preop assessment (1) Flashcards
1
Q
3 goals of pre op evaluation
A
1) ensure patient can safely tolerate anesthesia
2) mitigate periop risks ( does patient need optimization before surgery?)
3) clinical exam = H&P exam
2
Q
5 benefits of preop eval for patient
A
- reduce anxiety
- provide education (discuss options)
- discusses medications to stop before and meds for pain regimen
- reduces post-op morbidity
- Answers questions
3
Q
4 benefits of preop eval for anesthesia provider
A
- learn medical conditions of patient
- devise anesthetic plan intra-op and post-op
- schedule consults if needed
- discuss DNR
4
Q
3 benefits of preop eval for surgeon/hospital
A
- decrease cost of periop care
- improved efficiency
- decreases cancellations/delays
5
Q
How to calculate BMI in metric and imperial?
A
Metric –> kg/[m]^2
Imperial–> 703 x lbs / [in]^2
6
Q
underweight?
A
BMI < 18.5
7
Q
Normal BMI?
A
18.5-24.9
8
Q
Overweight BMI?
A
25-29.9
9
Q
Obese BMI?
A
> 30
10
Q
Ideal body weight calculation
A
men 50 + (0.91 × [height in centimeters − 152.4])
women 45.5 + (0.91 × [height in centimeters − 152.4])
11
Q
focused assessment 10 things
A
Baseline neuro exam
CV
Pulmonary
Airway
endocrine
hepatobiliary
renal
musculoskeletal disorder
immunocompromised
obesity
12
Q
Focused neuro
A
Baseline neuro exam
Ask about seizure/ CVA/ TIA
13
Q
Focused CV
A
CAD/MI/HTN/ CHF
14
Q
Focused pulmonary
A
Asthma/ COPD
15
Q
focused Airway
A
do airway assessment
ask about history of difficult intubation
Trach scars?
16
Q
Focused endocrine
A
Adrenal disorders
“mass on kidney” –> pheochromocytoma
diabetes
thyroid problems
17
Q
focused renal
A
Kidney problems?
18
Q
Focused Musculoskeletal
A
Musculoskeletal disorders requiring special positioning needs?
19
Q
focused Immunocompromised
A
Higher infection risk, do they need a special room
20
Q
Obesity
A
may require different dosage of drugs, positioning needs, etc
21
Q
Emergent Physical Examination Acronym
A
A= Allergies
M= Medications
P= Past medical history
L= Last meal eaten
E= events leading up to need for surgery / procedure
22
Q
Airway examination (6 things)
A
Mallampati classification
Inter-incisor gap
Thyromental distance
Forward movement of mandible
Range of cervical spine motion
Document loose or chipped teeth, tracheal deviation
23
Q
What type of complications account for almost half of the perioperative mortalities?
A
Cardiovascular
24
Q
Most significant respiratory event linked to anesthesia
A
Hypoxemia
25
What can decrease GFR?
Anesthetic agents and surgical stress
26
Renal impairment is called?
Acute kidney injury and chronic kidney injury
27
What can happen to the kindeys after getting contrast
Contrast induced nephropathy
28
Emphasis of preop evaluation for people with renal insufficiency?
CV system, cerebrovascular, fluid volume, electrolyte status and creatinine and BUN.
29
What kind of disorders have significant impact on drug metabolism/pharmacokinetics and clotting?
Hepatic disorders
30
What effects does advanced liver disease have on sedatives and opioids?
exaggerated effects in patients
31
Name 4 Hepatic disoeders mentioned in lecture
Hepatitis, alcoholic liver disease, obstructive jaundice, cirrhosis
32
How quickly can alcoholic withdrawal start?
within 12 hours of last drink.
33
what effects do seizure meds have on anesthetics?
burn through anesthetics faster
34
consideration for aneurysm and AV malformation
BP control
35
Parkinsons disease considerations?
try to avoid NMB's
36
Rhuematoid arthritis patients consideration when intubating
atlantoccipital joint may be instable
37
Salgo V. Leland Stanford Jr. Univeristy Board of Trustees
1957 court case that helped establish what the practice of informed consent should look like
38
What happened in the salg v leland stanford case?
