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Intro to Anesthesia > Pre-op Physical Assessment > Flashcards

Pre-op Physical Assessment Flashcards

1
Q

There are ___ categories of Surgery Types

A

5

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2
Q

What level is the risk for “Surgery Type” Category 1

A

minimal -independent of anesthesia

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3
Q

What level is the risk for “Surgery Type” Category 2

A

minimal -independent of anesthesia

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4
Q

What level is the risk for “Surgery Type” Category 3

A

moderate -independent of anesthesia

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5
Q

What level is the risk for “Surgery Type” Category 4

A

major risk -independent of anesthesia

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6
Q

What level is the risk for “Surgery Type” Category 5

A

critical risk –independent of anesthesia

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7
Q

How invasive is “Surgery Type” Category 1 and how much blood loss involved

A

minimally invasive with little to no blood loss

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8
Q

How invasive is “Surgery Type” Category 2 and how much blood loss involved

A

minimal to moderately invasive with blood loss less than 500 cc

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9
Q

How invasive is “Surgery Type” Category 3 and how much blood loss involved

A

moderate to significantly invasive with blood loss potential 500-1,500 cc

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10
Q

How invasive is “Surgery Type” Category 4 and how much blood loss involved

A

highly invasive with blood loss greater than 1,500 cc

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11
Q

How invasive is “Surgery Type” Category 5` and how much blood loss involved

A

highly invasive with blood loss greater than 1,500 cc

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12
Q

What are 3 important questions to ask yourself when completing pre-op prep of the patient for non-cardiac surgery?

A
  1. What tests should be ordered?
  2. When is a long-standing condition in satisfactory control or should have some additional study or meds added prior to operation?
  3. What are the risks of anesthesia and the surgery for the patient?
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13
Q

What are 9 main categories of conditions for which preoperative evaluation is strongly recommended prior to the day of surgery?

A
  1. general
  2. cardio circulatory
  3. respiratory
  4. neuromuscular
  5. hepatic
  6. musculoskeletal
  7. oncology
  8. gastrointestinal
  9. endocrine
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14
Q

Examples of General Conditions to do pre-op eval for.

A
  • Medical condition inhibiting ability to engage in normal daily activity
  • Medical condition that needs continual assistance or monitoring at home within the last 6 mts
  • Admission to the hospital within the past 2 mts for acute or exacerbated chronic condition
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15
Q

Examples of Cardio Circulatory Conditions to do pre-op eval for.

A
  • history of angina, coronary artery disease, myocardial infarction
  • symptomatic arrhythmias
  • poorly controlled hypertension (make sure it isn’t anxiety driven)
  • history of congestive heart failure
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16
Q

Examples of Respiratory Conditions to do pre-op eval for.

A
  • ashtma/COPD requiring chronic meds or with acute exacerbation and progression within the last 6 mts
  • history of or current major and/or lower airway tumor or obstruction
  • history of chronic respiratory distress requiring home ventilator assistance or monitoring (ie. at home CPAP)
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17
Q

Examples of Neuromuscular Conditions to do pre-op eval for.

A
  • history of seizure disorder or other significant CNS disease (eg, MS)
  • history of myopathy or other muscle disorders
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18
Q

Examples of Musculoskeletal Conditions to do pre-op eval for.

A
  • kyphosis and/or scoliosis causing functional compromise
  • temporomandibular joint disorder (TMJ)
  • cervical or thoracic spine injury
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19
Q

Examples of Oncology Conditions to do pre-op eval for.

A
  • receiving chemotherapy

* oncology process with significant physiological residual or compromise

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20
Q

Examples of Gastrointestinal Conditions to do pre-op eval for.

A
  • massive obesity (>140% ideal body weight)
  • hiatal hernia
  • symptomatic GERD
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21
Q

Examples of Hepatic Conditions to do pre-op eval for.

A

any active hepatobiliary disease and compromise

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22
Q

Examples of Endocrine Conditions to do pre-op eval for.

