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Anaesthesia > Pre- anaesthesia evaluation and preparation > Flashcards

Pre- anaesthesia evaluation and preparation Flashcards

1
Q

What are the cardiovascular hx to take?

A

Known conditions

  • IHD, previous AMI, arrhythmias, coronary disease, carotid artery stenosis
  • Cardiovascular risk factors (CVRF): DM, HTN, HLD, smoking
  • Decompensated heart failure (HF): refer to cardiovascular medicine (CVM), postpone surgery
  • Functional murmur (soft + change/disappears with change in posture) 🡪 Ix: 2DE (TTE)

Symptoms

  • Shortness of breath (SOB), chest pain, chest tightness, palpitations
  • Stable/unstable angina
  • Swelling, orthopnoea, paroxysmal nocturnal dyspnoea [fluid overload]

Medications (DHx)

  • Anticoagulants, antiplatelets
  • Diuretics
  • Antihypertensives – BP under control is better than uncontrolled

Investigations (Ix)

  • Last 2DE (TTE/TOE)
  • Last stress test
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2
Q

What is a MET 1 functional level of exercise?

A

eating, working at computer, dressing

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3
Q

What is a MET 2 functional level of exercise?

A

walking down stairs or in your house, cooking

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4
Q

What is a MET 3 functional level of exercise?

A

walking 1-2 blocks

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5
Q

What is a MET 4 functional level of exercise?

A

raking leaves, gardening

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6
Q

What is a MET 5 functional level of exercise?

A

climbing 1-2 flights of stairs, dancing, cycling

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7
Q

What is a MET 6 functional level of exercise?

A

playing golf, carrying clubs

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8
Q

What is a MET 7 functional level of exercise?

A

playing single tennis

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9
Q

What is a MET 8 functional level of exercise?

A

rapidly climbing stairs, jogging slowly

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10
Q

What is a MET 9 functional level of exercise?

A

jumping rope slowly, moderate cycling

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11
Q

What is a MET 10 functional level of exercise?

A

swimming quickly, running or jogging briskly

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12
Q

What is a MET 11 functional level of exercise?

A

skiing cross country, playing full court basketball

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13
Q

What is a MET 12 functional level of exercise?

A

running rapidly for moderate to long distances

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14
Q

What are the respiratory hx to take?

A

Patient-related risk factors (for perioperative pulmonary complications)

  • Smoking
  • Poor general health status (ASA > 2)
  • Old age (> 70)
  • Obesity
  • COPD, asthma, ILD
  • Previous TB, bronchiectasis
  • Pneumonia 🡪 urgent referral to respiratory medicine (RM), postpone surgery

Procedure related risk factors

  • Surgery > 3 hours
  • General anaesthesia
  • Type of surgery
  • *Recent URTI symptoms (runny nose/coryza, cough, sore throat)
  • Cx: increased airway reactivity 🡪 increased risk of laryngospasm, bronchospasms during airway manipulation (during inhalation of anaesthesia, during intubation, etc)
  • Cx: pooling of secretions in lung, as lung cannot cough sputum out during GA 🡪 increased risk of pneumonia
  • Hx: ascertain symptoms + time course (fever, rhinorrhoea, sore throat, productive cough, general malaise, myalgia, within 2 week of planned date)
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15
Q

Why is hepatic and gi hx important?

A
  • Hepatic disease can contribute to end-organ dysfunction (endocrine, pulmonary oedema, pulmonary hypertension, renal failure, cardiomyopathy) and increase risk during certain surgeries. Can also cause abnormal coagulation and altered drug pharmacokinetics (PK).
  • GIT disease may increase potential for aspiration, dehydration, electrolyte imbalances, and anaemia
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16
Q

What is the relevant hepatic and gi hx to take?

A

Ask about: hiatal hernia, diarrhoea, bloody stools, heartburn, food regurgitation, gastric ulcers, nausea, vomiting, viral hepatitis (e.g. hep B), alcohol intake

17
Q

What are the indications for rapid sequence induction (RSI)?

A
  • **N&V, regurgitation, GERD /reflux
  • Surgical condition affecting abdominal viscera (e.g. acute appendicitis, acute cholecystitis) (risk of paralytic ileus and delayed gastric emptying)
  • Raised intra-abdominal pressure, e.g. obesity, pregnancy
18
Q

What is the relevant heme hx to take?

A
  • Disorders of coagulation factors (e.g. haemophilia, von Willebrand disease)
  • Cancer
  • Thrombocytopenia
  • Leukaemia
  • Medications (e.g. warfarin, heparin, clopidogrel)
  • Platelet disorders (e.g. Bernard Soulier syndrome)
  • Liver disease
  • Anaemia, thalassaemia
  • Previous blood transfusions
19
Q

What is the relevant endocrine hx to take?

