Preop Assessment Flashcards
What are some regulatory requirements for preop assessment?
- AAANA standard of care
- American Society of Anesthesiologies- mandated
- JCAHO
- Center for medicaid and medicare- reimbursement
What are some goals of preoperative evaluation?
- reduce patient risk and morbidity associated with surgery and anesthesia
- prepare patient medically and psychologically
- promote efficiency
- reduce costs
What are some compoenents of preop evaluation?
- Pt medical hx (chart review and history taking)
- physical exam
- meds/allergies
- lab testing/dx testing
- medical consultation (if indicated)
- ASA-Physical status assignment
- NPO status
- formulation of anesthetic plan
- discussion of plan
- informed consent
- documentation
Where are preop evals/assessments conducted?
- presurgical testing centers - “wave of futre”
- hospitals
- or settings
- critical care unit
- specialty department
- OP center
What is the optimal situation for a preop clinic visit?
- 1 week preop
- patient interview
- physical exam
- develop anesthetic plan
- promote patient teaching and anxiety reducton
- allows time to schedule appointments with medicla consultants and complete required preop dx testing
- obtain informed consent prior to operative day
What typs of conditions wouild require an early preop assessment?
- angina, CHF, MI, CAD, poorly controlled HTN
- COPD/severe asthma, airway abnormalities, home O2 or ventilation
- IDDM, adrenal dx, active thyroid disease
- liver disease, ESRD
- Morbid obesity, symptomatic gerd
- severe kyphosis, SCI
What should be the basis of the preoperative interview?
- Introduction- title (SRNA, CRNA) role
- Confirmation- pt ID, dx, procedure (surgical site)
- Education- type of anesthetic, IV insertion, urinary cath, airway instrumentation, monitors, postop care
- Establish- trusting relationship
What should be discussed regarding history and medications in preop interview?
- History
- ROS
- CNS
- Cardiac
- ENT
- Pulm
- Vascular/HTN
- Endocrine
- GI/hepatic
- Renal
- Hematologic
- ROS
- Medications
- allergies
- prescription meds
- DC’ed
- taken this AM
- OTC (ASA, NSAIDS, herbals)
What should be discussed in past surgical history?
- Complications
- family history complications
- obstetrical deliveries
What other areas should be discussed in preop interview?
- ETOH use
- Drug abuse
- tobacco use
- female- LMP
- pain
- NPO status
- height/weight
What should be examined during the physical exam?
- General impression, mental status
- airway- regardless of plan!
- heart
- lungs
- CNS/PNS
- VS
- Height weight
What are mallampati classifciations?
- Class I
- soft palate, fauces, entire uvula, pillars
- Class II
- soft palate, fauces, portion of uvula
- Class III
- Soft palate, base of uvula
- Class IV
- Hard palate only
What are some indicators of a potential difficult airway from physical exam?
- long upper incisors
- thyromental distance
- 2-3 fingers or 6 cm.
- if >9 cm- hard to align glottic opening
- interincisor distance
- 3 cm, 2 fingers
- atlanto-occipital function
- 35 degree extension
- problematic if <23 degree
- mandibular protrustion test
- hyomental distance (mandibulohyoid)
- 2 finger breaths
- neck circumference
- male 15-16”
- women 13-14 “
- if >17 “, or 40 cm, 5% chance difficult airway
Indicators of difficult mask ventilation?
- Age >55 years
- OSA or snoring
- previous head/neck radiation, sx, trauma
- lack of teeth
- a beard
- BMI >26
What are indicators of difficult DL?
- Report of difficult intubation, aspiration PNA after intubation, dental or oral truma
- OSA or snoring
- previous head/neck radiation, surgery or trauma
- congenital disease: down syndrome, treacher collins, pierre robin syndrome
- inflammatory/arthritic disease, RA, ankylosing spondylitis, scleroderma
- obesity, cervical spine dx or previous sx
What is the prayer sign?
ask patient to bring hands together in front of chest. if knuckles don’t lie flat, indication that they’ve had some collagen deposits and may have problems with neck extension as well
seen in diabetics
Cardiac assessment on physical exam?
- Heart auscultation
- Rate
- Rhythm
- Murmurs
- Bruits (carotid)
- extremity pulses
- CV
- bruits
- extremity pulses
- extremity edema
Lung physical exam?
Inspection
Auscultation
Percussion
Palpation
What are you observing for on physical exam for neuro/MS system?
- Extent of neuro exam depends on baseline deficits, disease, or sx procedure
- Motor- gait, grip strength, ROM, ability to hold arms forward
- Sensory- distinction of vibration, pain light touch along dermatomes
- Muscle reflex- deep, superficila and pathologic
- Cranial nerve abnormalities
- mental status
- speech
What would show end target organ damage on ROS, Physical exam, CXR/EKG, labs?
- ROS- Heart attack, angina, stroke
- PE- carotid bruit, eye damage
- CXR/EKG- cardiomegaly, wide QRS, left axid deviation, inverted T waves
- Labs: elevated BUN/CR, decrease GFR, protein in urine
What is rule for choosing what preoperative testing is needed??
