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Health Assessment ORAL first half > Preop Assessment > Flashcards

Preop Assessment Flashcards

1
Q

What are some regulatory requirements for preop assessment?

4

A
  1. AAANA standard of care
  2. American Society of Anesthesiologies- mandated
  3. JCAHO
  4. Center for medicaid and medicare- reimbursement
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2
Q

What are some goals of preoperative evaluation?

4

A
  1. reduce patient risk and morbidity associated with surgery and anesthesia
  2. prepare patient medically and psychologically
  3. promote efficiency
  4. reduce costs
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3
Q

What are some components of preop evaluation?

11

A
  1. Pt medical hx (chart review and history taking)
  2. physical exam
  3. meds/allergies
  4. lab testing/dx testing
  5. medical consultation (if indicated)
  6. ASA-Physical status assignment
  7. NPO status
  8. formulation of anesthetic plan
  9. discussion of plan
  10. informed consent
  11. documentation
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4
Q

Where are preop evals/assessments conducted?

A
  1. presurgical testing centers - “wave of futre”
  2. hospitals
    • or settings
    • critical care unit
    • specialty department
  3. Outpatient center
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5
Q

What is the optimal situation for a preop clinic visit?

7

A
  1. 1 week preop
  2. can do patient interview
  3. do physical exam
  4. develop anesthetic plan
  5. promote patient teaching and anxiety reducton
  6. allows time to schedule appointments with medicla consultants and complete required preop dx testing
  7. obtain informed consent prior to operative day
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6
Q

What typs of conditions wouild require an early preop assessment?

A
  • 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
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7
Q

What should be the basis of the preoperative interview?

4

A
  • 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
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8
Q

What should be discussed regarding history and medications in preop interview?

A
  • History
    • ROS
      • CNS
      • Cardiac
      • ENT
      • Pulm
      • Vascular/HTN
      • Endocrine
      • GI/hepatic
      • Renal
      • Hematologic
  • Medications
    • allergies
    • prescription meds
      • DC’ed
      • taken this AM
    • OTC (ASA, NSAIDS, herbals)
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9
Q

What should be discussed in past surgical history?

8

A
  1. Complications
    • MH, psuedocholinesterase deficiency, had to stay intuabted for a long time, “allergic to anesthesia”
  2. family history complications
  3. obstetrical deliveries
  4. ETOH use/Drug abuse/tobacco use
  5. female- LMP
  6. pain
  7. NPO status
  8. height/weight
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10
Q

What should be examined during the physical exam?

7

A
  1. General impression, mental status
  2. airway- regardless of plan!
  3. heart
  4. lungs
  5. CNS/PNS
  6. VS
  7. Height weight
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11
Q

What are mallampati classifciations?

A
  • 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
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12
Q

What are some indicators of a potential difficult airway from physical exam?

7

A
  1. long upper incisors
  2. thyromental distance
    • 2-3 fingers or 6 cm.
    • if >9 cm- hard to align glottic opening
  3. interincisor distance
    • 3 cm, 2 fingers
  4. atlanto-occipital function
    • 35 degree extension
    • problematic if <23 degree
  5. mandibular protrustion test
  6. hyomental distance (mandibulohyoid)
    • 2 finger breaths
  7. neck circumference
    • male 15-16”
    • women 13-14 “
    • if >17 “, or 40 cm, 5% chance difficult airway
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13
Q

Indicators of difficult mask ventilation?

6

A
  1. Age >55 years
  2. OSA or snoring
  3. previous head/neck radiation, sx, trauma
  4. lack of teeth
  5. a beard
  6. BMI >26
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14
Q

What are indicators of difficult DL?

6

A
  1. Report of difficult intubation, aspiration PNA after intubation, dental or oral truma
  2. OSA or snoring
  3. previous head/neck radiation, surgery or trauma
  4. congenital disease: down syndrome, treacher collins, pierre robin syndrome
  5. inflammatory/arthritic disease, RA, ankylosing spondylitis, scleroderma
  6. obesity, cervical spine dx or previous sx
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15
Q

What is the prayer sign?

A

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 similar stiffness in neck.

seen in diabetics

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16
Q

Cardiac assessment on physical exam?

A
  • Heart auscultation
    • Rate
    • Rhythm
    • Murmurs
    • Bruits (carotid)
    • extremity pulses
  • CV
    • bruits
    • extremity pulses
    • extremity edema
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17
Q

Lung physical exam?

A

Inspection

Auscultation

Percussion

Palpation

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18
Q

What are you observing for on physical exam for neuro/MS system?

A
  • 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, superficial and pathologic
  • Cranial nerve abnormalities
  • mental status
  • speech
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19
Q

What would show end target organ damage on ROS, Physical exam, CXR/EKG, labs?