A

Diabetes mellitus (DM)

  • Type, duration, severity
  • Current therapy (diet, oral hypoglycaemic agent [OHGA], insulin)
  • Morning blood glucose, HbA1c (determine control)
  • Evaluate for IHD, HTN (because DM is a CVRF)
  • Serum creatinine (assess DM nephropathy)
  • Patients are instructed to take half their morning dose of insulin on the day of surgery but NOT omit it entirely (basal insulin should NEVER be stopped, as it can precipitate DKA which can be fatal!)
  • Should be scheduled for elective surgery early in the day (first case preferable) to minimise impact of prolonged fasting on glycaemia management
  • Start IV dextrose drip, if given insulin or CBG < 5.5
  • If CBG ≥ 12: [T1DM] endocrine consult + start SC insulin Q6H; [T2DM] SC Insulatard + SCSI Q6H. Intra-op requires monitoring Q2H/Q3H (T1/T2DM), Tx w insulin by sliding scale + SCSI Q6H if required, and monitor Q1H (ensure K+ ≥ 3.3)

Thyroid, parathyroid, carcinoid syndrome, adrenal, pituitary disease

20
Q

Why is the renal hx important to take?

A

Diabetes mellitus (DM)
Type, duration, severity
Current therapy (diet, oral hypoglycaemic agent [OHGA], insulin)
Morning blood glucose, HbA1c (determine control)
Evaluate for IHD, HTN (because DM is a CVRF)
Serum creatinine (assess DM nephropathy)
Patients are instructed to take half their morning dose of insulin on the day of surgery but NOT omit it entirely (basal insulin should NEVER be stopped, as it can precipitate DKA which can be fatal!)
Should be scheduled for elective surgery early in the day (first case preferable) to minimise impact of prolonged fasting on glycaemia management
Start IV dextrose drip, if given insulin or CBG < 5.5
If CBG ≥ 12: [T1DM] endocrine consult + start SC insulin Q6H; [T2DM] SC Insulatard + SCSI Q6H. Intra-op requires monitoring Q2H/Q3H (T1/T2DM), Tx w insulin by sliding scale + SCSI Q6H if required, and monitor Q1H (ensure K+ ≥ 3.3)
Thyroid, parathyroid, carcinoid syndrome, adrenal, pituitary disease

21
Q

What is the relevant neurologic hx to take?

A
  • Cerebrovascular accidents (CVA/stroke), seizures/epilepsy

- Convulsions, tremors, headaches, nerve injuries, multiple sclerosis, tingling, numbness of extremity

22
Q

What is the relevant MSK hx to take?

A
  • Cervical spine pathologies, e.g. ankylosing spondylitis, cervical spondylosis with cervical myelopathy 🡪 be careful when mobilising neck for intubation
  • MSK disorders (e.g. myopathies) 🡪 be careful in giving neuromuscular blockade/muscle relaxants
  • For rheumatoid arthritis (RA) patients 🡪 Ix: XR dynamic view C spine for atlantoaxial joint instability (C1/C2 joint) 🡪 if instability present 🡪 avoid airway manipulation, attempt awake fibre optic intubation instead
  • Any aches and pains – warn/counsel about back stiffness and pain from lying in a strange position
  • Low back pain, radicular pain, prolapsed IV discs, chronic pain managed with opioids
23
Q

What are the medications to be stopped before operation?

A

ARB, ACEi – withhold on morning of surgery (to avoid intraoperative profound hypotension); other antihypertensives are continued to maintain good BP control pre-op

Aspirin (may need to stop 7-10 days before surgery), warfarin and NOACs (e.g. warfarin to be stopped for 5 days (risk of thrombosis scored using CHA2DS2-VASc score 🡪 if high risk 🡪 bridging with heparin (Clexane))

DM medications (if continued, may cause hypoglycaemia due to concurrent need for prolonged fasting before surgery)

Traditional medications /supplement use (steroid content, antiplatelet effect)

24
Q

What are the relevant anaes history to take?

A

“Any anaesthesia before?” If so, any difficulty (inserting tube, prolonged sore throat, tracheostomy)? “I was told that my airway was difficult”

How many, and what type of anaesthesia was given (GA, LA, epidural)

Complications, e.g.

  • Airway difficulties
  • PONV (“in previous surgery, did you have PONV?”)
  • Unplanned ICU admissions: ‘Any unexpected admission into ICU after surgery?’
  • Adverse drug reactions (ADR), e.g. itch/pruritus with morphine
  • Previous size and doses given provides a useful guide
25
Q

What are the advantages of GA?

A
  • Control of airway and breathing
  • Adaptable to procedures of unpredictable duration or extent
  • Rapid onset and reversible
  • Can be administered with patient in supine position
  • Can be used in cases of sensitivity to LA

Anaesthesia (17 decks)

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