Pre-Op assessment

Question 1

3 main preop questions

Answer 1

1. is this the pts optimal health
2. could health problems or med unexpectedly influence preoperative events?
3. Can or should the pts physical or mental condition be improved before surg?

Question 2

optimal preop situation

Answer 2

1 week before in clinic

• interview, physical exam, make a plan,
• promotes teaching and decreases anxiety.
• allows time to schedule consults gets diagnostic testing
• obtain informed consent

Question 3

conditions that need early preop

Answer 3

• Cardiac: angina CHF, MI, CAD, poorly controlled HTN
• Resp: COPD, severe asthma, airway abnormalities, home O2, vent
• Endo: adrenal disease, active thyroid disease
• ESRD
• Liver disease
• Obesity
• Symptomatic GERD
• Severe kyphosis, spinal cord injury

Question 4

What the OR schedule tells you 5

Answer 4

-demographics
-procedure and diagnosis
-length of produce and position
-the surgeon
-type of anesthesia
additional meds needed
X-rays needed?
OR table position

Question 5

Preop interview 6 purpose

Answer 5

1. obtain pertinent medical hx
2. formulate plan
3. obtain informed consent
4. improve efficiency, decrease cost
5. patient education
6. utilize operative experience to motivate pt to more optimal health status

Question 6

Preop interview general

Answer 6

introduce
confirm ID, diagnosis, procedure
open ended ?
general to specific
individualized
controlled environment +/-family

Question 7

Preop interview includes

Answer 7

review of systems
LMP
Meds
Allergies 
Previous anesthetics and surg: complications, (pt and fam) and OB
exercise tolerance
Sleep apnea
ETOH/Drug/tobacco

Question 8

Physical exam summed up

Answer 8

general impression. ht/wt physical features
airway
heart
lungs
CNS/PNS
VS
Surg site
IV 
positioning
monitors needed

Question 9

physical exam airway

Answer 9

mallampati 
thyromental distance
head, neck mvmt
neck circumference
incisor distance
dentition
craniofacial deformities
**looking for prefecture of difficult airway

Question 10

physical exam heart and CV and lung

Answer 10

Auscultation: rate, rhythm, murmur, bruits, extremity pulse
edema
lung: inspection, auscultation, percussion palpation

Question 11

physical exam neuro

Answer 11

extent of exam depends on baseline defect

• motor: gait, grip, hold hands up
• sensory: vibration, pain, touch along dermatomes
• muscle reflexes: deep, superficial
• cranial nerve abnormalities
• mental status
• speech

Question 12

physical exam obesity basic

Answer 12

20% over IBW

BMI 30-39.9

Question 13

Pre-procedure lab testing goal 4

Answer 13

decrease anesthetic morbidity
increased quality of prop care
decreased cost
return pt to desirable functioning

Question 14

lab test down side

Answer 14

NOT good disease screening
follow up to abnormals can be $
nonindicated test increase risk to pt
can create medical/legal risk to provider 
decrease efficiency and increase cost.

Question 15

lab test questions

Answer 15

will the result of this test change my mgmt? improve pt care?
needed to confirm suspicion? but will result change plan?
suspected abnormality linked to morbidity?
higher than average likelihood of an abnormality?
***will the result affect the plan

Question 16

sensitivity

Answer 16

+ in pt that has disease

Question 17

Specificity

Answer 17

• in pt that does NOT have disease

Question 18

minimally invasive

Answer 18

little tissue trauma, minimal blood loss

Question 19

moderatley invasive

Answer 19

modest disruption of normal physiology
so blood loss
may need invasive monitors, possible ICU

Question 20

highly invasive

Answer 20

significant disruption of normal physiology

commonly requires transfusion and ICU care

Question 21

Lab test when/why

Answer 21

hospital policy
current expert organization guidelines
Anesthesia provider judgment 
Consider: 
H&H, Chem, Coags, LFT, renal, UA, Preg, ECG, Chest xray, pulm function

Question 22

consults

Answer 22

for help/guidance of anesthesia plan

-not “clear for surg”

Question 23

ASA status

Answer 23

reflection of prep status
undefended of operative procedure and surg risk
subjective communication tool btwn providers

Question 24

ASA 1

Answer 24

normal healthy pt, no systemic disease

Question 25

ASA2

Answer 25

mild to moderate systemic disease well controlled no function limits
-ex controlled HTN, smoking, mild obesity, preg

Question 26

ASA 3

Answer 26

severe systemic disease functional limitation

ex: controlled CHF, old MI, poorly controlled HTN chronic renal failure

Question 27

ASA 4

Answer 27

severe systemic disease that is a constant threat to life

ex: end-stage, symptomatic COPD, CHF, angina

Question 28

ASA 5

Answer 28

moribund pt not expected to survive with or without surg

ex: septic, less than 24hrs to live, multi orang failure

Question 29

ASA 6

Answer 29

pt declared brain dad whose organs are being harvested for donation

Question 30

ASA E

Answer 30

emergent operation required

Question 31

NPO guidelines

Answer 31

2hrs clear liquids all pt
4hrs breast milk
6hrs formula or solids light meal
8hrs heavy meal or fired or fatty, gum candy
*follow hospital policy
*use clinical judgement to determine aspiration risk

Question 32

aspiration risk 8

Answer 32

1age extremes 70
2Ascites
3Collagen Vascular disease, metabolic disorders (ESRD, hypothyroid, DM, obesity)
4hital hernia/GERD/esophageal surg
5mechanical obstruction-pyloric stenosis
6prematurity
7preg
8neurologic disease

Question 33

Formulate anesthetic plan

Answer 33

type of anesthsia
drugs
monitor
airway
positioning 
intraop monitoring 
post op care
*discussion of plan with: pt, surgeon, OR team

Question 34

Pt prep, what to tell pt

Answer 34

discuss choice of agnostic technique
consent
explain IV, monitors, meds: LA, fluids
discuss airway
discuss post op recovery PACU/ICU ,and PAIN mgmt plan
Explain process of transport to OR
airway possible outcomes: sore throat, blood transfusion, facial swelling, nasal packing

Question 35

informed consent

Answer 35

explanation of planned anesthetic
explain options
risk and benefits 
pt understands and cooperates
without consent--assault and battery
minors-consent from parent/guardian
signature or pt and witness

Question 36

Final pre op check list

Answer 36

IV/fluid status
premed
anesthetic plan
lab work...results
ECG, CXR needed?
blood products? available and need?
need for inhaler? steroid coverage, antibiotics assertion prophylaxis

Question 37

Documentation of pre op eval 8

Answer 37

H&P
informed consent
NPO status
meds
allergies
ASA 
pre op VS
labs, test, consults