PreOp Assessment Flashcards by Jacob Martinez

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

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When to evaluate patient medical history before planned surgery

One week prior

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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

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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

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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%

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LV dysfunction definition and
Risks

> morbidity
EF less than 50%
EF <35% = greater incidence of post op heart failure and death

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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

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Significant arrhythmias

A fib
Ventricular arrhythmias

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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

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Cardiac anesthetic management

Avoid extremes of HR and BP
If severe cardiac disease- a line and second IV
Add TEE or swan if needed

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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

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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

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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

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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

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CXR

Presence of active chest disease
Planned intrathoracic procedure
Age 60 or above

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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

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Primary concern with GI history patients

Aspiration, manage RSI with cricoid pressure (Sellick Maneuver) though controversial

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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

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Mendelson syndrome

Aspiration penumonia
aspirate gastric volume >25ml
PH <2.5
Particulate aspirate. clear aspirate

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Endocrine patient risks of happening from or after surgery

(T2D- 90-95%)
Increased risk of CAD, HTN, CHF, MI, Renal failure, Gastroparesis, difficult airway, autonomic neuropathy

Rules of diabetes treatment

Hold oral medication morning of surgery but metformin is 48hr before surgery
Take 1/2 insulin dose
Check BG on arrive
For total joints- always check BG regardless of diabetic

Hyperthyroid rules

Pre op goals- Eurthyroid state- anti thyroid meds 6-8weeks followed by iodine for 1-2 weeks
Consider intraoperative use of beta blockers to reduce peripheral conversion of T4 to T3 and controls sympathetic system

Hypothyroidism rules

No current recommendations to delay surgery
Treatment is T4 and IV fluids/ electrolytes

Long term steroid users and rules

Cushings disease and Addison disease
May need stress dose steroid for procedure

Pheocromocytoma triad

diaphoresis, tachycardia, headache high HCT over 45

Renal, liver, muscle rules

1- no benzo in renal patients 2- expect altered medication metabolism in liver patients 3- muscoskeletal patients might increase risk for MH

Smoking risks/ rules before surgery

Significant pulmonary complications that can be significantly reduced if patient doesnt smoke for 12-48 hours prior, even better if 8 weeks Smoking lowers PONV risk but increased aspiration risk Smoking increases HR and myocardial O2 demand More reactive airways and more secretions similar to asthmatics

Alcohol effects on anesthesia

Acute lowers anesthetic requirements, hypothermia, hypoglycemia Chronic increases anesthetic requirements, htn, tremors, delirium, seizures

Marijuana use

Consider delaying surgery if acute consumption Preop use may lead to tolerance to Sevo More likely to report postoperative pain scores

Opioid use effect on anesthesia

May increase anesthetic requirements

ASA physical status

1- Normal healthy 2- Mild systemic disease 3- Severe systemic disease 4- Severe systemic disease that is a constant threat to life 5- Morbidund patient who is not expected to survive without this operation 6- Declared brain dead patient whose organs are being removed

Assess for anesthesia history

Has anyone in your family experiences unusual or serious reaction to anesthesia? Might be familial Atypical pseudocholinesterase- post op vent support is needed until succ metabolizes PONV or difficult intubation

Most common allergies

Antibiotics anaphylaxis Rocuronim Propofol Shellfish/ contrast dye and protamine

BB use

Continue scheduled BBs Helps reduce operative ischemia Esmolol oftenly used fast on fast off Metoprolol and labetalol

Herbs that affect bleeding

Garlic Ginkgo Bilboa Ginseng

Goal HH before surgery

HCT- 25-35% HGB- 7g/dl only if patient without systemic disease

Pre op labs

Coags for spinals and epidurals

What must be asked before surgery

Name DOB Procedure Allergies Airway NPO time

NPO guidelines

Clear liquids- 2h Breast milk- 4h Formula or cow milk- 6h Light meal- 6h Fried food, meat- 8h

STOP BANG

Assessment of OSA Low- 0-2 Medium 3-4 High- 5-8 or 2/4 of STOP+male Snore loudly? Tired during the day? Observed you not breathing at night? Pressure high (Blood)? BMI over 35? Age over 50? Neck size over 17 male or 16 female? Gender male?

7 evals of airway to be done every time

Oral opening- difficult if <3cm Mallampati 1-4 Thyromental distance atleast 6cm Altano-occipital extension >35degrees Horizontal mindibular length at least 9cm

MOANS

Assessment for difficult mask ventilation Mask seal beards will alter Obesity/ pregnancy/ angioedema Age over 55 No teeth Sleep apnea or ards/ copd/ asthma

LEMON

Assessment for difficult laryngoscopy and intubation Look externally at mouth area Evaluate 332 rule Mallampati score Obstruction/Obesity- stridor, muffed voice, difficulty swallowing, Neck mobility

Failure to obtain informed consent

Breach of duty Battery Unless emergent

SOAPM

Required for CRNAs Suction Oxygen Airway Positive pressure ventilation and pharmacy Monitors and medications

Factors that influence anesthesia plan

Pt preference Body position for surgery Coexisting disease Duration of surgery Suspected difficult airway Suspected gastric content

Types of anesthesia plan

General- inhalation, TIVA, combo, no ability for pt to protect airway Regional- spinal, epidural, nerve blocks MAC- Pt should maintain airway reflexes, sedation could push into GA

When to reduce or avoid benzos

Elderly Intoxicated Hypovolemic Debilitated Central apnea Pulmonary disease Valvular heart disease