in neutral alignment.
- Examiner sits at eye level.
- Patient opens mouth maximally and protrudes tongue.
- No phonation.
What does Class I indicate in the Mallampati Classification?
Easy intubation expected.
What does Class III-IV indicate in the Mallampati Classification?
Difficult intubation expected.
What are the limitations of the Mallampati Classification?
- Not a reliable or sensitive predictor
- High incidence of false positives and false negatives
Define Thyromental Distance.
Distance from the thyroid cartilage prominence to the mandibular border.
What indicates a likely difficult intubation regarding Thyromental Distance?
<6-7 cm (3 adult fingerbreadths)
What is Interincisor Distance?
Distance between upper and lower incisors when mouth is open.
What Interincisor Distance indicates normal conditions?
≥4 cm (2-3 fingers)
What Interincisor Distance is associated with difficult intubation?
<2 fingerbreadths
What is the optimal positioning for Head and Neck Movement?
Moderate neck flexion + full atlantooccipital extension.
What challenges impair laryngoscopy during Head and Neck Movement?
- Cervical arthritis
- Small C1 gap
How is Mandibular Mobility assessed?
Patient should be able to move jaw forward and bite upper lip.
What is the incidence of dental injury in general anesthesia?
0.02% - 0.07%
What are common risk factors for dental injury during anesthesia?
- Preexisting poor dentition
- Limited neck mobility
- History of difficult intubation
- Craniofacial abnormalities
What is the purpose of preanesthesia dental inspection?
Document condition of teeth before laryngoscopy.
What should patients be informed about regarding dental injury risks?
Patients must be informed of dental injury risks.
What should be noted regarding prosthetics during preoperative assessment?
- Crowns
- Braces
- Partial plates
- Dentures
How is obesity evaluated in preoperative assessment?
- General assessment of size and stature
- Baseline height and weight
What defines Ideal Body Weight (IBW) criteria for obesity?
Body weight >20% above IBW → Obesity; Body weight ≥2× IBW → Morbid obesity.
What is the Body Mass Index (BMI) classification for Class 3 Obesity?
≥40 kg/m².
What are the risks associated with Class 3 obesity?
- Cardiopulmonary complications
- Sleep-disordered breathing
- Difficult airway management
What guidelines should be followed for preoperative cardiac assessment in obese patients?
Follow American Heart Association guidelines.
What is the prevalence of Obstructive Sleep Apnea (OSA) in bariatric surgery candidates?
> 70%
What are some characteristics of OSA?
- Periodic airway obstruction during sleep
- Snoring
- Apneic episodes
- Frequent nighttime awakenings
- Morning headaches
- Daytime sleepiness
What is the STOP-Bang Questionnaire used for?
Screening for OSA severity categorization.
What is the gold standard for OSA diagnosis?
Polysomnography (Sleep Study).
What should be evaluated regarding CPAP therapy preoperatively?
- Home CPAP units should be brought to the hospital.
- Assess CPAP interface, pressure settings, need for supplemental oxygen.
What is the incidence of difficult intubation in OSA patients compared to the general population?
8% vs. 1:2200.
What factors increase the risk of difficult intubation in OSA patients?
- Short, thick necks
- Awake tracheal intubation may be required
What weight-loss drugs should patients be questioned about?
- Amphetamines
- Non-amphetamine Schedule IV appetite suppressants
- Antidepressants (e.g., fluoxetine, sertraline)
These drugs may impact weight management and anesthesia considerations.
What musculoskeletal disorders affect anesthesia?
- Osteoarthritis (degenerative disk disease)
- Ankylosing spondylitis
- Rheumatoid arthritis (RA)
These conditions can lead to chronic pain and mobility issues.
What are the preoperative concerns for patients with musculoskeletal disorders?
- Chronic pain
- Inflammation
- Limited mobility
- Surgical positioning challenges
- Feasibility of regional anesthesia
These factors must be considered for safe anesthesia management.
What multimodal therapy is used for ankylosing spondylitis?
- NSAIDs
- Sulfasalazine
- Glucocorticoids
- Local corticosteroid injections
- Biologic therapies (TNF-α antagonists)
These treatments aim to manage symptoms effectively.
