Week 10 - Anesthesia Assessment Flashcards
1
Q
Anesthesia Assessment includes:
A
- Past Medical History
- Lab results
- Physical Status
- Airway evaluation
- Medication reconciliation.
2
Q
Pre-operative Evaluation goals:
A
- Reduce patient risk and morbidity associated with surgery and anesthesia.
- Prepare the patient medically and psychologically.
- Promote efficiency and cost-effectiveness
3
Q
Association that requires that all patients receive a preoperative anesthetic evaluation.
A
The Joint Commission (TJC)
4
Q
Contains the outline for minimum requirements for preoperative evaluation.
A
The American Society of Anesthesiologists (ASA) contains the:
ASA Basic Standards for Preanesthetic Care
5
Q
Conducting a preoperative evaluation is on the premise that it will: (2)`
A
modify patient care and improve outcomes.
6
Q
Good pre-op evaluation can (3):
A
- reduce cost of surgery.
- reduce cancellation rates.
- increase resources utilization.
7
Q
Components required in a pre- op: (7)
A
- Review of the medical record.
- History and Physical (pertinent to the surgery).
- Appropriate diagnostic tests.
- Appropriate Pre-op consultations.
- Determine whether the patient’s condition can be improved prior to surgery.
- Answer all questions.
- Obtain informed consent.
8
Q
Pre-operative Evaluation challenges (6):
A
- Patient’s having outpatient procedures come in day of surgery.
- Fast turn over between cases.
Limited time to:
- get to know the patient
- create relationship.
- engender trust
- answer questions
9
Q
Healthy Patient Approach
Standardization of Best Practices- enhances the process. The preop evaluation can serve as:
A
The basis for formulating best anesthetic plan tailored to the patient.
10
Q
Forms are Rated using 3 Categories:
A
Informational Content
Ease of Use
Ease of Reading
11
Q
Emergency Procedure:
Description:
Optimal timing:
Examples:
A
Description:
Life, limb, or organ-saving.
Optimal timing:
<6 hours.
Examples:
- Ruptured aortic aneurysm.
- Major trauma to thorax or abdomen.
- Acute increase in intracranial pressure.
12
Q
Urgent Procedure Classification-
Description:
Optimal timing:
Examples:
A
Description:
Conditions threaten life, limb or organ
Optimal timing:
6-24 hours.
Examples:
- Perforated bowel
- Compound fracture
- Eye injury
13
Q
Time Sensitive Urgency Classification
Description:
Optimal timing:
Examples:
A
Description:
Stable but requires intervention.
Optimal timing:
Days to weeks.
Examples:
- Tendon (Ex. Ruptured Achilles Tendon)
- Nerve injuries.
- Cancer
14
Q
Urgency of surgery must be weighed against the optimization of the patient.
Planned procedures: (Carotid) may require (2):
A
Neuro exam & cardiac workup/clearance.
15
Q
Elective Procedure Classification-
Description:
Optimal timing:
Examples:
A
Description:
Procedure planned at patient or surgeon convenience.
Optimal timing:
Up to 1 year.
Examples:
All other procedures that can be planned in advance.
16
Q
Positive and conflicting risk factors for PONV
A
positive risk factors:
- F emale
- O pioids postop
- G eneral anesthesia (v.s. regional).
FOG
- H istory of PONV or motion sickness.
- A ge (younger, <50)
- N onsmoker
- D uration of anesthesia
- S urgery Type: cholecystectomy, laparoscopic, and gynecologic.
HANDS
- A nesthesia types: Volatile anesthetic and N2O
A
Conflicting risk factors:
- M enstrual cycle
- A SA status
- M uscle relaxant reversal
- A nesthesia provider’s experience.
MAMA
17
Q
Apfel PONV risk scores:
A
No risk factor = 10% chance of PONV
1 risk factor= 20% chance
2 R.F.= 40% chance
3 R.F.= 60% chance
4 R.F.= 80% chance
18
Q
Ephedra usage and effects/interactions:
A
For weight loss.
- Tachycardia
- Hypertension
- Increased sympathomimetic effects with others (arrhythmia with digoxin and HTN with oxytocin) .
19
Q
Feverfew usage and effects/interactions:
A
for migraines.
