Preop Lecture 1-16 Flashcards
Pre-op
What are 3 anesthesia related complications?
Malignant hyperthermia
Hx of difficult airway
Pseudocholinesterase deficiency
What considerations do we have to have for someone who has a Hx of MH or Pseudocholinesterase deficiency?
-No volatile anesthetics
-No depolarizing muscle relaxants (Succs)
You can give Rocuronium, propofol, fentanyl, precedex
-Remove vaporizers, replace circuit, reservoir bag, and CO2 absorber & flush machine
What is Pseudocholinesterase deficiency?
A genetic disorder where you tay paralyzed for an extended period of time.
Ancef has a low cross reaction with _____
PCN
What medication causes angioedema?
lisinopril
Why is illicit drug use/ETOH important when obtaining Hx?
May need more or less of the anesthetic
How does smoking affect coming out of anesthesia?
May have a harder time coming out because excessive coughing
T/F: if there’s a difficult airway, you can intubate awake
T
BMI =
[wt (kg)] / [height (m)]2
or
[703 x wt (lbs)] / [height (in)]2
Describe the BMI chart
For adults over 20
Underweight: < 18.5
Normal: 18.5 - 24.9
Overweight: 25.0 - 29.9
Obese: >30.0
BMI does not account for ________
muscle
Muscle is heavier than fat
How do seizure medications affect NMB?
Decrease DOA
What is the acronym for emergent physical examination questions?
AMPLE
Allergies
Medications
Past medical history
Last eaten meal
Events leading up to the need for surgery
In an emergency situation, what do we always assume? Why?
They have a full stomach
SNS fight/flight response causes decreased GI motility
What does my airway examination consist of?
MITFRD
Mallampati classification
Inter-incisors gap
Thyromental distance
Forward movement of the mandible
Range of cervical spine motion
Document loose/chipped teeth
What is Mallampati classification and how do you assess?
Related to tongue size to visualize the oropharyngeal
Have them sit up straight with tongue out (no phonation)
What is Inter-incisors gap and how do you assess?
Space between the top and bottom teeth
Have patient open their mouth
What is Thyromental distance and how do you assess?
It is a space between your mandible and your thyroid that assesses your mandible space and ease of tongue displacement
Have them fully extend their neck and measure from the tip of the mandible to the upper broader thyroid cartilage
T/F: we can still move the mandible with a C-collar
F
What are considerations we should have if we see tracheal deviation?
pneumothorax/mass
-may ultrasound/CT scan
-glidescope to intubate
_______________ complications account for almost half of preoperative mortalities
Cardiovascular
A murmur around the neck could mean….
severe aortic stenosis
What are comorbities common in smokers?
Vascular disease
Cancer
Kidney issues
T/F: OSA is always correlated to body structure
F
Skinny people have OSA
When can you put someone under anesthesia with an active URI?
emergent situation only.
How do we control BGS in the OR?
IV only
we will only bring it down slight to help with wound healing if it is profoundly high.
Finger stick in preop & 30 mins after insulin given
Why is it better for the BGS to be high than low when giving anesthesia?
You cannot tell if a sugar is too low under anesthesia bc all of the S/S are masked by the anesthesia.
What is Pheochromocytoma?
A endocrine disorder:
catecholamine secreting tumor
Tx: Alpha blocker
S/S: Pt will feel belly pain
ultrasound: see something sitting on top of kidney
BP: elevated after anesthesia
Thyroid and adrenal disorders can have _______ imbalances
electrolyte
T/F: anesthetic agents tend to decrease GFR
T
What are two ways to treat contrast induced neuropathy?
Hydrate
Dialyze
How does liver disease affect anesthesia?
It impacts the drug metabolism and pharmacokinetics
Anesthetics might have exaggerated effects impatience with advanced liver disease
What is the number one malignancy in the USA?
Alcoholism
Hematological disorders include:
Anemia
Sickle Cell
G6PD
Coagulopathies
What consideration should I have for someone with sickle cell disease?
Consult Hematologist
-Incompatibilities with blood
-May need to come in the night before to get transfused
-not having anything to eat or drink for the Sx–> dehydrated–> clumping of sickles –> pain
What does smoking do to your hemoglobin?
Artificially increases it
Neurological diseases include:
Cerebrovascular disease
Seizure disorder
Multiple sclerosis
Aneurysm
AV malformation
Parkinson’s disease
Neuromuscular junction disorder
Neuromuscular dystrophy and myopathy
__________, a Parkinson’s medication, causes problems with anesthetics
Levodopa
What are some considerations with multiple sclerosis?
muscle weakness –> Harder time regaining muscle function & easier to loss muscle function
-don’t use full dose
-consider local/regional instead of NMB
Musculoskeletal & connective tissue disorders include:
Rheumatoid arthritis
Ankylosing spondylitis
Systemic lupus erythematosus
Reynaud phenomenon
What is ankylosing spondylitis? Where is it concerning at?
Hardening tissue that becomes brittle
Concerning in the neck
What is Reynaud’s phenomenon? What consideration should I have with this?
Constriction and vasospasms in the extremities
-use caution with vasoconstrictors
-pulse ox, not may not work on extremities (may have to put somewhere else like forehead)
-decrease perfusion
What consideration do we have with transplant patients?
Always consult with the transplant doctor and transplant center first, they may want to have the surgery there if the outcome might be better
-usually taking steroids
-vagus nerve severed –> won’t respond to neostigtme
What was the court case that helped established informed consent?