Martin salgo claimed Dr. franklin gerbode did not inform him or his family of the details and risks associated with an aortagram that left his lower extremities paralyzed
39
Informed consent involves what?
Respect for patient autonomy and a dute to inform patient about risks and alternatives to treatment, procedures and consequences
40
Goals of shared decision making?
1) communicating with patients about risks and benefits of possible intervention
2) understanding pts goals, values, concerns
3) assisting patient in how to conceptualize risks and benefits / how to approach decision
41
3 different types of DNR/ Resuscitate order during periop?
1) full attempt at resuscitation
2) limited attempt at resuscitation defined with regard to specific procedures
3) limited attempt at resuscitation defined with regard to pts goals and values
42
LAR w/ regard to specific procedures?
Patient can refuse certain resuscitation procedures. Anesthesia should inform pt of which procedures are necessary for the surgery and anesthesia.
43
Limited attempt at resuscitation in regards to the pts goals and values?
allows the anesthesia team and surgical team to use clinical judgement in determining appropriate resuscitation procedures
44
Three levels of surgical risk percentages? (high, intermediate, low) Give examples
45
What is the scale called that estimates the risk of a cardiac event after surgery?
Revised Cardiac Risk Index
46
What are the components that give 1 point each on the Revised cardiac risk index?
What score correlates with what percentage?
47
How do we assess cardiopulmonary functional capacity? what does it mean?
METs (metabolic Equivalent of task), it estimates patient patient risk for morbidity/mortality.
48
What is the cut off score for METs?
Anyone with a score of 4 or less likely needs more testing before surgery, (if patient cannot climb more than one flight of stairs they score 4 or less. )
49
1 MET = ?
3.5 ml/kg/min
50
Emergency surgery?
Life or limb would be threatened if surgery did not occur within 6 hrs or less.
Patient doesnt need CV preop assessment, instead focus on surveillance like serial cardiac enzymes, ECG's, cardiac monitioring
51
Urgent surgery?
life or limb would be threatened if surgery did not proceed within 6-24 hours. Ex// appendicitis
52
Time Sensitive surgery?
Delays exceeding 1-6 weeks would significantly affect patient outcomes
53
What are the 6 steps in the preoperative cardiac risk index algorithm?
54
American Society of Anesthesiologist Patient Status operative risk components (5)?
This is how Anesthesia determines a patients risk
1) Patient's physical status
2) the planned surgical procedure
3) The ability and skill of surgeon
4) Attention to post op care
5)Past experience of anesthetist in similar situations
55
What are the 6 ASA PS grades and what do they mean?
56
Preop test should satisfy these criteria to be useful (4)?
1) Diagnostic efficacy... correctly identify abnormalities?
2) Diagnostic effectiveness… change the diagnosis?
3) Therapeutic efficacy… change the management of the pt?
4) Therapeutic effectiveness… change the pt’s outcome?
57
Who get CBC/ H&H ?
Surgery with potential blood loss, All major surgeries,
PS 3/4 -undergoing intermediate risk procedures,
patient with history of increased bleeding,
anticoag therapy,
hematologic disorders,
poor nutritional status
58
Renal Function Testing?
- DM, HTN, cardiac disease, dehydration (N/V, diarrhea), renal disease, fluid overload
- ASA-PS 3 or 4 undergoing intermediate-risk procedures
- ASA-PS 2, 3, or 4 undergoing major procedures
59
Electrolytes (CMP, BMP)
-Suspected undiagnosed or worsening condition that will affect peri-op management
-Renal or hepatic disease, malnutrition, malabsorption, ETOH abuse, HF, arrhythmias, medications that may cause an imbalance
60
Liver Function Testing
- Liver injury and physical exam findings
- Hepatitis, jaundice, cirrhosis, portal HTN, biliary disease, gallbladder disease, bleeding disorders
61
What sort of patients have liver injuries we may not be able to see any physical findings of?
