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Anesthesia > Pre-Op > Flashcards

Pre-Op Flashcards

1
Q

Define “E” in ASA classification.

A

Delay in treatment –> loss of life, limb, sight or baby

Absence of elective situation

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2
Q

ASA 1

A

No organic pathology

1 localized pathology - NOT systemic

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3
Q

ASA 2

A

NO limitations in normal activities
MILD systemic disease
- DM, HTN, CHF, pH >7.3 10
- Pharyngitis, tobacco, isolated cancer, early renal disease

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4
Q

ASA 3

A

Ongoing symptoms or limitations in activity

  • DM + neuropathy
  • CHF II
  • Intestinal obstruction
  • PNA, TB
  • Renal failure + dialysis
  • Chronic smoking + cough +
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5
Q

ASA 4

A

CONSTANT THREAT TO LIFE

  • CHF III (pitting edema, DOE)
  • Trauma with irreparable damage (loss of limb, spleen)
  • Severe intestinal obstruction, bowel rupture, septic shock
  • Hemorrhagic shock
  • Renal failure + uremia, coagulopathy, severe acidosis
  • Cancer + mets, jaundice or uremia
  • COPD on O2 + dyspnea at rest
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6
Q

ASA 5

A

Moribound

Not expected to survive without operation

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7
Q

ASA 6

A

Brain dead-organ donor

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8
Q

Limitations of ASA Classification

A
  1. variability in assignment b/e providers

2. Inability to accurately quantify risk assoc w/ score

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9
Q

What should be assessed in the focused pre-anesthesia history and physical?

A

History - medical, anesthesia, medications
Diagnostic testing and review
Consultations
Airway, heart and lung exam

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10
Q

PE findings assoc w/ difficult mask ventilation or laryngoscopy

A 
Facial hair
Edentulous
Over/under bite
Small mouth opening
Small or receding chin
Short, thick neck
Limited neck extension
Facial deformity
Enlarged tongue or tonsil
High arches palate
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11
Q

4 anatomical features assoc w/ difficult intubation

A 
Mallampati (tongue size : mouth size)
Thyromental distance (48cm)
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12
Q

Mallampati 1

A

Everything visible including tonsils pillars

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13
Q

Mallampati 2

A

Most of uvula visible, fauces visible

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14
Q

Mallampati 3

A

Only base of uvula and soft palate visible

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15
Q

Mallampati 4

A

Can’t see soft palate

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16
Q

Cormack-Lehane 1

A

All laryngeal apparatus visible

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17
Q

Cormack-Lehane 2

A

Visualize only posterior arytenoids

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18
Q

Cormack-Lehane 3

A

Visualize only tip of epiglottis

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19
Q

Cormack-Lehane 4

A

Visualize only soft palate

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20
Q

What 2 Cormack-Lehan views are associated with Mallampati 4?

A

Grade 3 and 4

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21
Q

What are major cardiac risk factors for surgery?

A
  1. ACS (w/in 30 days)
  2. Decompensated CHF
  3. Severe valvular dysfxn (AS, MVS)
  4. Significant arrhythmias (high grade AV block, VT, SVT w/ uncontrolled ventricular rate)
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22
Q

What are intermediate cardiac risk factors/Lee’s Revised Cardiac Index (RCRI)?

A
  1. Ischemic heart disease (mild angina, old MI or q waves)
  2. Compensated or prior CHF
  3. DM requiring insulin
  4. Chronic renal failure (Cr >2.0)
  5. Cerebrovascular disease
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23
Q

What are minor criteria for cardiac risk - not shown to be predictors of preoperative cardiac events?

A
  1. Old age (>70)
  2. Abnormal EKG (LVH, LBBB, ST-T wave abnormalities)
  3. Rhythm other than sinus
  4. Uncontrolled systolic or diastolic HTN
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24
Q

What are examples of high cardiac risk procedures?

A

Risk >5%

  • Open aortic or other major vascular
  • Open peripheral vascular
  • Prolonged time or assoc large fluid shifts or blood loss
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25
Q

What are examples of intermediate cardiac risk procedures?

A

Risk 1-5%

  • Intraperitoneal, intrathoracic
  • Carotid endarterectomy
  • Head and Neck
  • Major oath
  • Prostate
26
Q

What are examples of low cardiac risk procedures?

