Preoperative Interview Flashcards
purpose of preop interview
- evaluate patient’s current physical status
- optimize patient for surgery
goals of preop interview
- obtain med/surgical history
- determine need for preop testing/consults
- form and deliver anesthetic plan
- minimize morbidity and mortality
- optimize patient safety/satisfaction
- prevent surgical cancellations/delays
AANA Standard 1
Patient’s Rights
AANA Standard 2
Preanesthesia patient assessment and evaluation
AANA Standard 3
Plan for anesthesia care
AANA Standard 4
Informed consent for anesthesia care and related services
AANA Standard 5
documenation
AANA Standard 6
equipment
components of anesthesia care documentation
- name and MRN
- name(s) of anesthesia professional(s) involved in care
- immediate preanesthesia assessment and evaluation
- anesthesia safety checks
- monitoring of patient
- airway techniques
- anesthesia meds (+ 5 rights)
- technique(s) used and positioning
- name + amounts of IV fluids
- IV lines
- complications, adverse reactions, or problems
- status of patient post-anesthesia
- document in timely and legible manner
Previous Pre-op anesthesia
- hospital admission prior to DOS
- preop interview by anesthesia provider
- many labs, x-rays, bowel prep, etc.
current pre-op anesthesia
- preoperative anesthesia interview clinics
- prior to actual DOS interview (phone or clinic)
- typically w/in 1-2 weeks of scheduled DOS
PAT clinic interviewers
- RN
- PA
- NP
- problem - they do not necessarily have all the in depth anesthesia knowledge to get all the information we need to provide safe anesthesia care
- why it is our job/obligation to verify all information on the DOS
essential components of anesthesia interview
- BMI (height and weight)
- allergies
- NPO status
- medications
- surgical history
- previous anesthetics/complications
- medical history
- pregnancy
- ROS
- Airway assessment
BMI Calculation
units = kg/m2
[weight (pounds) / height (inches)2] x 703
allergies
- allergen
- type of reaction
- differentiate between s/e and true allergic reactions
- throat/tongue swelling, difficulty breathing = anaphylaxis
- ask about –> drugs, dyes, contrast, latex, food, tape
anesthetic/surgical history
- type of surgery
- type of anesthesia
- date
- complications (PONV, MH, difficult intubation, recall, prolonged wake-up, unplanned post-op intubation)
past difficult intubation
- usually have letter/card from previous anesthesia provider or medic alert
- how to ask patient - sore throat for more than 2 days after surgery
- significant weight gain since last surgery? could make them a higher risk for difficult intubation
MH history
- MH = inherited myopathy (dysfunction of ryanadine receptor, cannot sequester calcium, sustained contraction, HEAT released, hypermetabolic state)
- inherited myopathy (autosomal dominant)
- triggered by volatile anesthetics and depolarizing NMBDs (succinylcholine)
- ask about patient or fam hx of MH + outcome
- ask about genetic testing
MH OR preparation
- remove vaporizers
- change CO2 absorbent
- change entire circuit
- flush machine with O2 flush
- know where emergency MH cart is
- try to make them the first case of the day
pertinent records to obtain
- associated with surgical or anesthetic complications
- consults
- special tests
- any records providing insight into patient’s status and/or complications
what does NPO stand for
- nil per os
- nothing by mouth
purpose of NPO guidelines
- reduce risk for aspiration
- educate patient on aspiration and importance of NPO guidelines
aspiration
accidental inhalation of gastric contents into lungs –> chemical burn of tracheobronchial tree and pulmonary parenchyma –> intense parenchymal inflammatory reaction
ideal GI environment for surgery
- gastric contents less than 25 mL
- pH > 2.5
patients with delayed gastric emptying times
- may require individualized guidelines
- DM
- recent injuries
- obesity
- abdominal complaints
- GERD
- pregnancy or recent delivery
- ascites
how do we manage increased aspiration risk
- neutralized stomach acid
- perform RSI (with ETT)
- induce with HOB up
- potential for NGT
2 hours
clear liquids (water, black coffee, tea, pulp-free juice, carbonated beverages)
4 hours
breast milk
6 hours
formula, cows milk, tea/coffee with milk, full liquids, light meal (low or nonfat), gum, sweets (hard candy)
8 hours
full meal, fried/fatty foods
Selleck’s Maneuver
- attempt to protect against aspiration
- straight downward force on cricoid cartilage
- compress the esophageal lumen between cricoid cartilage and cervical spine
- amount of force = 30-40 Newtons (or 3-4kg, 6.6-8.8 lbs)
Selleck’s Maneuver contraindications
- neck injury
- esophageal tear/rupture
- if pt is actively vomiting - can build up pressure and rupture esophagus
