Preoperative Evaluation Flashcards
Types of Anesthia
local
MAC
Neuraxial
TIVA
General
Local
- local/regional
- nerve block
- lidocaine for sutures, etc.
- low risk
- can be added with a MAC
MAC (Monitored Anesthesia Care)
- “twilight”
- colonoscopy or minor extremities
Neuraxial (epidural, spinal)
- usually along with MAC
- joint replacements, C-sections and childbirth
TIVA (total IV anesthesias)
- completely IV administered anesthesia
- no gas
- good for those with risk of malingnant hyperthermia
General
- a mix of inhaled gases and IV meds
- need intubation or LMA
Conditions related to Anesthesia
Malignant Hyperthermia
Pseudocholinesterase Deficiency
PONV
Malignant Hyperthermia
- a severe reaction to inhaled anesthestic drugs
- high body temp, rigid muscles, spams and tachycardia = fatal if not treated
- autosomal dominal genetic pattern of inheritance (ask about family history)
- inhaled gases or succinylchoine
Pseudocholinesterase Deficiency
- au autosomal recessive condition
- the body takes a while t “wake” from anesthesia, remaines paralyzed for longer, needing longer time to be intubated to protect airway
- can be triggered by succinylcholine or mivarcurium
PONV: post-op nausea vomiting
- prolonged N/V
- risk factors = female, motion sickness, nonsmoker < 50 y/o, general anesthesia, use of NO or opioids in the OR
Describe the ASA Classification Scale
1-6
ASA 1 = healthy patient
ASA2 = mild/moderate systemic disease, which is the surgery or another process, but medically controlled
- example: pt. with cholycystitis or 40 y/o with controlled HTN
ASA 3 = severe disease process, limits activity but not incapacitating
ASA 4 = severe disease which is constantly life threatening (ESRD, ilver disease)
ASA 5 = moribound pt. not expected to survive 24 hours with or without the surgery (elderly septic pt.)
ASA 6: brain dead for harvest
What is included in the Pre-Op Evaluation
(specific H and P)
Anesthesia History
- family personal history of malignant hyperthermia, psuedoacetlycholine, PONV
- family/personal hx. of prolonged awakening, etc.
- OSA? difficult intubation
PMH.
- cardiac, pulmonary or bleeding disorders?
- functional capactiy
Surgical history
- spinal fusion? cervical? = cant tilt head for intubation
- joint issue = cant move it
Medications
- coags/platelets
- supplements
- beta blockers
PE
- cerivcal ROM
- Mallampati score
- CV/Pulm listen
Mallampati Score Class I- IV
Class I: see entire soft palate
Class II: complete visualiztion of uvula
Class III: visualization of the base of uvula at the top only
Class IV: soft palate not visable (will need camera to intubate)
Pre-Op Evaulation
things which usually need to be included
Evaluation: ensuring pt. is ready for surgery
- youve discussed the surgery, risks, etc.
“Clearance” for lack of better term help to determine any underlying issues that need to be addressed before the OR
Labs (basics)
- CBC
- CMP
- EKG
- CXR
some pt. may need
- ECHO
- stress test
- PFTs
- Sleep study
guidelines of what labs/imaging are needed for what pt. and surgery vary by institution
- example: everyone = CBC , those > 40 = EKG those > 60 =CXR
Determining Readiness for the OR
Cardiovascualr Disease pt.
what is a MET score
Cardiovascualr Disease specifics that you need to consider for pt. before an operation
- those with an MI in the past 6 months = increased risk for stroke consider delaying surgery if possible
- CHF = increase risk of death by 60%
- if known history of CHF, make sure to documenr NYHA class and recent EF from echo
- CAD or lots of CAD risk factors = get cardiac evaluation before elective surgery
- Functional Capaticty or Exercise Tolerance is a large predictor of periop. complications
METS score: a number of how strenuous acitiveis are = if pt. can get > 4 mets, they dont need a caridac additional test before surgery
4 = climbing some stiars, walking for a while, running short distance, lots of chores, golf/dancing sports
3 if cant do these they need a cardaic eval = light housework, walking 3/4km/hour
Considerations for those with Pulmonary Disease before surgery
- COPD = longer time in the OR and 4x logner in PACU recoverying
- COPD = higehr mortality
- COPD = risk of PNA, respirtory failure, MI, sepsis, AKI and wound issues
OSA
- higher risk of pulmonary and cardaic complcatiosn
- use CPAP during post-op period
- risk of hypoventilation after extubation
Considerations for DM pts. Pre-Op
DM pts.
- chronic hyperglycemia = longer hospital stay
- infection & poor wound healing
- want the ALC < 7/8
- timing of procedure can be managed to adjust for their meds to limit time NPO
Liver Disease pt. Special Considerations for PReOp
Liver Disease
- risk of death much higher in these pts. because of
- malnutrtion
- low platelets
- impaired metabolism of drugs
- decreased intravascular volume
CTP score > 10 or MELD > 20 = avoid or delay surguries unless theyre urgent and life saving
Geriatics: special considerations with pre-op
extra assessments to make pre-op decisions
- cognitive function
- decision-making capacity
- functional status
- fall risk/farilty
- nutrtional status
- meds
- assess support system as they are super helpful in care
- likely to have multiple comorbidities and medications
Risk Assessment Tools to use to “clear” for surgery : 2 common ones
Prophalyatic ABx.
commonly used is the ACS national surgical quality improvement program
RCRI is common too
Prophylatic Abx.
- cefazolin is commong for hip/knee, vascualr, cardiac procecures
- cefotetan, ertapenem, cefoxitian, amp-sulbactum and cefazolin/metronidazole = colon
- cefazlin, cefotetan, amp/sulbac. or cefoxitin = hysterectomy
- commonyl given as an infusion completelt before surgery