- PLT inhibitor
- Increased breathing risk
- Rebound H/A with cessation.
20
Q
GBL; BD; & GHB usage and effects/interactions:
A
For body building/ weight loss. (illegal med)
- death
- seizures
- unconsciousness
21
Q
Garlic usage and effects/interactions:
A
an antioxidant and lowers cholesterol.
- decreased PLT aggregation.
22
Q
Ginger usage and effects/interactions:
A
anti-nausea
- potent inhibitor of thromboxane synthetase.
23
Q
Ginko usage and effects/interactions:
A
Blood thinner;
Increased bleeding in pts on anti-coags
24
Q
Ginseng usage and effects/interactions:
A
(energy/ antioxidant);
Inhibits PLT aggregation
25
Goldenseal usage and effects/interactions:
(laxative/diuretic)
Oxytocic= worsens edema & HTN.
26
Kavakava usage and effects/interactions:
Anxiolytic
potentiates sedatives and hepatotoxicity.
27
Licorice usage and effects/interactions:
Treatment of gastric ulcer.
HTN
Hypokalemia
Edema
28
St John’s Wort usage and effects/interactions:
(depression/anxiety);
Prolongs anesthetic effects.
29
Valerian usage and effects/interactions:
(anxiolytic/sedative);
potentiates sedative effects of anesthesia
30
Vitamin E usage and effects/interactions:
(slows aging);
Increases bleeding in conjunction with anti-coagulants & anti-thrombin meds
31
Estimated Energy Requirements for Various Activities
MET 1
- Daily self-care;
- eat; dress;
- walk indoors;
- walk a block or 2 on ground level 2-3mph
32
Estimated Energy Requirements for Various Activities
MET 4
- 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).
33
Estimated Energy Requirements for Various Activities
MET >10
Participate in strenuous sports like swimming; singles tennis; football; basketball or skiing
34
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
35
Excellent exercise tolerance (even in patients with stable angina) suggests that:
the myocardium can be stressed without failing
36
For trauma patients, it is best to intubate in what position?
Neutral
37
Patients with severe rheumatoid arthritis or Down’s syndrome require a thorough _______ evaluation.
C-spine
38
The presence of symptoms of cord compression may require ________exam.
What prompts cord compression?
X-ray exam;
Numbness in hand when lifting chin.
39
High perioperative risk of MI
Presence of unstable angina
40
In the periop period there are __________ surges; and patient goes into a _________ state therefore exacerbates underlying issues such as angina leading to MI
catecholamine;
hypercoagulable
41
Listen to the heart for murmur radiating to the carotids could reveal?
Aortic stenosis
42
An abnormal heart rhythm or gallops could be?
Heart failure
43
Presence of bruits over the carotid prior to surgery would mean?
Patients needs further work up for stroke risk
44
M.A.C.E- Major adverse cardiac events
values:
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
45
Advanced age are at increased risk of ______ and ________.
MACE and Ischemic stroke
46
What 3 diseases support and elevated risk of MACE?
- Cardiovascular disease
- Diabetes mellitus
- Cerebrovascular disease.
47
a validated method to assign perioperative risk using clinical **variables**
The Revised Cardiac Risk Index (RCRI)
48
6 independent predictors of complications in the The Revised Cardiac Risk Index (RCRI)
- High-risk type of surgery
- History of Ischemic Heart Disease
- History of Congestive Heart Failure
- History of Cerebrovascular Disease
- Pre-operative treatment with Insulin
- Pre-operative Serum Creatinine (>2mg/dL)
*Cardiac complications increase with increased risk factors*
49
**Diabetes associated with CV disease-**
Diabetes accelerates ________ disease.
Diabetics have a higher incidence of:
Diabetes requiring _________ is a risk factor in the RCRI
The pre-op ECG should be evaluated for presence of ______.
atherosclerotic;
silent MI and myocardial ischemia.
Insulin for treatment;
Q-waves
50
Hypertension is associated with increased incidence of
silent MI
*Aggressive treatment of BP is associated with reduction in long-term MI risk*
51
Treat SBP > ______mmHg
Treat DBP > ______mmHg (in pts 60yrs old or >)
Elective surgery should be delayed for DBP > _______mmHg*
150;
90;
110
52
High risk procedures:
Major vascular; Abdominal;
Thoracic and
Orthopedic surgeries.
