Pre-Op Eval Flashcards
What are the 3 main goals of pre-op evaluation?
- Ensure pts can safely tolerate anesthesia for surgery
- Mitigate periop risks
- Clinical exam: H&P
What’s an example of something we CAN’t mitigate before surgery?
Something we CAN?
Can’t: decompensated heart failure
Can: Need for dialysis, pt ate in the AM before surgery
During pre-op eval, we are trying to obtain pt info regarding and in order to: (4)
- Pt medical hx
- Formulate an assessment of the pt’s periop risk
- Develop a plan for any request clinical optimization
- Planning post op pain management in the background of preop pain medication
What are the benefits of the pre-op eval for the patient?
- reduces anxiety
- provides education
- discusses medications
- reduces post - op morbidity
- answers questions
What are the benefits of the pre-op eval for the anesthesia providers?
- learn of medical conditions
- devise anesthetic plan (intra/post op)
- time for consultants
- Code status
What are the benefits of pre-op evaluations for the surgeon/hospital?
- decreases cost of periop care
- improves efficiency
- decreases cancellations/delays
T/F:
Giving vasoactive meds in surgery to someone with a DNR violates their DNR
True!
Always verify code status and tailor periop plan to what the pt wants
Surgical procedures performed under anesthesia require preop evaluation for what 3 reasons?
- anesthesia is an added risk to surgery
- pre-anesthetic eval of pts improve clinical safety
- minimizes morbidity in appropriately prepared pts
What are common home meds (classes) we should worry about in pre op?
- anticoagulants
- things that alter BP (-ace, -arbs)
List the medical history components (9)
- underlying condition requiring surgery
- known medical problems/past medical issues
- previous surgeries/anesthetic history
- anesthetic-related complications
- review of systems
- medications
- allergies
- tobacco/ETOH/illicit drugs
- functional capacity
Common “red flags” of PMH for anesthesia
Malignant hyperthermia
Acetylcholinesterase deficiency
Difficult airway
What are the two common illicit drugs we worry about and why?
Meth: similar to ephedrine, drugs may not work as well if BP is low
Cocaine: destroys heart
Correct diagnosis can be made in ___% of cases on the basis of history alone
56
A BMI of <18.5 is considered:
Underweight
A BMI of 18.5-24.9 is considered:
Normal
A BMI of 25.9-29.9 is considered:
Overweight
A BMI of 30.0 and above is considered:
Obese
What is the metric formula for BMI?
BMI = weight (kg) / [height (m)]2
What is the imperial formula for BMI?
BMI = 703 X weight (lbs) / [height (in)]2
List the most important vital signs to know
BP, HR, RR, O2, temp, height/weight, BMI, ideal body weight
What 4 things can the BMI be used for?
- estimate drug doses
- determine fluid volume requirement
- calculate acceptable blood loss
- adequacy of urine output
Why is it important to test for neuro deficits before surgery?
If they wake up after surgery with a deficit, you need to know if it’s new or their baseline
Seizure meds ____ the rate of action of paralytics
Decrease
What two CV conditions do we commonly cancel surgery cases for?
Decompensated heart failure
Unstable angina
What can we do for asthma/COPD in preop to mitigate risks?
Give nebs and steroids
It is better for diabetics if we manipulate blood sugar in the ______ term
Short
The biggest source of renal dysfunction in the OR is ______
Hypotension
Example of when we may do anesthesia for immunocompromised pts
Bone marrow biopsy
We need to know the underlying disease of someone who is immunocompromised, in case we needed to:
Give a transfusion
What is the emergent physical exam accronym and what does it stand for?
A: Allergies
M: Medications
P: Past medical history
L: Last meal eaten
E: Events leading up to need for surgery
In an emergent physical exam, what are some other things we may need to pay special attention to:
Vitals
Airway
What are the 6 things that are included in an airway exam?
- Mallampati
- Inter-incisor gap
- Thyromental distance
- Forward movement of the mandible
- Range of cervical spine motion (flexion and extension)
- Document loose or chipped teeth & tracheal deviation
What is an inter-incisor gap?
The gap between the incisor teeth
What is the thyromental distance?
Distance between the thyroid and the jaw
What is an example of when someone might have trouble with the forward movement of the mandible?