27
Q

Describe levels of exercise tolerance

  1. > 10 METs
  2. 4-10 METs
  3. 4 METs
  4. 3 METs
  5. 1 MET
A
  1. Strenuous activities - swimming, basketball, tennis, football, skiing
  2. Heavy work around the house - scrubbing, lifting or moving furniture
  3. 4 = walking up a flight of stair, hill, raking, gardening, walk 4 blocks
  4. 3 = scrub floors, clean windows, walk 3mph
  5. 1 = able to take care of self, eat, dress or use toilet
28
Q

ACC/AHA Class 1 Recommendations

A
  1. Emergency noncardiac surgery –> OR and continue perioperative surveillance and postoperative risk factor management
  2. Active cardiac conditions should be evaluated and treated per ACC/AHA guidelines and, if appropriate, proceed to the operating room.
  3. Low risk procedures should most often proceed to surgery.
  4. Patients with poor (less than 4 METs) or unknown functional capacity and no clinical risk factors should proceed to surgery.
  5. People taking a beta blocker = continue
29
Q

ACC/AHA Class 2a Recommendations

A
  1. Lack cardiac symptoms + exercise tolerance = 4 METs can proceed to surgery.
  2. ***Noninvasive cardiac testing should be considered for patients
30
Q

ACC/AHA Class 2b Recommendations

A
  1. Noninvasive testing might be considered if it will change management for patients
31
Q

Wha are the recommendations for surgery in patients who have undergone PCI and are currently on Dual-antiplatelet Therapy (DAPT)?

A

Postponing elective procedures for the duration of DAPT. Patients requiring emergent surgery may proceed while continuing DAPT

2 wks after balloon angioplasty
4-6 wks after BMS
1 year after DES

32
Q

Who will benefit from preoperative coronary revascularization?

A

Ppl with Left Main CAD

33
Q

When to get a pre-op CBC/Hb;Hct?

A

Potential for large blood loss, i.e. will you type and screen them

Higher than normal probability of anemia - recent GI bleed, heavy menses, suspected nutritional imbalance, renal disease, cancer, liver disease, recent bleeding, extremes in age, hematologic disorders

Pt taking warfarin in past 7 days = get INR

34
Q

When to get a pre-op BMP/CMP?

A

Endocrine disorders, renal dysfunction, hepatic dysfunction and certain medications such as thiazide diuretics.

Examples:

  1. Diabetes, hypertension, a history of renal or hepatic disease or transplantation, and congestive heart failure.
  2. Patients with dehydration, nausea and vomiting and ascites
  3. Patients taking diuretics should have a preoperative potassium level checked.
  4. Measurement of serum creatinine is recommended in patients who are to receive IV contrast dye.

DM = check glucose the day of surgery

35
Q

When to order a pre-op EKG?

A
  1. at least one risk factor (ischemic heart disease, heart failure, cerebrovascular disease, diabetes and renal insufficiency) and undergoing vascular surgery.
  2. known congestive heart failure, peripheral vascular disease, or cerebrovascular disease undergoing intermediate risk surgery
  3. no risk factors + vascular surgery
  4. consider if 1 risk factor + intermediate surgery
  5. NOT done if asymptomatic and low risk surgery
36
Q

When to get a pre-op CXR?

A

CONSIDER w/ recent upper respiratory infection, chronic obstructive pulmonary disease (COPD), smoking and cardiac disease.

37
Q

In the absence of changes in health or condition, how long are lab tests good for?

38
Q

Describe the following about the esophagus:

  1. Types of muscle
  2. Intrinsic innervation
  3. Extrinsic Para and sympathetic innervation
  4. UES resting pressure
  5. LES resting pressure
A
  1. Lower 2/3 is smooth, Upper 1/2 is skeletal
  2. Auerbach and Meisner plexuses
  3. Para = vagus, sympathetic = cervical and thoracic ganglia
  4. 15-60mmHg
  5. 10-30mmHg - primary barrier against GERD, most IV and inhaled agents lower LES tone, AVOID MASK VENTILATION >20mmHg
39
Q

What 3 medical conditions dec LES tone?

A

Pregnancy, obesity, hiatal hernia

40
Q

What are the guidelines for NPO status by # of hours preceding surgery?