Salgo vs Trustees of Leland Stanford Hospital
1959 - California
Stated the procedure left him paralyzed, and he wasn’t informed of the risks
Most DNR’s are _______ during Sx. But you should know your facilities policy.
Suspended
How does nutritional status play a part in anesthetics?
malnutrition –> decreased albumin –> decreased anesthesia working
When do we need to d/c tube feeds? what other options do we have?
prone or supine flat
dophoff
Define Frailty
A state of increase vulnerability to physiological stressors
What are my high risk surgical procedures?
> 5%
Aortic and major vascular
Peripheral vascular
What are my intermediate risk procedures?
1-5%
Intra-abdominal surgery
Intrathoracic surgery
Carotid endarterectomy
Head/neck surgery
What are my low risk surgery procedures?
Ambulatory surgery
Breast surgery
Endoscopic procedures
Cataract surgery
Skin surgery
Urologic surgery
Orthopedic surgery
Based on the Revised Cardiac Risk Index (RCRI), what components increase risk for major cardiac events after surgery?How do you score this?
-High risk surgery
-ischemic heart disease
-Hx of congestive heart failure
-Hx of cerebral vascular disease
-DM requiring insulin
-creatinine greater than 2
Each is worth 1 point
Risk or major cardiac event
0 = 0.4%
1 = 1.0%
2 = 2.4%
3 or more = 5.4%
What does functional capacity do?
-Assesses cardiopulmonary fitness
-estimates patient’s risk for a major postop morbidity or mortality
-assesses preoperative risk
With functional capacity, what is considered a good METs score?
> 4 METs
How do we normally test functional capacity?
METs score of 5:
Climbing 1 flight of stairs
What are the times for urgency of surgeries?
Emergent: 30 minutes - 6 hours
Urgent: 6 to 24 hours
Time sensitive: 1 to 6 weeks
What is the Preop Cardiac risk assessment algorithm?
Step 1. Emergency –> Sx
Step 2. Active cardiac conditions:
ACS
decompensated HF
significant arrhythmia
severe valvular disease
–> Postpone until eval/Tx
Step 3. Estimate risk using RCRI –> less than 2 –> Sx
Step 4. Assessed functional capacity –> greater than 4 –> Sx
Step 5. Assess whether testing will impact care.
Step 6. Proceed to Sx or consider alternative strategies.
Describe ASA I
A normal healthy patient
Non-smoking
Minimal or no alcohol use
Describe ASA II
A pt w/ mild systemic disease w/o substantial functional limitations
Current smoker
Social alcohol drinker
Pregnant person
Obesity (BMI between 30-40)
Well controlled DM/HTN
Mild lung disease
Describe ASA III
A pt with severe systemic disease and substantial functional limitations
Poorly controlled DM/HTN
COPD
morbid obesity (BMI >40)
Active hepatitis
Alcohol dependence/abuse
Pacemaker
Moderate reduction in EF
ESRD with dialysis
Premature infant postconceptual age <60 weeks
Hx of MI/CVA/TI/CAD/stents (>3 months)
where disability starts
Describe ASA IV
A pt with severe systemic disease that is a constant threat to life
MI/CVA/TIA/CAd/stents (< 3 months)
Ongoing cardiac ischemia
Severe valve dysfunction
Severe reduction in EF
Sepsis
DIC
ARDS
ESRD without dialysis
Describe ASA V
A moribund pt who is not expected to survive without surgery
Ruptured abdominal/thoracic aneurysm
Massive trauma
Intracranial bleed with mass effect
Ischemic bowel in the face of significant cardiac pathology
Multiple organ/system dysfunction
Describe ASA VI
A declared brain dead pt whose organs are being removed for donor purposes
THIS IS ALWAYS AN EMERGENT CASE
What is in a CBC? Who needs one drawn?
Hgb/Hct/Plt/WBC
Hx of increased bleeding
Hematologic disorders
Anticoagulant therapy
Poor nutritional status
ASA-pt 3/4: intermediate risk procedures
All patients undergoing major procedures (ASA 5)
What is renal function testing under? Who needs one drawn?
Chemistry panel
ASA-pts3/4: intermediate risk procedures
ASA-pts2/3/4/5: major procedures
How much does Succs raise K?
0.5
How can we give K?
CVC: 20-40 meq/hr
peripheral: 10-20meq/hr
Can give PO at the same time as IV
Who needs coag labs?
pts with identified coagulopathies during preop
known bleeding disorders
Chronic hepatic (liver) disease
Anticoagulant use
ASA-pt 3/4: intermediate, major, complex surgical procedures
Decadron________ glucose levels
increases
Who needs a serum glucose and A1c lab?
Known DM
Obesity (BMI >50)
Cerebral vascular/intracranial disease
Steroid history
Who needs a urinalysis?
Suspected urosepsis
Hip replacement surgery
Unexplained fever or chills
How does Suggamdex affect birth control?
Inactivates it for about a week
NEED TO INFORM PT TO USE DIFFERENT METHOD OF BIRTH CONTROL
Who needs an ECG?
Ischemic heart disease
HTN
DM
HF
Chest pain
Palpitations
Abnormal valve murmurs
Dips on exertion
Syncope
Arrhythmias
Known IHD
PAD
CVD
Significant structural heart disease undergoing intermediate or high risk procedures
ASA pt 3/4: intermediate risk procedures
ASA pt 2/3/4: major high risk procedures
Who needs a chest x-ray?
Based on abnormalities identified in preop
Advanced COPD
Bollous lung disease
Pulmonary edema
Pneumonia
Mediastinal masses
Tracheal deviation
Rales
if patient cannot tell you, you might need x-ray to identify
