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A1 > PreOp Assessment > Flashcards

PreOp Assessment Flashcards

1
Q

When does responsibility begin?

A

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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2
Q

When to evaluate patient medical history before planned surgery

A

One week prior

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3
Q

CV METS

A

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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4
Q

HTN patients

A

> 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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5
Q

Risk of MI
MI Guidelines

A

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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6
Q

LV dysfunction definition and
Risks

A

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

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7
Q

Valvular disease patients risks for surgery

A

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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8
Q

Significant arrhythmias

A

A fib
Ventricular arrhythmias

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9
Q

Pacer/ AICD rules for surgery

A

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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10
Q

Cardiac anesthetic management

A

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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11
Q

Pulmonary system risks and complications in surgery

A

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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12
Q

Predictors (surgery specifics) of pulmonary complications

A

Thoracic, aortic, upper abdominal, neck, and neurosurgery
Over 2 hour long surgery
Complications increase as surgical site approaches diaphragm

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13
Q

How does GA influence complications

A

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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14
Q

Biggest comorbidities influencing pulmonary complications

A

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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15
Q

CXR

A

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

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16
Q

GI patient risks and plan for surgery

A

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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17
Q

Primary concern with GI history patients

A

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

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18
Q

Increased aspiration risk conditions

A

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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19
Q

Mendelson syndrome

A

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

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20
Q

Endocrine patient risks of happening from or after surgery

A

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

21
Q

Rules of diabetes treatment

A

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

22
Q

Hyperthyroid rules

A

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

23
Q

Hypothyroidism rules

A

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

24
Q

Long term steroid users and rules

A

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

25
Q

Pheocromocytoma triad

A

diaphoresis, tachycardia, headache
high HCT over 45

26
Q

Renal, liver, muscle rules

A

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

27
Q

Smoking risks/ rules before surgery

A

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

28
Q

Alcohol effects on anesthesia

A

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

29
Q

Marijuana use

A

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

30
Q

Opioid use effect on anesthesia

A

May increase anesthetic requirements

31
Q

ASA physical status

A

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

32
Q

Assess for anesthesia history

A

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

33
Q

Most common allergies

A

Antibiotics anaphylaxis
Rocuronim
Propofol
Shellfish/ contrast dye and protamine

34
Q

BB use

A

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

35
Q

Herbs that affect bleeding

A

Garlic
Ginkgo Bilboa
Ginseng

36
Q

Goal HH before surgery

A

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

37
Q

Pre op labs

A

Coags for spinals and epidurals

38
Q

What must be asked before surgery

A

Name
DOB
Procedure
Allergies
Airway
NPO time

39
Q

NPO guidelines

A

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

40
Q

STOP BANG

A

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?

41
Q

7 evals of airway to be done every time

A

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

42
Q

MOANS

A

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

43
Q

Failure to obtain informed consent

A

Breach of duty
Battery
Unless emergent

44
Q

SOAPM

A

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

45
Q

Factors that influence anesthesia plan

A

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

46
Q

Types of anesthesia plan

A

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

47
Q

When to reduce or avoid benzos

A

Elderly
Intoxicated
Hypovolemic
Debilitated
Central apnea
Pulmonary disease
Valvular heart disease

48
Q

LEMON

A

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

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