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Spring 2020 - APA Foundations 1 > PreOP Assessment - Quiz 1 > Flashcards

PreOP Assessment - Quiz 1 Flashcards

1
Q

What Is Anesthesia

A

Reversible, drug-induced depression of Central Nervous system resulting of loss of response & perception of external stimuli

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2
Q

Type of Anesthesia

A

General

Regional

MAC

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3
Q

Anesthetic States

A

Unconsciousness

Amnesia

Analgesia

Immobility

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4
Q

Goals of Anesthesia

A
  • Optimize: Patient care, satisfaction, comfort, convenience
  • Minimize Perioperative Mortality & Morbidity
  • Minimize delays/cancels
  • Determine post op plan
  • Evaluate health status
  • Optimize preexisting conditions
  • Formulate anesthetic plan
  • Communicate issue
  • Educate Patient
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5
Q

Slow PreOp Eval

A

Perform Early

Take Your Time

Cover Everything

Build Relationship

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6
Q

Fast PreOp Eval

A

Perform when you can

Time Crunch

Cover Important

Build Relationship

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7
Q

Superfast PreOp Eval

A

Trauma/Emergency

Get what you can

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8
Q

Preanesthetic Assessment Clinic

A
  • One stop shop - medical history & physical exam
    • done well before surgery day
    • at least 1 wk before surgery for complex patients
  • Teach - what meds to take day of surgery, preps, NPO
  • Coordinate meeting with other consultants
  • Complete other pre-op diagnostics
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9
Q

Chart Review

A
  • History - Medical, Surgical, Social, Anesthesia (MH, PONV)
  • Meds/Herbals
  • Labs
    • Chemistry - Renal Patients, DM, HTN
    • Coags - when indicated - spinal/epidural, hx of pt. on anticoags
  • Tests - stress, echo
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10
Q

Hematocrit Percentage that is well tolerated in healthy patient

A

25-30%

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11
Q

Acceptable HGB for patients without system disease

A

HGB of 7g/dl

  • Can cause ischemia in CAD patients
  • Eval each patient individually for etiology & duration of anemia
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12
Q

Patient Interview

A
  • Always Name/DOB/Procedure/Allergies/Airway/NPO time
    • This might be it in emergencies
  • Head-Toe run through of problems
    • Confirm what you already know
  • Establish relationship
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13
Q

Purpose of PreOp Assessment

A
  • Build Relationship
  • Modify plan to adjust for risks associated with comorbidities
    • A line, CVC
    • Fluid Warmer, Type & Screen
    • LMA vs ETT
    • Regional vs. General vs. MAC
    • Glidoscope/Fiberoptic
    • Management - Induction/Maintenance/Emergence
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14
Q

Musculoskeletal Assessment

A
  • Obesity - OSA, Cardiac, DM
  • Diseases
    • Ankylosing Spondylitis
    • RA
    • Muscular Dystrophy
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15
Q

Neurologic History

A
  • Significant Pathologies
    • stroke, MS, Parkinsons
    • seizure - increase MAC value, may need higher doses due to inducing CYP450 enzymes
  • GCS
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16
Q

Cardiovascular History

A
  • Pre-existing cardiac issues
  • Disease severity/stability
  • Risk associated with procedure
  • HTN
  • Ischemic Heart Disease/LV Dysfunction
  • Valve Disease
  • Arrhythmias, Pacer/AICD
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17
Q

CV Assessment - 1 MET

A

​Poor Functional Capacity

  • Self care
  • Eating, dressing, using toilet
  • Walking indoors, round the house
  • Walking 1-2 blocks
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18
Q

CV Assessment - 4 METs

A

Good Functional Capacity

  • Light housework - dusting, washing dishes
  • Climbing stairs w/o stopping
  • Brisk walking
  • Running short distance
  • Heavy House work - scrubbing, moving furniture
  • Moderate Fun Stuff - golf, dancing, tennis, throwing ball
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19
Q

CV Assessment - 10+ METs

A

Excellent Functional Capacity

  • Strenuous Sports - bball, jump rope, soccer, swimming, weights
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20
Q

What is METs Assessment

A

Metabolic Equivalents to Excercise Tolerance

Way to quantify amount of exertion a patient can tolerate.

