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Physical Assessment - Spring '24 > Pre-op assessment > Flashcards

Pre-op assessment Flashcards

1
Q

When there is a delay in surgery, what changes in preoperative care could help to eventually proceed with surgery?

A
  1. Optimize comorbid diseases
  2. Refer to other specialists
  3. Refer to specialized testing
  4. Iniatiate interventions intended to decrease perioperative risk
  5. indentify previously unrecognized comorbid conditions
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2
Q

What are some steps involved preparation for surgery?

A
  1. Preoperative instructions for surgical patient
  2. Discuss perioperative care
  3. Arrange appropriate level of postoperative care
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3
Q

What are some steps involved in follow-up care?

A
  1. Specialist follow-up facilitated by preanesthesia evaluation
  2. Follow-up by anesthesiologist-led service (e.g. acute pain service
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4
Q

What are the goals fro pre-operative evaluation?

A
  1. Ensure patients can safely tolerate anesthesia for surgery
  2. Mitigate perioperative risks
  3. Clinical examination - history and physical examination

-Obtain medical history
-Formulate an assessment of the patient’s perioperative risk
-Develop a plan for an requisite clinical optimization
-Planning postop pain management in the backgroup of preoperative pain

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5
Q

What are some benefits for patients of a pre-op evaluation?

A
  1. Reduces anxiety
  2. Provides education: Options
  3. Discusses medications
  4. Reduces post-up morbidity
  5. answers questions
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6
Q

Benefits of Pre-op evaluation for anesthesia providers?

A
  1. learn medical conditions
  2. Devise an anesthetic plan: Intra-op and Post-op; Discuss with patient
  3. Time consultations:
  4. DNR: Patient may be changed back to full code for the perioperative period.
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7
Q

Benefits of pre-op evaluation for surgeon/hospital?

A
  1. decreases cost of peri-operatvie care
  2. improves efficiency
  3. decreases canellations/delays
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8
Q

What are the medical history components?

A
  1. underslying condition requiring surgery
  2. known medical probelms/past medical issues
  3. previous surgeries/anesthetic complications
  4. anesthetic-related complications
  5. review of systems
  6. medications
  7. allergies
  8. tobacco/ETOH/Illicit drug use
  9. Functional capacity: What are you able to do?
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9
Q

What should you assess in a focused neuro exam?

A
  1. Establish a baseline, especially if there is a neuro related complain: brain/spine. Awake, oriented, move everything, follow commands? Objective Pupils. This will help identify changes after case.
  2. Seizures? When was last szr, medicated? Neuromuscular blockers lose their duration of action if someone is taking seizure medication.
  3. CVA/TIA: Maintain high blood pressure to allow perfusion and prevent ischemia.
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10
Q

What should you assess in a focused CV exam?

A
  1. CAD: worry about perfusion - narrowing of coronary arteries; stimulation will increase HR and decrease perfusion. Refer to cardiology/PCP and Maybe order a stress test. May need cath/stents
  2. Stented patients: note that these patients may be on blood thiners. May need to defer elective cases for recent stents for at least 6 months to a yr to allow healing.
  3. Acute MI: Anesthesia is provided if needed. This may happen in the cath lab. Pt may have an acute MI during an emergent CABG and try to cath him and are unable to place a stent?
  4. CHF: 2 hard stops for anesthesia. 1 - active unstable angina or chest pain. 2. Decompensated HF - pulmonary edema may be the indicator the patient may have decompensated HF. Order ECHo but do not get hyperfixated on EF. Assess valves, right side of heart, PF’s
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11
Q

What should you assess in a focused pulmonary exam?

A

Asthma: Are you on meds? when was your last attack? were you hospitalized? Ever been ventilated/put on ventilator for your asthma?

COPD: Severity of disease and functional status. Oxygen needed? Additional testing: PFT’s? Meds? Steroids: may increase risk of infection. interactions with meds. Pt may not respond appropriately to meds. bc cortisol levels may be affected they may not respond to hypotension appropriately. May need a pressor sooner

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12
Q

What should you assess in a focused endocrine exam?

