Pt Assmt Flashcards
Standardization of Best Practices- enhances the process by
Basis for formulating best anesthetic plan
Tailored to the patient
True Emergency
Life, Limb or Organ Saving
surgery <6hours-
⭐️
Examples of True Emergency
ruptured aortic aneurysm
major trauma to thorax or abdomen
acute increase in ICP
Urgent
Conditions threaten life, limb or organ; surgery within 6-12 hours
examples: perforated bowel; compound fracture; eye injury
Time sensitive
Stable but requires intervention
surgery within days-weeks
examples: tendon; nerve injuries; cancer
Elective
Procedure planned at patient or surgeon convenience
surgery within 1 year- examples: all other procedures that can be planned in advance
Preanesthetic Eval Screen
ROS
everything on the ppt came from this chart
Although not life-threatening, ______ after a previous surgery may be the patient’s most negative and lasting memory.
persistent nausea and vomiting
⭐️
vomiting after inhalation anesthesia identified four risk factors:
female gender
prior motion sickness or postop nausea
nonsmoking,
use of postop opioids
KNOW this chart!
Components of the Airway Examination That Suggest Difficult Tracheal Intubation
⭐️
Know Dat Mallampati!
standard for assessing the relationship of the tongue size relative to the oral cavity
The Mallampati classification
⭐️
assessment of the cervical spine is critical for these pts
severe rheumatoid arthritis (RA) or Down syndrome
Evaluation of the airway involves examination of …
oral cavity, including dentition
thyromental distance
neck size
potential tracheal deviation/masses
flex the base of the neck/extend head
T/F
POCT slightly high is better than low POCT
T
Thyroid strom is a differential Dx to ___
MH
Best Bronchodilating IA
Sevo
⭐️
Know these OTC drugs
Ephedra: (wt. loss) Tachycardia; HTN; increased sympathomimetic effects with others (arrythmia with digoxin and HTN with oxytocin)
Feverfew: (migraines) PLT inhibitor; Increased bleeding risk; rebound H/A with cessation
GBL; BD; & GHB (body building/ wt. loss) Illegal; death; seizures; severe bradycardia; unconsciousness
Garlic: (antioxidant/lowers cholesterol) decreased PLT aggregation
Ozempic- Gastroparesis
The Apfel simplified risk score
predicts PONV with 0, 1, 2, 3, or 4 risk factors as 10%, 20%, 40%, 60%, and 80%, respectively
Apfel scoring for pt w/ no risk factors
10% risk
Work synergistically to prevent PONV
prop
decadron
zofran (5HT3)
The presence of ___ has been associated with a high perioperative risk of myocardial infarction (MI)
unstable angina
The perioperative period is associated with a ___ and surges ___, both of which may exacerbate the underlying process in unstable angina, increasing the risk of acute infarction.
hypercoagulable state
in endogenous catecholamines
⭐️
Herbal OTC
Ginger: (anti-nausea) Potent inhibitor of thromboxane synthetase; Increased bleeding time
Gingko: (blood thinner) Increased bleeding in pts on anti-coags
Ginseng: (energy/ antioxidant) Inhibits PLT aggregation
Goldenseal: (laxative/diuretic) Oxytocic= worsens edema & HTN
Kavakava: (Anxiolytic) potentiates sedatives & hepatotoxicity
Licorice: (Tx of gastric ulcers) HTN; Hypokalemia & edema
St John’s Wort (depression/anxiety) prolongs anesthetic effects
Potent inhibitor of thromboxane synthetase; Increased bleeding time
Ginger: (anti-nausea)
Gingko
(blood thinner) Increased bleeding in pts on anti-coags
Inhibits PLT aggregation
Ginseng: (energy/ antioxidant)
potentiates sedatives & hepatotoxicity
Kavakava: (Anxiolytic)
Goldenseal
(laxative/diuretic) Oxytocic= worsens edema & HTN
(Tx of gastric ulcers) HTN; Hypokalemia & edema
Licorice
St John’s Wort
(depression/anxiety) prolongs anesthetic effects
Valerian
(anxiolytic/sedative) potentiates sedative effects of anesthesia
Vitamin E
(slows aging) Increases bleeding in conjunction with anti-coagulants & anti-thrombin meds
Estimated Energy Requirements for Various Activities
1 MET
Daily self-care; eat; dress; walk indoors; walk a block or 2 on ground level 2-3mph
Climb a flight of stairs or walk up a hill; walk on ground level 4mph; run a short distance; heavy work around the house; participate in moderate activities (golf, bowling, dancing, doubles tennis)
4METs
> 10METs
Participate in strenuous sports like swimming; singles tennis; football; basketball or skiing
⭐️
remains one of the MOST important predictors of Peri-op risk for non-cardiac surgery; also helps define the need for further testing
Exercise tolerance
Excellent exercise tolerance (even in patients with stable angina) suggests that…
the myocardium can be stressed without failing
poor exercise tolerance
inability to walk four blocks or climb two flights of stairs)
can be an independent risk factor for serious complications
Indications for Further Cardiac Testing
(algorithm integrates clinical hx; surgery specific risk & exercise tolerance)
1) Evaluate urgency of Sx & appropriateness of formal pre-evaluation
2) recent revascularization or CV work up??
