Preoperative Planning & Management Flashcards
1
Q
Clinic Visit Occurs:
A
Days to weeks preprocedure
2
Q
Phone call occurs:
A
Scheduled procedure
Night before
3
Q
Bedside Assessment Occurs:
A
Same day, night before (if inpatient), in ED/OR/cath lab (if emergent)
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
5
Q
Cardiac Assessment Determines:
A
- preexisting cardiac disease
- disease severity, stability and prior treatment
- comorbidites
- surgical procedure
6
Q
What do you do if it is a new onset cardiac issue?
A
have evaluated prior to anesthesia
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
8
Q
Unstable Coronary Syndromes:
A
unstable or severe angina
MI w/i 30 days
9
Q
Significant Arrhythmias
A
high grade AV block symptomatic ventricular arrhythmias ventricular rate >100 beats/min symptomatic brady ventricular tachy
10
Q
Severe valvular disease
A
severe AS (gradient pressure >40, area <1cm2, or symptomatic) symptomatic MS
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)
12
Q
What is a good functional capacity?
A
4 METS
13
Q
Determine functional capacity by asking these two questions:
A
- Are you able to climb two flights of steps w/o stopping?
2. Are you able to walk four city blocks w/o stopping?
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
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
16
Q
> 10 METS
A
excellent functional capacity
strenuous sports, rope skipping, running, soccer, swimming
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)
18
Q
Estimated complication %: 0 risk factors
A
0.4%
19
Q
Estimated complication %: 1 risk factor
A
0.9%
20
Q
Estimated complication %: 2
A
7%
21
Q
Estimated complication %: 3 or more
A
11%
22
Q
Risks of HTN
A
CAD, increased intraop mortality
23
Q
Stage 3 uncontrolled HTN
A
SBP >180
DBP >110
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
25
Coronary Stents
increased risk for stent thrombosis
perioperative MI
hemorrhagic complications
death in patients having noncardiac surgery performed early after stent placements
26
Information important for cardiac implantable electronic devices
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
Respiratory disease that places you at risk for post-op complications
COPD, emphysema, asthma
28
Respiratory: when to post-pone surgery
severe dyspnea, wheezing, pulmonary congestion, pac02 >50
29
OSA questions
- Do they have diagnosed OSA?
- Do they use CPAP?
- Does family know how to use unit?
30
STOP-bang
Snoring, Tired, Observed (stop breathing), blood Pressure
B-BMI, A-age, N-neck circumference, Gender- male
31
URI Pediatric Patient
Increases risk for post-op respiratory related adverse events
32
Decision to proceed with pediatric surgery with URI
urgency?
duration?
complexity?
need for instrumentation of airway?
33
Neurologic Assessment
Document baseline-muscle weakness, neuropathy, mental status
Consider risk for post-op delirium
Neuro assessment may inform if patient can tolerate MAC
34
Patients that may not tolerate MAC
tremors, confused, anxious, not able to follow commands
35
Pre-op evaluation of GI system
Is my patient at risk for aspiration?- n/v, abd distention, dysphagia, gastroparesis, reflux
Is my patient hypovolemic? - diarrhea, gi bleeding, prep
36
How to determine severity of GERD:
```
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
Full stomach: elective surgery
delay procedure
38
If elective surgery and full stomach r/t obstruction/gastroparesis:
place awake NGT
39
Emergent surgery: full stomach
RSI and asleep OG/NG
40
NPO guidelines: clear liquids, breast milk, formula, non-human milk, solids
```
clear liquids: 2 hours
breast milk: 4 hours
infant formula: 6 hours
non-human milk: 8 hours
solids: 8 hours
```
41
Hepatic Assessment
screening for acute of chronic liver disease
if present: avoid certain drugs, optimize hepatic blood flow
42
Renal Assessment on dialysis:
```
where is their fistula
dialysis schedule
last dialysis treatment
how much fluid was removed
serum K
```
43
DM
Schedule early in day
44
Hyperthyroidism
continue antithyroid medication and beta blocker
is not euthyroid: reschedule if elective
increased risk for mortality if thyroid storms
45
Hypothyroid
Continue Synthroid
| increased risk for mortality if myxedema coma
46
Smoking assessment
packs per day/years
quitting date (>8 weeks improves outcomes)
chronic symptoms
47
ETOH
history
drinks per week/day
h/o DTs
48
Non-prescription drugs
cocaine-avoid ephedrine
marijuana, amphetamines, narcotics, benzos
OTC
herbals
49
Instructions for smokers
stop smoking at least 12-48 hours or 4 weeks
| 12 hour abstinence reduces effects of nicotine & carbon monoxide
50
Medication assisted treatment
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
Anesthesia History
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
Labs/test pre-op
age/diagnosis protocol per institution
EKG >45
CXR- age or disease
pregnancy test
53
Indication for CXR
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
Indication for EKG
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
ASA I
normal healthy patient, non-smoker, no or minimal ETOH
56
ASA II
patient with mild systemic disease
smoker, social alcohol drinker, pregnancy, obesity, well controlled DM/HTN, mild lung disease
57
ASA III
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
ASA IV
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
ASA V
not expected to survive without operation
| ruptured AAA, massive trauma, ICH w/ mass effect, ischemic bowel
60
ASA VI
Brain dead
61
Discuss plan
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
Pediatric pre-op
can refuse but cannot legally consent
explanations should be age appropriate
parent or legal guardian if under 18
consider parent for induction
