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N928 - Basics of Anesthesia > Preoperative Interview > Flashcards

Preoperative Interview Flashcards

1
Q

purpose of preop interview

A
  • evaluate patient’s current physical status

- optimize patient for surgery

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2
Q

goals of preop interview

A
  • 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
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3
Q

AANA Standard 1

A

Patient’s Rights

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4
Q

AANA Standard 2

A

Preanesthesia patient assessment and evaluation

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5
Q

AANA Standard 3

A

Plan for anesthesia care

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6
Q

AANA Standard 4

A

Informed consent for anesthesia care and related services

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7
Q

AANA Standard 5

A

documenation

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8
Q

AANA Standard 6

A

equipment

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9
Q

components of anesthesia care documentation

A
  • 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
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10
Q

Previous Pre-op anesthesia

A
  • hospital admission prior to DOS
  • preop interview by anesthesia provider
  • many labs, x-rays, bowel prep, etc.
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11
Q

current pre-op anesthesia

A
  • preoperative anesthesia interview clinics
  • prior to actual DOS interview (phone or clinic)
  • typically w/in 1-2 weeks of scheduled DOS
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12
Q

PAT clinic interviewers

A
  • 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
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13
Q

essential components of anesthesia interview

A
  • BMI (height and weight)
  • allergies
  • NPO status
  • medications
  • surgical history
  • previous anesthetics/complications
  • medical history
  • pregnancy
  • ROS
  • Airway assessment
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14
Q

BMI Calculation

A

units = kg/m2

[weight (pounds) / height (inches)2] x 703

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15
Q

allergies

A
  • 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
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16
Q

anesthetic/surgical history

A
  • type of surgery
  • type of anesthesia
  • date
  • complications (PONV, MH, difficult intubation, recall, prolonged wake-up, unplanned post-op intubation)
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17
Q

past difficult intubation

A
  • 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
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18
Q

MH history

A
  • 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
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19
Q

MH OR preparation

A
  • 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
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20
Q

pertinent records to obtain

A
  • associated with surgical or anesthetic complications
  • consults
  • special tests
  • any records providing insight into patient’s status and/or complications
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21
Q

what does NPO stand for

A
  • nil per os

- nothing by mouth

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22
Q

purpose of NPO guidelines

A
  • reduce risk for aspiration

- educate patient on aspiration and importance of NPO guidelines

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23
Q

aspiration

A

accidental inhalation of gastric contents into lungs –> chemical burn of tracheobronchial tree and pulmonary parenchyma –> intense parenchymal inflammatory reaction

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24
Q

ideal GI environment for surgery

A
  • gastric contents less than 25 mL

- pH > 2.5

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25
Q

patients with delayed gastric emptying times

A
  • may require individualized guidelines
  • DM
  • recent injuries
  • obesity
  • abdominal complaints
  • GERD
  • pregnancy or recent delivery
  • ascites
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26
Q

how do we manage increased aspiration risk

A
  • neutralized stomach acid
  • perform RSI (with ETT)
  • induce with HOB up
  • potential for NGT
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27
Q

2 hours

A

clear liquids (water, black coffee, tea, pulp-free juice, carbonated beverages)

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28
Q

4 hours

A

breast milk

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29
Q

6 hours

A

formula, cows milk, tea/coffee with milk, full liquids, light meal (low or nonfat), gum, sweets (hard candy)

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30
Q

8 hours

A

full meal, fried/fatty foods

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31
Q

Selleck’s Maneuver

A
  • 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)
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32
Q

Selleck’s Maneuver contraindications

A
  • neck injury
  • esophageal tear/rupture
  • if pt is actively vomiting - can build up pressure and rupture esophagus
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33
Q

Physical exam baseline components

A
  • heart/lung sounds
  • breathing pattern
  • bruising/scarring
  • peripheral pulses
  • edema
  • VS
  • mental status
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34
Q

airway assessments

A
  • 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
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35
Q

Mallampati Class

A
  • 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
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36
Q

MP 0

A

visualize faucial pillars, hard palate, soft palate, uvula and epiglottis

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37
Q

MP 1

A

visualize faucial pillars, hard palate, soft palate, and uvula

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38
Q

MP 2

A

visualize faucial pillars, soft palate, and partial uvula

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39
Q

MP 3

A

visualize soft palate and base of uvula

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40
Q

MP 4

A

visualize hard palate only

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41
Q

mouth opening/inter-incisor gap

A

-want patient to be able to open mouth at least 3 fingerbreadths

42
Q

temporomandibular joint (TMJ)

A

-maxilla and mandible meet (upper and lower jaw)
-ball and socket joint used to chew, talk, yawn
composed of muscles, tendons, bones

43
Q

TMJ disorders

A
  • limited mouth opening
  • teeth grinders
  • gum or fingernail chewers
  • stress - clench teeth
  • jaw trauma
44
Q

thyromental distance/Patil’s test

A
  • assessment of mandibular space

- head fully extended from the mentum to the thyroid notch (upper edge of thyroid cartilage to chin)

45
Q

short thyromental distance

A
  • 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
46
Q

normal thyromental distance

A

3 fingerbreadths

>7 cm usually associated with easy intubation

47
Q

short thyromental distance

A

<6 cm may predict difficult intubation

48
Q

prayer sign

A
  • 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)
49
Q

decreased cervical mobility

A

-prevents proper positioning for intubation/prevents optimal view of glottic opening