If they are in a C-collar
Why is it important to document loose/chipped teeth in preop?
Important from a legal standpoint in case you knock them out
What could be causing someone’s tracheal deviation?
What further assessment could you do?
Pneumothorax / Mass
Use ultrasound or CT to determine if it’s above or below the glottis
Previous CV conditions may lead to serious ______ op adverse events and account for almost ___ of the mortalities during this OR phase
Peri
Half
Things that will reduce CV events in the OR:
Maximize pt
- oxygenate (getting airway, etc)
- maintaining BP
CV disorders to specifically worry about in pre op:
Aortic stenosis
Heart failure
Ischemia
Common CV disorders we may see:
HTN
Ischemic heart disease
Heart failure
Valvular heart disease
Rhythm disturbances
Coronary stents
Pacemakers/ICDs
PAD
What is the most difficult valvular disease to worry about in the OR? Why?
Severe aortic stenosis
Hard to manage their BP
What are some reasons a young patient might have an ICD or pacemaker?
Drugs, congenital, cardiomyopathy
What are the two main things that might cause hypoxemia in the OR?
No airway
No BP to circulate O2
What are the common S/S that might come from hypoxemia (really anything neuro)?
Seizures, coma, death
Respiratory function is inextricably linked to _________
Practice of anesthesia
What type of anesthesia has significant effects on respiratory function and lung physiology/mechanics?
General
What is the most common and most significant adverse respiratory event that can occur during anesthesia?
Hypoxemia
Common pulmonary disorders we may see
URI
Asthma
COPD
Chronic smokers
Restrictive lung disease
OSA
Pts scheduled for lung resection
What is most pt population that we see upper respiratory tract infections in?
Children
What does chronic smoking lead to (most significant one for us in the OR)?
Vascular disease
Why is it important to note if someone has restrictive lung disease?
They might be difficult to ventilate
T/F
Someone with OSA might have it NOT based on their body habitus
True
What is the most common reason pts get lung resections?
Cancer
Common endocrine disorders we may see
Diabetes Mellitus
Thyroid disorders
Hypothalamic- pituitary- adrenal disorders
Pheochromocytoma
Hypoglycemia in surgery can cause:
Poor wound healing
What route of adminstration do we use to give insulin in the OR?
IV
What is one specific thing we worry about with thyroid disorders in the OR?
Goiters
They can cause issues with intubations, and we may also see electrolyte imbalances (calcium)
What would you administer to someone in preop if you were aware they had a pheochromocytoma?
Alpha or beta blockade
We can’t recognize hypoglycemia during anesthesia until:
Severe hemodynamic instability
Common renal system disorders we may see
Surgical stress, anaesthetic agents tend to decrease GFR
Renal impairment- CKD/ AKI
Contrast induced nephropathy
The number 1 predictor for post op renal dysfunction:
Preop renal dysfunction
If someone has contrast induce nephropathy, we can do what?
Give IVF
Dialysis
Monitor I/O
The emphasis of the pre op eval of pts with renal insufficiency are on what?
CV system
Cerebrovascular system
Fluid volume
Electrolyte status
Common hepatic disorders we may see
Hepatitis
Alcohol liver disease
Obstructive jaundice
Cirrhosis
Liver diseases have significant impact on _______ and _______
Drug metabolism
Pharmacokinetics
Number 1 cause of malignancy is:
Alcohol
What drug class might have exaggerated effects in pts with advanced liver disease?
Sedatives/opiods
Common hematologic disorders we may see
Anemia
Sickle cell disease
G6PD deficiency
Coagulopathies
A lot of hematologic disorders become apparent during ________ in females
Pregnancy
Anesthesia can cause dilutional _______ due to IVF
Anemia
Smoking can cause high ________ levels
Hemoglobin
In sickle cell disease, hypotension can cause ____
Clumping
It’s important to pre hydrate pts with sickle cell prior to OR because:
They may be dehydrated at baseline due to NPO status
Can cause flare up
What is the disorder where you lack an enzyme and could have hemolytic anemia?
