Preoperative Interview Flashcards
What is the goal of the preoperative interview?
to bring the patient back to baseline or better
How you you calculate BMI?
weight in pounds/height in inches^2 x 703
The five A’s of the anesthesia exam include:
allergies, ate (NPO status), previous anesthesia hx., airway, & alert (LOC)
Why do we complete a preoperative interview?
standard 2
develop repoire w/ pt. & devise plan
reduces morbidity and mortality
allows us to optimize patient
Which standard refers to the care plan?
Standard 3
Which standard pertains to the consent?
Standard 4
Students never obtain consent; DO NOT SIGN the consent form as a student
Know the fast-hand method to calculate pounds to kg
patient is 120 pounds
120/2= 60 60-6= 54 kg
Why do we assess for MH & what precautions would we take?
MH is deadly and thus we want to prevent patient from developing; take vaporizers out of room, flush gas machine; patient should be first case of the day; remove succinylcholine from the room
What is OPL?
stands for oral pharyngeal laryngeal and we assess patient’s cervical ROM to see if we will be able to line up our axes
The purpose of the preoperative evaluation is to
evaluate current physical status and optimize the patient for surgery
Goals of the preoperative evaluation is
obtain medical and surgical histories
evaluate the patient and determine the need for preoperative studies or specialty consultations, formulate and deliver safe anesthetic plan, minimize perioperative morbidity and mortality, optimize patient safety and satisfaction, prevent surgical cancellations and delays
AANA’s standard 5
Documentation
AANA’s standard 2
Preanesthesia assessment and evaluation: general health, allergies, medication hx., preexisting conditions, anesthesia history, and relevant diagnostic tests
Included in an preoperative interview is:
verify 2 patient identifiers & verify and document the proposed surgical procedure and preoperative diagnosis
What is the purpose of preoperative interviews?
allows patients to come in within 1-2 weeks prior to surgery to allow for patient optimization, pre-arrange anticipated needs, order appropriate tests and prevent delayed or cancelled surgeries
Essential components of the anesthesia interview include
BMI (height & weight), allergies, NPO instructions, medications, previous anesthetics/complications, family history of MH, possibility of pregnancy, systems review, baseline level of cognition, airway assessment
When asking about allergies it is important to evaluate
allergies to drugs, dyes, contrasts, latex, foods, & tape as well as the reaction (anaphylaxis vs. hypersensitivty)
When asking about previous anesthetics/surgeries, it is important to evaluate:
type of surgery, type of anesthesia, date, complications: PONV, MH, difficult intubation, recall, prolonged wake-up, unplanned postop intubation
also has there been a significant weight gain since previous surgery
Malignant hyperthermia is
an inherited myopathy (autosomal dominant); triggered by volatile anesthetics and depolarizing muscle relaxants leading to–> hypermetabolic state
What does PAGES stand for?
phenylephrine, atropine, glycopyrrolate, edrophonium, and succinylcholine
emergency drugs that must be drawn up
What is the purpose of NPO guidelines?
reduce the risk of aspiration which leads to high incidence of morbidity and mortality
What is aspiration?
accidental inhalation of gastric contents into the lungs–>chemical burn of the tracehobronchial tree and pulmonary parenchyma–> intense parenchymal inflammatory reaction
What are the current NPO guidelines?
2 hours: clear liquid (water, black coffee, tea, pulp-free juice, carbonated beverages)
4 hrs: breast milk
6 hrs: formula or cows milk, tea & coffee with milk, full liquids, light meal, gum, sweets (hard candy)
8 hrs: full meal, fried, or fatty food
What are ways to prevent aspiration?
rapid sequence intubation
crichoid pressure
possibly NG tube
give bicitra (no tums) to neutralize stomach acid
Who is most at risk for aspiration?
Diabetes, obese, delayed gastric emptying, GERD (uncontrolled), pregnancy after 13 weeks, stroke patients, bowel obstruction, trauma or emergency (SNS engagement)
What is the ideal volume and pH of gastric juices for surgery?
<25 mL and pH >2.5
What is Selleck’s Maneuver?
holding cricoid cartilage pressure to protect against aspiration
How much force is applied with cricoid pressure?
3-4 kg; start at 3 lbs and progress to 6.6-8.8 lbs
Describe the Mallampati classes
0: epiglottis, pillars, uvula, soft, and hard palate
1: pillars, uvula, soft & hard palate
2: uvula, soft, & hard palate
3: soft palate & base of uvula
4: hard palate & tongue
What Mallampati class is associated with a difficult intubation?