We want at least 4 METS

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21
Q

HTN History

A
  • Sys > 140 or Dia > 90
    • If associated with LVH - greater risk for MI/CVA’
  • Diuretic Use - Hypovolemia, Electrolyte Imbalance
    • The pts’ BP tend to drop more with induction
    • Preload with IVF to minimize this
  • Maintain pt within 20% of baseline BP
    • Altered autoregulation
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22
Q

Ischemic Heart Disease History

A
  • Unstable angina places pt at risk for MI w/ stress of surgery & anesthesia
  • Stents - ask about plavix, coumadin, other anticoags/antiplatelets
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23
Q

Perio-Operative Risk of Infarction

A
  • Overall Population: 0.3%
  • Past MI - 6%
  • <30 Days prior - 33%
  • 1-2 Months prior - 19%
  • 3-6 Months prior - 15%
  • < 3 months - 30%

If reinfaction occurs, mortalitiy is** **50%

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24
Q

Left Ventricular Dysfunction History

A

Defined as EF < 50%

Greater Morbidity

EF < 35% = greater incidence of postop HF & Death

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25
Q

Heart Valve History

A

Aortic Stenosis - Greatest risk for Non-Cardiac surgery MI

  • Angina - 5 Years
  • Syncope - 2 Years
  • CHF - 1 Year
  • 14x increase of perioperative sudden death
  • If symptoms are severe, elective surgery should be delayed until cardiac consult.
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26
Q

Pacer/AICD History

A
  • Interrogate before and after surgery
    • Cautery can misread as arrhythmias so we turn off sensing, and put them into demand mode with magnet (have one)
  • Pacers can mask ischemia symptoms
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27
Q

Anesthetic Managment of Patients with Cardiac History

A
  • Avoid extremes of HR & BP
    • HR main component of myocardial oxygen demand
  • Expect to use A-Line & second IV to intervene quickly
  • TEE or Swan if needed
  • Always have patient continue scheduled beta blocker
    • ​If pt missed dose, make sure we give it
    • Reduce risk of perio-operative ischemia
    • SCIP
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28
Q

Cardiac Dignostic Testing

A

12 Lead ECG

Stress ECG

Stress Myocardial Perfusion Imaging (MPI)

Stress Echo, TEE

29
Q

PeriOperative Pulmonary Complications

A

Major cause of morbidity & mortality r/t surgery and anesthesia

  • 5-10% Incidence in major non-cardiac surgery
  • Atelectasis
  • Aspiration Pneumonia
  • Bronchospasms
  • Respiratory Failure needing mechanical ventilation
  • Pneumonia
  • Bronchitis
  • Hypoxemia
  • Acute COPD
30
Q

Predictors of Pulmonary Complication in Surgery

A
  • Surgical Site
    • Thoracic, Aortic, Upper Abdominal, Neck, Neurosurgery
  • Lenth of Surgery > 2-3 hours = higher risk
  • General Anesthetics
31
Q

How does General Anesthetics increase Pulmonary Complications

A
  • Altered breathing cycle
    • V/Q mismatch
    • Dead space ventilation
    • Decreased FRC
  • Microscopic Affects
    • Inhibition of Mucociliary Clearance
    • Increased alveolar-capillary permeability
    • Inhibition of surfactant
    • Blunted ventilatory response to hypoxia and hypercarbia
32
Q

Pulmonary History - Asthma

A
  • Assess cause/severity/frequency/frequency of inhaler use
  • How responsive pt is to inhaler
  • Every been hospitalized from asthma attack?
  • Have patient take inhaler before taking them to surgery
    • Can also give IV steroid
  • Reactive airway (bronchospasm) - change induction/emergernce, ventilation plan
33
Q

Pulmonary History - Smoking

A
  • 6x increase in pulmonary complications
  • Nicotine
    • Increase HR, Oxygen Demand, BP, Peripheral vascular resistance
    • Carbon monoxide binds to HGB stronger than O2
    • Non smoking for 12-48 hours really reduces this
  • ​Reactive airway and make more secretions
  • Lower incidence of PONV, but increased aspiration risk
34
Q

Pulmonary History - OSA

A
  • Small doses of meds can cause apnea without pain relief
    • monitor pulse-ox 24 hours after anesthetic
  • Bring CPAP for PostOp
  • Decrease narcotics - sensitive to resp effects
  • No deep Exubations
35
Q

Questioning OSA Risk

A

STOP

  • Snoring Loudly?
  • Tired during day?
  • Oberved - anyone see you stop breathing while sleep?
  • Pressure Problems - only any BP meds?