When might perioperative steroid supplementation be needed?
- Patients on >20 mg hydrocortisone daily for >3 weeks in the past year
- Patients with adrenal insufficiency or corticosteroid replacement therapy
Minimizing steroid supplementation is crucial to reduce surgical risks.
What airway and respiratory complications may occur in AS and RA?
- Difficult intubation due to limited temporomandibular joint & cervical spine mobility
- Airway narrowing and vocal cord dysfunction from cricoarytenoid arthritis
- Systemic manifestations: restrictive lung disease, polychondritis, pleural/pericardial effusions, cardiac conduction abnormalities
These complications can complicate anesthesia management.
What are the complications associated with DMARDs and biologic agents in RA?
- Delayed wound healing
- Wound dehiscence
- Increased surgical site infections
Some DMARDs and biologic agents should be held perioperatively to minimize these risks.
What is the goal of a preoperative neurologic evaluation?
Identify CNS or peripheral nervous system dysfunction
This evaluation helps tailor anesthesia and surgical plans.
What components are included in a neurologic examination?
- Motor system
- Sensory system
- Muscle reflexes
- Cranial nerve abnormalities
- Mental status and speech
Each component helps assess neurologic function.
What are the signs of increasing intracranial pressure (ICP)?
- Documented signs of increasing ICP
- Common causes: vasospasm post-subarachnoid hemorrhage
Increased ICP can affect anesthesia and surgical outcomes.
What is the Glasgow Coma Scale (GCS) score indicating a comatose state?
GCS < 8
A low GCS score indicates severe neurologic impairment.
What diagnostic tests are used for neurologic disorders?
- Electromyography (EMG)
- Conduction velocity studies
- Electroencephalography (EEG)
- Computed Tomography (CT)
- Magnetic Resonance Imaging (MRI)
- Cerebral arteriography
These tests help identify the extent of neurologic diseases.
What are the indications for a preoperative neurology consultation?
- Extremity weakness
- Pain
- Paresthesia
- Risk factors for peripheral neuropathy (e.g., long-standing diabetes, uremia, chronic alcoholism)
Patients with these signs may require further evaluation.
What findings suggest raised ICP?
- ≥0.5 cm midline shift on CT/MRI
- Other radiologic findings: mass effect, hydrocephalus, cerebral edema
These findings indicate potential intracranial hypertension.
What does cerebral arteriography determine?
- Aneurysm size and location
- Collateral circulation in cerebrovascular disease
This information guides surgical planning.
What is the importance of assessing functional capacity in preoperative cardiovascular risk assessment?
- Determines patient’s ability to walk four blocks or climb two flights of stairs
- Predicts good functional capacity (>4 METs) vs. poor functional capacity (<4 METs)
Functional capacity is critical for evaluating surgical risk.
What is the updated classification for hypertension?
- Normal BP: <120/80 mm Hg
- Elevated BP: 120-129/<80 mm Hg
- Stage 1 Hypertension: 130-139/80-89 mm Hg
- Stage 2 Hypertension: ≥140/≥90 mm Hg
Understanding BP levels helps in managing perioperative risks.
What are the major risk factors for ischemic heart disease (IHD)?
- Age >65 years
- Smoking
- Diabetes mellitus
- Hypertension
- Chronic pulmonary disease
- Previous myocardial infarction (MI)
- Left ventricular dysfunction
- Peripheral vascular disease
These factors significantly increase perioperative risk.
What should be evaluated in the preoperative assessment for ischemic heart disease?
- Severity, progression, and functional limitation
- Presence of myocardial ischemia, arrhythmias, or LV dysfunction
This assessment helps in planning safe surgical procedures.
What is the risk of myocardial infarction (MI) postoperatively?
General risk of MI postoperatively is 0.3%
Understanding this risk is essential for patient management.
What should be done for unstable angina before elective surgery?
Cancel elective surgery and perform cardiac evaluation
Unstable angina poses the highest perioperative MI risk.
What are the causes of uncontrolled hypertension?