A

DM II
Thyroid disorders
Adrenal disorders: cushings, addision’s, pheochromocytoma (may be an incidental finding)

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13
Q

Focused examination: Hepatobiliary

A

Gall stones
ERCPs
Esophageal varices
Liver matters bc clotting

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14
Q

Focused examination: Renal

A

Impaired renal function: may prolong drug duration. May need to adjust meds.

Monitor fluid status: monitor for patients with kidney patients or children - maybe use mini-drip of fluids

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15
Q

Focus examination: musculoskeletal

A

Multiple sclerosis
Myasthenia gravis: Muscle relaxant may cause a problem to these patients. These patients do not breathe well. May need at different anesthetic techniques that do not involve general anesthesia

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16
Q

Focused examination: Immunocompromised

A
  1. Chemo/radiation - may alter monitoring devices, may need to put lines in different places.
  2. Current opinion is that it doesnt matter where IVs are place in patients that have had lymphatics affected.
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17
Q

Focus examination: Obesity

A

Airway/ventilation may be problematic
Medications: some volatile anesthetics and propofol dissipate into fatty tissues and it may take longer to come out.

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18
Q

What should you consider when performing an emergent physical examination? AMPLE

A

AMPLE
1. Allergies
2. Medications
3. Past medical history
4. Last meal eaten
5. Events leading up to need for surgery/procedure

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19
Q

What elements should you consider during an airway examination?

A
  1. Mallampati classificatioin
  2. Inter-incisor gap
  3. Thyromental distance
  4. Forward movement of mandible
  5. Range of cervial spine motion: flexion and extension
  6. Document loose or chipped teeth, tracheal deviation
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20
Q

What is trismus?

A

Lockjaw - sustained tetanic spasms of the muscles of mastication

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21
Q

What is the most common cause of trismus in the OR?

A

Not brushing teeth/poor dentation

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22
Q

What is an are some options airway management in someone with oral fixation?

A

Nasal intubation

Have OMFS (oral maxillofacial surgeon)

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23
Q

What thyromental measurement would you expect for a difficult intubation?if the patient has a thyromental distance of less than 3 cm or 3 fingerbreadths?

A

A thyromental measurement of < 6.5 cm or 3 fingerbreadths would be considered a difficult intubation

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24
Q

What inter-incisor gap would be considered a difficult intubation?

A

A distance of 5 cm or 3 finger breadths.

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25
Q

What is another name for thyromental distance assessment/test?

A

Patil’s test

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26
Q

Define Mallampati classification 1:

A

**All structures are present: **
Tonsillar pillars
Uvula
Fauces
Hard palate
Soft palate.

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27
Q

Describe mallampati classification 2:

A

Tip of uvula is masked by base of tongue

Seen: soft palate, uvula, and fauces

Tonsillar pillars not seen

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28
Q

Describe mallampati classification 3.

A

Only soft pallate and base of uvula is visible

Difficult intubation

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29
Q

Describe mallampati classification 4:

A

Soft pallate is not visible. No other structure is visible

Difficult intubation

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29
Q

Why do we assess jaw protussion?

A

Limited ability to protrude one’s jaw, such that lower incisors are anterior to the upper incisors can predict difficult intubation

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30
Q

Describe Class A jaw protrusion:

A

Lower incisors can be protureded anterior to the upper incisors

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31
Q

Describe Class B jaw protrusion:

A

Lower incisors can be brought edge to edge with upper incisors

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32
Q

Describe Class C jaw protrusion:

A

Lower incisors cannot be brought edge to edge with the upper incisors.

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33
Q

Why does range of neck movement important to assess?

A

Reduced neck movement (particularly extension) increases the difficulty of laryngoscopy

It can be more precisely quantified by grading the degree of reduction of atlanto-axial joint extension

Chin down to chest, head back 100 degrees, ear to shoulder

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34
Q

What is a grade 1 range of neck movement?