A
  • non-diet controlled diabetes (insulin or oral hypoglycemic agents such as metformin)
  • adrenal disorders
  • active thyroid disease
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23
Q

How many ASA classifications are there?

A

ASA 1, 2, 3, 4, 5, 6

E (emergency)

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24
Q

Description of ASA 1

A

normal healthy patient

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25
Q

Description of ASA 2

A

mild systemic disease with no functional limitations

–ex. controlled HTN or DM, tobacco use, extreme age

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26
Q

Description of ASA 3

A

severe systemic disease with functional limitations

–ex. uncontrolled HTN or DM with vascular complications, prev. MI

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27
Q

Description of ASA 4

A

severe systemic disease that is constant threat to life

–ex. CHF, unstable angina, advanced pulmonary dysfunction, ESRD (end stage renal disease)

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28
Q

Description of ASA 5

A

not expected to survive without surgery
–ex. ruptured AAA (abdominal aortic aneurysm), PE (pulmonary embolism), head injury with increased intracranial pressure

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29
Q

Description of ASA 6

A

organ procurement on a brain-dead patient

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30
Q

Description of E (emergency)

A

patient whom an emergency procedure is required

–can have E with any of the other ASA categories

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31
Q

Medications that should be stopped 2 weeks prior to surgery? (unless otherwise directed by their PCP, specialist or the surgeon)

A
  • aspirin or meds that contain it
  • anti-platelets
  • anti-inflammatory/NSAIDS
  • arthritis meds
  • migraine/headache meds
  • pain meds
  • selective COX-2 inhibitors
  • all diet meds (prescribed, OTC, herbal, supplemental)
  • all herbal meds
  • ulcerative colitis meds
  • psychiatric meds/anxiety/sleep meds
  • MAO inhibitors
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32
Q

Use should be stopped 48 hours prior to surgery

A

alcohol

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33
Q

use should be stopped 72 hours before surgery

A

illicit drugs

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34
Q

use should be stopped 24 hours before surgery

A

tobacco

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35
Q

2 main questions when going over Anesthesia History

A
  1. past problem with anesthesia
    - -difficult airway, PONV, any adverse or unpleasant reactions
  2. hereditary disorders
    - -malignant hyperthermia
    - -pseuodocholinesterase deficiency
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36
Q

10 symptoms of malignant hyperthermia

A
  1. hypercarbia
  2. tachycardia
  3. tachypnea
  4. hyperthermia (late sign)
  5. HTN
  6. cardiac dysrhythmias
  7. hypoxemia
  8. hyperkalemia
  9. skeletal muscle rigidity
  10. myoglobinuria
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37
Q

What is a diagnostic test for malignant hyperthermia?

A

halothane-caffeine contracture test

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38
Q

2 adjustments to general anesthesia for patients with known history of malignant hyperthermia

A
  • do not use succinylcholine

* use virgin anesthesia machine (no volatile agents vapors)

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39
Q

3 ways to ensure you have a virgin anesthesia machine for patients with known history of malignant hyperthermia

A
  • best to have them scheduled first thing in the morning to ensure there are no volatile agents vapors in the machine.
  • if not first surgery of morning – flush the machine per manufactures instructions and change CO2 absorbent
  • place a specialized filter on the inspiratory and expiratory arms of the anesthesia machine
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40
Q

What is the first thing you will do if a patient begins having symptoms and is confirmed to have malignant hyperthermia during surgery?

A

get the malignant hyperthermia cart and call the hotline for malignant hyperthermia that is on it

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41
Q

What is malignant hyperthermia?

A

An inherited disorder that is the result of a mutation in the calcium channel in the skeletal muscles. It causes a hypermetobolic state when triggered.

42
Q

What can result from triggering malignant hyperthermia?

A

renal failure and patient may die from multiorgan failure

43
Q

What is pseuodocholinesterase deficiency?

A

less than normal amount of pseuodocholinesterase

44
Q

What is the mode of action of pseuodocholinesterase?

A

breaks down acetylcholine

45
Q

During GA, what are the metabolic results of a pseuodocholinesterase deficiency?