Along with the Resp assmt, we should also assess the pts ability to…
ability to breathe through their nose
The presence of symptoms of cord compression may require ….
X-ray exam
“Metabolic syndrome”
disorder comprising a group of risk factors:
-high blood pressure
-atherogenic dyslipidemia (↑TRG, ↓HDL)
-high fasting glucose
-central obesity
Metabolic syndrome has been associated with higher rates of …
cardiovascular, pulmonary, and renal perioperative events
wound infections
Asthma Assmt
History of asthma
Last time use of a rescue inhaler
Last asthma attack
unstable cardiac disease
MI
CHF
Valvular disease
arrhythmia
(use cardiac monitor!)
A preoperative 12-lead ECG can provide important information about the patient’s heart rhythm as well as (2)
evidence for left ventricular hypertrophy
prior MI
ECG
____ in high-risk patients are highly suggestive of a past MI
Abnormal Q waves
“silent infarctions”
30% of MIs
NO symptoms
only be detected on screening ECGs,
highest in DM/HTN patients
murmur radiating to the carotids
aortic stenosis
Abnormal rhythm or gallop
heart failure
Presence of Bruits over the carotid
needs further work up for stroke risk
plaque
❌
M.A.C.E- Major adverse cardiac events
Low risk procedure= <1% risk of MACE
High risk procedure= >1% risk of MACE
Advanced age = increased risk of MACE and ischemic stroke
Hx of CV disease; DM; Cerebrovascular disease= Elevated risk of MACE
pt has DMI and angina
CV risk?
higher for adverse cardiac event
⭐️
The Revised Cardiac Risk Index (RCRI)-
assigns peri-op risk using clinical variables
increased risk factors = more complications
⭐️
Clinical evidence of heart failure:
Dyspnea
Limited exercise tolerance
Orthopnea
JVD
Crackles
Third heart sound
Peripheral edema
Diabetes associated with CV disease
accelerates atherosclerotic disease
higher incidence of silent MI and myocardial ischemia
insulin depdent = RCRI risk factor
pre-op ECG should be evaluated for presence of Q-waves
pre-op ECG should be evaluated for
presence of Q-waves
(old MI!)
When to treat BP
Treat SBP > 150mmHg
Treat DBP > 90mmHg (in pts 60yrs old or >)
Aggressive treatment of BP is associated with…
reduction in long-term MI risk
Elective surgery should be delayed for DBP > ___
110mmHg
highest incidence of complications
Major open vascular procedures
High risk procedures:
major vascular
abdominal
thoracic
orthopedic
Which Sx is a/w extremely low incidence of morbidity and mortality
Peripheral procedures
Patients with good exercise tolerance that have stable angina suggests that
myocardium can be stressed without failing
Patients with dyspnea associated with chest pain during minimal exertion
extensive CAD and greater perioperative risk
⭐️
Patients with Coronary Artery Stents
Delay non-cardiac surgery for 14 days after balloon angioplasty
Delay non-cardiac surgery for 30 days after bare metal stent
⭐️
Early surgery after stent placement
adverse cardiac events (incidence of periop death and hemorrhage)
⭐️
Delay non-cardiac surgery after drug eluding stents
12 months
T/F
Delays after CAD procedures only applies to elective surgeries.