Young alcoholics, or people on certain meds.
62
Coagulation Testing
-petechiae, bleeding gums, unexplained bruising
-Known or suspected coagulopathy identified on pre-op evaluation
-Known bleeding disorder, hepatic disease, and anticoagulant use
-ASA-PS 3 or 4; undergoing intermediate, major, or complex surgical procedures; known to take anticoagulant medications or chronic liver disease
63
Serum Glucose and Glycated Hemoglobin (HbA1c)
-Known DM (or family history), obesity (BMI > 50), cerebrovascular or intracranial disease, or steroids history
-All diabetic patients
64
Urinalysis
-Suspected UTI and unexplained fever or chills
-Don’t want to do ortho cases if people are infected because significantly increases risk for infection
65
Pregnancy Test
- Sexual activity, birth control use, and date of last menstrual period
- Recommendation… all women of childbearing potential of the possibility of pregnancy and women possibly pregnant made aware of the risks of anesthesia/surgery to the fetus
66
What drugs do we give that are VERY teratogenic?
Benzodiazepines and Nitrous Oxide
67
What can cause HCG to be positive?
Tumors
68
Two types of preg test?
HCg and Quantitative
69
ECG
- Ischemic heart disease, HTN, DM, HF, chest pain, palpitations, abnormal valvular murmurs, dyspnea on exertion, syncope, arrhythmia
- Known IHD, significant arrhythmia, PAD, CV disease, significant structural heart disease undergoing intermediate- risk or high-risk procedures
- Routine in ASA-PS 3 or 4 undergoing intermediate- risk
-Routine ASA-PS 2, 3, or 4 major/high-risk procedures
70
Chest Xray
- Based on abnormalities identified during pre-op evaluation
- Advanced COPD, bullous lung disease, pulmonary edema, pneumonia, mediastinal masses, suspicious physical exam findings (rales, tracheal deviation)
71
Laboratory studies!! Fishbones
72
Types of Anesthesia (4)
General
IV/ Monitored (MAC -Monitored anesthesia care)
Regional
Local
73
General anesthesia
Total loss of consciousness and airway control, LMA/ ETT
Used for major surgeries
74
IV/ Monitored Anesthesia Care
Level of sedation ranges… minimal (drowsy, able to talk) to deep (sleeping, may not remember surgery/procedure
NC or face mask
Ex: minor surgeries/procedures or shorter, less complex procedures… biopsy, colonoscopy
75
Regional Anesthesia
Pain management method that numbs a large part of the body using a local anesthetic
Epidural or spinal, Peripheral nerve block
Ex: childbirth or joint replacements in elderly pts
76
Local Anesthesia
Pain management method, usually a one-time injection of local anesthetic that numbs a small area of the body
Can be used with general or conscious sedation depending on the surgery and pt history
Ex: skin or breast biopsy, bone/joint repair
77
When planning for post op pain management what is and important baseline you need to get? And what should you discuss?
Baseline pain
Any tolerances to pain meds and realistic expectations of pain after surgery
78
What is the #1 NMB that causes allergic reactions?
Rocuronium
79
What is the most common category of meds anesthesia gives that causes allergic reactions?
Neuromuscular Blockers
80
What type of patients are typically allergic to Latex?
Spina bifida
81
In order what are the most common allergies?
Muscle relaxers, latex, Chlorohexidine, antibiotics, opioids
82
Latex allergy risk factors?
-History of multiple surgeries,
-Occupational exposure to latex
-Food allergies that cross-react (mango, kiwi, avocado, passion fruit, banana, and chestnuts)
83
Antibiotics
Cefazolin and PNC?
Vancomycin considerations?
Cephalosporins and PNC have 10-15% cross reactivity.
Vancomycin- is it red man syndrome or actual allergy?
84
What class is Lidocaine
Amides! Amides typically have two "i" in it
85
What are ester reactions usually due to?
the preservative PABA! (para-aminobenzoic acid)
86
Why do people say they are allergic to local anesthetics?
