Preoperative Evaluation and Anesthesia Documentation Flashcards
1
Q
purpose of preop evaluation
A
evaluate current physical status and optimize the patient for surgery
2
Q
goals of preop evaluation
A
obtain medical and surgical hx
evaluate the pt and determine the need for preop studies or consults
formulate and deliver safe anesthetic plan
minimize periop morbid/mortality
optimize pt safety and satisfaction
prevent surgical cancellations and delays
3
Q
which standards relate to the preop eval and documentation?
A
standard 2: preanesthesia patient assessment and evaluation
standard 4: informed consent for anesthesia care
standard 5: documentation
4
Q
what does standard 2 entail?
A
perform and document or verify documentation of a preanesthesia eval of the pt’s general health, allergies, medication hx, preexisting conditions, anesthesia hx, and any relevant diagnostic tests. Perform and document or verify documentation of an anesthesia focused physical assessment to form the anesthesia plan of care
5
Q
anesthesia care documentation
A
- name and facility ID number of pt
- name all anesthesia professionals involved in the pt’s care
- immediate preanesthesia assessment and evaluation
- anesthesia safety checks
- monitoring of the patient
- airway management techniques
- name, dosage, route, and time of admin of drugs and anesthetics
- techniques used and pt positioning
- name and amounts of IV fluids
- IV/intravascular lines inserted
- any complications, adverse reactions, or problems during anesthesia
- status of pt at the conclusion of anesthesia
- documentation in a timely and legible manner
6
Q
What would be an acceptable modification of the AANA standards?
A
emergency cases
7
Q
before the delivery of anesthesia care, the provider is responsible for
A
- reviewing the available medical record
- interviewing and performing a focused exam of the patient to discuss the medical hx and assess the pt’s physical condition that might affect decisions
- ordering and reviewing pertinent available tests and consultations as necessary
- ordering appropriate preop meds
- ensuring that consent has been obtained
- documenting in the chart that the above has been performed
8
Q
the record should include documentation of
A
- patient interview assessing pt and procedure, anticipated dispo, medical, surgical, and anesthetic hx, current meds, allergies, NPO status, advance directives
- appropriate physical exam
- objective diagnostic data
- medical consults
- ASA
- the anesthetic plan
- informed consent
- appropriate premed and prophylactic antibiotic admin
9
Q
essential components of the anesthesia interview
A
BMI, allergies, NPO instructions, meds, previous anesthetics/complications, family hx of MH, possibility of pregnancy, systems review, baseline level of cognition, airway assessment
10
Q
BMI - other name, equation
A
Quetelet Index
BMI (kg/m^2) = [weight (pounds) / height (inches)^2] x 703
11
Q
Normal range for BMI
A
18.5 - 24.99
12
Q
Overweight BMI
A
> 25
13
Q
Obese BMI
A
> 30
14
Q
Obese class I BMI
A
30-34.99
15
Q
Obese class 2 BMI
A
35-39.99
16
Q
Obese class 3 BMI
A
> 40
17
Q
preobese BMI
A
25-29.99
18
Q
underweight BMI
A
<18.5
19
Q
ask allergies to:
A
drugs, dyes, contrast, latex, foods, and tape
20
Q
things to consider when asking about allergies
A
exaggerated immune response or hypersensitivity?
allergen and the type of reaction
side effects
throat or tongue swelling, difficulty breathing?
21
Q
things to consider/ask when asking about anesthetic and surgical histories:
A
previous anesthesia/surgeries: type of surgery, type of anesthesia, date, complications (PONV, MH, difficult intubation, awareness/recall, prolonged wakeup, unplanned postop intubation)
did you receive a letter from anesthesia after your surgery?
prolonged sore throat after surgery?
significant weight gain since last surgery?
22
Q
things to ask about history of MH
A
family hx of MH?
did they survive?
have you had genetic testing?
23
Q
purpose of NPO guidelines?
