Week 1 Flashcards
The purpose of Pre-op
provide the patient with an estimate of anesthetic risk
obtain informed consent
anesthetic plan
identify patients that will have that will need additional testing or patients that are so poor condition it will cause death
pre-op items
H&P-to include- planned procedure, allergies, medications(current and past), substance abuse, responses to previous anesthesia. illness (current and past) (METs). (ASA standards). last oral intake.
consults
specific diagnostic testing
Metabolic equivalent of 4 or more
predicts a low risk of preoperative complications
ASA 1
a normal health patient. health, non smoking no or minimal alcohol use.
ASA II
a patient with mild systemic disease
mild diseases only without substantive functional limitation. Eg smoker, social drinker, pregnancy obesity BMI 31-39. well controlled dm/htn mild lung disease
ASA III
a patient with severe systemic disease
substantive functional limitations; one or more moderate to severe diseases. poorly controlled dm. htn cold morbid obesity active hepatitis alcohol dependence or abuse. BMI >=40 implanted pacemaker moderate reduction of ejection fraction. ESRD undergoing scheduled dialysis. premature infant PCA <60 weeks history >3 months of MI, CVA, TIA, or CAD/stents
ASA IV
a patient with severe systemic disease that is a constant threat to life.
< 3 months MI, CVA, TIA, or CAD/Stents, ongoing cardiac ischemia or severe valve dysfunction. severe reduction of ejection fraction, sepsis, dic, ards, or esrd not undergoing regularly scheduled dialysis.
ASA V
a moribund patient who is not expected to survive without a operative
examples include but are not limited to reputed abdominal thoracic aneurysm, massive trauma, intracranial bleed with mass effect, ischemic bowl in the face of significant cardiac pathology or multiple organ/system dysfunction.
ASA VI
a declared brain dead patient whose organ are being removed for donor purposes
ASA E
Emergency surgery - delay of the patient would lead to a significant increase in the threat to life or body part.
1 MET=
3.5mlO2/min/kg of body weight.
Difficult Mask Ventilation
age greater than 55 BMI Greater than 26 beard lack of teeth OSA previous head/neck/radiation/surgery or trauma
Findings for difficult direct laryngoscopy
osa
hx difficult intubation/aspiration pna after intubation/ dental or oral trauma following intubation.
previous head/neck/radiation/surgery or trauma
obesity cervical spinal disease or surgery
congenital disease: downs syndrome teacher collins & pierre robin
inflammatory arthritic disease. rheumatoid arthritis, enclosing spondylitis, scleroderma.
Findings for difficult airway examination component
length of upper incisors relationships of maxillary and mandibular incisors during normal jaw closure. relationship of maxillary and mandibular incisors during voluntary protrusion of mandible inter incisor distance visibility of uvula compliance of the mandibular/oral space thyromental distance length of neck thickness of neck range of motion of the head and neck
micrognathia
a short distance between the chin and the hyoid bone. prominent upper incisors, a large tongue, limited range of motion of the temporomandibular joint or cervical spine, or a short or thick neck suggest that difficulty may be encountered in direct laryngoscopy for tracheal intubation
mallampati class1, 2, 3, 4
class 1 = soft palette, uvula, fauces, pillars
class 2= soft palette, uvula, fauces
class 3 = soft palette base of uvula
class 4= soft palette not visible
STOP-BANG
snoring tiredness observed- stop breathing pressure Bmi greater than 35 Age>50 N-neck Gender male
when should anti platelets be held after Bare metal stent
1 month
albumin
anasarca, liver disease, malnutrition, malabsorption
b-hcg
suspected pregnancy
cbc
alcohol abuse, anemia, dyspnea, hepatic or renal disease
consultation done
specific advice regarding diagnose or management of a condition in order to aid safe anesthetic planning
when should anti platelets be held after drug eluding stent- stable
hold 6 months after placement
when should anti platelets be held after drug eluding stent- unstable
hold 12 months after placement
aspirin
continue
urgent surgery anti platelets should be held
3-6 months following DES placement if delayed surgery is greater than the stent thrombosis risk
EKG class III
routine preoperative resting 12 lead ECG is not useful for asymptomatic patients undergoing low risk surgical procedures
EKG Class IIb
preoperative resting 12 lead egg may be considered for asymptomatic patients without known coronary heart disease
EKG Class IIa
preoperative resting 12-lead egg is reasonable for patients with known coronary heart disease, significant arrhythmia, peripheral arterial disease, cva, or other significant structural heart disease, except for those undergoing low risk surgery.
HTN
degree of end organ damage
morbidity and mortality
maintain BP within 20% of baseline for adequate organ perfusion.
systolic greater than 200- MI
coronary artery disease
mild, stable or severe,
significant complications during anesthesia. MACE- major adverse cardiovascular events
not all patients with cad require
stable- no testing
cad- decompensated heart failure- severe valuable heart disease. new onset angina. acute coronary syndrome- further investigate
mets greater than 4- no because they have a good functional capacity.
otherwise get a consultation.
Preoperative events that may be discussed with the patient
nausea vomiting myalgia dental injury sore throat/hoarness death
DNR
discuss with the patient- usually dnr are resented in or
GI issues
gerd is a disastrous pulmonary complication of surgical anesthesia. high risk include- pregnant women )2nd and 3rd trimester)
no LMA with gerd
albumin
anasarca, lliver disease. malnutrition malabsorption
b hcg
pregnancy
cbc
alcohol abuse, anemia, dyspnea, hepatic or renal disease, malignancy, malnutrition. bleeding, poor exercise tolerance, recent chemo or radiation
creatinine
renal disease, poorly controlled diabetes
chest xray
active, acute or chronic significant pulmonary symptoms such as cough dyspnea abnormal physical findings of palpitations decompensated heart failure, malignancy with thorax, radiation therapy
echo
alcohol abuse active cardiac condition severe obesity syncope amidolarone or digoxin
electrolytes
alcohol abuse, cardiovascular hepatic renal or thyroid disease. malnutrition or dig or diuretics
glucose
steroids and dm
lft
alcohol abuse, hepatic disease, recent hepatitis undiagnosed bleeding disorder
platelet count
alcohol abuse, hepatic disease, bleeding disorder hematologic malignancy recent chemo or radiation thromcytopenia
pt
alcohol abuse hepatic disease malnutrition bleeding disorder warfarin
Tsh t3t4
goiter thyroid disease unexplained dyspnea, fatigue, palpitations tachycardia
ua
suspected UTI
trisomony 21
large tongue, small mouth
pierre robin
large tongue, small mouth
goldenhar
hypoplasia mandibular
cervical spine immobility
klippel feil
neck rigidity because of cervial vertebral fusion
teacher collins
laryngoscopy difficult
turner syndrome
difficulty intubation