A

abnormally slow metabolic breakdown of choline ester drugs such as succinylcholine resulting in respiratory paralysis persisting for prolonged period of time

46
Q

Is pseuodocholinesterase deficiency acquired, inherited, or both

A

both

47
Q

If a patient has history of MI, intermittent or chronic CHF, and/or paroxysmal nocturnal dyspnea (PND), what are they exhibiting?

A

cardiac dysfunction

48
Q

What are signs of cardiac dysfunction found during physical examination?

A
  • hypotension/tachycardia (sign of severe CHF)
  • prominent neck veins (sign of blood pooling into neck veins due to heart working slowly)
  • rales (an abnormal rattling sound heard when examining unhealthy lungs with a stethoscope)
  • pitting edema (When swollen skin remains indented after being pressed)
49
Q

3 test to diagnose cardiac dysfunction

A
  1. electrocardiogram
  2. chest x-ray
  3. cardiac testing
50
Q

What LVEDP value in cardiac testing indicates cardiac dysfunction?

A

> 18

51
Q

What does Ejection Fraction (EF) value of <40% indicate?

A

cardiac dysfunction

52
Q

What are the heart wall motion abnormalities evaluated in cardiac dysfunction testing?

A
  • hypokinesis
  • akinesis
  • dyskinesia
53
Q

What 2 occurrences may be the first indication of a patient with IHD (ischemic heart disease)?

A
  • acute myocardial infarction

* sudden death

54
Q

A postoperative MI is a lethal lesion with ___% chance of mortality rate?

A

> 50

55
Q

4 risk factors for IHD

A
  1. age: male >= 45yrs female >=55 yrs or premature menopause without estrogen replacement therapy
  2. family history of premature CHD
  3. current cigarette smoking
  4. hypertension >= 140/90 mmHg or on antihypertensives
56
Q

Physical exams and tests before surgery

A
  1. airway assessment
  2. lung auscultation
  3. cardiac exam and auscultation
  4. renal
  5. gastrointestinal
  6. neurological
57
Q

6 red flags when examining respiratory function during physical exam

A
  1. smoker (determine pack years)
  2. COPD
  3. lung cancer (chemo or radiation)
  4. asthma
    • -last attack (even if they were a child last attack) and inhaler used
  5. OSA
    • -CPAP?
  6. emphysema
58
Q

How many grades are there in the Assessment of Dyspena

A

Grade 0-IV

59
Q

“The Assessment of Dyspnea” definitions

Grade 0

A

no dyspnea while walking at a normal pace

60
Q

“The Assessment of Dyspnea” definitions

Grade I

A

able to walk as far as they like as long as they take their time

61
Q

What is the Grade in “The Assessment of Dyspnea”
of a patient with specific street block limitations
ex. have to take a break after walking one or two blocks

A

Grade II

62
Q

“The Assessment of Dyspnea” definitions

Grade III

A

dyspnea on mild exertion

–ex. have to stop and rest while going from kitchen to bathroom

63
Q

What is the Grade in “The Assessment of Dyspnea” of a patient with dyspnea at rest

A

Grade IV

64
Q

When do you assign a patient a Dyspnea Grade?

A

During the respiratory examination before surgery.

65
Q

What types of tests should be completed for patients with suspected or known respiratory issues?

A
  • chest x-ray
  • arterial blood gases
  • pulmonary function test
66
Q

What are the 4 D’s of Airway evaluations?

A
  1. dentition
  2. distortion
  3. disproportion
  4. dysmobility
67
Q

A visual test used to predict the ease of endotracheal intubation. The score is assessed by asking the patient, in a sitting posture, to open his or her mouth and to protrude the tongue as much as possible

A

Mallampati Classification

Class 1-4

68
Q

If a patient is a Mallampati Class 1, what do you see?

A

Soft palate, uvula, fauces, pillars visible.

69
Q

You look into a patient’s mouth and you see the soft palate, and base of uvula. What Mallampati Class is this?

