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
What is the Revised Cardiac Index?
Offers a predictive risk index for major postoperative complications.
- 0 Risks = 0.4% 1 Risk Factor = 0.9%
- 2 Risks = 7% 3 or more Risk Factors = 11%
Risk Factors Include:
- High-risk surgery (aortic, major vascular, peripheral vascular)
- Ischemic heart disease
- Hx CHF
- Hx cerebrovascular disease
- Diabetes Mellitus (with or without pre-op insulin)
- Renal Disease (Creatinine > 2 mg/dL)
What is The New York Heart Association classification tool?
Can be used to categorize the degree of cardiovascular disability. During the preoperative assessment, the anesthesia professional should ask about the presence of fatigue, chest pain, syncope and factors that predispose to angina.
Class I- IV (I = no limitations IV = severe limitations)
For patients ago 30-59, what is considered hypertension?
BP 130/80 mmHg
For patients ago 60 and older, what is considered hypertension?
BP of 140/90 mmHg
Potential risks of hypertension
- Coronary artery disease
- Increased periop mortality
What would be considered stage 3 hypertension?
- Systolic pressure greater than 180 mm Hg
- Diastolic pressure greater than 110 mm Hg
What should we do as anesthesia providers for patients with stage 3 hypertension?
(elective vs. emergent cases)
If elective, postpone and refer for management
If Emergent procedure
- Manage blood pressure, consider arterial line, monitor for periop cardiac ischemia
- Refer postop for management
General Facts about Coronary Stents
- Over half a million coronary stents are placed in the US every year
- Approximately 5% of these patients will require noncardiac surgery within 1 year after placements of coronary stents
- There is an increased risk for stent thrombosis, perioperative MI, hemorrhagic complications and death in patients having noncardiac surgery performed early after stent placements
For patients with bare metal stent, how long should you wait to perform an elective surgery after implanation?
30 days
For patients with a drug-eluting stent, how long should you wait to perform an elective surgery after implanation?
3-6 months
Ideally, > 6 months
What is essential information that must be communicated to the perioperative team by the cardiac implantable electronic device team?
- date of last interrogration (should be within 6 months if ICD and 12 mos if pacemaker)
- device type, manufacturer and model
- indication for device placement
- battery longevity
- any leads placed within the last 3 months
- current programming
- is the pt pacemaker dependent?
- device response to magnet placement
- any alert status on device
- last pacing threshold
- individualized perioperative recommendations
Which patients are at greater risk for postoperative pulmonary complications?
Patients with COPD, emphysema and asthma
Which respiratory symtpoms would warrant postponing of surgery?
- Severe dyspnea, wheezing
- Pulmonary congestion
- PaCO2 greater than 50 MM HG
Once you know the patient has asthma, what are some helpful Qs to ask.
What causes their asthma?
What inhaler(s) they use?
What helps to mitigate their asthma attacks?
Do they take inhaled steroids or albuterol? (This may clue you in to incorporate that into their pre-op meds)
Questions to ask once you are aware that a patient has obstructive sleep apnea
Do they have diagnosed sleep apnea?
Do they use positive airway pressure (PAP) device at night?
Do they use their unit?
If so, bring to facility especially if inpatient
Does their family know how to use the PAP unit?
Children with URIs (upper resp tract infections) have an increased risk for ______.
respiratory-related adverse events during the perioperative period
- Signs and symptoms of URIs include sore throat, sneezing, nasal congestion, cough, fever and laryngitis
- The decision to operate depends on the urgency, duration and complexity of the surgery, and the need for instrumentation of the airway
Preoperative evaluation of the neurologic system includes ____.
What is important to document?
the CNS and peripheral nervous system
- Document baseline neurologic assessment (eg muscle weakness, neuropathy, mental status) as this will be important to communicate to the PACU team
- Consider risk for postoperative delirium
- A thoughtful neurologic assessment will also help inform whether the patient may tolerate a MAC anesthetic
What important questions should we be asking about a GI pre-op anesthesia assessment?
- Is my patient at risk for aspiration?
* the presence of nausea and vomiting, abdominal distention, dysphagia, gastroparesis or degree of reflux - Is my patient hypovolemic?
* The presence of diarrhea, GI bleeding or bowel prep
What neurologic components may lead us away from a MAC anesthetic?
Tremors, confusion, they don’t respond well to verbal commands, or if they’re extremely anxious (they may not be down for less anesthetic)
What Qs can we ask to determine the severity of GERD?
- How often do you experience GERD?
- What causes your GERD?
- How is it managed?
- How many pillows do you use under your head to sleep?
- Do you wake up in the middle of the night with acid in the back of your throat?
How will the answers to the GERD Qs impact our anesthesia plan?
Based on the severity of GERD, the anesthesia professional may give little anesthesia, secure the airway with an ETT using a rapid sequence intubation and emerge the patient more awake.
It’s all about aspiration risk.