- Inadequate treatment
- Noncompliance with medication
Addressing these issues is critical for safe surgical outcomes.
When should elective surgery be postponed due to hypertension?
- Uncontrolled Stage 3 hypertension
- Target-organ damage
Ensuring control of hypertension minimizes perioperative risks.
What symptoms should be assessed in preoperative history for hypertension?
- Syncope
- Dizziness
- Medications used
These symptoms may indicate significant underlying issues.
What is the pathophysiology of myocardial ischemia?
- Insufficient oxygen and nutrient supply to myocardium
- Caused by increased myocardial oxygen demand, reduced coronary blood supply, or both
Understanding this helps in managing patients with IHD.
How many coronary stents are placed annually in the U.S.?
528,000
What is the restenosis rate for Bare Metal Stents (BMS)?
20%
What is the restenosis rate for Drug-Eluting Stents (DES) at 2 years?
5%
What does Dual Antiplatelet Therapy (DAPT) include?
- Aspirin (indefinite use)
- P2Y12 inhibitor (clopidogrel, prasugrel, ticagrelor) for ≥6 months
What is the risk of noncardiac surgery within 1 year post-stent placement?
Higher risk of stent thrombosis, MI, hemorrhage, and mortality
What are the two subsets of heart failure?
- Heart failure with preserved ejection fraction (HFpEF, EF >50%)
- Heart failure with reduced ejection fraction (HFrEF, EF <49%)
What are key clinical signs of heart failure?
- Moist rales (often with tachypnea)
- Resting tachycardia
- Third heart sound (S3)/ventricular gallop
What are the indications for preoperative left ventricular function testing?
- Unexplained dyspnea
- Worsening heart failure symptoms
- No prior evaluation within 12 months
What defines systolic dysfunction in terms of ejection fraction (EF)?
EF <50%
What is the higher incidence of postoperative heart failure and mortality EF threshold?
EF <35%
What is the most common cause of adult valvular disease?
Rheumatic heart disease
What types of lesions are involved in valvular heart disease?
- Stenosis
- Incompetence (regurgitation)
What is the greatest perioperative risk among valvular lesions?
Severe Aortic Stenosis
What should be done if moderate-severe stenosis/regurgitation is suspected?
Obtain an echocardiogram
What are the goals of preoperative evaluation of arrhythmias?
- Determine arrhythmia type
- Identify associated heart disease
- Assess antiarrhythmic therapy effectiveness
What types of cardiovascular implantable electronic devices (CIEDs) are there?
- Pacemakers
- Implantable cardioverter-defibrillators (ICDs)
What are the key considerations for preoperative planning for patients with CIEDs?
- Device type and function
- Indication for use
- Battery status, lead performance, current settings
What is the indication for preoperative cardiology consultation related to pacemakers?
Pacemaker malfunction (no pacing response, patient symptoms return)
What is the preferred test for noninvasive cardiac testing in high-risk patients?
Exercise Stress ECG
What are common ACE inhibitors used in perioperative management?
- Captopril
- Enalapril
- Lisinopril
- Benazepril
- Ramipril
What are the components of Dual Antiplatelet Therapy (DAPT)?
- Aspirin
- P2Y12 inhibitors (clopidogrel, prasugrel, ticagrelor, cangrelor)
What should be done if a P2Y12 inhibitor must be stopped before surgery?
- Continue aspirin
- Restart P2Y12 inhibitor ASAP postoperatively
What is the recommended delay for elective noncardiac surgery after bare metal stent (BMS) implantation?
≥30 days
What is the recommended delay for elective noncardiac surgery after drug-eluting stent (DES) implantation?
≥6 months
What are the indications for Novel Oral Anticoagulants (NOACs)?
Atrial fibrillation (AF), Deep vein thrombosis (DVT), Pulmonary embolism (PE), Certain prosthetic heart valves.
What are the types of NOACs?
Factor Xa Inhibitors: Rivaroxaban, Apixaban; Direct Thrombin Inhibitor: Dabigatran.
How is perioperative management of NOACs determined?
