PreAnesth Eval Flashcards
4 components of evaluation
Review of patient records / patient interview / focused medical exam / medical testing and eval
Characteristics of evaluation components
Patient interview: very important, assess awareness, MH, expectations etc / Physical Exam: not thorough, focused to card/pulm status. Medical testing: always f/u any abnormals, verifying conditions on H&P.
Timing of Important Tests
W/I 6 months - ECG, noninvasive tests, CXR W/I 1-3 months CBC W/I week coags, chemistries
Keys to Cardiac Eval
HTN controlled? / CAD=PVD=MI Hx (no sx if MI < 6 months / CHF/CM recent EF / Dysrhythmia/Pacer controlled HR, anticoag, syncope
Major Cardiac signs/symptoms
angina, claudication (=CAD), exercise tolerance (major!, 4-5 min goal/carrying groceries?), syncope, orthopnea/dyspnea (lay flat?)
ECG Testing pearls: Pt hx
ECG males= 40-45 yo, females= >50 yo / DM, HTN, obeses, CNS disease, smoker, pulm disease, family Hx, radiation therapy, High cholesterol / ECG w/i 30 days
ECG Testing pearls: Sx type
Resting ECG for any vascular sx / presence of risk factors (CHF, CAD, DM, CereVasc disease, renal insuff
What are considered active cardiac conditions?
Clinical Risk Factors?
unstable angina, recent MI, CHF active, significant arrhythmia, severe valvular disease // Hx ischemic heart, hx heart failure, Hx CVA, DM, renal insuff
Categories of Sx risk w/ CV problems
High: vascular surgery InterMed: intraperitoneal, intrathoracic, head/neck, ortho, prostate (invading cavities) Low: endoscopic, superficial, breast, ambulatory
CV system prep/planning per condition 1/2
HTN: cont meds, 180/110 or less, avoid ace-inh/ARB / CAD/angina: no HD extremes, no tachy, BB and ST seg monitor / CHF: poss invasive monitors, cont BB, MAPs 20% NL / PVD-BB rx (=CAD) / Dysrhythmia: consult for mgmt
CV system prep/planning per condition 2/2
Valve disease: specific to disease, fluid mgmt / CM: specific to type, fluid mgmt / pacemaker: avoid electrocautery, magnet around, poss get recent interrogation results
Pulm Conditions of interest
Asthma (degree, freq, hospital, PFTs) / COPD (PFTs) / OSA / Smoker (20+yrs = sig disease) / recent URI (at risk for complications / +PPD
Major Pulm signs/symptoms
exercise tolerance, dyspnea/orthopnea, cough/sputum production, wheezing
Pulm Testing
Asthma - PFT, peak flow / COPD - PFT, peak flow, CXR / OSA - sleep studies / smoking/infection - CXR
Pulm system prep/planning per condition
Asthma & COPD - bronchD, poss steroids / OSA - CPAP?, not ambu sx / smoker - cessation x8 wks / recent URI - delay sx, poss Abx
Pulm disease mgmt pearls
bronchospastic disease - give bronchoD priior to OR, think LMA, steroids of on already / OSA = CPAP in PACU / smokers - poss incr in mucous if recently stopped (2 weeks OK)
GI conditions of interest
GERD (clinically sig type), Obesity, Hepatic disease (ETOH, coag status, w/d?) / Malnutrition (poor healing/immune fxn, dehydration, low PRO effects) / ETOH abuse (varicies)
GI testing
Hepatic disease - LFTs, coags, albumin, CBC, glucose / Malnutrition - albumin, lymph, pre-alb / ETOH - combo of above / coags/alb more specific than LFTs
GI System prep/planning per condition
Obese - AW issues, aspiration prophy, IS post op / GERD - RSI, aspiration prophy / Hepatic - vit-k, FFP, glucose mgmt, variceal bleed, enzyme induced / ETOH - use benzos (8 hr since last drink)
Neuro Conditions of interest
Stroke/TIA/Carotid Disease (most important) / NM disease (MH risk), peri neuropathy (positioning), Sz (anesthetics lower threshold, PACU risk of sz, Rx enzyme inducing), arthritis, Connective tissue (SLE/scleroderma produce end organ disease)
Neuro Testing
Stroke/TIA req work up / Carotid disease (poss duplex ??)