Patient has a full stomach the day of surgery. What next?
If elective surgery, delay procedure until npo guidelines are met
If elective surgery and the patient may have a full stomach because of GI disease (eg obstruction, gastroparesis), consider placing an awake NG
If emergent surgery, perform an RSI and place and consider an asleep OG/NG
•Assessing the antrum of the stomach with ultrasound imaging may offer objective information on the amount and type of particulate within the stomach
What are the general NPO guidelines?
Examples of clears
- Clear liquids- 2 hours prior to surgery
- Breast milk- 4 hours
- Infant formula- 6 hours
- Non-human milk- 8 hours
- Solids- 8 hours
Clears = water, gatorade, clear juices without pulp, carbonated beverages, and tea/coffee with no cream
Preoperative evaluation of the hepatic system includes _____.
screening of acute or chronic liver disease such as hepatitis or cirrhosis such as jaundice, ascites, esophageal varices
Based on the presence and severity of hepatic disease, the anesthesia professional may adjust the anesthesia plan to optimize hepatic blood flow and avoid certain pharmacologic agents
What is ALT?
Normal range?
ALT is an enzyme found in the liver that helps convert proteins into energy for the liver cells. When the liver is damaged, ALT is released into the bloodstream and levels increase.
Normal = 7 to 55 units per liter (U/L)
What is AST?
Normal range?
AST is an enzyme that helps metabolize amino acids. Like ALT, AST is normally present in blood at low levels. An increase in AST levels may indicate liver damage, disease or muscle damage
Normal = 8 to 48 U/L
What is ALP?
Normal range?
ALP is an enzyme found in the liver and bone and is important for breaking down proteins. Higher-than-normal levels of ALP may indicate liver damage or disease, such as a blocked bile duct, or certain bone diseases.
Normal = 40 to 129 U/L
What is Albumin?
Normal range?
Albumin is one of several proteins made in the liver. Your body needs these proteins to fight infections and to perform other functions. Lower-than-normal levels of albumin and total protein may indicate liver damage or disease.
Normal = 3.5 to 5.0 grams per deciliter (g/dL)
What is Bilirubin?
Normal range?
Bilirubin is a substance produced during the normal breakdown of red blood cells. Bilirubin passes through the liver and is excreted in stool. Elevated levels of bilirubin (jaundice) might indicate liver damage or disease or certain types of anemia.
Normal = 0.1 to 1.2 milligrams per deciliter (mg/dL)
Evaluation of the kidneys and urinary tract includes
inquiries about the patient’s volume status and kidney status
•Based on the presence and severity of renal disease, the anesthesia professional may adjust the anesthesia plan to optimize renal blood flow, fluid status and avoid certain pharmacologic agents
Follow up information to find out if a patient is HD dependent
where is their fistula, what is their normal dialysis schedule is, when was their most recent dialysis, how much fluid was removed and what was their post dialysis serum potassium levels
Normal Urea Nitrogen
5-25 mg/dL
Normal Creatinine
0.5-1.5 mg/dL
Normal sodium level
133-147 mmol/L
Normal potassium level
3.2-5.2 mmol/L
Normal chloride level
94-110 mmol/L
Normal CO2 level
22-32 mmol/L
Normal uric acid level
2.5-7.5 mg/dL
Normal Calcium level
8.5-10.5 mg/dl
Normal Phosphorous level
2.2-4.2 mg/dl
General Rules of Thumb for surgical pts with diabetes
Schedule early in the day (Contact provider managing diabetes for orders, oral hypoglycemic, insulin, insulin pump management)
•fasting BS on admission (Maintain Less than 180 mg/dL & AVOID HYPOGLYCEMIA)
If pt RECEIVING INSULIN….
- IV WITH 5% DEXTROSE ON PUMP
Peri-operative guidelines for hyperthyroidism
- Continue antithyroid medications and beta blockers perioperatively
- If patient is scheduled for elective surgery and not euthyroid, consider canceling and the case and get an endocrine consult
- Increase risk for mortality in the setting of thyroid storm
Peri-operative guidelines for hypothyroidism
- Continue synthroid perioperatively
- Increase risk for mortality in the setting of myxedema coma
Goiters can present what issues anesthetically?