A

No appreciable reduction in extension

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35
Q

What is a grade 2 range of neck movement?

A

Approximately 1/2 redcution of atlantooccipital joint extension

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36
Q

What is a grade 3 range of neck movement?

A

Approximately 2/3 reduction in atlantooccipital joint extension

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37
Q

What is a grade 4 range of neck movement?

A

No appreciable extension. Complete reduction in atlantooccipital joint extension.

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38
Q

What is the 3-3-2 rule?

A

The patient should have at least
3 fingerbreadths interincisor distancte
3 fingerbreadths in hyoid mental distance
2 fingerbreadths from thyroid to floor of the mouth.

39
Q

Describe the thyromental distance ranges by level of difficulty:

A

> 6.5 cm - normal
6.0 - 6.5 increasing difficulty
< 6.0 highly difficult

40
Q

What assessments should you perform when examinating the airway?

A
  1. Mallampati classification
  2. Inter-incisor gap
  3. Thyromental distance
  4. Forward mandible movement
  5. Range of cervical spine motion: flexion & extension
  6. Document loose or chipped teeth; tracheal deviation
41
Q

What accounts for almost half of the perioperative mortalities

A

Cardiovascular complications

42
Q

What blood pressure goal should be aimed for the paint?

A

10-20 % of the true baseline

43
Q

What is one of the main things we fail to detect from the cardiovascular standpoint?

A

Undiagnosed Ischemic heart disease: primarily in wome and diabetics (abdominal pain or fatigue)

44
Q

What are two CV conditions that will prevent a patient from going to the OR?

A

Unconpensated HF or unstable angina

45
Q

What electrolytes contribute to arrhythmias?

A

K and Mg

46
Q

What are some examples of high risk surgeries (>5%)

A

Aortic and major vascular

Peripheral vascular

47
Q

What are some examples of intermediate risk surgeries (1-5%)

A

Intraabdominal

intrathoracic

Carotid endarterectomy

Head/neck surgery

48
Q

What are some examples of low risk procedures (<1%)?

A

Ambulatory surgery
Breast surgery
Endoscopic procedures
cataract surgery
Skin surgery
Urologic surgery
Orthopedic surgery

49
Q

What are the 6 components of Revised Cardiac Risk Index

A
  1. High risk surgery (Intraperitoneal, intrathoracic, or suprainguinal procedure)
  2. Ischemic heart disease (by any diagnostic criteria)
  3. History of congestive HF
  4. History of cerebrovascular disease
  5. Diabetes mellitus requiring insulin
  6. Creatinine >2.0 mg/dL

One point each. >3 is high risk

50
Q

With a revised cardiac risk index score of 0, what would be your risk of major cardiac events? (Scoring from the revised cardiac risk index)

A

0.4%

51
Q

With a revised cardiac risk index score of 1, what would be your risk of major cardiac events? (Scoring from the revised cardiac risk index)

A

1.0%

52
Q

With a revised cardiac risk index score of 2, what would be your risk of major cardiac events? (Scoring from the revised cardiac risk index)

A

2.4 %

53
Q

With a revised cardiac risk index score of >3, what would be your risk of major cardiac events? (Scoring from the revised cardiac risk index)

A

5.4%

54
Q

What is the purpose of functional capacity assessment?

A

It asseses cardiopulmonary fitness and estimates pt risk for major post-op morbidity or mortality.

Determines if further testing is necessary.

Poor functional capacity = increased peri-op risk.

55
Q

How is functional capacity measured?

A

It is measured in METs (metabolic equivalent of task) which is defined by the amount of oxygen consumed while sitting at rest.

56
Q

What is one MET equivalent to?

A

3.5 mL/kg/min of oxygen consumed at rest

57
Q

What constitutes an emergent surgery?

A

One where life or limb could be threatened if surgery does not occur 2-6 hrs.

58
Q

What constitutes an urgent surgery?