  1. 8hrs
  2. 6hrs
  3. 4hrs
  4. 2 hrs
A
  1. Food and fluids as desired
  2. Light meal (dry toast, clear liquid, infant or non-human milk)
  3. Breast milk
  4. Clear liquids
41
Q

Steps in reducing risk of aspiration

A
  1. Follow oral intake guidelines
  2. Inc gastric emptying/dec volume
    - metoclopramide 15-30min b4
  3. Inc pH
    - antacid 15-30min b4
    - H2 blocker 1-3hrs b4
    - PPI 3 days b4 or
  4. ? cricoid pressure + cuffed ETT + succ + extubate awake
    - cric pressure can move esophagus lateral to cricoid ring
42
Q

Clinical signs and sx assoc w/ delayed gastric emptying

A

Think autonomic neuropathy
- pre syncope, reduced resting heart rate variability, elevated resting heart rate, visual symptoms related to reduced pupillary size adjustments, constipation, early satiety, sexual dysfunction, urinary sphincter dysfunction, and temperature regulation disturbances (anhidrosis or hyperhidrosis)

43
Q

What medications dec LES tone?

A
  • IV anesthetics (propofol, thiopental, opioids, anticholinergics)
  • volatile inhalational anesthetics
  • β-agonists
  • tricyclic antidepressants
  • anticholinergics (e.g., glycopyrrolate)
44
Q

What medications INC LES tone?

A
  • antacids
  • metoclopramide
  • cholinergics
  • succinylcholine
  • α-adrenergic agonists
  • metoprolol

H2 blockers and non-depol NM blockers do NOT alter tone

45
Q

What is the class 1 recommendation for preoperative statin therapy?

A

Taking + non cardiac surgery = continue

46
Q

What is the recommendation for preoperative alpha-2 agonists?

A

POISE-2 –> DO NOT TAKE

? Continue d/t rebound HTN, HA, tremor, agitation?

47
Q

What is the class 2a recommendation for ACE inhibitors?

A

Continuation is reasonable

If held, reasonable to restarts as soon as feasible

48
Q

Which antihypertensives should be continued prior to surgery?

A

BBs
alpha-2 agonists
CCBs

Antiarrhythmics
Statins
Digoxin

49
Q

Which diuretics may be continued on the day of surgery?

A

Thiazide

Furosemide in the setting of severe CHF, ascites

50
Q

Should ACE and ARBS be continued on the morning of surgery?

A

Held - large fluid shifts, sitting position, multiple antihypertensives

51
Q

Should short acting insulin be continue preoperatively?

A

No - except insulin pumps

Pumps - set to basal amount

52
Q

How much long-acting peakless insulin should type 1 diabetics take before surgery?

A

***75-100% long-acting peak less insulin (Lantus, Levemir)

50% long-acting peaking or intermediate NPH

53
Q

How much long-acting peakless insulin should type 2 diabetics take before surgery?

A

***75% of long-acting peakless

0-50% long-acting peaking or intermediate

54
Q

Generally speaking, are oral hypoglycemic agents held the morning of surgery?

55
Q

Are antidepressants typically discontinued before surgery?

A

NO - continue them

56
Q

Should Aspirin, NSAIDs, and COX-2 inhibitors be routinely continued or discontinued before surgery?

A

No - does not contraindicate neruaxial block. cardiac risk vs. bleeding must be evaluated

57
Q

How is the decision made regarding discontinuation of antiplatelet therapy prior to surgery?

A

No coronary stent
- stop clopidogrel 5-7d

BMS

  • dual anti-platelet 4-6 weeks
  • delay surgery 30d

DES

  • dual anti-platelet 365d
  • delay surgery 365d
58
Q

Are the guidelines for infective endocarditis the same as current surgical site infection antibiotic prophylaxis?

A

No

prophylaxis is recommended for patients at high risk for infective endocarditis:

  • prosthetic heart valves
  • uncorrected congenital heart disease
  • surgically constructed systemic or pulmonary shunts
  • history of endocarditis.
59
Q

What antibiotics are associated with potentiation or prolongation of neuromuscular blocking agents?

A

Aminoglycosides (gentamicin)
Polymyxins (e.g. neosporin)
Clindamycin
Tetracyclines (Doxy)

60
Q

In patients with a history of anaphylaxis to penicillin, what other antibiotics have similar structure and should be avoided?

A

cephalosporins carbapenems

61
Q

What is red man syndrome? How can it be avoided?

A

facial and truncal flushing (red man syndrome) and hypotension from histamine release

Give vanc over 60 minutes

Anesthesia (25 decks)

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