Physical exam baseline components
- heart/lung sounds
- breathing pattern
- bruising/scarring
- peripheral pulses
- edema
- VS
- mental status
airway assessments
- have many different tools we can use to determine whether or not patient will be a difficult intubation
- subjective assessments - dependent on provider as well as patient participation/position
Mallampati Class
- ID hard palate, soft palate, tonsils/faucial pillars, and uvula
- rating I-IV
- instruct patient - look at you with chin elevated, mouth open wide, and tongue sticking out
- MP class III or IV means greater chance of difficult airway
MP 0
visualize faucial pillars, hard palate, soft palate, uvula and epiglottis
MP 1
visualize faucial pillars, hard palate, soft palate, and uvula
MP 2
visualize faucial pillars, soft palate, and partial uvula
MP 3
visualize soft palate and base of uvula
MP 4
visualize hard palate only
mouth opening/inter-incisor gap
-want patient to be able to open mouth at least 3 fingerbreadths
temporomandibular joint (TMJ)
-maxilla and mandible meet (upper and lower jaw)
-ball and socket joint used to chew, talk, yawn
composed of muscles, tendons, bones
TMJ disorders
- limited mouth opening
- teeth grinders
- gum or fingernail chewers
- stress - clench teeth
- jaw trauma
thyromental distance/Patil’s test
- assessment of mandibular space
- head fully extended from the mentum to the thyroid notch (upper edge of thyroid cartilage to chin)
short thyromental distance
- less space to displace tongue
- visualization (intubation) may be difficult
- anterior larynx
- more acute angle
- less space for the tongue to be compressed into by the laryngoscope blade
normal thyromental distance
3 fingerbreadths
>7 cm usually associated with easy intubation
short thyromental distance
<6 cm may predict difficult intubation
prayer sign
- indicative of degree of mobility of joints (subtle or overt joint contractures, decreased joint/cartilage mobility)
- ask patient to place palms together
- negative prayer sign - can stick palms together, no space
- positive prayer sign - unable to stick palms flat together, could be indicative of difficult intubation (d/t potential for limited alanto-occipital joint movement)
decreased cervical mobility
-prevents proper positioning for intubation/prevents optimal view of glottic opening
assess cervical mobility
- ask patient to turn their head from side to side
- touch their chin to their chest
- point their chin to the ceiling
- ask about numbness/tingling in upper extremities while performing cervical mobility
sniffing position
- optimal position for intubation
- aligning of axes
OPL
- axes we want to align for intubation
- oral
- pharyngeal
- laryngeal
teeth/dentition
- assess teeth as good, fair or poor according to visible decay
- any loose, cracked, chipped teeth? –> document location
- note any dentures, partials, caps, crowns
neck circumference
- large neck circumference = >45 cm
- combination of this with large BMI could mean a difficult intubation
- increased adipose tissue is forced down by gravity when patient supine and has the potential to occlude airway
STOP BANG
- assessment tool for OSA
- Snore
- Tired
- Observed apneic/not breathing
- Pressure (high BP)
- BMI >35kg/m2
- Age older than 50 years
- Neck circumference > 40cm
- Gender (males more)
facial hair
- difficult mask seal
- disguise potential airway problems - retrognathia or short thyromental distance
possibility of pregnancy
- in biologically female patients
- LMP?
- sexually active?
- facility policy - may be required to obtain pregnancy test prior to surgery
- HCG - human chorionicgonadotropin
medications
- current medications (OTC, prescription, vitamins, herbal supplements, home remedies)
- which to take/hold DOS (pre op clinic)
- is patient reliable to report meds
meds to take before surgery
- beta-blockers
- GERD meds
- calcium channel blockers
- bronchodilators
- antiarrhythmics
- steroids
- diuretics (if hx CHF)
- antipsychotics
- sz medications
- thyroid meds
meds to hold before surgery
- oral hypoglycemics
- ACE inhibitors
- A2RBs
- diuretics (if no hx CHF)
- herbal supplements
- anticoagulants (on case by case basis per surgeon)
HTN (CV)
- duration of disease
- exercise tolerance
- recent EKG
- medication regimen (antihypertensives, compliance, well-controlled)
Angina/CAD/MI (CV)
- exercise tolerance, symptoms, precipitating factors
- last chest pain, date of MI, methods of relief
- interventions if any
- EKG, ECHO, Cath, most recent cardiologist visit, cardiac clearance
recent MI
6 months
newly diagnosed CHF or CHF + exacerbation requiring hospitalization in last 6 months
6 months
aortic stenosis
12 months
valvular disease (CV)
- do they have it? AS, AR, MS, MR, MVP?
- symptomatic, chest pain, SOB?
- prophylactic abx for dental work?
