Pre-Operative Planning Flashcards
What is the value of a preoperative assessment?
- Reduce patient anxiety and improve satisfaction
- Review past health & anesthesia history, acquire current status
- Patient and provider relationship for trust and engagement
- Education, satisfaction, plan agreement, informed consent
•Improved outcome and communication for safety
- Engage specialty practitioners in planning
Members of the Preanesthesia Team
- RN
- Nurse Practitioner
- Anesthesia provider
What does an anesthesia chart review consist of?
- Review history, tests, request optimization
- Communicate concerns for periop team
Bedside Preoperative Assessment Steps
- Chart Review
- Order pre-op test/consults
- Order pre-op medications
- Patient interview
- Perform physical exam
- Assess current status
- Answer questions
- Obtain informed consent
- Modify care plan
- Documentation
Components of a Chart Review
- Previous hospital records
- Anesthesia records
- Discharge summary\
- Pre existing conditions
- Lab/X-Ray/EKG, etc.
- Consultations
- Patient interview/exam
- Discussion with surgical or medical teams
Preoperative Interview and Physical Assessment
- Height, weight, vital signs, allergies
- Medication history (prescribed, OTC, Herbal)
- Medical History
- Social history (alcohol, tobacco, illegal drugs)
- Surgical history
- Anesthesia history
- Physical assessment
- Cardiopulmonary assessment
- Airway & Dental assessment
Patient Demographics
- Check ID (two identifiers)
- Confirm site and side of surgery
- Patient age, height, weight
- Mental competency to give consent
- Pending information/tests
- Special consideration
- DNR
- Religion
- Mental competency
Allergy and Medication History
Allergic Reactions
- Medication (When?), Manifestation (rash, wheeze, arrest) & Treatment (epi, steroids)
- Latex allergy
- Foods
Medications and Dosage
- Compliance (especially Cardiac meds, Inhalers, Steroids, Insulin)
- most recent dose/use
What are the most crucial medications to focus on during pre-anesthesia evaluation?
- Antihypertensives (especially *ACE inhibitors or Beta blockers)
- Anticoagulants
- Diabetes
- Chronic steroids
- Pain Medications
- Non prescription/Herbal
What is the focus with herbal medications?
- know the drug, dose, frequency
- when possible, as a rule of thumb, disscontinue herbal supplements 2-3 weeks prior to surgery
What are the risks of Garlic: Allium Sativum?
When do you hold it pre-operatively?
Potential to increase risk of bleeding, especially when combined with other medications that inhibit platelet aggregation
Hold at least 7 days prior to surgery
What are the risks of Ginkgo: duck foot tree, maidenhair tree, silver apricot?
When do you hold it pre-operatively?
Potential to increase risk of bleeding, especially when combined with other medications that inhibit platelet aggregation
Hold at least 36 hours prior to surgery
What are the risks of Ginseng?
When do you hold it pre-operatively?
- hypoglycemia
- potential to increase risk of bleeding
- potential to decrease anticoagulation effect of warfarin
- HOLD at least 7 days before surgery
What are the risks of Kava: intoxicating pepper?
When do you hold it pre-operatively?
- potential to increase sedative effect of anesthetics
- potential for addiction, tolerance, and withdrawal after abstinence (unstudied)
- HOLD at least 24 hours prior to surgery
What are the risks of St. John’s Wort?
When do you hold it pre-operatively?
- inhibition of neurotransmitter reuptake
- induction of cytochrome p450 enzymes which can affect cyclosporines, warfarin, steroids, protease inhibitors, and possibly benzodiazepines
- HOLD at least 5 days prior to surgery
What are some key components to review within a focused systems review for pre-op assessment?
(CV, Resp, Neuro, GI)
Cardiac: VS , angina, CHF , arrhythmias, current symptoms
Respiratory: assess for asthma, COPD, acute disease, obstructive sleep apnea
Neuro: deficits, seizure history, orientation, LOC
GI: hiatal hernia and reflux = Aspiration risk
What are some key components to review within a focused systems review for pre-op assessment?
(Endocrine, Hepatic, Renal, Psych, GYN, Airway)
Endocrine: diabetes, thyroid disease
Hepatic: h/o hepatitis, labs, coags, ETOH
Renal: BUN, Cr. Patient history of disease
Psych: anxiety, depression (use MAO inhibitors)
GYN: Pregnancy (institutional testing policies)
Airway: assess for intubation or other instrumentation or mask management
The cardiac assessment should determine ____.
1) preexisting cardiac diseases,
2) disease severity, stability and prior treatment,
3) comorbidities and
4) surgical procedure
What are some cardiac considerations pre-operatively?
Is the patient optimized if being treated?
If new onset, have evaluated prior to anesthesia.
If emergent, advise patient of risk, plan to minimize risk, possible invasive monitoring, TEE intraop.
Active Cardiac Conditions for which the patient should undergo evaluation and treatment before noncardiac surgery
- Unstable Coronary Syndromes (severe angina or MI within past 30 days)
- Decompensated Heart Failure (high grade AV block, symptomatic ventricular arrythmias, supraventricular arrythmias = rate >100bpm at rest, symptomatic bradycardia, newly recognized ventricular tachycardia)
- Severe Valvular Disease (severe aortic stenosis = mean gradient pressure > 40mmHg with an area < 1cm2 OR symptomatic)
- Clinical Risk Factors (hx ischemic MI, hx heart disease, hx cerebrovascular disease, insulin dependent diabetes, renal failure = serum creatinine > 2mg/dL)
What do we know about functional capacity?
Patient’s functional capacity, measured in metabolic equivalents, can be assessed preoperatively. Helps to inform us whether a patient will tolerate changes in their vital signs (during the case) safely.
Patients with good functional capacity (4 METS) may be determined by affirmative answers to:
1) Are you able to climb two flights of steps without stopping?
2) Are you able to walk four city blocks without stopping?
Patients with moderate to poor functional capacity should be assessed further to identify cardiac risk factors.
Exercise Tolerance for 1 MET
Reflects Poor Functional Capacity
(self care, eating, dressing, or using the toilet. Walking indoors and around the house. Walking one to two blocks on level ground at 2-3 mph)
Exercise Tolerance for 4 MET
Good functional capacity
(light housework, climbing a flight of stairs without stopping, or walking up a hill longer than 1 to 2 blocks, walking on ground level at 4mph or running a short distance)
Exercise Tolerance for 10 MET
Excellent functional capacity
Strenuous sports