G6PD deficiency
Coagulopathies come from:
Medications
Genetics
Herbal agents (garlic/ginseng)
Common neuro disorders we may see
Cerebrovascular disease
Seizure disorders
Multiple sclerosis
Aneurysm and AV malformation
Parkinson disease
Neuromuscular junction disorders
Muscular dystrophy and myopathy
In MS, what drugs may you want to avoid? Why?
Paralytics
Can prolong the muscle from coming back; paralyzed longer
MS is seen most commonly in what pt population?
Middle aged people
We worry about ______ in Parkinsons pts
Wasting
What Parkinsons drug can cause issues with anesthesia?
Levodopa
Common musculoskeletal and connective tissue disorders
Rheumatoid Arthritis
Ankylosing Spondylitis
Systemic Lupus Erythematosus
Raynaud Phenomenon
Pt’s with RA may not respond to _____ normally because the surge in ______ doesn’t affect them due to steroids
Stress
Cortisol
Ankylosing Spondylitis makes it difficult for pts to _____. Their bones may be ________
Extend/flex
Hard and brittle
In pt’s with Raynaud’s, they may be baseline _______. This can cause issues with what?
Vasoconstricted
Pulse ox may not work
Alters assessment of pt
May not want to use pressors
Sympathetic overload can be caused by:
Chronic pain
Fibromyalgia
POTS
Lupus
Miscellaneous conditions we may see
Morbidly obese patient
Patient with transplanted organs
Patient with allergies
Patient with substance abuse
Pre-op Evaluation flow chart:
Pre-op assessment form:
In morbidly obese pts, we worry about:
Positioning, airway
In pt’s with transplanted organs, we worry about _____ due to chronic use of _____
Immunosuppression
Steroids
In pts with heart transplants, they have severed _____ so what drugs would not work?
Vagus nerves
Robinul and atropine
What are a few specific patient populations that would have certain considerations?
Children
Pregnant women
Breast feeding women
Elderly pts
What consideration is important in breast feeding pts?
Dictates what medications we can give
What court case dictated informed consent? What happened?
Salgo v Trustees of Leland Stanford Hospital
Martin Salgo sued the hospital and Dr. Frank Gerbode for not being informed. Had an aortogram and was left paralyzed in lower extremities
Importance of informed consent:
Respect for pt autonomy
Duty to inform pts about the risks and alternatives to treatment, procedures, and consequences
Importance of shared decision making
- Communicating with pts about the risks and benefits of possible interventions
- Eliciting pts’ goals, values, and concerns
- Assisting pts in how to conceptualize the risks and benefits/how to approach the decision
What are the 3 different types of DNR orders in the peri-op period?
- Full attempt at resuscitation
- Limited attempt at resuscitation defined with regard to specific procedures
- Limited attempt at resuscitation defined with regard to the pt’s goals and values
T/F
Anesthesia cannot refuse to do a procedure if the pt refuses to reverse DNR/DNI
False
Important things to not with elderly pts
- Need to inform of surgical risk and identify targets for pre-op optimization
- Goal is to identify modifiable risk factors to optimize surgical outcomes
- Functional and cognitive impairment = poor post-op outcomes
- Function decline is associated with morbidity, mortality, and loss of function after surgery
- Cognitive impairment = delirium, complications, functional decline, and death post-op
- Poor nutritional status = infectious complications, wound complications, and increased length of stay
- Frailty is a state of increased vulnerability to physiologic stressors
- Underdiagnosed - anxiety, depression, substance abuse, and social isolation
Common things you may see in an elderly pt:
Poor physical function
Malnutrition (poor wound healing)
Low albumin (not as responsive to meds)
Almost all anesthesia increases the risk of _____
Falls
What are common things that poor nutritional status in elderly pts can lead to:
Surgical site infection
Pneumonia
UTI
Dehiscence
Anastomotic leaks
What are the percentages for low, intermediate, and high risk of surgeries?
Low: <1%
Intermediate: 1%-5%
High: >5%
Examples of high risk surgeries
Aortic and major vascular
Peripheral vascular
Examples of intermediate risk surgeries
Intraabdominal surgery
Intrathoracic surgery
Carotid endarterectomy
Head/neck surgery
Examples of low risk surgery
Ambulatory
Breast
Cataract
Skin
Urologic
Orthopedic
Endoscopic procedures
Revised cardiac risk index chart:
What is the point of this chart?