airway compromise, stridor, positional dyspnea, dysphagia, altered voice
Items we are looking for with smoking/drinking history
Smoking
- Packs per day/how many years
- Quitting date ( > 8 weeks improved outcomes)
- Chronic symptoms
ETOH
- History
- Drinks per week/day
- h/o DT’s
Patient instructions for smoking pre-operatively
Stop smoking at least 12-48 hours or 4 weeks
Less than 12 hour abstinence Reduces effects of nicotine & carbon monoxide
- Reduce HR, BP
- Circulating catecholamine levels
- Carboxyhemoglobin normal
Illicit drug use signs
IV use
- Track marks, phlebitis, lymphadenopathy
Pupil changes
- Constricted: Opioids
- Dilated: Amphetamines
- Nystagmus: Phencyclidines (PCP)
S&S of acute cannabis use
- tachycardia, labile BPs, HA
- euphoria, dysphoria, panic reaction, depression
- poor memory and decreased motivation associated with chronic use
S&S of acute Cocaine/Amphetamines use
- tachycardia, labile BP, HTN, arrythmias
- excitement, delirium, hallucinations
- euphoria
- hyperreflexia, tremors, convulsions
S&S of acute use of hallucinogens: LSD, PCP
- weak analgesic effects
- altered perception and judgment, may progress to toxic phycosis
- PCP produces dissociative anesthesia
S&S of acute opioid use
- resp depression, hypotension, bradycardia, constipation
- euphoria (heroin)
- pinpoint pupils with overdose, decreased LOC
Facts about Medication assisted treatment (MAT)
- Methadone and buprenorphine address opioid use
- Disulfiram and Acamprosate are used for alcohol use
- naltrexone can be for both alcohol and opioids
- Do not taper, discontinue or abruptly change MAT regimen perioperatively
- Collaborate with addiction professional or MAT prescriber
- May require addition of a rescue opioid at a higher dose
Components of an anesthesia history
- Postoperative nausea & vomiting
- Elevated temperature post operatively, self or relative
- Difficult airway
- Emergence delirium, post op delirium
- Anaphylaxis, cardiopulmonary collapse
- Post op weakness, intubation (atypical plasma cholinesterase)
- Recall may be brought up
What are some indications that a patient should have a chest radiograph pre-operatively?
- previous abnormal chest imaging
- malignancy in which a lung met may alter the surgery
- history of positive TB test
- history of pulmonary infection
- suspected intrathoracic tumors
- congenital heart disease
- history of prematurity with residual bronchopulmonary dysplagia
- severe OSA
- down syndrome (c/f subluxation of the atlantoaxial juntion)
- symptomatic or debilitating asthma
What are some indications that a patient should have an electrocardiogram pre-operatively?
- pts at risk for cardiac disease
- history of previously unevaluated pathologic-sounding murmur or palpitation
- family history reveals possibility of inherited prolonged QT syndrome
- history of morbid obesity, moderate to severe OSA, or chronic anatomic airway obstruction because they may be at risk for right sided heart strain
ASA score is looking at ____
physical status
ranges from ASA I to ASA V
ASA I definition and example
normal healthy patient
“healthy non smoking, non drinking individual”
ASA II definition and example
A patient with mild systemic disease WITHOUT substantial functional limitations
“current smoker, social drinker, pregnancy, obesity, well-controlled DM/HTN, or mild lung disease”
ASA III definition and example
A patient with severe systemic disease and substantial functional limitation; one or more moderate to severe diseases
“poorly controlled diabetes/HTN, COPD, morbid obesity (BMI >40), active hepatitis, alcohol dependence, implanted pacemaker, moderate reduction of EF, ESRD undergoind regular scheduled dialysis”
ASA IV definition and example
a patient with severe systemic disease that is a constant threat to life
Recent MI < 3mos ago, CVA, TIA, CAD/stents, ongoing cardiac ischemia, severe reduction in EF, shock, sepsis, DIC, ARDS, ESRD not going to HD regularly
ASA V definition
A moribund patient who is not expected to survive without the operation
Ex. ruptured abdominal aneurysm, massive trauma, intracranial bleed
ASA VI
brain-dead
Discussing the anesthesia plan with the patient
- CMS Requirement
- Type of Anesthesia (general, regional, monitored Anesthesia Care)
- Special Monitoring (CVP, TEE): requires consent
- Transfusion: requires consent
- Pre op instructions
- If more than one option is presented to be decided on day of surgery, document that
- Alternative options explained to patient—ex. MAC with GA back up, labor epidural analgesia/C-section anesthesia
Informed Consent and documentation
- Confirm patient identity and knowledge
- Plan for type of anesthesia, with possible alternatives
- Name surgery and site (varies)
- Risks delineated
- Answer all Questions for patient and family
- Clearly sign legal name. Print it if illegible
- Your legal professional name is the one on your RN license
- Document your credential. SRNA or RN *MUST BE co-signed (cms)
- Date and time note is written. Day of surgery.
- Document any lab value or test pending to make the patient ready for surgery.
- Assessment reviewed on day of surgery, Plan reviewed with patient, any questions are answered
Pediatric patient pre-op plan
- Can refuse but cannot legally consent
- Explanations should include child as developmentally appropriate
- Parent or legal guardian for under 18, except emancipated minor
- Separation anxiety, consider parent presence for induction
Different surgical options for DNR
Full Attempt at Resuscitation
Limited Attempt at resuscitation defined about Specific Procedures (chest compressions, defibrillation, intubation)
Limited Attempt at resuscitation defined about the Patient’s Goals and Values: The surgical procedural team uses clinical judgement
