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Anesthesia Concepts 1 > Preoperative Planning & Management > Flashcards

Preoperative Planning & Management Flashcards

1
Q

Clinic Visit Occurs:

A

Days to weeks preprocedure

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2
Q

Phone call occurs:

A

Scheduled procedure

Night before

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3
Q

Bedside Assessment Occurs:

A

Same day, night before (if inpatient), in ED/OR/cath lab (if emergent)

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4
Q

Bedside Assessment Steps

A
  • chart review
  • order pre-op test/consults
  • order pre-op meds
  • patient interview
  • physical exam
  • assess current status
  • answer questions
  • obtain informed consent
  • modify care plan
  • documentation
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5
Q

Cardiac Assessment Determines:

A
  1. preexisting cardiac disease
  2. disease severity, stability and prior treatment
  3. comorbidites
  4. surgical procedure
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6
Q

What do you do if it is a new onset cardiac issue?

A

have evaluated prior to anesthesia

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7
Q

What is new onset cardiac issues and need emergent surgery?

A

advise risk to patient
plan to minimize risk
possible invasive monitoring
TEE intraop

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8
Q

Unstable Coronary Syndromes:

A

unstable or severe angina

MI w/i 30 days

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9
Q

Significant Arrhythmias

A 
high grade AV block
symptomatic ventricular arrhythmias 
ventricular rate >100 beats/min
symptomatic brady
ventricular tachy
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10
Q

Severe valvular disease

A 
severe AS  (gradient pressure >40, area <1cm2, or symptomatic)
symptomatic MS
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11
Q

Clinical Risk Factors (cardiac)

A 
history of myocardial disease
currently stable but history of heart disease
history of cerebrovascular disease
diabetes
renal failure (creat >2)
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12
Q

What is a good functional capacity?

A

4 METS

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13
Q

Determine functional capacity by asking these two questions:

A
  1. Are you able to climb two flights of steps w/o stopping?

2. Are you able to walk four city blocks w/o stopping?

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14
Q

1 MET

A

Poor functional capacity
self-care:eating, dressing or using toilet
walking indoors
walking 1-2 blocks on ground level @ 2-3mph

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15
Q

4 MET

A

Minimal goal: good functional capacity
Light housework, flight of stairs w/o stopping, walking up hill longer than 1-2 blocks, walking ground level @ 4mph, running short distance, heavy housework, moderate recreational activities

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16
Q

> 10 METS

A

excellent functional capacity

strenuous sports, rope skipping, running, soccer, swimming

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17
Q

Cardiac Risk Index: Risk Categories

A
  • High risk surgery (aortic, vascular)
  • Ischemic heart disease
  • history of compensated CHF
  • history of CVA
  • DM
  • Renal insufficiency (creatinine >2)
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18
Q

Estimated complication %: 0 risk factors

A

0.4%

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19
Q

Estimated complication %: 1 risk factor

A

0.9%

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20
Q

Estimated complication %: 2

A

7%

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21
Q

Estimated complication %: 3 or more

A

11%

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22
Q

Risks of HTN

A

CAD, increased intraop mortality

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23
Q

Stage 3 uncontrolled HTN

A

SBP >180

DBP >110

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24
Q

Patients presenting for surgery with uncontrolled HTN

A

if elective: postpone

if emergent: manage bp, consider a-line, monitor for periop cardiac ischemia, refer post-op management

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25
Q

Coronary Stents

A

increased risk for stent thrombosis
perioperative MI
hemorrhagic complications
death in patients having noncardiac surgery performed early after stent placements

26
Q

Information important for cardiac implantable electronic devices

A

Date of last interrogation: 6mo for ICD, 12 mo for pacer

  • device type, manufacture, model
  • indication for placement
  • battery longevity
  • any leads placed w/i 3 months
  • current programing
  • are they dependent
  • device response to magnet placement
  • any alert status on device
  • last pacing threshold
27
Q

Respiratory disease that places you at risk for post-op complications

A

COPD, emphysema, asthma

28
Q

Respiratory: when to post-pone surgery

A

severe dyspnea, wheezing, pulmonary congestion, pac02 >50

29
Q

OSA questions

A
  • Do they have diagnosed OSA?
  • Do they use CPAP?
  • Does family know how to use unit?
30
Q

STOP-bang

A

Snoring, Tired, Observed (stop breathing), blood Pressure

B-BMI, A-age, N-neck circumference, Gender- male

31
Q

URI Pediatric Patient

A

Increases risk for post-op respiratory related adverse events

32
Q

Decision to proceed with pediatric surgery with URI

A

urgency?
duration?
complexity?
need for instrumentation of airway?