Estimates risk of cardiac complications after surgery
How do we assess cardiopulmonary status in pts and if someone is increased for periop risk?
Functional capacity
Functional capacity chart:
If someone has poor functional capacity, they are at increased:
Peri op risk
On the functional capacity chart, what is the number that is considered good functional capacity?
> 4
Who determines if a surgery is emergent?
Surgeon
Life or limb would be threatened in how many hours for emergent, urgent, and time-sensitive surgery?
Emergent: 6 hours or less (usually in the OR in less than an hour)
Urgent: 6 to 24 hours
Time-sensitive: 1 to 6 weeks
What is important to monitor if your surgery is turned emergent?
AMPEL assessment
Surveillance (serial cardiac enzymes, hemodynamics, serial ECGs)
Early treatment of post op CV complications
Pre op Cardiac Risk Assessment Algorithm ACC/AHA guideline chart:
Risk stratification includes what 4 things, other than pt’s physical state?
Who described this?
-The planned surgical procedure
-The ability and skill of the surgeon in the particular
procedure contemplated
- The attention to postoperative care
- The past experience of the anesthetist in similar
circumstances
Meyer Saklad
Influences of various components on poor perioperative outcome chart:
ASA physical status chart:
Pre op testing is based on:
Comorbidities
Operative risk
Findings from H&P
Pre op testing is only indicated if it will ________ your anesthetic plan
Change
Tests should satisfy the following criteria to be useful:
Diagnostic efficacy… correctly identify abnormalities?
Diagnostic effectiveness… change the diagnosis?
Therapeutic efficacy… change the management of the pt?
Therapeutic effectiveness… change the pt’s outcome?
What would be some reasons to need a CBC pre op?
- Hematologic disorder
- Sick pts (already admitted to the hospital)
- Increased risk pts/increased risk procedure
- Anticoagulant therapy
- ASA-PS 3 or 4 undergoing intermediate risk
Reasons to get renal function testing pre op:
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, or 4 undergoing major procedures
Reasons to get electrolyte testing pre op:
Suspected undiagnosed or worsening condition that will affect peri-op management
Renal or hepatic disease, malnutrition, malabsorption, ETOH abuse, HF, arrhythmias, medications that may cause an imbalance
Reasons to get LFT pre op:
Liver injury and physical exam findings
Hepatitis, jaundice, cirrhosis, portal HTN, biliary disease, gallbladder disease, bleeding disorders
What is the problem is someone has low calcium?
Heart may not contract as well, so low BP
May not clot well (bleeding)
A lot of the things we do raise _____ levels, including:
Potassium
If something is “dead” (kidneys, gut)
Succs (.5 raise)
In a bleeding trauma pt, what would you expect in their calcium and potassium levels?
Potassium can go up and calcium can go down
Reasons to get coagulation testing pre op:
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; known to take anticoagulant medications or chronic liver disease
Reasons to get serum glucose and glycated hemoglobin (HbA1c) preop:
Known DM (or family history), obesity (BMI > 50), cerebrovascular or intracranial disease, or steroids history
HbA1c long-term measurement of glucose control (3 months)
All diabetic patients
PT/INR is used for what medication monitoring?
Warfarin
Ptt is used for what medication monitoring?
Heparin
Bacteria in urine increases risk of _____ for what type of surgeries?
Infection
Hip surgeries
We won’t put hardware in people who are infected
We would get a UA if we suspected:
UTI or unexplained fever/chills
Reasons to get a pregnancy test pre op:
Sexual activity, birth control use, and date of last menstrual period
What is one of the drugs we use that can inactivate birth control? How long should pt’s use an alternative BC?
Suggamaddex
1-2 weeks
Reasons we would get ECG in preop
- Ischemic heart disease, HTN, DM, HF, chest pain, palpitations, abnormal valvular murmurs, dyspnea on exertion, syncope, arrythmia
- Known IHD, significant arrhythmia, PAD, CV disease, significant structural heart disease undergoing intermediate- risk or high-risk procedures
- Routine in ASA-PS 3 or 4 undergoing intermediate- risk
- Routine ASA-PS 2, 3, or 4 major/high-risk procedures
Reasons we would get CXR in pre op
Based on abnormalities identified during pre-op evaluation
Advanced COPD, bullous lung disease, pulmonary edema, pneumonia, mediastinal masses, suspicious physical exam findings (rales, tracheal deviation)
Very rarely would a ____ alter management of anesthesia.