Cessation Timing Based on CHADS₂ Score:
- CHADS₂ Score >4 (high risk) → Bridging therapy recommended.
- CHADS₂ Score 3-4 (intermediate risk) → Case-dependent.
- CHADS₂ Score <3 (low risk) → Minimal perioperative anticoagulation needed.
What is the cessation timing for NOACs without a reversal agent?
Stop drug ≥3 elimination half-lives before surgery.
When should NOACs be resumed postoperatively?
Resume NOACs 24-48 hours postoperatively if surgical bleeding is controlled.
What is bridging therapy in the context of NOACs?
Bridging therapy (e.g., heparin) is considered for high-risk patients.
What is available for emergency dabigatran reversal?
Idarucizumab (Praxbind) is available for emergency dabigatran reversal.
What is the prevalence of lung disease in adults?
Lung disease affects approximately 25% of adults.
What is a major risk factor for postoperative pulmonary complications?
COPD (chronic bronchitis, emphysema, asthma) is a major risk factor.
What is the second leading cause of perioperative mortality?
Lung disease is the second leading cause of perioperative mortality, after coronary artery disease.
What are risk factors for postoperative pulmonary complications?
Preoperative sepsis, Emergency surgery, Age ≥50, Smoking history, Comorbid diseases (e.g., cardiovascular disease), ASA physical status III or greater.
What should be done for patients with severe dyspnea before elective surgery?
Elective surgery should be postponed in patients with severe dyspnea or wheezing, pulmonary congestion, or hypercarbia (PaCO₂ >50 mm Hg).
What key interventions are recommended for COPD preoperative optimization?
Treat pulmonary infections with antibiotics, chest physiotherapy, incentive spirometry, and smoking cessation.
What does a FEV₁/FVC ratio <80% indicate?
It indicates obstructive disease.
What are key characteristics of asthma?
Reversible airway obstruction caused by inflammation, triggered by allergens, exercise, infections, stress, and unknown factors.
What are indications for postponing elective surgery in asthma patients?
Persistent cough, wheezing, dyspnea, or tachypnea on the day of surgery; recent asthma exacerbation requiring hospitalization.
What preoperative diagnostic tests are indicated for asthma?
ECG if right ventricular hypertrophy is suspected, chest radiograph if infection is suspected, ABGs for chronic respiratory insufficiency.
What should be done for asthma management on the day of surgery?
Continue all asthma medications, administer prophylactic β₂-agonist, ensure adequate hydration, consider stress-dose corticosteroids.
What are the risk factors for adverse events in pediatric patients with URI?
Children <1 year old have a 2-7x increased risk of respiratory-related adverse events; risk persists for up to 6 weeks post-infection.
What are some perioperative complications associated with URI?
Laryngospasm, bronchospasm, post-extubation croup, atelectasis, mucous plugging, impaired oxygenation.
What factors influence the decision to proceed with surgery in patients with URI?
Urgency of surgery, duration and complexity of the procedure, need for airway instrumentation.
What guidelines exist for managing pediatric patients with URI before surgery?
Postpone surgery for productive cough, purulent nasal discharge, fever >38°C, or lower respiratory tract symptoms.
What does CBC (WBC count) indicate in surgical decision-making?
Often not useful for surgical decision-making.
When should nasal/throat cultures be considered?
If bacterial infection suspected.
Is a chest radiograph required for all pediatric patients undergoing surgery?
Not required unless abnormal lung sounds.
What is the recommendation regarding endotracheal intubation in pediatric patients with mild URI?
Avoid endotracheal intubation if possible.
What should be administered preoperatively to prevent bronchospasm?
Albuterol as prophylaxis.
When should surgery be postponed for pediatric patients with mild URI?
If febrile, wheezing, or abnormal chest X-ray findings.
What symptoms are considered key components of GI evaluation?
Symptoms include nausea, vomiting, diarrhea, gastrointestinal bleeding, abdominal pain, and dysphagia.
What indicates the need for evaluating fluid and electrolyte status in GI patients?
Symptoms of weight loss or malabsorption.
What is a key preoperative consideration for peptic ulcer disease?
