Preoperative Evaluation and Management

Question 1

What questions should you ask yourself?

Answer 1

Does it make sense physiologically?
Is it based on evidence and/or consensus based guidelines?
Will it affect the procedure type, anesthetic choice or outcome?
Will it prevent a delay or cancellation?

Question 2

What to look for Peop Evaluation of the Airway?

Answer 2

Teeth-large, loose, overbite
Jaw mobility-ant/post, size
mouth opening- obvious, why
mallampate-Low PPV
mandibular compliance-radiation, mass
thyromental distance-3 fingerbreaths
Neck-size, short, thick, immobile

Question 3

ASA classification I?

Answer 3

Normal, healthy patient

Question 4

ASA classification II?

Answer 4

Mild systemic disease

Question 5

ASA classification III?

Answer 5

Severe, not incapacitating systemic disease

Question 6

ASA classification IV?

Answer 6

Incapacitating disease that is a constant threat to life

Question 7

ASA classification V?

Answer 7

Moribund pt. not expected to survive 24 hrs regardless of surgery

Question 8

ASA E classification

Answer 8

Suffex added to class, any pt in whom an emergency operation is required

Question 9

What do you look for in Preop Eval of the Pulmonary system?

Answer 9

Patient related factors - age (>60, >70), COPD (other lung dz), smoking, CHF, functional dependence, cognitive impairment, ASA classification, Obesity?, OSA?
Procedure related factors - site (most important), type, duration, anesthetic technique?, emergency surgery?

Question 10

What would look for an Pulmonary physical?

Answer 10

decreased breath sounds during auscultations, assess respiratory rate, use of accessory muscles, nail color, METs, upper respiratory infection, stridor, SOB, cough, tobacco use, OSA

Question 11

What do you see in an Airway classification !? (Mallampati and Grade after intubation)

Answer 11

Mallampati - soft palate, fauces, uvula, pillars

Grade - entire cords

Question 12

Airway classification II?

Answer 12

Mallampati - soft palate, fauces, uvula

Grade - half the cords

Question 13

Airway classification III?

Answer 13

Mallampati - soft palate, uvualar base

Grade - tip of epiglottis

Question 14

Airway classification IV?

Answer 14

Mallampati - hard palate only

Grade - no glottal structures

Question 15

What Pulmonary test will be performed?

Answer 15

CXR (you can have a baseline), Sprometry/PFT’s (only for lung dzs), BUN > 21, Serum Albumin<3.5

Question 16

What are some strategies to reduce pulmonary post op complications?

Answer 16

stop smoking, lung expansion modalities, NMBA’s and residual blockade, newroaxial techniques, nutritional support, NG tube and PAC

Question 17

How to evaluate OSA?

Answer 17

STOP BANG
Snoring, Tired, OSA, blood Pressure (high), BMI>35, Age>50, Neck >40cm, Gender (male)
CPAP available?

Question 18

Peop Evaluation for Cardiac?

Answer 18

AHA guidelines - active cardiac conditions, clinical risk factors, other minor clinical predictors, type of surgery, exertional capacity

Question 19

What would be considered active cardiac conditions?

Answer 19

Unstable coronary syndromes (angina), Decompensated HF (worsening or new onset), Significant arrhythmias (AV block, a-fib, v-tach, brady), Severe valvular disease (aortic or mitral stenosis)

Question 20

What do you look for in a cardiac history?

Answer 20

ischemic heart disease, CHF, CVD, Diabetes Mellitus, REnal Insufficiency

Question 21

What would be considered MET 1?

Answer 21

take care of yourself?
eat, dress, or use the toilet?
walk indoors around the house?
walk a block or 2 on level ground at 2 to 3 mph?

Question 22

MET 4?

Answer 22

do light work around the house like dusting or wash dishes?

climb a flight of stairs or walk up a hill?

Question 23

MET >10?

Answer 23

participate in strenuous sports like swimming, singles tennis, football, basketball or skiing

Question 24

What do you look at in an Electrocardiogram?

Answer 24

Significant findings - arrhythmias, Q waves, LVH with strain pattern, ischemia
Less significant - ST changes, BBB, poor R wave progression

Question 25

what to look at during a stress test?

Answer 25

Stressors/ Vasodilators (treadmill, dobutamine, DP), Test (EKG, echo, nuclear scan), coronary calcium scoring, CT coronary angiography, Catheterization

Question 26

What to ask when the patient has a stent?

Answer 26

``` Bare metal, drug eluting, type Date, location, difficulty Size, overlap, h/o previous thrombosis Patient's comorbidities, including CAD antiplatelet therapy risk of thrombosis vs surgical bleeding ```

Question 27

What other major comorbidities to consider?

Answer 27

DM - control BS 140-180, HgbA1C<9, pump thyroid - make euthyroid Renal Disease - baseline All other - not much direct intervention

Question 28

What other testing to look for?

Answer 28

CBC, Diff, Chem basic, Chem comp, Coagulation studies, UA and culture, Pregnancy testing

Question 29

What minor questions to as in the Preop?

Answer 29

Medication management, NPO, aspiration, SBE prophylaxis, Preop Medication Goals

Question 30

What to ask and look for in preop medication management?

Answer 30

In the last 7 days - Flavix, NSAIDS?, Herbals, Chemo Coumadin - 5days NIght Before - oral hypoglycemic agents, long acting insulin, parkinson's meds Morning of - stimulants, ACEI, ARBs, Diuretics

Question 31

Medications we should give for preop management?

Answer 31

``` Cardiac - antiarrhythmics, angina drugs Pulm - inhalers, nebs, po meds Endo - steroids, synthroid GI - PPIs, H2 blocks Psych meds Statins and beta blockers Seizure meds Eye drops, pain meds, transplant meds ```

Question 32

Recommendations of statins in Class I patients?

Answer 32

for pts currently taking statins and scheduled for non cardiac surgery, statins should be continued

Question 33

Recommendations of statins in Class IIa patients?

Answer 33

For patients undergoing vascular surgery with or without clinical risk factors, statin use is reasonable

Question 34

Recommendations of statins in Class IIb patients?

Answer 34

For patients with at least 1 clinical risk factor who are undergoing intermediate-risk procedures, statins may be considered

Question 35

What Herbals affect platelet function and inhibit clotting?

Answer 35

Affect platelet function - bilberyy, bromelain, don quoi, feverfew, fish oil, flax seed oil, garlic, ginger, ginko biloba, grape seed extract, saw palmetto Inhibit clotting - chamomile, dandelion root, dong quoi, horse chesnut, chonroitin

Question 36

What are the NPO guidelines?

Answer 36

Clear liquids - 2 hrs Breast Milk - 4 hrs Formula, light meal, other milk - 6 hrs Solid Food - 8 hrs or more

Question 37

What other problems can herbals cause?

Answer 37

worsen inflammation post op prolong anesthesia - kava kava, st johns wort, valerian garlic Cause post-op HTN - ephedra, ginseng, licorice, goldenseal, garlic Drug interaction - SJW, ephedra, echinacea, goldenseal, licorice, valerian, bromelain Evening primrose oil can cause seizures

Question 38

What are the Peop medication goals?

Answer 38

``` Anxiolysis, sedation Amnesia, analgesia Drying of secretion - glyco vs scop Blunting autonomic relfexes Reduce anesthetic requirements Facilitate smooth induction Antiemetics, reduction of gastric stuff ```