True
AICDs can be impaired by electromagnetic interference from…
Bovie (cauterization)
could shock the pt!
put a magnet on it
Which cardiac device always needs to have magnet on it during cautrztn surgery?
AICD
pacemaker doesn’t always need
Risk of re-infarction under general anesthesia after previous MI
MI within 3 months or less = 30% incidence
MI within 3-6 months = 15% incidence
MI greater than 6 months = 6% incidence
⭐️
IF re-infarction occurs, the mortality rate is
50%!
⭐️
T/F
POST-OP RESPIRATORY FAILURE = MAJOR CAUSE OF M&M
lol true
Post-operative pulmonary complications occur more frequently than cardiac in patients having …
non-cardiac surgery
T/F
ExTT too early can cause pulm edema
True
pulling against against closed glottis
proven to have limited benefit in predicting peri-operative respiratory failure and complications
Pulmonary functions testing (PFT) and chest X-rays (CXR)
increases risk of peri-operative pulmonary morbidity
Decreased serum Albumin levels & Increased BUN
⭐️
procedures associated with the HIGHEST RISK of peri-operative pulmonary morbidity
Open aortic, thoracic and upper abdominal
surgeries associated with a HIGH RISK of peri-operative pulmonary morbidity
Cranial, vascular and neck
Smoking effects
Increased carboxyhemoglobin levels
Decreased ciliary function
Increased sputum production
CV stimulation from Nicotine
⭐️
amount of time smoking cessation needed to decrease the incidence of post-operative complications
4-8 weeks
T/F
Airways of smokers are very reactive
True
don’t have them quit the day before pls
“stress dose” of inhaler may be helpful in asthmatics that
take regular corticosteroids (d/t renal insuff)
Obstructive Sleep Apnea (OSA)
periodic obstruction of upper airway during sleep
Obstructive Sleep Apnea (OSA)
clinical effects
chronic sleep deprivation
Chronic pulmonary HTN
RHF
⭐️
OSA
considerations for anesthesia
These patients are susceptible to respiratory depressants!
Use judiciously!
⭐️
These surgeries lead to decreased vital capacity, FRC, & diaphragmatic dysfunction= hypoxemia and atelectasis
Open aortic, thoracic and upper abdominal
Cranial, vascular and neck
⭐️
decreased vital capacity, FRC & diaphragmatic dysfunction leads to
hypoxemia and atelectasis
leading cause of renal failure requiring dialysis
DM
DM
care considerations
Increased risk for CAD; HTN; CHF & Peri-op MI
Higher incidence of cerebral vascular, peripheral vascular and renal vascular disease
peripheral neuropathies= careful positioning
Gastroparesis= theoretical increased aspiration risk
Stiff joints d/t glycosylation of proteins (could affect airway)
⭐️
When to delay a Diabetic pt’s elective surgery
A1c above target range (DM1:<7.5% for DM2: <7%),
abnormal electrolytes,
or
ketonuria
POCT Goalz
Cardiac surgery= maintain sugar 80-100 mg/dL
non-cardiac surgery= maintain sugar <200mg/dL
(trust the pt, they know their body best)
T/F
Hold oral hypoglycemic meds the day of surgery
True
Screen for s/sx of hyper/hypothyroidism-
Hypo= hypothermia; hypoglycemia; hypoventilation; hyponatremia & heart failure
Hyper= THYROID STORM- tachycardia; A-fib; CHF; tremor; muscle weakness & anemia
⭐️
T/F
enlarged thyroid may create airway difficulty
True
Draw which lab for hyperparathyroidism
Ca
Thyroid storm
S/S
Diff Dx for MH
hyperparathyroidism
S/S
HYPER Ca
weakness
lethargy
headache
insomnia
apathy
bone pain
epigastric pain
⭐️
When to stress dose Adrenal cortical suppression pts
if steroids were taken for one month or greater within the last 6-12 months (if more than a minor procedure)
Which to use in Renal Dz?