A
reduce the risk of aspiration
24
Q
aspiration
A
accidental inhalation of gastric contents into the lungs = chemical burn of the tracheobronchial tree and pulmonary parenchyma = intense parenchymal inflammatory reaction
25
patients typically with longer stomach emptying times
diabetics, recent injuries, obesity, abdominal complaints, acid reflux, pregnant
26
what do we consider emergency/trauma cases in terms of NPO status?
full stomach
27
increased abdominal pressure/ascites puts patients at risk for
aspiration
28
clear liquids recommended fast
2 hours
29
examples of clear liquids
water, black coffee, tea, pulp free juice, carbonated beverages
30
breast milk recommended fast
4 hours
31
formula or cows milk, tea, coffee with milk/cream, full liquids, light meal, gum, sweets recommended fast
6 hours
32
full meal, fried or fatty food recommended fast
8 hours
33
What is Selleck's Manuever
straight downward force on the cricoid cartilage and cervical spine
attempts to protect against aspiration
compresses the esophageal lumen between the cricoid cartilage and cervical spine
34
how much force is used with the selleck's manuever
30-40 Newtons = 3-4 kg = 6.6-8.8 pounds
35
baseline physical exam includes
heart/breath sounds, breathing pattern, bruising/scarring, peripheral pulses/edema, vital signs, mental status, sensory/motor deficits, airway
36
airway assessment
identify hard and soft palate, tonsil, faucial pillars, and uvula
determine Mallampati class (I-IV)
have patient look at you at chin level, open wide, stick tongue out
37
Mallampati Class I
faucial pillars, hard and soft palate, and uvula
38
Mallampati Class II
faucial pillars, soft palate, and partial uvula
39
Mallampati Class III
soft palate and base of uvula
40
Mallampati Class IV
hard palate only
41
which class(es) are at greatest chance of a difficult airway?
Mallampati III and IV
42
Who typically has TMJ disorders?
teeth grinders, gum or fingernail chewers, malocclusion, stress (teeth clenchers), jaw trauma
43
What makes up the temporomandibular joint?
where the maxilla and mandible meet, muscles, tendons, and bones
it is a ball and socket joint
used to chew, talk, and yawn
44
Thyromental distance assessment
have pt fully extend from the mentum to the thyroid notch (Patil's test)
45
a short thyromental distance indicates
visualization during intubation difficult
more acute angle
less space for the tongue to be compressed by the blade
46
What is a normal thyromental distance
3 fingerbreadths
>7 cm = easy intubation
<6 cm = difficult intubation most likely
47
Prayer Sign assessment
shows if pt has decreased mobility of joints and cartilage
| difficult intubation = unable to put palms flat against eachother
48
cervical spine involvement results in limited _____ motion
atlanto-occipital joint
indicates difficult intubation
49
decreased cervical mobility
prevents proper positioning for intubation
| prevents an optimal view of the glottic opening
50
cervical mobility assessment
turn head side to side, touch chin to chest, point chin to ceiling
51
aligning airway axis is called
sniffing position
52
teeth assessment
good, fair, poor according to visible decay
ask if they have any loose, cracked, or chipped teeth
document which tooth/teeth
note dentures, partial plates, caps, or crowns
53
neck circumference risk for difficult intubation
>45 cm + BMI >40 kg/m^2
54
what is a concern with someone who has facial hair?
may not want to shave
difficult mask seal
disguises potential airway problems (short thyromental distance, retrognathia)
55
what should you ask females?
LMP, possibility of pregnancy, sexually active
| look at facility policy for blood or urine Hcg test
56
which categories of meds should prompt further questioning?
anticoags, antidysrhythmics, antihypertensives, beta blockers, bronchodilators, diuretics, opioids, vasodilators
57
which meds should patients generally take day of surgery?
beta blockers, GERD meds, Ca+Ch blockers, bronchodilators, antiarrhythmics, steroids, diuretics, antipsychotics, thyroid meds
58
which meds should patients generally hold day of surgery?
oral hypoglycemics, ACE inhibitors, ARBS, diuretics used for HTN, herbal supplements, and anticoagulants per surgeon order
59
which preop conditions should get a CBC prior to surgery?
procedures with blood loss, >60, malignancy, radiation therapy, bleeding disorder, CNS disease
60
which preop conditions should get a PT/PTT?
hepatic disease, hepatitis hx, renal disease, bleeding disorder, coumadin therapy
61
which preop condition should get platelet function assay?
bleeding disorder
62
which preop conditions should get basic chemistry?
cardiovascular disease, renal disease, diabetes, diuretic use, digoxin use, steroid use (long term), CNS disease
63
which preop condition should get glucose testing day of surgery?
diabetes, steroid use, CNS disease
64
which preop conditions should get liver panel testing?
hepatic disease, hepatitis hx
65
which preop conditions should get an ekg?