MP 3 or 4
What is Patil’s test?
thyromental distance… with the head fully extended measure from the mentum to the thyroid notch
<6 cm associated with difficult intubation; greater than 7 cm is what we want to see
less space for the tongue to be compressed/displaced by the laryngoscope blade
What is the upper lip bite test?
tells us the patients ability to move maxilla and mandible
limited mouth opening is associated with a more difficult intubation
What does the prayer sign assess for?
subtle or overt joint contractures which allows us to assess cervical mobility
limited atlanto-occipital joint motion
a positive prayer sign test is bad
What does the cervical mobility tell us?
decreased cervical mobility prevents proper positioning for intubation (prevents optimal view of the glottic opening)
cannot be placed in ideal sniffing position
Dentition assessment is important because
we want to return patient to baseline so we need to know decay of teeth, loose teeth, cracks, chips, do you have any teeth that aren’t your own?
Important assessment with female patients
pregnancy assessment
should be asked in private to maintain patient privacy
What could prevent an appropriate mask seal?
facial hair;
could also disguise a short thyromental distance or retrognathia
What neck circumference is associated with a difficult intubation?
BMI > 40 kg/m2 + large neck circumference (>45 cm)
Describe the differences between general anesthesia, regional anesthesia, and IV sedation
general: total loss of consciousness; does not equal ET tube- could mean mask or LMA
regional: specific to a region of the body
IV sedation: might hear noises but keep them comfortable, sleepy, and breathing on own
What medications should be taken prior to surgery?
beta-blockers, GERD medications, calcium channel blockers, bronchodilators, antiarrhythmics, steroids, diuretics (if history of CHF), antipsychotics, thyroid medications
What medications should be held prior to surgery?
oral hypoglycemics, ACE-I, ARBs, diuretics if no hx. of CHF, herbal supplements, per surgeon’s decision- anticoagulants
What cardiovascular conditions do we assess during our preop assessment?
hypertension, angina, CAD, MI, valvular disease, syncope, CHF, edema, dyspnea, cardiac arrhythmias
What respiratory conditions do we assess during our preop assessment?
asthma, COPD, recent URIs, emphysema, bronchitis, pneumonia, tuberculosis, obstructive sleep apnea, tobacco use
What nervous system conditions do we assess during our preop assessment?
stroke, transient ischemic attacks, migraines, headaches, seizures, neuropathy
What GI conditions do we assess during our preop assessment?
GERD, bowel obstruction/hiatal hernia
At what pressure can the lower esophageal sphincter open?
the LES can open at 20 cmH2O if manually ventilating
What endocrine conditions do we assess for during our preop assessment?
diabetes, thyroid
Additional preop assessments include:
autoimmune (RA, CSpine), musculoskeletal (MS, myasthenia gravis, myopathy, fibromyalgia, myotonias, obesity, Sjogerns syndrome); alcohol & drug use; coagulation or hematologic disorders, hx of malignancy, psychiatric illness, infectious disease
What hepatic assessments do we assess for?
hepatitis, jaundice, cirrhosis, alcohol
consider coags: PT/PTT, liver panel, and EKG
What renal assessments do we perform?
RF, ESRD, Dialysis
lab tests: lytes, CBC, PT/PTT, LFT’s and EKG
Describe ASA 1
normal healthy patient
Describe ASA 2
mild systemic disease; well-managed diabetes or reflex
Describe ASA 3
severe systemic disease
Describe ASA 4
severe systemic disease that is a constant threat to life; dialysis, valve disease
Describe ASA 5
moribund patient not expected to survive without surgery
Describe ASA 6
declared brain-dead; anticipating organ procurement (donor)
ASA could also have an
E status which means emergency
Tests for a procedure with blood loss
CBC
Test to order for patient who is 50-60
EKG
Test to order for patient >60
EKG & CBC
Test to order for patient with cardiovascular disease
basic chem & EKG
Test to order for patient with pulmonary disease
EKG
Test to order for patient with malignancy
CBC & EKG
Test to order for patient with radiation therapy
CBC & EKG
Test to order for patient with hepatic disease or hepatitis history
PT/PTT, Liver panel, and EKG
Test to order for patient with renal disease
PT/PTT, basic chem, and EKG
Test to order for patient with bleeding disorder
CBC, PT/PTT, Platelet function
Test to order for patient with diabetes
Basic chem, glucose POC, EKG
Test to order for patient who is possibly pregnant
pregnancy test
Test to order for patient taking diuretic
Basic chem
Test to order for patient using digoxin
Basic chem, EKG, Digoxin level
Test to order for patient using long term steroids
Basic chem, Glucose POC
test to order for pt with CNS disease
CBC, basic chem, POC glucose, EKG
Test to order for pt with coumadin therapy
PT/PTT
Test to order for pt with recent pna (w/in two months)
CXR
Tests to order for patient with RA or down’s syndrome
Flexion, extension C-spine films
