PreOp Assessment Flashcards
When does responsibility begin?
At pre anesthetic assessment
Except in emergencies, CRNA must complete thorough evaluation and determine that relevant tests have been obtained and reviewed
When to evaluate patient medical history before planned surgery
One week prior
CV METS
How much exertion a patient can tolerate
You want at least 4 METS- climbs a flight of stairs
“Can you walk up a flight of stairs without getting SOB?”
1- watching TV
10- playing strenuous sports
HTN patients
> 140 over >90
If associated with LVH greater risk for MI/CVA
Tend to drop pressure more than normal with induction
Maintain 20% of pt baseline
Risk of MI
MI Guidelines
AHA recommends waiting at least 60 days after an MI for elective surgery
Highest risk is within 30 days- 33%
1-2 months- 19%
<3 months- 30%
3-6months- 15%
Known MI in past- 6%
Overall population- 0.3%
LV dysfunction definition and
Risks
> morbidity
EF less than 50%
EF <35% = greater incidence of post op heart failure and death
Valvular disease patients risks for surgery
Aortic stenosis-greatest risk for non cardiac urgery MI
Angina- 5 years
Syncope- 2 years
CHF-1 year
Associated with 14x increased in periooperative sudden death
If symptoms are severe elective surgery should be delayed until after cardiac surgery
Significant arrhythmias
A fib
Ventricular arrhythmias
Pacer/ AICD rules for surgery
Interrogate device before and after surgery
Electrocautery can be misread as arrhythmias so we often turn sensing functions off, and put them in demand mode for surgery
Have magnet in room- will activate the demand mode of pacer and shut off sensing
Pacers can mask ischemia symptoms
Cardiac anesthetic management
Avoid extremes of HR and BP
If severe cardiac disease- a line and second IV
Add TEE or swan if needed
Pulmonary system risks and complications in surgery
Major cause of morbidity and mortality related to anesthesia and surgery
Incidence 5-10% of af major, non cardiac surgeries
Complications- atelectasis, pneumonia, aspiration pneumonia, bronochospams, respiratory failure requiring mechincal ventilation, hypoxemia, COPD exacerbation
Predictors (surgery specifics) of pulmonary complications
Thoracic, aortic, upper abdominal, neck, and neurosurgery
Over 2 hour long surgery
Complications increase as surgical site approaches diaphragm
How does GA influence complications
Leads to VQ mismatches
Deadspace ventilation
Decreases FRC
Inhibition of mucociliary clearance
increased alveolar capillary permeability
inhibition of surfactant release- atelectasis
Blunted ventilatory response to hypoxia and hypercarbia
Biggest comorbidities influencing pulmonary complications
Asthma- assess how frequently they use inhaler, how effective it is, if they have been hospitalized big red flag! Have pt take hit prior to heading back, use IV steroids, may bronchospasm
Smoking
OSA- more difficult to mask ventilate, oropharyngeal collapses when they sleep, bring CPAP for post op, decrease narcotic use, NO DEEP EXTUBATIONS, regional preferred
URI
CXR
Presence of active chest disease
Planned intrathoracic procedure
Age 60 or above
GI patient risks and plan for surgery
SBO- high risk for aspiration/ RSI
Electrolyte abnormalities
GERD
Suction stomach proir to induction
If had previous gastric bypass- dont place NG/OG, suture can be disrupted
Primary concern with GI history patients
Aspiration, manage RSI with cricoid pressure (Sellick Maneuver) though controversial
Increased aspiration risk conditions
Age extremes <1 or >70
anxiety/ depression
ascites or pregnancy
esophageal injury, hiatal hernia, ulcers,
medications like opioids
head injury
pain
failed intubation history
Mendelson syndrome
Aspiration penumonia
aspirate gastric volume >25ml
PH <2.5
Particulate aspirate. clear aspirate