However, what 3 things will?
12 lead ECG
A-fib, acute MI, acute electrolyte imbalances
What are the 4 types of anesthesia?
General
IV/monitored sedation
Regional
Local
Uses and considerations of general anesthesia
Total loss of consciousness and airway control
ET or LMA used
Ex: major surgeries… total joints, open-heart surgery, bowel surgery
Uses and considerations of IV/monitored sedation
Level of sedation ranges… minimal (drowsy, able to talk) to deep (sleeping, may not remember surgery/procedure
NC or face mask
Ex: minor surgeries/procedures or shorter, less complex procedures… biopsy, colonoscopy
What drug has a larger margin of safety than versed/fentanyl? Why?
Propofol
It wears of faster
Local anesthesia in the eye can go into the ____ causing _______ to drop
Brain
HR/BP
What are some reasons we may not use a LMA?
Anatomy
Obstruction
High risk aspiration
Uses and considerations of regional anesthesia
Pain management method that numbs a large part of the body using a local anesthetic
Epidural or spinal
Ex: childbirth or joint replacements in elderly pts
Uses and considerations of local anesthesia
Pain management method, 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 repair
What’s the difference in local and regional anesthesia?
Regional is a region (obviously lol)
Local is injected right at the site
Important considerations for planning post op pin management
- All patients have the right to appropriate assessment and treatment of pain
- A preoperative evaluation should include baseline pain assessment
- Provides an important opportunity to discuss and plan for the management of acute postoperative pain
- Specific issues include their tolerance to usual doses of opioid analgesics and the potential for acute withdrawal reactions should be assessed
Most common agents that cause anaphylaxis?
Neuromuscular blockers
Antibiotics
Chlorhexidine
Latex
Opioids
We would know if a pt is having an allergic reaction based on:
Vitals (hypotension, tachycardia)
Hives
Can’t tube/ventilate (high airway pressures)
The incidence of true anaphylaxis anesthesia is:
1:20,000
What is the most common paralytic people have allergic reactions to?
Roc
Who is the most common people that we see with latex allergies? Other risk factors?
Healthcare workers
Pt’s with spina bifida
Food handlers
history of multiple surgeries
food allergies that cross-react (mango, kiwi, avocado, passion fruit, banana, and chestnuts)
What two abc are the most common causes of anaphylaxis?
PCN and cephalosporins
With vanc allergies, it’s important to distinguish between allergy and _________
Red man syndrome
What type of local anesthetics are pt more allergic to? This is due to them having what?
Esters
PABA
Neuromuscular blocking agents can have cross-reactivity with allergies to _______ and ________
Neostigmine and morphine
True allergies to _____ is rare; they are usually just typical side effects
Opioids
Pre op medications to continue:
Antihypertensive medications
Cardiac medications (ex. Beta-blockers, digoxin)
Anti-depressants (TCAs), anxiolytics, and other psychiatric medications
Thyroid medications
Oral contraceptive pills (unless high risk thrombosis)
Eye drops
GERD medications
Opiods
Seizure meds
Asthma meds
Corticosteroids
Statins
ASA (prior PCI, high grade ischemic disease)
COX2 inhibitors
MAOI (avoid demerol, ephedrine)
Pre op medications to discontinue:
ASA: 10-14 days before sx
ACE/ARBS BP meds
P2Y12 inhibitors
Topical medications (day of)
Diuretics (except HCTZ)
Sildenafil (24 hrs before, worry about BP)
NSADIS (48 hrs before)
Warfarin (5 days before)
Post menopausal HRT (4 weeks before)
Non insulin anti diabetics
Insulin (if short acting insulin pump, keep)
Why is it important to d/c -ace and -arbs?