Usually due to epinephrine in the lidocaine, increases HR sometimes and they think its an allergy
87
What reversal drug has a high cross reactivity with morphine?
Neostigmine
88
continue or D/c HTN meds? Exceptions?
CONTINUE
Unless ACE/ARBS d/c 24 hrs prior
89
Cardiac meds? (ie: digoxin, beta blockers) What is special about Beta blocker?
CONTINUE
Core measure is if patient is on beta blocker to make sure they have taken it 24 hours prior to surgery
90
(C or D/c) Anti-depressants, anxiolytics, and other psychiatric medications?
CONTINUE
91
Consideration for tricyclic antidepressant?
Order ECG, chance of prolonged QTc
92
C or d/c thyroid meds?
Continue
93
C or D/C oral contraceptives?
exceptions?
Continue, unless high risk for Blood clots then d/c 4 weeks prior to surgery
94
C or D/c eye drops?
Continue
95
C or d/c GERD medications?
CONTINUE, don't want aspiration!
96
C or D/c Opioids?
Continue! Its hard to catch up with pain if they stop!
97
What reversal drug can effect oral contraceptives?
SUGAMMADEX
98
c or d/c Anticonvulsants? Considerations?
Continue, don't want them to seize! "They decrease the life span of the NMB's"
99
C or d/c asthma meds?
CONTINUE! Keeps their airway better managed
100
C or D/c Statins?
Continue
101
C or d/c ASA? Considerations?
Typically d/c in patients 10-14 days prior to surgery BUT if they have had PCI, ischemic heart disease or significant cv disease we may continue
102
C or D/c COX 2 inhibitor (celecoxib)? Exceptions?
Continue, unless....
Long term cox 2 inhibitor use can cause decreased bone/wound healing. So we d/c it about 2 weeks before surgery to give them a “free period” but we may still give it to them the day of the surgery.
103
C or D/c Monamine Oxidase inhibitors?
What meds can cause trouble with these and why?
May continue these.
Meperidine and ephedrine.
Meperidine may cause Serotonin syndrome/ seizures.
May not respond as well as they should to ephedrine.
104
C or D/C P2Y12 inhibitors?
Considerations?
(clopidogrel, ticagrelor, prasugrel, ticlopidine)
DISCONTINUE
- Clopidogrel, ticagrelor… d/c 5-7 days
- Prasugrel… d/c 7-10 days
- Ticlopidine… d/c 10 days
-Do not d/c in drug-eluting stents until 6 months of dual antiplatelet therapy is completed***
-Continue in pt for cataract sx w/ topical or general anesthesia***
105
C or D/c Topical medications?
D/C especially if they are patches! Don't want metal to be in them and then electrical current get sent through them
106
C or d/c diuretics?
D/C day of surgery unless its thiazide for BP management then continue it.
107
C or D/c sildenafil?
D/C if for ED 24 hours prior
Keep taking it for pulm HTN.
108
C or d/c NSAIDS
D/C 24 hrs prior to surgery
109
c or d/c warfarin?
Considerations?
D/c 5 days prior to surgery. Continue in pt for cataract sx w/ topical or general anesthesia***
110
c or d/c post menopausal hormone replacement therapy?
D/c 4 weeks prior
111
c or d/c Non insulin diabetic meds?
what med needs special consideration?
D/c day of surgery.
SGLT2 d/c 24 hours before
112
INSULIN considerations...
Short acting?
What about an insulin pump?
Type 1 considerations long acting?
Type 2 considerations long acting/ combo?
-Short acting d/c day of surgery.
-Leave basal rate insulin pump going
-type 1: take 1/3 dose of long acting insulin on morning of surgery
type 2: can take up to 1/2 normal dose of long acting or combo insulin day of surgery
113
WHy do we give stress dose steroids and what is the dosing regimen?
Exogenous steroids cause suppression of cortisol secretion at the HPA axis. So these patient's may have adrenal insufficiency and wont respond to drugs that increase BP.
We give 100 mg q 8 hr
114
What condition and steroid dosing may put someone at risk for HPA suppression?