BANG

  • BMI > 35
  • Age > 50
  • Neck circumfrerence > 40 cm
  • Gender - Male

High Risk > 3

Low Risk < 3

36
Q

Mendelson Syndrome

A

Another name for chemical pneumonitis

  • Aspirate Gastric Volume > 25 mL
  • pH < 2.5
  • Particulate aspirate > clear aspirate
37
Q

NPO Guidelines

A
  • Clear Liquids
  • Meds can be taken PO with up to 150 mL of water in the hour before anesthesia
  • Applies to healthy patients, elective surgery - no gaurantees of gastric emptying
  • Breast milk until 4 hours before
  • No formula, non human milk, or light meal for at least 6 horus before surgery
  • No gum/candy after Midnight
38
Q

Endocrine History - DM

A
  • Most common endocrine disorder - 8.3%
  • 90-95% DM 2
  • 5-10% DM 1
  • Increased Risk of
    • Automnomic neuropathy, gastroparesis, difficult airway, CAD, HTN, CHF, MI, Renal Fail, Stiff Joint
39
Q

How to manage diabetes perioperatively?

A
  • Hold oral diabetic med morning of surgery (48 hours for metformin)
  • Take 1/4 - 1/2 insulin
  • ALWAYS check BG for total joints during precedure regardless if diabetic or not
40
Q

Endocrine History - Hyperthyroidism

A
  • Hypermetabolic State - sympathetic overactivity
  • PreOp Goals
    • Euthyroid State - antithyroid drugs for 6-8 weeks
      • Followed by Iodine for 1-2 wks
    • Consider intraoperative beta blockers (only propranolol)
      • ​BB reduce peripheral conversion of T4 to T3
      • Control sympathetic system
41
Q

What are the recommendations to delay surgery for Hypothyroidism

A

None

42
Q

Endocrine History - Adrenal

A
  • Cushing Syndrome - long term steroid use
    • may need stress dose steroids for the procedure
  • Addison’s disease - Adrenocortical difficiency
43
Q

What kind of disorders have some higher incidence of malignant hyperthermia?

A

Musculoskeletal Disorders

44
Q

Alcohol History

A
  • Acute intoxication
    • Lowers anesthetic requirements
    • Hypo/Hyperthermia
  • Withdrawal - Increased anesthetic requirements
45
Q

Recreational Drug History

A
  • Stimulants
    • Palpitations, True Angina, Labile BP, Lower threshold for serious arrhythmia, convulsions
  • Cocaine - do not use beta blockers
    • Unopposed alpha stimulation d/t beta blocker further decreases coronary flow
    • Use calcium channel blockers
46
Q

Allergy History

A
  • Antiobiotics - Anaphylaxis
  • Induction Agents
    • Propofol - egg allergy
    • Rocuronium - most common cause of intraop allergic reaction
  • Shellfish & Seafood
    • Cross reaction with IV contrast dye & Protamine
47
Q

History of Difficult Anesthesia

A
  • Anyone in your family had serious reaction to anesthesia?
    • MH is familial
    • Atypical Pseudocholinersterase - takes longer for succinylcholine to wear off
  • Difficult intubation, significant PONV
48
Q

ASA Class I

A

No organic, physiological, biochemical or psychiatric disturbance

Healthy Patient

49
Q

ASA Class II

A

Mild to moderate Systemic Disturbance

Heart disease that slightly limits physical activity, essential HTN, DM, chronic bronchitis, anemia, obesity, age extremes