Risk of aspiration and aspiration pneumonitis requires prophylactic measures.
What are the signs and symptoms of early-stage hepatic disease?
Malaise, weight loss, abdominal discomfort, mild jaundice.
What should be done if unexplained jaundice or elevated transaminases is found preoperatively?
Elective surgery should be postponed.
What indicates advanced hepatic failure?
Markedly abnormal liver function tests, coagulopathy, extreme jaundice, hepatic encephalopathy.
What is the most reliable marker of acute hepatic dysfunction?
Prothrombin time (PT) and INR.
What does the Child-Pugh score assess?
Predicting surgical mortality in cirrhosis.
What is the mortality risk associated with Class A in the Child-Pugh score?
10% mortality.
What should be assessed in the preoperative evaluation of the kidneys?
Volume status, signs of polyuria, infections, and urinary retention.
What are the criteria for Acute Kidney Injury (AKI)?
Creatinine increase >26.4 µmol/L within 48 hours, urine output <0.5 mL/kg/hr for 6 hours.
What does a creatinine clearance of <10 mL/min indicate?
Renal failure.
What is a common cause of chronic renal failure?
Obstructed urinary outflow due to prostatic hypertrophy or renal calculi.
What is a major endocrine disease of concern in preoperative evaluation?
Diabetes mellitus.
What percentage of diabetes cases are Type 2?
90%-95%.
What is the leading cause of death in diabetic patients?
Atherosclerosis complications.
What HbA1c level indicates diabetes?
≥6.5%.
What is a significant risk factor for diabetic patients undergoing surgery?
Increased morbidity and mortality rates due to renal and autonomic involvement.
What preoperative management should be considered for chronic renal failure?
Fluid and electrolyte balance assessment.
What should be avoided in patients with hepatic encephalopathy?
Sedative premedications.
What is the effect of hyperkalemia in preoperative patients?
Can cause cardiac effects; elective surgery should be delayed until potassium levels are managed.
What is the goal of perioperative glucose management?
Maintain blood glucose <180 mg/dL while avoiding hypoglycemia.
When should blood glucose be checked during the perioperative period?
Preoperatively and at 1-4 hour intervals intraoperatively & postoperatively.
What is preferred: mild hyperglycemia or hypoglycemia?
Mild hyperglycemia preferred over hypoglycemia.
How should diabetic medications be adjusted based on surgery?
Adjusted based on surgery type/duration.
What is the recommendation for long-acting insulin the night before surgery?
Continue evening dose; reduce to 2/3 usual amount if patient is tightly controlled.
What should be done with short, simple procedures regarding diabetes medications?
Delay diabetes meds until the patient can eat postoperatively.
Fill in the blank: Oral hypoglycemic agents, such as ________, are withheld the day of surgery.
[Short-acting agents (e.g., repaglinide)]
Which type of insulin should be held unless blood glucose >200 mg/dL?
Short-acting insulin.
What should Type 1 diabetics receive on the morning of surgery?
50% of usual morning dose of intermediate/long-acting insulin + 5% glucose infusion.
What factors should be assessed for insulin pump management?
- Type of insulin used in pump
- Basal rate & insulin sensitivity factor
- Patient’s ability to recognize & manage hypoglycemia
- Signs of irritation or leakage at the pump site
What are common causes of hyperthyroidism?
- Graves’ disease
- Toxic goiter
- Thyroid carcinoma
- Pituitary tumors secreting TSH
What is the goal of preoperative management for hyperthyroidism?
Attain euthyroid state before surgery.
What medications are used for the preoperative management of hyperthyroidism?
- Antithyroid drugs (Methimazole, Propylthiouracil)
- Iodine therapy
- Beta-blockers (Propranolol, Atenolol)
True or False: Elective surgery should be postponed until a euthyroid state is achieved.
True.
What is the primary cause of hypothyroidism?
Chronic thyroiditis (e.g., Hashimoto’s disease).
What treatment is commonly used for hypothyroidism in the preoperative period?
Levothyroxine (T4, Synthroid) replacement therapy.
What are the clinical features of Cushing Syndrome?