A

Class 3

70
Q

If a patient is a Mallampati Class 4, what do you see?

A

Only hard palate visible.

71
Q

You look into a patient’s mouth and you see the soft palate, top part of uvula, and fauces. What Mallampati Class is this?

A

Class 2

72
Q

This system classifies views obtained by direct laryngoscopy based on the structures seen.

A

Cormack and Lehane classification

Grade I-IV

73
Q

If your layngoscopy view is the full glottis and airway anatomy, what is the Cormack and Lehane grade?

A

Grade I

74
Q

If you have a partial view of the glottis or aryteniods, what is the Cormack and Lehane grade?

A

Grade II

75
Q

If only the epiglottis is visible, what is the Cormack and Lehane grade?

A

Grade III

76
Q

If neither the glottis or epiglottis is visible, what is the Cormack and Lehane grade?

A

Grade IV

77
Q

What is the ideal thyromental distance?

A

3 fingers or 6cm from the thyroid notch to the mandible

78
Q

This represents the potential space into which the tongue will be displaced during direct laryngoscopy?

A

thyromental distance

79
Q

What techniques can be used to help intubate a patient with a short thyromental distance?

A

use a videoscope or intubate the patient awake

80
Q

What 2 syndromes might a patient have with only one finger of breadth between thyroid notch and mandible?

A

Pierre Robin or Treacher Collins syndrome

81
Q

Can you attempt laryngoscopy on a patient with Pierre Robin or Treacher Collins syndrome?

A

Yes, but only once and gently

82
Q

What adjustments could you make for a patient with a large tumor on their neck?

A
  • smaller diameter of ETT than for an average adult, but combine that with increase in positive airway ventilation
  • let them breath on their own if possible
83
Q

Airway examinations

A
  1. Mallampati Classification
  2. Cormack and Lehane classification
  3. thyromental distance
  4. Atlanto-axial joint mobility
  5. mouth opening (width, loose teeth?, protruding upper teeth, high arched palate?, long narrow mouth?, TMJ
  6. obstruction (tumor, swelling, etc)
  7. skull pathology
84
Q

OBESE acronym for difficult mask ventilation

A 
O-bese
B-earded
E-lderly
S-orers
E-dentulous
85
Q

What pre-surgery medication might a patient be taking that will interfere with anesthesia meds that need to increase BP?

A

steroids

–they cause steroid depression

86
Q

Red flags of a gastrointestinal exam?

A
  • GERD
  • cancer
  • PUD (peptic ulcer disease)
  • Hx of GI bleeding
  • hiatal hernia
  • obesity —use BMI chart
87
Q

Red flags of a neurological exam?

A
  • CVA (cerebral vascular accident
  • TIA’s (transient ischemic attack)
  • seizure disorder
  • mental status
  • alertness
  • numbness
88
Q

The name for the systolic sound heard over the carotid artery area during auscultation?

A

carotid bruit

89
Q

What could carotid bruit be a sign of?

A

artery stenosis but not a definitive test

–more testing needed

90
Q

3 main neurological tests

A
  1. MRI
  2. CT scan
  3. Carotid ultrasound
91
Q

What to check in extremities?

A
  • hand grip
  • head lift
  • numbness
  • tingling
92
Q

Height: 1 in = ___cm

A

2.54cm

93
Q

weight: 2.2 lbs = ___kg

A

1kg

94
Q

BMI = ____/____

A

mass (kg)/ Ht (m2)

95
Q

Ideal body weight equation

A

weight (kg) = height (cm) -x
x= 100 in adult males
x=105 in adult females

96
Q

normal adult blood pressure

A

120/80

97
Q

normal adult pulse rate

A

60-100bpm

98
Q

normal adult RR

A

12-18 bpm

99
Q

normal adult body temp

A

98.6 F

100
Q

Cardio tests

A

EKG
echocardiogram
stress test
chest x-ray

101
Q

GI tests

A

CBC –complete blood chemistry
serum chemistry
LFT (liver function test)

Intro to Anesthesia (2 decks)

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