A

One where life or limb could be threatened if surgery does not occur 6-24 hrs

59
Q

What constitutes a time-sensitive surgery?

A

delays exceeding 1-6 weeks would adversely affect patient outcomes.

60
Q

During an emergent surgery, you should wait until the pre-op cardiac assessment is completed. T or F.

A

False. You should proceed directly to emergency surgery w/o pre-op cardiac assessment.

Focus on surveillance (serial cardiac enzymes, hemodynam monitoring, serial ECG’s) and early treatment of any post-op CV complications

61
Q

What does someone with ASA (American Society of Anesthesiologists) PS I look like?

A

Healthy. nonsmoking, no or minimal alcohol use.

62
Q

What is an example of ASA II

A

Patient with mild systemic disease

Mild diseases w/o subtantive functional limitations.
Ex. Current smoker
social drinker
pregnancy
obesity (30< BMI<40)
Well-controlled DM/HTN
mild lung disease.

63
Q

What is an example of ASA III

A

Patient with severe system disease

Substantive functional limitations. One or more moderate to severe diseases.

Ex:
Poorly controlled DM/HTN
COPD
morbid obesity >40 BMI
Active hepatitis
Alcohol dependence/abuse
Implanted pacemaker
Moderate EF reduction
ESRD - dialysis compliant
Premature postconceptual age <60 weeks
History of MI (>3 mos)
CVA
TIA
CAD/stents

64
Q

What is an example of ASA IV

A

Patient with severe systemic disease that is a constant threat to life

Ex:
Recent MI <3 mos
MI
CVA
TIA
CAD/Stents
Ongoing cardiac ischemia
Severe valve dysfunction
Severe EF reduction
Sepsis
DIC
ARDS
ESRD - dyalisis noncompliant

65
Q

What is an example of ASA V

A

Moribund patient who is not expected to survive without operation
Ex:
1. Ruptured abdominal/thoracic aneurysm
2. Massive trauma
3. Intracranial bleed with mass effect
4. Ischemic bowel in the face of significant cardiac pathology or multiple organ/system dysfunction

66
Q

What is an example of ASA VI

A

A declared brain-dead patient whose organs are being removed for donor purposes

67
Q

Who is preop testing ordered?

A

It is ordered based on comorbidities, operative risk, and findidng from the history and physical exam.

The testing is indicated if it can identify abnormalities, change the diagnosis or management plan or the pt’s outcome

68
Q

When would you order a CBC or H/H?

A

All patients undergoing major procedures

Surgery, potential blood loss, individualized pt clinical indications

ASA-PS 3 of 4 undergoing intermediate-risk procedures

69
Q

When would you order Renal function testing?

A

Pt’s with DM, HTN, cardiac disease, dehydration (N/V, diarrhea), renal disease, fluid overload

ASA-PS 3 or 4 undergoing intermediate-risk procedures

ASA-PS 2, 3, 4 undergoing major procedures.

70
Q

When would you order electrolyte labs?

A

Suspected undiagnosed or worsening condition that will affect peri-op mgmt.

Renal or hepatic disease, malnutrition, malabsorption, ETOH abuse, HF, arrhythmias, medications that may cause imbalance.

71
Q

When would you order liver function tests?

A

Liver injury and physical exam findings

Hepatitis, jaundice, cirrhosis, portal HTN, biliary disease, gallbladder disease, bleeding disorders

72
Q

When should you order coagulation testing?

A

Known or suspected coagulopathy identified on pre-op evaluation

Known bleeding disorder, hepatic disease, and anticoagulant use

ASA-PS 3 or 4; undergoing intermediate, major, or complex surgical procedures; know to take anticoagulant medications or chronic liver disease

73
Q

When should you order serum glucose or glycated hemoglobin (HbA1c)?

A

Known DM (or family history), obesity (BMI >50), cerebrovascular or intracrania disease, or steroids history.

HbA1C long-term measurement of glucose control (3 months): better assessment of diabetic therapy than random/fasting glucose.