50
Q

ASA Class III

A

Severe Systemic Disease that Limits Activity

Heart/Chronic pulmonary disease, poorly controll essential HTN, DM with vascular complications, angia pectoris, Hx of MI

51
Q

ASA Class IV

A

Severe systemic disease that is constantly life threatening

CHF, persisent angina, advanced pulmonary, renal, hepatic dysfunction

52
Q

ASA Class V

A

Moribund patient, undergoin surgery as a resuscitative effort, despite minimal chance of survival

Uncontrolled hemorrhage from AAA, PE, head injury with increased ICP

53
Q

ASA Class VI

A

Declared brain dead, harvesting organs

54
Q

ASA Class IE

A

Emergency surgery required

EX:

Healthy 30 y/o female needs D&C for moderate persistent hemorrhage

55
Q

ASA Standard II

A

Informed Consent

  • CRNA shall obtain/verify that an informed consent has been obtained by qualified provider
  • Discuss options and risks
  • Document consent obtained
  • Aspects of care outside realm of common experience
    • Intubation, ICU, invasive monitoring, regional techniques, blood products
  • Alternative Plans
56
Q

Failure to obtain consent is considered _________, and the act of performing a procedure without proper consent is __________

A

Breach of Duty, Battery

  • No consent needed for emergencies - covered under doctrine of implied consent
57
Q

What should an Anesthesia Consult Note have?

A

Medico-Legal Document In Permanent Hospital Record

  • Date/Time of Interview
  • Planned Procedure
  • Description of Extraordinary Circumstances
  • Allergies, Medications, Labs
  • Disease Processes/Treatments
  • ASA Status
58
Q

ASA Standard III

A

Formulate a Patient-Specific Plan for anesthesia care

Plan should be based on comprehensive patient assessment, problem analysis, anticipated surgical/therapeutic procedure, patient & surgeon preferences, and current anesthesia principles

59
Q

What equipment are required for ALL anesthetics

A

SOAPM

  • *S**uction
  • *O**xygen
  • *A**irway equipment
  • *P**ositive Pressure Ventilation
  • Pharmacy
  • *M**onitors, medications
60
Q

Factors that Influence Anesthesia Plan

A
  • Patient, Surgeon, Anesthesia Preference
  • Site of Surgery
  • Body Position need for Surgery
  • Elective vs Emergency Surgery
  • Co-Existing Disease
  • Duration of Surgery
  • Pt. Age
  • Suspected Difficult Airway
  • Suspected increased gastric contents at induction
61
Q

General Anesthesia

A

Inhalation

Intravenous - TIVA

Combination

62
Q

What do patients lose any time they lose consciousness and cant respond purposefully?

A

The ability to protect their airway

63
Q

MAC

A

Monitored Anesthesia Care

  • Should be able to respond if stimulated
  • Should maintain airway reflexes - protect airway
  • Sedation could progress quickly to General
64
Q

Sodium Bicitrate

A

Increase gastric pH

65
Q

Robinul

A

Decrease amount of secretions

66
Q

Principles of Benzos

A

Used to Facilitate Induction and Help with anxiety/memory

Anxiolysis
Anterograde Amnesia
Sedation
Anticonvulsant
Spinal Cord-Mediated Skeletal Muscle Relaxation

67
Q

How do Benzos Work?

A

Enhances the affinity of the receptors for GABA (Principle Inhibitory Neurotransmitter)

GABA causes Chloride influx hyperpolarizing neurons, reducing sponteaneous action potential firing –> CNS Inhibition

68
Q

Versed

A
  • 1-5 mg IV
  • 2.5-5 mg IM
  • Onset: 30-60 secs. IV, 15-30 min PO
  • Peak: 3-5 minutes IV
  • Duration: 15-80 min
  • Rapid onset & peak, while having shorter DOA when compared to other Benzos
  • PK: rapid absorption and quickly passes BBB - lipid soluble
69
Q

How is Versed Metabolized

A

By Hepatic Cytochrome P450 (CYP3A4) enzymes to active/inactivate metabolites

  • This is slowed by presence of drugs that inhibit CYP450, resulting in profound effects of midazolam greater than expected.

Spring 2020 - APA Foundations 1 (10 decks)

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