50
Q

assess cervical mobility

A
  • 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
51
Q

sniffing position

A
  • optimal position for intubation

- aligning of axes

52
Q

OPL

A
  • axes we want to align for intubation
  • oral
  • pharyngeal
  • laryngeal
53
Q

teeth/dentition

A
  • assess teeth as good, fair or poor according to visible decay
  • any loose, cracked, chipped teeth? –> document location
  • note any dentures, partials, caps, crowns
54
Q

neck circumference

A
  • 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
55
Q

STOP BANG

A
  • 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)
56
Q

facial hair

A
  • difficult mask seal

- disguise potential airway problems - retrognathia or short thyromental distance

57
Q

possibility of pregnancy

A
  • in biologically female patients
  • LMP?
  • sexually active?
  • facility policy - may be required to obtain pregnancy test prior to surgery
  • HCG - human chorionicgonadotropin
58
Q

medications

A
  • current medications (OTC, prescription, vitamins, herbal supplements, home remedies)
  • which to take/hold DOS (pre op clinic)
  • is patient reliable to report meds
59
Q

meds to take before surgery

A
  • beta-blockers
  • GERD meds
  • calcium channel blockers
  • bronchodilators
  • antiarrhythmics
  • steroids
  • diuretics (if hx CHF)
  • antipsychotics
  • sz medications
  • thyroid meds
60
Q

meds to hold before surgery

A
  • oral hypoglycemics
  • ACE inhibitors
  • A2RBs
  • diuretics (if no hx CHF)
  • herbal supplements
  • anticoagulants (on case by case basis per surgeon)
61
Q

HTN (CV)

A
  • duration of disease
  • exercise tolerance
  • recent EKG
  • medication regimen (antihypertensives, compliance, well-controlled)
62
Q

Angina/CAD/MI (CV)

A
  • 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
63
Q

recent MI

A

6 months

64
Q

newly diagnosed CHF or CHF + exacerbation requiring hospitalization in last 6 months

A

6 months

65
Q

aortic stenosis

A

12 months

66
Q

valvular disease (CV)

A
  • 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
67
Q

syncope (CV)

A
  • faint or pass out
  • ask about cause
  • last episode
  • treatment
68
Q

arrhythmias (CV)

A
  • 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
69
Q

CHF (CV)

A
  • 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
70
Q

asthma (resp)

A
  • 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)
71
Q

bronchitis/pneumonia (resp)

A
  • date of last event
  • med regimen
  • pulmonary reports (CXR, PFT, ABG)
72
Q

URI (resp)

A

-symptoms
-amount/color drainage
-treatment (abx?)
peds patients - change in activity level, appetite, fluid intake

73
Q

emphysema (resp)

A
  • oxygen at home
  • meds (inhaler, neb, corticosteroids)
  • pulm reports (PFTs, CXR, ABG)
74
Q

TB (resp)

A
  • 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
75
Q

OSA (resp)

A
  • CPAP or BiPAP (bring DOS)

- settings?

76
Q

tobacco use (resp)

A
  • 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
77
Q

stroke (neuro)

A
  • date of occurrence
  • CBF studies
  • carotid doppler
  • angiogram
  • residual deficits - hemiparesis, dysphagia, visual disturbance
78
Q

HA (neuro)

A
  • frequency
  • precipitating factors
  • what relieves pain
  • debilitating migraines
  • seen neurologist?
79
Q

seizures (neuro)

A
  • 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
80
Q

neuropathy (neuro)

A
  • ID potential unique positioning needs
  • site of neuropathy
  • type (numbness, tingling, pain, loss of sensation)
81
Q

GERD (GI)

A
  • 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
82
Q

hiatal hernia/bowel obstruction (GI)

A

-both at increased risk for aspiration

83
Q

DM Type I or Type II (endocrine)

A
  • 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
84
Q

hypothyroid disease (endocrine)

A
  • 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)
85
Q

hyperthyroid disease (endocrine)

A
  • weight loss
  • increased HR (may be on beta blocker)
  • heat sensitivity
  • nervousness
  • anxiety - may need benzos
86
Q

RA (autoimmune)

A
  • 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
87
Q

MSK

A
  • MSK d/o with implications r/t meds or positioning

- muscular dystrophies (NO succinylcholine)

88
Q

hepatic

A
  • hepatitis - type, date, tx
  • jaundice - origin
  • cirrhosis - tx
  • alcohol - amt, frequency, type
  • consider coagulation studies - PT/PTT, liver panel, ECG
89
Q

renal

A
  • renal failure (acute/chronic)
  • ESRD - dialysis schedule, date of last dialysis, lytes, CBC, PT/PTT, LFTs, ECG
  • dialysis (hemo or peritoneal)
90
Q

social history

A

-alcohol
-tobacco produces
-recreational drugs
type, frequency, amount, time of last use

91
Q

heme/onc

A
  • hx of anemia
  • coagulopathies
  • ITP/TTP/HUS
  • DVT
  • PE
  • anticoagulation
  • sickle cell
  • transfusions hx
  • bleeding tendency
  • cancer/malignancy
92
Q

anesthetic plan components

A
  • 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)
93
Q

ASA 1

A

normal healthy patient

94
Q

ASA 2

A

mild systemic disease

95
Q

ASA 3

A

severe systemic disease

96
Q

ASA 4

A

severe systemic disease that is a constant threat to life

97
Q

ASA 5

A

moribund patient not expected to survive without surgery

98
Q

ASA 6

A

declared brain dead; organ procurement

99
Q

E classification

A
  • emergency surgery; add to any of the ASA classifications
  • get consent if possible
  • anticipate equipment needs
  • med considerations
  • blood products
  • additional help
100
Q

informed consent

A
  • as a student NEVER GET CONSENT
  • discuss plan, alternatives, risks, potential complications with patient
  • address patient questions
  • obtain written consent (phone, verbal)

N928 - Basics of Anesthesia (17 decks)

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