Pre-Op assessment Flashcards
3 main preop questions
- is this the pts optimal health
- could health problems or med unexpectedly influence preoperative events?
- Can or should the pts physical or mental condition be improved before surg?
optimal preop situation
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
conditions that need early preop
- 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
What the OR schedule tells you 5
-demographics
-procedure and diagnosis
-length of produce and position
-the surgeon
-type of anesthesia
additional meds needed
X-rays needed?
OR table position
Preop interview 6 purpose
- obtain pertinent medical hx
- formulate plan
- obtain informed consent
- improve efficiency, decrease cost
- patient education
- utilize operative experience to motivate pt to more optimal health status
Preop interview general
introduce confirm ID, diagnosis, procedure open ended ? general to specific individualized controlled environment +/-family
Preop interview includes
review of systems LMP Meds Allergies Previous anesthetics and surg: complications, (pt and fam) and OB exercise tolerance Sleep apnea ETOH/Drug/tobacco
Physical exam summed up
general impression. ht/wt physical features airway heart lungs CNS/PNS VS Surg site IV positioning monitors needed
physical exam airway
mallampati thyromental distance head, neck mvmt neck circumference incisor distance dentition craniofacial deformities **looking for prefecture of difficult airway
physical exam heart and CV and lung
Auscultation: rate, rhythm, murmur, bruits, extremity pulse
edema
lung: inspection, auscultation, percussion palpation
physical exam neuro
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
physical exam obesity basic
20% over IBW
BMI 30-39.9
Pre-procedure lab testing goal 4
decrease anesthetic morbidity
increased quality of prop care
decreased cost
return pt to desirable functioning
lab test down side
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.
lab test questions
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
sensitivity
+ in pt that has disease
Specificity
- in pt that does NOT have disease
minimally invasive
little tissue trauma, minimal blood loss
moderatley invasive
modest disruption of normal physiology
so blood loss
may need invasive monitors, possible ICU
highly invasive
significant disruption of normal physiology
commonly requires transfusion and ICU care
Lab test when/why
hospital policy current expert organization guidelines Anesthesia provider judgment Consider: H&H, Chem, Coags, LFT, renal, UA, Preg, ECG, Chest xray, pulm function
consults
for help/guidance of anesthesia plan
-not “clear for surg”
ASA status
reflection of prep status
undefended of operative procedure and surg risk
subjective communication tool btwn providers
ASA 1
normal healthy pt, no systemic disease
ASA2
mild to moderate systemic disease well controlled no function limits
-ex controlled HTN, smoking, mild obesity, preg
ASA 3
severe systemic disease functional limitation
ex: controlled CHF, old MI, poorly controlled HTN chronic renal failure
ASA 4
severe systemic disease that is a constant threat to life
ex: end-stage, symptomatic COPD, CHF, angina
ASA 5
moribund pt not expected to survive with or without surg
ex: septic, less than 24hrs to live, multi orang failure
ASA 6
pt declared brain dad whose organs are being harvested for donation
ASA E
emergent operation required
NPO guidelines
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
aspiration risk 8
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
Formulate anesthetic plan
type of anesthsia drugs monitor airway positioning intraop monitoring post op care *discussion of plan with: pt, surgeon, OR team
Pt prep, what to tell pt
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
informed consent
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
Final pre op check list
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
Documentation of pre op eval 8
H&P informed consent NPO status meds allergies ASA pre op VS labs, test, consults