53
High risk procedures?
Which one is at highest risk of complication?
Major vascular; Abdominal;
Thoracic and
Orthopedic surgeries.
*Major open vascular procedures are associated with the highest incidence of complications*
54
One of the most important predictors of perioperative risk for non-cardiac surgery (helps define the need for further testing and invasive monitoring).
Exercise Tolerance
*Patients with good exercise tolerance that have stable angina suggests that the myocardium can be stressed without failing*
55
Patients with dyspnea associated with chest pain during minimal exertion would signal?
Extensive CAD and greater perioperative risk
56
Early surgery after stent placement = adverse cardiac events (incidence of periop death and hemorrhage)
Delay of non-cardiac surgery for 14 days after: __________.
Delay of non-cardiac surgery for 30 days after: __________.
Delay of non-cardiac surgery for 12 months after: ______.
balloon angioplasty
bare metal stent placement
drug eluding stents
57
Risk of re-infarction under general anesthesia after previous MI:
MI within 3 months or less = _____ incidence
MI within 3-6 months = _____ incidence
MI greater than 6 months =_____ incidence
*IF re-infarction occurs, the mortality rate is _______!*
30%;
15%
6%
50%
58
T/F: Post-operative pulmonary complications occur more frequently than cardiac in patients having non-cardiac surgery.
True
59
Post-op pulmonary complications: (5)
- Atelectasis
- Respiratory failure requiring post-op ventilation.
- Exacerbation of COPD
- Pulmonary edema
- And Pneumonia
60
MAJOR CAUSE OF Morbidity & Mortality post-op*
Post-op respiratory failure.
61
Pre-operative pulmonary testing:
Pulmonary functions testing (PFT) and chest X-rays (CXR)-
*proven to have limited benefit in predicting peri-operative respiratory failure and complications*
62
**Decreased** serum Albumin levels & **Increased** BUN correlates with increased risk of:
Peri-operative **pulmonary** morbidity
63
Procedures are associated with the HIGHEST RISK of peri-operative pulmonary morbidity:
and
Surgeries associated with a HIGH RISK of peri-operative pulmonary morbidity:
Open aortic,
Thoracic
Upper abdominal
and
Cranial,
Vascular,
Neck Surgeries
*These surgeries lead to decreased vital capacity; decreased FRC; and diaphragmatic dysfunction= hypoxemia and atelectasis*
64
Tobacco can cause (4)-
- Increased carboxyhemoglobin levels.
- Decreased ciliary function.
- Increased sputum production.
- Cardiovascular stimulation from Nicotine.
65
________ weeks of smoking cessation is needed in order to decrease the incidence of post-operative complications* (Airways are very Reactive!!)
4-8
66
Consider a "____ _____" if patient takes regular corticosteroids d/t adrenal insufficiency.
stress dose
67
defined as periodic obstruction of upper airway during sleep
Obstructive Sleep Apnea (OSA)-
68
Obstructive Sleep Apnea (OSA) leads to:
- chronic sleep deprivation.
- Chronic pulmonary hypertension.
- Right heart failure.
*These patients are susceptible to respiratory depressants! Use judiciously!*
69
Obstructive Sleep Apnea (OSA) characteristics:
**NOT NU** or **NO NUT**
- **N** eck large
- **O** besity
- **N** asal obstruction
- **U** pper airway abnormalities
- **T** onsils large
70
Questions to ask an OSA patient:
Do you snore?
Do you wake yourself up at night from snoring?
Are you tired in the daytime?
Do you have a hard time breathing?
71
Diabetes Mellitus are at increased risk for
- CAD, HTN, CHF, and Peri-op MI.
- incidence of cerebral vascular, peripheral vascular and renal vascular disease.
- Renal failure: requiring dialysis.
- peripheral neuropathies= careful positioning
- Gastroparesis= theoretical increased aspiration risk
- Stiff joints d/t glycosylation of proteins (could affect airway)
72
Diabetes Mellitus
Draw blood glucose on arrival, hgbA1c; Lytes; creatinine and ECG
Type 1 Diabetics= hgbA1c <_______
Type 2 Diabetics= hgbA1c <______ - or ________ or_______ .