A
  • ROS- hx of Heart attack, angina, stroke
  • PE- carotid bruit, eye damage
  • CXR/EKG- cardiomegaly, wide QRS, left axis deviation, inverted T waves
  • Labs: elevated BUN/CR, decrease GFR, protein in urine
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20
Q

What is the reccoemndation for ordering preoperative testing?

A

2012 ASA practice advisory for preanesthesia eval states that routine pre-op tests do not make an important contribution to pre-anesthetic evaluation of asymptomatic patient

21
Q

Preop testing should be selevtively ordered based on:

3

A
  1. patient medical hx and physical exam
  2. planned sx
  3. expected introp blood loss
22
Q

What does selective preop testing accomplish?

3

A
  1. expedites patient care
  2. reduces healthare cost
  3. improves delivery of periop meds
23
Q

What is sensitivity?

A

sensitive test is very good at identifying those who have the disease; true positive

A sensitive test with negative result rules out a disease (SnNOUT)

24
Q

What is specificity

A

specific test is good at identifying those without the disease; true negative

A speicifc test with a positive result usually rules in disease–> SpPIN

25
Q

What determines a minimal invasive sx?

A

little tissue trauma, minimal blood loss (<500mL)

(ie skin lesion)

26
Q

What is a moderately invasive surgery?

A

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)

27
Q

What is a highly invasive sx?

A

vascular sx, TURP, TJR, radical neck dissection

signficiant disruption of normal physio

blood loss >1500 mL

commonly require transfusion and ICU care

28
Q

When might you get a CXR before sx?

A
  • 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
29
Q

When should you get a CXR on smokers?

A

20 pack years or more

pack year= ppd * years smoking

30
Q

What are the recommendations for obtaining a 12-lead EKG?

A
  • 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
31
Q

What are guidliens for NPO status?

Clear liquids

Breast milk?

Formula or solids (light meal)?

Heavy meal with fried or fatty food?

A
  • Clear liquids- 2 hours
  • Breast milk- 4 hours
  • formula or solids- 6 hours
  • heavy meal- 8 hours
32
Q

What disorders might impact NPO status?

9

A
  1. age extremes <1 yo or >70 yo
  2. ascites (ESLD)
  3. Collagen vascular dx, metabolic do (DM, Obesity, ESRD hypothyroid
  4. hiatal hernia /GERD/esophageal surgery
  5. mechanical obstruction
  6. prematurity
  7. pregnancy
  8. neuro dx
  9. having eaten food or non-clear drinks
33
Q

What are the ASA-PS classifications?

A
  • 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)
34
Q

What are guidlines for antihypertensive meds around sx?

A

continue on day of surgery except ACEIs and ARBs

35
Q

Guidlines for aspirin periop?

A

Continue ASA in pt with prior percutaneous coronary intervention, high grade IHD, and sig CVD

otherwise, d/c ASA 3 days before sx

36
Q

Recommendation for insulin periop?

A
  • 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
37
Q

Non insulin antidiabetic med recommendations?

A

d/c day of sx (SGLT2 inhibitors should be d/c’ed 24 hours before)

38
Q

Recommendation for NSAIDS periop?

A

d/c 48 hours before sx

39
Q

Recommendation warfarin periop?

A

d/c 5 days before sx

40
Q

Recommendation for MAOIs?

A

Continue meds and adjust anesthesia plan accordingly

41
Q

Equation for IBW? male/female?

A

men: 50 +2.3 kg per inch >5 feet
female: 45.5 +2.3 kg per inch >5 feet

42
Q

Suggested testing for COPD patient?

A

EKG

+/- CXR

CBC

drug levels if on theophylline

43
Q

Preop testing for DM?

A

ekg

Creatinine

glucose

+/- electrolytes

44
Q

Preop testing for morbid obesity?

A

EKG

+/- CXR

Glucose

45
Q

What are examples of ASA II

A

current smoker,

social alcoholic,

drinker,

pregnancy,

obesity (30-40 BMI),

well controlled DM/HTN,

mild lung disease

46
Q

Examples of ASA III?

A

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

47
Q

ASA IV

A

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

48
Q

Example of ASA class V?

A

ruptured abd/thoracis aneurysm,

massive trauma,

intracranial bleed with mass effect,

ischemic bowl w/ sig cardiac pathology,

multiple organ/system dysfx

49
Q

DC MEDS and when

7

A

ACE-I, aRBs - DC do not take day of surgery

ASA- 3 days prior , unless PCI, or high grade iHD, or significant CVD

P2Y12 Inhibitors:

  • clopidogrel 5-7 days prior
  • ticagrelor 5-7 days prior
  • prasugrel 7-10 days prior
  • ticlopidine 10 days

except with drug eluding stent

NSAIDs - 48 hrs before surgery

Warfarin - 5 days prior, unless catatract surgery

diuretics: DC day of surgery except thiazides.

SGLTinhibitors for DM - dc 24 hrs before

Health Assessment ORAL first half (7 decks)

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