- recent and/or comparative ECG, ECHO, cardiology note/consult/clearance
syncope (CV)
- faint or pass out
- ask about cause
- last episode
- treatment
arrhythmias (CV)
- type
- intermittent or continuous
- interventions
- current medical management
- anticoagulants or antiarrhythmics
- review past/current ECG, cardiology notes
- heart block patients may have pacemaker/AICD
- may need device rep present (manufacturer’s card will have information); some places have trained device teams so no need for rep
CHF (CV)
- current disease status
- recent weight gain (get weight DOS)
- peripheral edema/anasarca
- dyspnea or difficultly breathing while lying flat
- recent exacerbation requiring hospitalization
- recent changes in medical management
- current EKG and recent ECHO with documented EF
- take diuretics DOS
asthma (resp)
- frequency of attacks
- trigger
- date of last attack
- hospitalizations, intubations, or ER
- treatment regiment (inhaler/neb type, how often, current or past oral steroids, home oxygen)
bronchitis/pneumonia (resp)
- date of last event
- med regimen
- pulmonary reports (CXR, PFT, ABG)
URI (resp)
-symptoms
-amount/color drainage
-treatment (abx?)
peds patients - change in activity level, appetite, fluid intake
emphysema (resp)
- oxygen at home
- meds (inhaler, neb, corticosteroids)
- pulm reports (PFTs, CXR, ABG)
TB (resp)
- active TB or positive PPD
- active or latent
- symptoms - persistent cough, chest pain, fatigue, loss of appetite, weight loss, fever, chills, night sweats
- new onset or worsening symptoms
- isoniazid therapy?
- CXR indicated if symptomatic
OSA (resp)
- CPAP or BiPAP (bring DOS)
- settings?
tobacco use (resp)
- packs per day (ask about vape, snuff, all tobacco products)
- years of use
- pack year = # years smoked x packs/day
- former smoker ask same details
stroke (neuro)
- date of occurrence
- CBF studies
- carotid doppler
- angiogram
- residual deficits - hemiparesis, dysphagia, visual disturbance
HA (neuro)
- frequency
- precipitating factors
- what relieves pain
- debilitating migraines
- seen neurologist?
seizures (neuro)
- hx of seizures
- type (grand mal, tonic clonic)
- frequency
- date of last activity
- cause (ETOH, head injury, febrile)
- med regimen
- assess anticonvulsant blood level (want therapeutic bc don’t want seizure during surgery)
- take anticonvulsant DOS
neuropathy (neuro)
- ID potential unique positioning needs
- site of neuropathy
- type (numbness, tingling, pain, loss of sensation)
GERD (GI)
- aspiration concern
- use and frequency of meds
- associated past surgeries (Nissen, esophageal dilation)
- factors and frequency of reflux
- dysphagia or chocking
- take GERD prescription meds DOS
hiatal hernia/bowel obstruction (GI)
-both at increased risk for aspiration
DM Type I or Type II (endocrine)
- insulin dependent
- oral hypoglycemics
- duration of disease
- followed by endocrinologist
- compliant with meds/BG checks
- talk to endo/patient about how to dose
- rule of thumb - HOLD oral hypoglycemics 24-48hrs + basal insulin will decrease night before and no short acting insulin in AM
hypothyroid disease (endocrine)
- weight gain since last surgery
- cold intolerance (bair hugger)
- fatigue
- depression (prescription meds)
- dry skin (careful with tape)
- muscle cramp
- assess goiter (potential encroachment on airway)
hyperthyroid disease (endocrine)
- weight loss
- increased HR (may be on beta blocker)
- heat sensitivity
- nervousness
- anxiety - may need benzos
RA (autoimmune)
- inflammation/chronic pain
- hoarseness or dysphagia
- steroid use
- stridor
- limited mouth opening
- possible cervical spine instability
- potential difficult airway d/t TMJ disease, decreased cervical spine mobility, or arytenoid joint mobility
MSK
- MSK d/o with implications r/t meds or positioning
- muscular dystrophies (NO succinylcholine)
hepatic
- hepatitis - type, date, tx
- jaundice - origin
- cirrhosis - tx
- alcohol - amt, frequency, type
- consider coagulation studies - PT/PTT, liver panel, ECG
renal
- renal failure (acute/chronic)
- ESRD - dialysis schedule, date of last dialysis, lytes, CBC, PT/PTT, LFTs, ECG
- dialysis (hemo or peritoneal)
social history
-alcohol
-tobacco produces
-recreational drugs
type, frequency, amount, time of last use
heme/onc
- hx of anemia
- coagulopathies
- ITP/TTP/HUS
- DVT
- PE
- anticoagulation
- sickle cell
- transfusions hx
- bleeding tendency
- cancer/malignancy
anesthetic plan components
- type of anesthesia (general, TIVA, regional)
- airway devices (ETT, LMA)
- type of induction (standard, RSI)
- medications
- monitoring modalities/special equipment (standard monitors, art line, central line, US, doppler, fluid warmer, bair hugger)
ASA 1
normal healthy patient
ASA 2
mild systemic disease
ASA 3
severe systemic disease
ASA 4
severe systemic disease that is a constant threat to life
ASA 5
moribund patient not expected to survive without surgery
ASA 6
declared brain dead; organ procurement
E classification
- emergency surgery; add to any of the ASA classifications
- get consent if possible
- anticipate equipment needs
- med considerations
- blood products
- additional help
informed consent
- as a student NEVER GET CONSENT
- discuss plan, alternatives, risks, potential complications with patient
- address patient questions
- obtain written consent (phone, verbal)