33
Q

Neurologic Assessment

A

Document baseline-muscle weakness, neuropathy, mental status
Consider risk for post-op delirium
Neuro assessment may inform if patient can tolerate MAC

34
Q

Patients that may not tolerate MAC

A

tremors, confused, anxious, not able to follow commands

35
Q

Pre-op evaluation of GI system

A

Is my patient at risk for aspiration?- n/v, abd distention, dysphagia, gastroparesis, reflux
Is my patient hypovolemic? - diarrhea, gi bleeding, prep

36
Q

How to determine severity of GERD:

A 
How often do you experience GERD?
Causes?
Management?
# of pillows at night?
Do you wake up in the middle of the night with acid?
37
Q

Full stomach: elective surgery

A

delay procedure

38
Q

If elective surgery and full stomach r/t obstruction/gastroparesis:

A

place awake NGT

39
Q

Emergent surgery: full stomach

A

RSI and asleep OG/NG

40
Q

NPO guidelines: clear liquids, breast milk, formula, non-human milk, solids

A 
clear liquids: 2 hours
breast milk: 4 hours
infant formula: 6 hours
non-human milk: 8 hours
solids: 8 hours
41
Q

Hepatic Assessment

A

screening for acute of chronic liver disease

if present: avoid certain drugs, optimize hepatic blood flow

42
Q

Renal Assessment on dialysis:

A 
where is their fistula
dialysis schedule
last dialysis treatment
how much fluid was removed
serum K
43
Q

DM

A

Schedule early in day

44
Q

Hyperthyroidism

A

continue antithyroid medication and beta blocker
is not euthyroid: reschedule if elective
increased risk for mortality if thyroid storms

45
Q

Hypothyroid

A

Continue Synthroid

increased risk for mortality if myxedema coma

46
Q

Smoking assessment

A

packs per day/years
quitting date (>8 weeks improves outcomes)
chronic symptoms

47
Q

ETOH

A

history
drinks per week/day
h/o DTs

48
Q

Non-prescription drugs

A

cocaine-avoid ephedrine
marijuana, amphetamines, narcotics, benzos
OTC
herbals

49
Q

Instructions for smokers

A

stop smoking at least 12-48 hours or 4 weeks

12 hour abstinence reduces effects of nicotine & carbon monoxide

50
Q

Medication assisted treatment

A

Methadone and buprenorphine address opioid use
Disulfiram and Acamprosate are used for alcohol use
naltrexone can be for both alcohol and opioids
Do not taper, discontinue or abruptly change MAT regimen perioperatively
Collaborate with addiction professional or MAT prescriber
May require addition of a rescue opioid at a higher dose

51
Q

Anesthesia History

A

Postoperative nausea & vomiting
Elevated temperature post operatively: self or relative
Difficult airway
Emergence delirium, post op delirium
Anaphylaxis, cardiopulmonary collapse
Post op weakness, intubation (atypical plasma cholinesterase)
Recall

52
Q

Labs/test pre-op

A

age/diagnosis protocol per institution
EKG >45
CXR- age or disease
pregnancy test

53
Q

Indication for CXR

A

previous abnormal result
history of malignancy where pulmonary mets will alter surgery
history of TB or +skin test and no treatment
signs of pulmonary infection
suspected intra-thoracic condition- tumor
congenital heart disease
premature with residual bronchopulmonary dysplasia
severe OSA
down syndrome
symptomatic or debilitating asthma, COPD or cardiovascular disease

54
Q

Indication for EKG

A

risk for CV disease (cocaine use, htn, cp, CKD, PVD, thyroid disease, DM, inability to exercise, significant pulmonary disease, smoking, ischemic heart disease, heart failure, CVA, murmur, inherited prolonged QT syndrome, OSA, morbid obesity

55
Q

ASA I

A

normal healthy patient, non-smoker, no or minimal ETOH

56
Q

ASA II

A

patient with mild systemic disease

smoker, social alcohol drinker, pregnancy, obesity, well controlled DM/HTN, mild lung disease

57
Q

ASA III

A

severe systemic disease

functional limitations. one or more moderate to severe disease
poorly controlled DM, HTN, COPD, morbid obesity, hepatitis, alcohol dependence or abuse, impaired pacemaker, poor EF, ESRD w/ dialysis, MI, CVA, CAD

58
Q

ASA IV

A

patient with severe systemic disease that is a constant threat to life

recent <3 mo MI CVA TIA CAD, ongoing cardiac ischemia, severe reduction in EF, shock, sepsis, DIC, ARD, ESRD no on dialysis regularly

59
Q

ASA V

A

not expected to survive without operation

ruptured AAA, massive trauma, ICH w/ mass effect, ischemic bowel

60
Q

ASA VI

A

Brain dead

61
Q

Discuss plan

A

CMS Requirement
Type of Anesthesia (general, regional, monitored Anesthesia Care)
Special Monitoring (CVP, TEE): requires consent
Transfusion: requires consent
Pre op instructions
If more than one option is presented to be decided on day of surgery, document that
Alternative options explained to patient

62
Q

Pediatric pre-op

A

can refuse but cannot legally consent
explanations should be age appropriate
parent or legal guardian if under 18
consider parent for induction

Anesthesia Concepts 1 (5 decks)

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