Preoperative Evaluation

Question 1

ASA Classification system

Answer 1

ASA 1: Normal, healthy patient
ASA 2: Pt with mild systemic disease
ASA 3: Pt with severe systemic disease
ASA 4: Pt with severe systemic disease that is a constant threat to life
ASA 5: Moribund pt who is not expected to survive without the operation
ASA 6: Brain-dead pt whose organs are being harvested for donation

Question 2

Assessing Metabolic Equivalents of Functional Capacity (METS):

Answer 2

1. Eating, working at computer, dressing
2. Walking down stairs; walking in home; cooking
3. Walking 1-2 blocks
4. Raking leaves, gardening
5. Climbing one flight of stairs, dancing, bicycling
6. Playing golf (carrying clubs)
7. Playing singles tennis
8. Rapidly climbing stairs, jogging slowly
9. Jumping rope (slowly), moderate cycling
10. Swimming quickly, running, jogging briskly
11. Cross-country skiing, playing full-court basketball
12. Running rapidly for moderate-to-long distances

Question 3

Pulmonary:

Answer 3

• Smoking
• Sleep apnea
• Acute processes:
  
  1. URI
  2. LRI (pneumonia, bronchitis)
• Chronic processes:
  
  1. COPD – bronchitis and emphysema
  2. Asthma – important questions to ask about severity
• Rarer processes
  
  1. Pulmonary HTN
  2. Pulmonary fibrosis
  3. Scoliosis
  4. Cancer–chemo

Question 4

Evaluation modalities for pulmonary disease:

Answer 4

plain films, CT, and PFT’s, ABG’s and indications for further workup

Question 5

Evaluation modalities for cardiac disease:

Answer 5

EKG, echo, stress tests, PCT and the indications for further workup

Question 6

DM

Answer 6

1. Type I – medications (insulin types and doses); typical blood sugars; last HbA1c level; sequellae (micro- or macro-vasular disease)
   
   2. Type II – diet-controlled vs medication (oral vs insulin) vs uncontrolled; typical blood sugars; last HbA1c level; sequellae (micro- or macro-vascular disease)
   3. Anesthetic implications (ie gastroparesis)

Question 7

Congenital hematologic diseases:

Answer 7

1. Hemophilia
2. Sickle cell
3. Antithrombin III (ATIII) deficiency
4. Factor V Leiden
5. Von Willebrand disease

Question 8

Acquired hematologic diseases:

Answer 8

1. Anticoagulants
   
   2. Liver disease  decreased synthesis of coag factors
   3. Antiphospholipid antibodies
   4. Anemia
   5. Idiopathic/Immune thrombocytopenic purpura (ITP)
   6. Heparin-Induced Thrombocytopenia
   7. DVT and PE

Question 9

Pregnancy effect on MAC?

Answer 9

MAC decrease by 40%

Question 10

Pregnancy effect on O2 consumption, FRC, TV, RR?

Answer 10

o O2 consumption increases by 20-50%
o FRC decrease by 20% so pts become hypoxic quickly!
o Tidal volume increases by 40%
o Respiratory rate increases by 15%

Question 11

Pregnancy effect on cardiovascular system?

Answer 11

o	Blood volume increases by 35%
o	Plasma volume increases by 45%
o	Cardiac output increases by 40%
	Stroke volume increases by 30%
	Heart rate increases by 20%
o	SBP decreases by 5%
o	DBP decreases by 15%

Question 12

Hemotologic effects of pregnancy?

Answer 12

o Hemoglobin decreases by 20%
o Platelets by decrease 10%
o Clotting factors increase by 30-250%

Question 13

Renal effects of pregnancy

Answer 13

GFR increases by 50%

Question 14

GI effects of pregnancy

Answer 14

Predisposed to gastric aspiration (30-50% have GERD, baby pushing upwards on stomach)

Question 15

Airway exam:

Answer 15

1. Mallampati classification
2. mouth, tongue, teech
3. Thyromental distance
4. Neck circumgerence/thickness
5. Neck ROM
6. Craniofacial anomalies
7. Heavy facial hair
8. Neck mass or hardware
9. Hx. of radiation to head/neck

Question 16

NPO instructions: before elective procedures minimum fasting duration for clear liquids is:

Answer 16

2 hours for clear liquids (water, fruit juice without pulp, clear tea, black coffee, Pedialyte, carbonated beverages)
Acceptable volumes:
• 13 years: no more than 8 ounces

Question 17

NPO instructions: before elective procedures minimum fasting duration for breast milk is:

Answer 17

4 hours

Question 18

NPO instructions: before elective procedures minimum fasting duration for infant formula or cows milk is:

Answer 18

6 hours

Question 19

NPO instructions: before elective procedures minimum fasting duration for meal is:

Answer 19

8 hours

Question 20

Medication instructions for DM:

Answer 20

• Diabetics to take 75% of normal insulin dose (and have glucose ready in case of hypoglycemia). Hold oral hypoglycemic

Question 21

Medication instructions for patients taking beta-blockers:

Answer 21

Pts taking beta-blockers should take them on day of surgery

Question 22

Hold which medications?

Answer 22

Hold antiplatelet/anticoagulants

Question 23

Anesthesia consent major risks:

Answer 23

• Allergic reactions
• Death
• Stroke
• MI
• Loss of airway

Question 24

Anesthesia consent minor risks:

Answer 24

• Dental/oral damage
• Eye damage (corneal scratching, etc)
• Sore throat
• Body aches
• N/V
• Peripheral nerve injury
• Pain