All diabetic patients

74
Q

How does HbA1C take glucose levels into account?

A

1/2 is from the previous 30 days and 1/2 from the period of 2 to 3 months.

75
Q

When should urinalysis studies be done?

A

Suspected UTI and unexplained fever or chills

76
Q

When should pregnancy tests be ordered?

A

Based on sexual activity, birth control use, and date of last menstrual period

Recommendations: all women of childbearing potential present the possibility of pregnancy and women possible pregnand made aware of the risks of anesthesia/surgery to the fetus.

77
Q

When should you order an EKG?

A

Any type of cardiovascular disesase: Ischemic heart disease, HTN, DM, chest pain, palpitations, abnormal valvular murmust, dyspnea on exertion, sycope, arrhythmias, PAD, significant structural heart disease

Routine in ASA-PS 3 or 4 undergoing intermediate risk

Routine ASA-PS 2, 3, 4 undergoing major/high risk procedures

Within 6 mos to 1 yr if with some heart disease

78
Q

What does general anesthesia entail?

A

Total loss of consciousness and airway control

ET or LMA

Major surgeries: total joints, open-heart, bowel surgery

79
Q

What does IV/Monitored Sedation (MAC) entail?

A

Level of sedation ranges: minimal (drowsy able to talk) to deep (sleeping and may not remember)

NC or face mask

Ex: minor surgeries/procedures or shorter, less complex… biopsies, colonoscopies.

80
Q

What does regional anesthesia entail?

A

Pain mgmt method that numbs a large part of the body using local anesthetic.

Ex: epidural or spinal; childbirth or joint replacements in elderly

81
Q

What does local anesthesia entail?

A

Pain mgmt method that is usually a one-time injection of local anesthetic that numbs a small area of the body.

Can be used with general or conscious sedation depending on the surgery and pt history.

Ex: skin or breast biopsy, bone/joint repain

82
Q

Which are the most common cause of anaphylaxis among anesthetics?

A

Rocuronium

Antibiotics

Latex

Chlorhexedine

83
Q

What type of antibiotics are the most common cause of anaphylaxis?

A

PCN and cephalosporins; Avoid in true IgE-mediated allergy

84
Q

What should you distiguish between when giving vancomycin?

A

True allergy and histamine-induded “red man syndrome”

85
Q

What is typically what causes allergic reactions in ester local anesthetics?

A

Para-aminobenzoic acid (PABA)

86
Q

What type of compounds in neuromuscular blocking agents may cause an allergy?

A

Quarternary ammonium compounds: succinylcholine & pancuronium

87
Q

What blood pressure medications should be discontinued 24 hrs before surgery?

A

Angiotensin converting enzyme (ACE-Is) and angiotensin receptor blockers (ARBs)

88
Q

You should stop taking cardiac medications prior to surgery. T or F

A

False. You may continue cardiac meds like beta-blockers and digoxin

89
Q

What test should you order if a patient is on tricyclic antidepressants?

A

Order an ECG d/t possible prolonged QT interval

90
Q

What other component of the heart should assess besides EF?

A

Valvular function

91
Q

What should you determine about patients with cardiac stents?

A

What type of stents

How long they’ve had them

What anti-coagulants they’re on

92
Q

What should you know about patients with pacemakers or ICDs?

A

Location of device

What type of device

93
Q

What is a surgical consideration consideration for cauterization during surgery?

A

In patients with pacemakers or ICDs, depending how close to site, consider a bipolar cauterate rather than monopolar cauteragte

94
Q

What’s another name for pre-diabetes?

A

Metabolic syndrome

95
Q

What does anesthetic agents tend to do to Kidneys?

A

Decrease GFR. It may be enough to tip someone over into AKI if kidney function is not great or BP is high (because it drops perfusion)

96
Q

What is hepatic disorder consideration?

A

Medications may not metabolize. May have exaggerated effect.

Physical Assessment - Spring '24 (2 decks)

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