They can become profoundly hypotensive and difficult to manage
Pre op medication management for steroids and HPA suppression:
- Cortisol is produced by the adrenal gland
- Hydrocortisone is an equally potent synthetic version
- Exogenous glucocorticoids suppress cortisol secretion at HPA axis
- May lead to adrenal insufficiency and adrenal atrophy
- May blunt the normal cortisol hypersecretion associated with surgery
What is the dose of hydrocortisone that we would give to some with suppression of cortisol activity?
100 mg every 6-8 hours
HPA suppression management:
No HPA suppression with short duration, low-dose steroids
HPA suppression with >20 mg prednisone/day >3 weeks and in pts with Cushingoid appearance
Preop management of steroids:
Assess duration, dose, and potency of all steroids taken during the past year
Stress dose for steroids in the OR:
Physiologic replacement doses are required
Dosage varies based on surgical procedures
Steroid dosing chart:
Pre-operative medication managementherbals and vitamins
- Direct effects… intrinsic pharmacologic effects
- Pharmacodynamic interactions… alters action of conventional drugs at effector site
- Pharmacokinetic interactions… alters absorption, distribution, metabolism, and elimination of conventional drugs
- Approximately 50% of pts take multiple herbs
- 25% take prescription drugs
Echinacea pharmacologic effects, peri op concerns, d/c before surgery?
Activation of cell mediated immunity
Allergic reactions, decreases effectiveness of immunosuppressants, potential for immunosuppression with long term use
No data
Ephedra pharmacologic effects, peri op concerns, d/c before surgery?
Increases HR and BP through indirect/direct sympathomimetic effects
Risk of myocardial ischemia/stroke from tachycardia and HTN; Ventricular arrhythmias with halothane; long term use depletes endogenous catecholamines, my cause intraop hemodynamic instability; life threatening interaction with MAOI
24 hrs
Garlic pharmacologic effects, peri op concerns, d/c before surgery?
Inhibits plt aggregation, increases fibrinolysis, equivocal antiHTN activity
May increase risk of bleeding
7 days
Ginger pharmacologic effects, peri op concerns, d/c before surgery?
Antiemetic; anti platelet aggregation
May increase risk of bleeding
No data
Ginkgo pharmacologic effects, peri op concerns, d/c before surgery?
Inhibits platelet-activating factor
May increase risk of bleeding
36 hrs
Ginseng pharmacologic effects, peri op concerns, d/c before surgery?
Lowers BG, inhibits plt aggregation, increased PT/Ptt in animals
Hypoglycemia, increased risk of bleeding, may decrease anticoagulant effect of warfarin
7 days
Green tea pharmacologic effects, peri op concerns, d/c before surgery?
Inhibits plt aggregation; inhibits thromboxane A2 formation
May increase risk of bleeding; may decrease anticoagulant effect of warfarin
7 days
Kava pharmacologic effects, peri op concerns, d/c before surgery?
Sedation, anxiolytics
May increase sedative effect of anesthetics; increase in anesthetic requirements with long term use
24 hrs
Saw palmetto pharmacologic effects, peri op concerns, d/c before surgery?
Inhibits 5a reductase, inhibits cyclooxygenase
May increase risk of bleeding
No data
St John’s Wort pharmacologic effects, peri op concerns, d/c before surgery?
Inhibits neurotransmitter reuptake; MAO inhibition unlikely
Induction of CP450, affects cyclosporine, warfarin, steroids, and protease inhibitors; decreased serum digoxin levels, delayed emergence
5 days
Valerian pharmacologic effects, peri op concerns, d/c before surgery?
Sedation
May increase sedative effect of anesthetics, benzodiazepines-like acute withdrawal
No data
What is the risk associated with being NPO at midnight?
Dehydration, hypoglycemia
Fasting guidelines chart:
Clear liquids doesn’t necessarily mean see through, but something without ______
Particulate matter
As part of the ERAS protocol, some pts are given what 30min-1hr before surgery?
Gatorade
Risk factors for pulmonary aspiration (chart):
What increases morbidity and mortality when discussing aspiration? What does this include?
Mendelson syndrome
> 25 ml gastric residual volume
pH <2.5
Aspiration prophylaxis:
- Decrease gastric volume and acidity
- Non-particulate antacids (sodium citrate)… increase gastric pH
- Histamine-2 receptor antagonists (ranitidine, cimetidine, famotidine… increase gastric pH, decrease gastric acid secretion
- Proton pump inhibitors (omeprazole, pantoprazole)… increase gastric pH, decrease gastric acid secretion
- Dopamine-2 antagonist (metoclopramide)… reduces gastric volume
What is Mendelson syndrome named after?