50-60 year olds, >60, cardiovascular disease, pulmonary disease, malignancy, radiation therapy, hepatic disease, hepatitis hx, renal disease, diabetes, digoxin use, CNS disease
66
which preop condition should get flexion extension c spine films?
rheumatoid arthritis, down's syndrome
67
pertinent things to cover in cardiovascular review
HTN, angina, CAD, MI, valvular disease, syncope, CHF, edema, cardiac arrhythmias
68
Hypertension things to consider
duration of disease, exercise tolerance, recent ekg, medication regimen
69
Angina/CAD/MI things to consider
exercise tolerance, symptoms, precipitating factors, last chest pain, date of MI, methods of relief, interventions if any (stents, ED visit, nitro, cath lab), ekg, echo, cardiac cath, most recent cardiologist visit, cardiac clearance
70
recent MI (within past 6 months) cardiac clearance
within 6 months
71
newly diagnosed CHF or exacerbation with hospitalization within past 6 months cardiac clearance
within 6 months
72
aortic stenosis cardiac clearance
within 12 months
73
valvular disease things to consider
which valve(s)?, stenosis or regurg? symptomatic?, do you take antibiotics for dental work?, recent ekg, echo, cardiology notes/consults/clearance
74
syncope and cardiac arrhythmias things to consider
do you faint or pass out? if yes, what causes it and last episode, what treatment
consider conduction block
75
someone with pacemaker/AICD considerations
look at info card, last check of device, facilitate manufacturer representative is there day of surgery, review ekg, notes, cardiac clearance
76
CHF considerations
current disease status, recent weight gain, edema, dyspnea, recent exacerbation requiring hospitalization, recent changes to management, current ekg and recent echo with EF
have them take diuretics DOS
77
respiratory diseases/conditions that prompt more investigation
asthma, chronic bronchitis, emphysema, recent URI, pneumonia, tuberculosis, OSA, tobacco use
78
things to consider with asthma
frequency of attacks, triggers, last attack, hospitalizations, intubations, treatment regimen, do they use an inhaler or nebulizer, how often do they use their meds, any steroid use, do they need oxygen
79
bronchitis/pneumonia/URI considerations
date of event, medication regimen, any notes, cxray, PFTs, abgs, what symptoms, antibiotics?
for pediatrics: activity level, appetite, fluid intake
80
emphysema considerations
require home o2?, use inhaler, neb, corticosteroids?, notes, PFTs, abgs, cxrs
81
tuberculosis considerations
active? symptomatic? new onset or worsening of symptoms? isoniazid therapy? cxray
82
OSA considerations
use CPAP or BIPAP? document settings, have patient bring machine with them
83
tobacco use considerations
number of packs per day, number years smoked, ask about vaping, chew, dip, if former smoker still ask and when they quit
(# cigarettes per day x years smoked) / 20
84
which conditions should prompt further questioning for nervous system
stroke, TIA, headaches, seizures, neuropathy
85
stroke/TIA considerations
date of occurrence, cerebral blood flow studies, carotid doppler, angiogram, residual deficits?
86
headache considerations
how frequently? precipitating factors? treatment that relieves? are they debilitating?, referred or seen a neurologist?
87
seizure considerations
hx? (type, frequency, last seizure, cause, med regimen), assess blood levels, have them take anticonvulsants on DOS
88
neuropathy considerations
identify positioning needs, get a baseline, influences choice of anesthetic, where is the neuropathy, what type of neuropathy, is it related to type of procedure they are having (ACDF)?
89
the lower esophageal sphincter can open if
exceed 20 cmH2O and manual ventilating
90
anesthetic plan includes
type of anesthesia, airway devices, type of induction, medications, monitoring modalities/special equipment
91
ASA 1
normal healthy pt
92
ASA 2
mild systemic disease
93
ASA 3
severe systemic disease
94
ASA 4
severe systemic disease that is a constant threat to life
95
ASA 5
moribound pt not expected to live without procedure
96
ASA 6
declared brain dead, organ procurement
97
ASA/Emergency cases
consent if possible, consider full stomach, blood products?
98
what to document?
patient ID verified, invasive procedures, techniques used, special equipment used, ventilation modes, incision, induction, intubation, extubation, verified surgical procedure, gas machine check, times (in room, antibiotics), transport, patient status, collaborative efforts, name individuals that did procedures