2012 ASA practice advisory for preanesthesia eval states that routine preop tests do not make an important contribution to preanesthetic eval of asymptomatic patient
Preop testing should be selevtively ordered based on:
- patient medical hx and physicla exam
- planned sx
- expected introp blood loss
What does selective preop testing accomplish?
expedites patient care
reduces healthare cost
improves delivery of periop meds
What is sensitivity?
sensitive test is very good at identifying those who have hte disease; true positive
A sensitive test with negative result rules out a disease (SnNOUT)
What is specificity
specific test is good at identifying those without the disease; true negative
A speicifc test with a positive result usually rules in disease–> SpPIN
What determines a minimal invasive sx?
little tissue trauma, minimal blood loss (<500mL)
(ie skin lesion)
What is a moderately invasive surgery?
modest disruption of normla physio
anticipate some blood loss (500-1500 mL)
may need invasive monitors and/or ICU
(ie- inquinal hernia, tonsillectomy, knee arthro)
What is a highly invasive sx?
vascular sx, TURP, TJR, radical neck dissection
signficiant disruption of normal physio
blood loss >1500 mL
commonly require transfusion and ICU care
When might you get a CXR before sx?
- assessment of periop risk- questionable
- should not be ordered routinely
- Decision: based on abnormalities id’ed during preop (ie rales, SOB, intercostal retractions, deviated trachea)
- Indication: severe COPD, suspected pulmonary edema, PNA, susp mediastinal massess or PE
When should you get a CXR on smokers?
20 pack years or more
pack year= ppd * years smoking
What are the recommendations for obtaining a 12-lead EKG?
- Class II A- resonable to perform procedure for patients with IHD, sig arrhythmia, PAD, CVD, structural heart disease
- Class IIB- Procedure may be considered for asymptomatic patient without known coronary heart dx, except those undergoing low risk sx procedures
- Class III- Procedure should not be performed because it is not helpful for asymptomatic patients undergoing low risk surgical procedures
What are guidliens for NPO status?
Clear liquids
Breast milk?
Formula or solids (light meal)?
Heavy meal with fried or fatty food?
- Clear liquids- 2 hours
- Breast milk- 4 hours
- formula or solids- 6 hours
- heavy meal- 8 hours
What disorders might impact NPO status?
- age extremes <1 yo or >70 yo
- ascites (ESLD)
- Collagen vascular dx, metabolic do (DM, Obesity, ESRD hypothyroid
- hiatal hernia /GERD/esophageal surgery
- mechanical obstruction
- prematurity
- pregnancy
- neuro dx
- having eaten food or non-clear drinks
What are hte ASA-PS classifications?
- I- normal, healthy patient, no systemic dx
- II- mild systemic dx, well contorlled, no functional limitation
- III- severe systemic disease, functional limitation
- IV- severe systemic dx that is a constant threat to life
- V- moribound pt, not expected to survive with or without sx procedure
- VI- pt declaed brain dead whose organs are being harvested for donation
- E- emergency operation required (can be added to any classification level)
What are guidlines for antihypertensive meds around sx?
continue on day of surgery except ACEIs and ARBs
Guidlines for aspirin periop?
Continue ASA in pt with prior percutaneous coronary intervention, high grade IHD, and sig CVD
otherwise, d/c ASA 3 days before sx
Guidliens for clopidogrel before sx?
- patient having cataract sx with topical/general anesthesia do not need to stop taking.
- if reversal of plt inhibition is necessary, the time interval for d/c meds is 5-7 days for clopidorrel
- do not d/c clopidorgrel in pt with drug-eluting stents until they have completed 6 mo dual antiplatelet therapy, unless pt, surgeon and cardiologist have discussed risk of d/c
Recommendation for insulin periop?
- d/c all short acting insulin on DOS
- Patient with T2DM should take none, or up to one half of their dose of long acting on the DOS
- T1DM should take small amount (usually 1/3) of their morning long acting insulin on DOS
- patients with pump should continue basal rate only
Non insulin antidiabetic med recommendations?
d/c day of sx (SGLT2 inhibitors should be d/c’ed 24 hours before)
Recommendation for NSAIDS periop?
d/c 48 hours before sx
Recommendation warfarin periop?
d/c 5 days before sx
Recommendation for MAOIs?
Continue meds and adjust anesthesia plan accordingly
Equation for IBW? male/female?
men: 50 +2.3 kg per inch >5 feet
female: 45.5 +2.3 kg per inch >5 feet
What should you obtain preop on patient with hear failure?
CXR (+/-)
EKG
What is suggested preop testing for someone with HTN?
EKG
+/- CXR
Electolytes
creatinine
Suggested preop testing for chornic atrial fib?
ECG
drug levels if on digoxin
Suggested testing for COPD patient?
EKG
+/- CXR
CBC
drug levels if on theophylline
Preop testing for DM?
ekg
Creatinine
glucose
+/- electrolytes
Preop testing for renal disease?
CBC
Electrolytes
Creatinine
Preop testing for morbid obesity?
EKG
+/- CXR
Glucose
What are examples of ASA 1?
healthy, non-smoking, no/minimal alcohol abuse
What are examples of ASA II
current smoker,
social alcoholic,
drinker,
pregnancy,
obesity (30-40 BMI),
well controlled DM/HTN,
mild lung disease
Examples of ASA III?
poorly controlled DM/HTN,
COPD,
morbid obesity (BMI > 40),
active hepatitis,
alcohol dependence/abuse,
implanted pacemaker,
mod reduction in EF,
ESRD undergoing dialysis,
premature infant PCA < 60 weeks,
history (> 3 mo) of MI, CVA, TIA, or CAD/stents
ASA IV
recent (< 3 mo) MI,
CVA, TIA, or CAD/stents,
ongoing cardiac ischemia,
severe valve dysfx,
severe reduction in EF,
sepsis, DIC, ARD,
ESRD not undergoing reg dialysis
Example of ASA class V?
ruptured abd/thoracis aneurysm,
massive trauma,
intracranial bleed with mass effect,
ischemic bowl w/ sig cardiac pathology,
multiple organ/system dysfx