Nimbex
Roc
Nimbex
Liver Dz
drug binding is affected by
decreased plasma proteins
Liver Dz pt needs regional anesthesia. What should we do first?
Obtain coags
(also do this for ETOH Hx)
When to draw coags
liver or kidney disease; bleeding disorder; anticoagulant use; chemotherapy
Serum chem (glucose, lytes, renal & liver function)
when to draw
liver or kidney disease; DM; CNS disease; Endocrine disorder; Elderly; Malnutrition; type & invasiveness of surgery
When to draw CBC
extremes of age; liver or kidney disease; anticoagulant use; bleeding; hematologic disorders; malignancy; type & invasiveness of surgery
T/F
ECG is ordered in pts with pulmonary tests.
True
T/F
Patients can refuse a preop pregnancy test.
True
the anesthesia provider can ALSO refuse to do that case
Which pts get pregnancy test
all women of childbearing age
The decision to go forward with surgery-
Are risk factors modifiable?
Will delaying the procedure add to peri-op risk or morbidity?
What can we do peri-op to decrease risk?
Do we have enough information to make an informed decision?
T/F
Emergency surgeries are all considered full stomach
True
Aspiration Risk:
NPO times
Bicitra
Increases gastric pH in 100% of the cases it is used – Highly effective antacid
Famotidine
Increases gastric pH
Reglan
Increases gastric emptying
(obese; pregnant; diabetics; trauma & emergency surgery)
T/F
Advanced directives are part of the pre op eval.
True (in ppt slide 72)
Innervation of larynx
Structures of larynx
Preop eval
Renal Dz
Assess electrolytes
Make patient euvolemic prior to induction (likely dry if hemodialysis recently)
Be mindful of meds metabolized by kidneys
Adrenocortical Suppression
S/S
Be suspicious of those on long term steroid use
(Cushing’s- moon face; skin striation; truncal obesity & HTN)
periop experience comes with increased serum glucose d/t ….
stress (cortisol and catecholamine release)
Glycemic control
benefits
decreases:
morbidity
infection rate
stroke incident
+improves wound healing
T/F
continue insulin @ full dose of insulin for DM.
Continue insulin (consider half dose)
“prayer sign”
DM
unable to completely oppose their hands (with no space between) = changes in other joints = potentially impacting airway manipulation
Malam. Score
if pt cant open mouth
automatic 4
When can we perform elective noncardiac surgery after stent placement?
-elective noncardiac surgery may be considered after 6 months
(surgery benefits vs stent thrombosis and myocardial ischemia)
-after drug-eluting stents: 12 months
A patient with CHF is an ASA _
4
T/F
Unstable angina = ASA 3
False
Stable angina = ASA 3
ASA class?
Mild-to-moderate systemic disease that is well controlled and causes no organ dysfunction or functional limitation (e.g., treated hypertension)
2
For patients using inhaled steroids, they should be administered regularly, starting at least ___ prior to surgery for optimal effectiveness.
48 hours
T/F
DM patients are more susceptible to positioning injuries both during and after surgery
true
Preop assmt interventions for DM
blood glucose
hemoglobin A1c
serum electrolytes
creatinine
ECG
Systems Approach
CV goal
identify clinical risk and need of pre-op cardiac testing
Forms are Rated using 3 Categories:
Informational Content
Ease of Use
Ease of Reading
Pre-op Eval required components
Review medical record
H&P (pertinent to Sx)
diagnostic tests
Pre-op consultations
Can pt condition be improved by Sx?
Answer all questions
Obtain Informed Consent
What happens when we place a magnet over an ICD?
PACEMAKER fxn unaffected
BUT
electromagnetic interference still possible
most often causes bradycardia
(depends on pacer)
best option: reprogram to asynchronous mode
To avoid electromagnet interference, it’s best to put the pacemaker into __ mode
asynchronous mode
When to place magnet over ICD
if Sx above umbilucus & using cuatery