HPA suppression with >20 mg prednisone/day >3 weeks and in pts with Cushingoid appearance
115
Echinacea peri op concerns?
Allergic reaction, DECREASE EFFECTIVENESS OF IMMUNOSUPPRESSANTS
116
Ephedra periop concerns?
MI/ Stroke from HTN, Tacchyarrhythmias,
Long term use may deplete catecholamines so less responsives to epi/norepi
interaction with MAOi's --> serotonin syndrome
117
Garlic periop concerns?
INHIBITS PLATELETS AGGREGATION
INCREASES FIBRINOLYSIS
118
Ginger periop concerns?
inhibits platelet aggregation
119
Gingko periop concerns?
Inhibits platelet activating factor
120
Ginseng periop concerns?
Lowers blood glucose, Inhibits platelet aggregation, may decrease anticoagulation effect of warfarin
121
Green tea
inhibits platelet aggregation
122
Kava
Sedation, anxiolysis... so you may need to increase anesthetics you are giving if this patient uses this supplement long term.
123
Saw palmetto
increase chances of bleeding b/c inhibits 5a- reductase and inhibits cycloxygenase
124
St johns wort
Induction of cytochrome P450 enzyme, warfarin, steroids, benzos, CCB, Can cause decreased digoxin serum levels, adn cause delayed emergence.
125
Valerian
Sedation, may increase sedative effects of anesthetics, if stopped can cause benzo like withdrawals, if used long term patient may have higher anesthetic requirements.
126
NPO status (hrs and what they can have)... bonus where do TF's fall?
127
What is mendelson's syndrome? and what are the paramaters?
Increased risk of aspiration. Associated with someone who has more than 25 ml gastric residual volume and stomach pH is <2.5
128
Treatments for mendelson's syndrome?
Aspiration prophylaxis
-Decrease gastric volume and acidity
-Non-particulate antacids (sodium citrate)… increase gastric pH
-Histamine-2 receptor antagonists (ranitidine, cimetidine, famotidine… increase gastric pH, decrease gastric acid secretion
-Proton pump inhibitors (omeprazole, pantoprazole)… increase gastric pH, decrease gastric acid secretion
-Dopamine-2 antagonist (metoclopramide)… reduces gastric volume
129
WHat are two PONV risk scoring systems?
What are the components of each?
130
PONV number of risk factor and associated percentage?
131
PONV scale
1 to 2 risk factor = ?
Treatment?
Moderate risk
Prevention with 2 to 3 drugs from different classes
132
PONV scale
3 to 4 risk factor = ?
Treatment?
Severe risk
- Consider avoiding GA or use a propofol-based anesthetic (TIVA total intravenous anesthetic)
- Minimize opioids
- Prevention with 3 drugs from different classes
133
Scopolamine patch
Class?
administration?
S/E?
-Premedication for surgery
-acetylcholine muscarinic antagonist
-Crosses blood-brain barrier
-TD patch can be applied night before surgery, lasts up to 72 hours
-S/E: sedation, dry mouth, blurry vision, confusion, mydriasis… can worsen narrow-angle glaucoma
134
Pregabalin
Class?
administration?
S/E?
– GABA analogue
-Effects on PONV unclear, reduces opioid requirement
-Administered pre-induction
-S/E: visual disturbances, resp depression
135
Ondansetron
Class?
admin?
S/E?
– serotonin antagonist
- Administer before conclusion of surgery
- S/E: blurred vision, headache, prolong QTc
136
Promethazine
Class?
admin?
S/E?
– histamine H1 antagonist
- Administer small doses
- S/E: sedation, dry mouth, blurred vision, prolong QTc
137
Dexmethasone
Class?
admin?
S/E?
- steroid
-Administer after induction
-May modulate release of endorphins or inhibit prostaglandin synthesis
-S/E: perineal irritation/burning, increased blood sugars
138
Antibiotic core measures?
Vanc and fluoroquinolone?
-all patient should have antibiotics 1 hr prior to SURGICAL INCISION
-Vanc and fluoroquinolone should be given 2 hrs prior to surgery