- Hypertension
- Truncal obesity
- Abdominal/gluteal striae
- Moon facies
- Easy bruising
- Personality changes
What is the primary cause of adrenal insufficiency?
Addison’s disease.
What are the clinical signs of adrenocortical insufficiency?
- Skin hyperpigmentation
- Weight loss
- Hypotension
- Hypoglycemia
- Hyperkalemia
Fill in the blank: Patients at risk for HPA axis suppression have received ≥20 mg ________ for ≥5 days.
[Prednisone]
What is the purpose of the ACTH stimulation test?
Assess adrenocortical function.
What should be done for patients at risk for adrenal insufficiency during surgery?
Evaluate for exogenous corticosteroid supplementation.
What is the purpose of preoperative diagnostic testing?
- Evaluates surgical and anesthetic risk
- Guides necessary healthcare modifications
What should be considered before performing a preoperative test?
- Cost-effectiveness
- Positive benefit-risk ratio
- Availability of results
- Unique information
- Impact on patient care
True or False: Routine preoperative testing alters patient care in a significant percentage of cases.
False.
What is the validity period for most preoperative tests?
Up to 6 months if results were normal and health has not changed.
What is the recommendation for pregnancy testing before surgery?
Should be offered with consent if patient is concerned.
What is the predictive value of routine chest radiography for postoperative respiratory problems?
Minimal predictive value.
What is the limitation of routine ECGs in low-risk patients?
Not cost-effective and poor predictor of perioperative complications.
Who determines the fasting interval for patients?
The anesthesia provider
The goal is to balance aspiration risk and the negative effects of prolonged fasting.
What is the goal of fasting in anesthesia?
Balance aspiration risk vs. negative effects of prolonged fasting.
True or False: Modern fasting practices indicate that reduced fasting intervals increase aspiration risk in healthy individuals.
False
Studies show reduced fasting intervals do not increase aspiration risk.
What benefits does preoperative carbohydrate ingestion provide?
- Shorter hospital stays
- Faster bowel function recovery
- Less muscle mass loss
This practice is part of ERAS protocols.
What are some negative effects of prolonged fasting?
- Dehydration
- Hypoglycemia
- Hypovolemia
- Increased irritability and anxiety
- Reduced compliance with fasting orders
- Hunger, thirst, headaches, and discomfort.
What must solids be digested to before passing the pylorus?
<2 mm diameter.
How long do liquids typically take to empty from the stomach?
1-2 hours.
How does minimizing fasting improve patient comfort?
- Less irritability
- Less thirst
- Less hunger
- Fewer headaches
- Better tolerance of the preoperative period.
What are acceptable clear liquids for healthy, non-premedicated patients?
- Water
- Apple juice
- Black coffee
- Black tea
- Clear juice drinks
- Clear broth
- Clear Jell-O
- Ice, popsicles
- Pedialyte
- Reduced-fat milk in coffee may be acceptable.
True or False: Chewing gum or sucking on candy warrants surgery cancellation or delay.
False.
What is the purpose of premedication for patients at high aspiration risk?
To reduce aspiration risk.
Who are considered high-risk patients for aspiration?
- Diabetic patients
- Patients with abnormal gastrointestinal physiology.
Name one pharmacologic intervention to reduce aspiration risk.
Metoclopramide
It promotes gastric emptying.
When was the ASA Physical Status Classification System developed?
1941.
What is the key purpose of the ASA Physical Status Classification System?
Provides standardized communication among anesthesia staff.
What does the ASA classification NOT account for?
- Surgical complexity
- Perioperative monitoring level
- External factors.
What does ASA Class I represent?
Healthy individual except for the surgical condition.
What does ASA Class IV represent?
Severe systemic disease that is a constant threat to life.
What is a limitation of the ASA Classification System?
Not detailed enough to classify all patient conditions accurately.
What does the Joint Commission’s Universal Protocol aim to eliminate?
- Wrong site surgery
- Wrong procedure surgery
- Wrong patient surgery.
True or False: The Universal Protocol applies only to hospitals.
False
It applies to all surgical settings, including ambulatory surgery centers and office-based surgeries.