What should you do if these are abnormal?
7.5%;
7%,
abnormal lytes,
ketonuria
DELAY **ELECTIVE** SURGERY!! *optimize patient then bring them back*
73
Glycemic control decreases:
- morbidity,
- infection rate,
- stroke incident
- improves wound healing.
74
Goals- Cardiac surgery= maintain sugar __________ mg/dL
80-100.
75
Goals- non-cardiac surgery= maintain sugar <________mg/dL
200
76
T/F: On day of surgery: hold oral hypoglycemic meds the day of surgery and hold insulin.
False
Hold oral hypoglycemic meds the day of surgery.
Continue insulin (consider half dose)
77
Screen for s/sx of hypothyroidism-
- Hypothermia
- Hypoglycemia
- Hypoventilation
- Heart failure
78
Screen for s/sx of hyperthyroidism -
**THYROID STORM**-
Tachycardia;
Enlarged thyroid - may create airway difficulty .
A-fib;
Muscles weakness
CHF;
Anemia
Tremor
**TEAM CAT**
79
Hyperparathyroidism= _________ (draw ______)
hypercalcemia; Ca++
80
Hyper**parathyroidism** s/s: (7)
*B AWHILE*
- **B** one pain
- **A** pathy
- **W** eakness
- **H** eadache
- **I** nsomnia
- **L**ethargy
- **E**pigastric pain
81
Adrenal cortical suppression:
Be suspicious of those on long term steroid use Cushing’s- S//S:
moon face;
skin striation;
truncal obesity &
HTN
82
Adrenal cortical suppression:
Make sure that they get a stress dose if steroids were taken for _____ month(s) or greater within the last ______ months (if more than a minor procedure).
one;
6-12
83
Stress dose
Max dosing= 100mg hydrocortisone IVP before surgery, then q8h x 1 day, then 50mgIVP--- highly debated*
84
What things to keep in mind with renal disease pt in pre-op? (3)
Assess electrolytes
Make patient euvolemic prior to induction (likely dry if hemodialysis recently)
Be mindful of meds metabolized by kidneys
85
What things to keep in mind with liver disease pt in pre-op? (3)
- Coagulopathy (know levels before regional).
- Decreased plasma proteins- affects drug binding.
- Consider labs if increased ETOH history
86
When to get a CBC:
extremes of age;
liver or kidney disease; anticoagulant use; bleeding;
hematologic disorders; malignancy;
type & invasiveness of surgery
87
When to get COAGS:
Bleeding disorder;
Liver disease or
Anticoagulant use;
Chemotherapy
Kidney disease;
**BLACK**
88
When to get Serum Chemistry:
(Glucose, Electrolytes, renal and liver function).
- Liver or kidney disease;
- DM;
- CNS disease;
- Endocrine disorder;
- Elderly; Malnutrition;
- Type & invasiveness of surgery.
89
When to get to CXR:
- pulmonary disease or clinical findings (r/o pneumonia or pulmonary edema);
- unstable cardiovascular disease;
- type & invasiveness of surgery
90
When to get to ECG:
- CV disease or clinical findings;
- pulmonary disease;
- type & invasiveness of surgery
91
When to get pregnancy test:
possible pregnancy (child bearing years)
92
Aspiration risks (10):
**ROO INHALED**
1. Reflux
2. Obesity
3. Opiates
4. Inadequate (light) Anesthesia
5. Neuro Deficits
6. Hiatal Hernia
7. Abdominal pathology
8. Lithotomy
9. Emergency Surgery
10. Difficult Intubation
93
Fasting Times-
Clear liquids=
Breast milk=
Infant formula=
Non-human milk=
Light meal=
2 hour minimum
4 hour minimum
6 hour minimum
6 hour minimum
6 hour minimum
94
Aspiration Risk:
Medications and what do they do?
**Bicitra**: Increases gastric pH in 100% of the cases it is used – Highly effective antacid
**Famotidine**: Increases gastric pH
**Reglan**: Increases gastric emptying
95
Reglan is good for which patients?
obese;
pregnant;
diabetics;
trauma & emergency surgery.
