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Anesthesia Concepts 2 > Pre-operative Assessment > Flashcards

Pre-operative Assessment Flashcards

1
Q

Components of a preoperative assessment

A

Patient history (chart review); physical exam; laboratory testing; medical consultation;ASA class; NPO status; formulation plan; discussion of plan; informed consent; documentation

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2
Q

Who mandates preoperative assessment?

A

JCHO; preprocedure and within 48 hours post-procedure

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3
Q

What are the preoperative assessment goals?

A

Optimize care, minimize morbidity, surgical delays, determine appropriate post operative disposition, evaluate health status, formulate anesthetic care plan, optimize communication among members of the surgical team.

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4
Q

3 main questions answered by the preoperative assessment?

A

Is the patient in optimal health?
Could health problems or medications unexpectedly influence preoperative events?
Can, or should, the patients physical or mental condition be improved before surgery?

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5
Q

Where do we get the data for the history?

A

Pt’s medical history (records)
Physical exam
Diagnostic tests
Specialist consultation/reports

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6
Q

What would you prefer to do 1 week pre-op?

A

Patient interview, physical examination, develop anesthetic plan, promote patient teaching and anxiety reduction, allows time to schedule appointments with medical consultants and diagnostic tests, informed consent early.

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7
Q

Who requires an early preoperative assessment?

A

Angina, CHG, MI, CAD, poorly controlled HTN, COPD/severe asthma, airway abnormalities, home vent/O2; IDDM, adrenal disease, active thyroid disease, liver disease, ESRD, massive obesity, symptomatic GERD, kyphosis, spinal cord injury

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8
Q

What do you look at during the chart review?

A

Demographics (age, name, sex); diagnosis/procedure; surgical consent; prior H&P; nursing notes; patient questionnaire; lab tests; EKGs, PFTS, Xray; vitals, medication list; allergies
If inpatient: progress notes, med sheets, nursing notes, anesthetic records

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9
Q

Preoperative interview: 6 purposes

A
  1. Obtain pertinent medical history
  2. Formulate plan of anesthetic care
  3. Obtain informed consent
  4. Patient education
  5. Improve efficiency, reduce cost of perioperative care
  6. Utilize operative experience to motivate patient to more optimal health
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10
Q

What are the steps of the preoperative interview?

A
  1. Introduce anesthesia provider 2. Confirm pt ID, diagnosis, procedure/site (open ended quest., general to specific, organized and systematic, layperson, individualized, control environment). 3. Look for coexisting diseases (review of systems) 4. Medications (allergies, prescriptions, OTC, herbals) 5. Previous anesthetics, exercise tolerance, sleep apneal, ETOH/drug abuse, tobacco, LMP
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11
Q

What are the systems you will review during the preoperative interview while you look for co-existing diseases

A

CNS/NM; cardiac; ENT;pulmonary; vascular/HTN; Endocrine; GI; Hepatic; Renal; Hematologic

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12
Q

What does your physical assessment of the airway consist of?

A

Mallampati classification; thyromental distance; head and neck movement; neck circumference, inter incisor distance dentition; craniofacial deformities; predictors of difficult airway management.

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13
Q

What does your physical exam of the heart consist of?

A

Heart auscultation: rate, rhythm, murmurs, bruits (carotid), extremity pulses
CV: bruits (carotid), extremity pulses, extremity edema

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14
Q

What does your physical exam of the lungs consist of?

A

Lungs
Inspection, Auscultation, Percussoin, Palpation.
When you listen to lungs, do upper left first, then upper right, then down the back.

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15
Q

What does your physical exam of the neurologic system consist of?

A

Depends on baseline deficits, disease, or procedures. Motor gait, grip, strength; Sensory: vibration, pain, light touch along dermatomes
Muscle reflexes: deep superficial, pathologic
Cranial nerve abnormalities, mental status, speech

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16
Q

What does your physical exam of the musculoskeletal system?

A

Gait, ROM
Obesity: 20% over ideal body weight.
BMI= 30-39.9 kg/m2

17
Q

What is the ideal body weight calculation for males and females?

A 
males= 105 lbs +6lb for each inch >5ft
females= 100lbs +5lbs for each inch >5ft
18
Q

What are the goals of preoperative laboratory testing?

A
  1. Reduce anesthetic morbidity
  2. increase quality of preoperative care
  3. Decrease the cost of preoperative care
  4. Return patient to desirable functioning
19
Q

What are the downsides of doing lab tests?