Neuro System prep/planning per condition
Stroke - ? use of Succs with incr K risk, use nerve stim on NL side / TIA/Carotids - req strict BP mgmt / NM disease - avoid succs, MH trigger, close monitoring / arthritis/PeriNeuropathy - careful positioning
Renal/GU conditions of interest
Only renal failure/insuff and pregnancy
Renal/GU testing
CRF - caogs, cbc, CMP, UA, Cr clearance (best renal fxn test) / Prego - serum hcg (must watch for intraop hypotension/hypoxia, no benzos/N2O)
Renal/GU system prep/planning per condition
CRF - dialysis day before or day of sx, +/- transfusion or epo, consider DDAVP, careful mgmt of fluid/lytes / prego - cancel/delay sx, want 2nd trimester (1=organogenesis/3=risk PTL), no N2O, benzos, no hypotension/hypoxia
Endocrine conditions of interest
DM, Hypo/Hyper Thyroid (mostly hypothy, mild-mod has little clinical effects) / Adrenocortical insuff
Endocrine Condition Testing
DM - glucose (current mgmt), HbA1C for end organ assessment, lytes, renal / Thyroid/Adrenal - lytes
Endocrine system prep/panning per condition: DM
DM - glucose control, no hypoglycemia (reduced dosing), know current regimen, “prayer sign” = neck arthritis, gastroparesis = ANS dysfxn, type 1 at risk ketoacidosis/type 2 hyperosmolar risk
Endocrine system prep/panning per condition: Hypothyroid/hyperthyroid // adrenal insufficiency
hypo: Can hold levothyroxine, severe disease may need supplement, at risk for hypoglycemia/hypovent/hypothermia // hyper: risk for thyroid storm, hyperPTH=excess calcium
Endocrine system prep/panning per condition: adrenal disorder
d/t long term steroid use / cushing syndrome, need IVF (typical hypovolemic) and lytes (sodium loss) // pheo: unexplained HTN, HA, tachy & sweaty
Hematologic System testing
Anemia: CBC, coags, T&S, T&X / Coag Disorder: coag studies, T&S, T&X / Hgb Disorders: Sickle = h/h, T&S, T&X / Thaless = varies
Hematological system prep/panning per condition:
Anemia - transfusion, erythroPOT, iron / Coag - congenital replace specific Fx deficit, hold culprit meds, reverse as needed / HyperCoag - DVT prophy / SS anemia - avoid hypoxia, hypovolemia, hypothermia
Family Hx w/ Anesthesia
MH - halothane contracture test = avoid all triggers
Atypical PseudoChol - dibucaine test = avoid succs and ester metab Rxs (esmolol, local anes “esters”
PONV & Awareness
Medication History
ETOH = enzyme induced, incr/decr Rx and Anesthetic effect / BB = bradys, decr BP, depr SNS / Abx = prolong NMB / ACE-inh/ARBs = excess hypotension / Benzos/Narc = anesthetic tolerance / Diuretics = hypovolemia and lyte abnls (K) / MAOIs - no demeral/pressore –> HTN crisis, TCA - no pressors –> HTN crisis (SSRIs all OK)
Medication History
Herbals stopped x2 weeks / diuretics, anti-plates, anti-coag are held, hypoglycemic agents held/reduced / cont most others
Allergy History
Known allergies: latex, dyes, foods. Food allergy of avocado & banana = latex allergy. *allergy not = to intolerance. Nature of allergic reaction
Pre-Op Medicaitons/effects
anxiolysis/amnesia = versed / analgesia = fentanyl / increase gastric pH = ranitidine/famotidine, bicitra / decr gastric volume = metoclopramide / antisialogogue = glycopyrrolate
Components of Physical Exam
airway and denitition / vitals signs / weight / auscultate heart/lungs / skin jaundice/edema / spine for neuraxial block –> ASA physical status at end of eval
ASA status classification
Class 1 - healthy, no medical issues / Class 2 - mild systemic disease (all prego, chronic meds, no fxnl limits) / Class 3 - severe systemic disease, non incapacitating (DM w/ PVD, limiting Pulmo disease) Class 4 - severe systemic disease constant threat to life (acute CHF, unstable angina) / Class 5 - no life >24 hours / Class 6 - brain dead, harvest // add E to class for emergency surgery
Anesthetic Plan Goals
high pt satisfaction and safety, excellent operating conditions, rapid recovery, inexpensive, minimize post op effects
Types of Anesthetic Techniques
general, neuraxial, peripheral nerve block, local anesthesia + MAC
Determinants of Choice of technique
Party preference, co-existing disease, surgical site, intraop positioning, full stomach (regional)/fasted, condition of airway, elective vs emergency, clinical setting
Variations w/i each technique: General
General: IV vs inhalation, induction routine vs rapid sequence, choice of specific agents // AW mgmt, ETT vs LMA vs Mask, balanced vs single agent, muscle relaxants depends on surgical field
Variations w/i each technique: Neuraxial & Peripheral block
SAB vs CLE: SAB simpler to perform, rapid onset, reliably dense, great for sacral // CLE less dramatic HD effects, can re-dose intraop and postop // localized effect for sicker patient, but req coop patient, technically more diff, risk of IV injection