Curtis Lester Mendelson’s original 1946 description of his namesake syndrome, chemical pneumonitis was described in young and healthy obstetrical patients following aspiration of gastric acid under anesthesia. The standard use of regional anesthesia for most laboring women and increased awareness among anesthesia providers regarding the high risk of aspiration and potential difficult airway management in parturients has increased the safety in this population. This complication of anaesthesia led, in part, to the longstandingnil per os(abbr. NPO; a Latin phrase meaning nothing by mouth) recommendation for women in labour
Koivuranta PONV risk scoring system includes:
Female gender
History of PONV/motion sickness
Nonsmoking status
Age (less than 50)
Duration of surgery
*these are in decreasing order of significance
Simplified Apfel score for PONV includes:
Female
History of PONV/motion sickness
Nonsmoking status
Post op opiods
- these are in decreasing order of significance
Reduce PONV by:
- give antiemetics (zofran)
- Give decadron in combo with zofran
- Zofran is good at preventing PONV but not treating
- Can use scopalamine (but makes you sleepy, thirsty, crazy pupils, older pts become delirious; takes a while to work so may need to give as a prescription prior to surgery)
PONV risk factors in adults and children chart:
If a pt has 1 to 2 risk factors for PONV, they are considered:
Moderate to severe risk
If a pt has 3 to 4 risk factors for PONV, they are considered:
Severe risk
Risks of PONV associated with the number of risk factors:
Zero risk factors: 10%
One risk factor: 20%
Two risk factors: 40%
Three risk factors: 60%
Four risk factors: 80%
Meds to use for N/V prevention:
Scopalamine
Pregabalin
Ondansetron
Promethazine
Dexmethasone
*See slide 64 for further info
Premedication pain prevention considerations:
Baseline pain assessment
Develop pain management plan
- Peri-op pain control a concern
- Pre-op pain instructions may help improve post-op pain
- Regional anesthesia techniques
- Consult pain management for chronic pain
-Tolerance and acute withdrawal reactions
Adjunct analgesics
-NSAIDs, gabapentin, pregabalin, clonidine, acetaminophen
Premedication antibiotic considerations:
Core measure SCIP-INF (Infection)
All pts should have received prophylactic antibiotics within 1 hour before surgical incision
Pts who received vancomycin or a fluoroquinolone for prophylactic antibiotics should have the antibiotics initiated within 2 hours before surgical incision
What are the considerations for cefazolin pre op?
Most commonly administered antibiotic for surgery
Broad-spectrum β-lactam antimicrobial agent
Most aerobic gram-positive bacteria that cause surgical site infections
-Staphylococci, streptococci strains
Cross-reactivity to PCN
What are the considerations for clindamycin pre op?
Effective against gram-positive aerobic bacteria
- Staphylococci, streptococci, pneumococci strains
Most gram-positive and gram-negative anaerobic bacteria
Alternative for a β-lactam allergy or a MRSA infection
Treats infections of the head and neck, respiratory tract, bone, soft tissue, abdomen, and pelvis
Recommended in hysterectomies, cesareans, appendectomies, gastroduodenal tract, biliary tract, small intestine, colon, and rectum
What are the considerations for vancomycin pre op?
Gram-positive bacteria
- Staphylococci, streptococci strains
Alternative for a β-lactam allergy or MRSA infection
Recommended for distal ilium, colon, appendix surgical sites
Dosing for preop antibiotics in adults and children
Cefazolin:
- adult: 2g, 3g if >120kg
- children: 30 mg/kg
Clinda:
- adult: 900 mg (cut to 600 mg if renal impaired)
- children: 10 mg/kg
Vanc:
- adult: 15 mg/kg
- children: 15 mg/kg
The preop eval clinic is a visible partnership among the departments of:
Nursing, anesthesia, surgery, and hospital admin
What are the positives to a preop eval clinic?
- decreased cost
- efficient services
- clinical productivity
- timely access to clinic
- pt and surgeon satisfaction