A

Lab tests are NOT good disease screening tools
follow up of “abnormal” results is costly
non indicated tests increase risks for patients
batteries of test present medico legal risk to providers
excessive testing decreases facility efficiency

20
Q

What is the Litmus Test?

A
  1. Will the results of this “test” change my management of this anesthetic?
  2. Will the results of this “test” improve this patient’s outcome?
21
Q

What are the types of procedures based on invasiveness?

A

minimally invasive- little tissue trauma, minimal blood loss
moderately invasive- modest disruption of normal physiology, anticipate some blood loss, may need invasive monitors/ICU
highly invasive- significant disruption of normal physiology commonly require transfusion and ICU care

22
Q

How do you determine what lab tests when?

A

Institutional policy; ACC/AHA guidelines; anesthesia provider judgement; H/H; chemistry, coags, LFTS, renal function tests, UA; pregnancy; EKG, xray, PFT

23
Q

Do you need consults?

A

Controversial; avoid the terms “cleared for surgery”; “cardiac clearance”; does peri-op management of a patient’s disease process go beyond your comfort level? (do you need advice from an expert on the patient’s care that could guide your management?)

24
Q

What is the definition of ASA status?

A

“To classify the physical condition of the patient requiring anesthesia and surgery”

  1. Reflection of pre-operative status
  2. ASA is independent of the operative procedure and surgical risk
  3. Subjective communication tool used between anesthesia providers institutions etc.
25
Q

What are the classifications of ASA physical status classification?

A

I -normal, healthy, patient; no systemic diseases
II- mild to moderate systemic disease, well controlled, no functional limitation
III- severe systemic disease, functional limitation
IV- severe systemic disease that is constant threat to live
V- moribound patient, not expected to survive without the surgical procedure
VI- patient declared brain dead whose organs are to be donated
E- emergency operation required

26
Q

NPO guidelines

A

Based on CURRENT ASA guidelines that balance risk factors of fasting with pulmonary aspiration risk

2 hours for clear liquids all patients
4 hours breast milk
6 hours formula or solids; light meal
8 hours heavy meal fried or fatty food, gum and candy

Follow your institutions policy however!
* note: some clinicians remain skeptical and use more conservative guidelines NPO 6-8 hours etc.

27
Q

Who is at risk for aspiration?

A 
Age extremes 70 yr
Ascites (ESLD)
Collagen vascular disease, metabolic disorders (DM, obesity, ESRD, hypothryoid)
Hiatal Hernia/GERD/Esophageal surgery
Mechanical obstruction (pyloric stenosis)
Prematurity
Pregnancy
Neurologic diseases
28
Q

Who do you discuss the anesthetic plan with?

A

Supervising staff
Patient
Surgeon
OR team

29
Q

Information the Patient Requires from an Anesthesia Professional

A

Discuss choices of anesthetic technique (consent) Verbal & Written consent
Explain IV catheter
Describe use of local anesthetics, medications, fluids
Discuss airway management plan
Explain monitors- placement, purpose
Discuss postoperative recovery
Discuss pain management plan
Explain process of transport to OR
Postoperative- PACU, pain relief, airway
Possible outcomes- sore throat, blood transfusion, facial swelling, nasal packing, etc.

30
Q

What are the components of informed consent?

A 
Explanation of the planned anesthetic
Explanation of options available
Risks and Benefits
Pt. understanding & cooperation
Without consent – Assault and Battery
Minors – consent from parents or guardian
Signature of pt. & witness
31
Q

What components of the procedure do you want to confirm with the OR team?

A 
Time, length procedure
Anatomical location
Position 
Xray needed?
Additional medications needed?
Procedure (s)
OR table position
32
Q

What is on the final preoperative checklist?

A

IV/Fluid status
Pre-medication
Anesthetic Plan
Labwork- results, labwork needed?
EKG, CXR, needed?- use old for comparison
Blood products?-availability & need
Need for inhaler, steroid coverage, antibiotics, aspiration prophylaxis?

33
Q

What do you DOCUMENT regarding the preoperative evaluation?

A 
H&P (review of systems)
Informed consent
NPO status
Medications
Allergies
ASA Physical Status Class
Pre-operative Vital Signs
Labs, tests, and consults
34
Q

What is the difference between sensitivity and specificity

A

Sensitivity- it will be positive with a patient with the disease
Specificity- it will be negative in a patient without the disease

Anesthesia Concepts 2 (10 decks)

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