Week 13 - Preop Evaluation Flashcards
According to ASA what should be done during the preanesthesia visit?
- An interview with the pt or guardian to establish a medical, anesthesia and medication history
- An appropriate physical examination
- Indicated diagnostic testing
- Review of diagnostic data (labs, EKG, tests, consultations)
- Assignment of an ASA physical status score
- A formulation and discussion of anesthesia plans with the patient or a responsible adult before obtaining informed consent
What is the general definition of each ASA score?
ASA I = normal healthy patient
ASA II: patient with mild systemic disease (3040)
ASA IV: patient with severe systemic disease that is a constant threat to life
ASA V: moribund patient who is not expected to survive without the operation
ASA VI: declared brain dead patient whose organs are being removed for donor purposes
What should you look up in the chart before the preanesthesia visit?
- Assess pt’s surgical diagnosis and surgical procedure
- Weight and BMI
- Problem list, health history
- Review surgical clinic notes and any other pertinent notes
- Review outside records
- Allergies and current medications
- Review labs and tests
When should you order labs/tests?
Only if the result will impact the decision to proceed with the planned procedure or alter the care plans
-healthy patients of any age and patients with known, stable, chronic diseases undergoing low to intermediate risk procedures are unlikely to benefit from any routine test
What are the appropriate indications for preop testing?
When an abnormal result is suspected based on clinical risk factors and this result will:
- establish a new diagnosis
- direct further preoperative testing or consultation
- inform preoperative medication use
- alter intraoperative monitoring or management
- influence choice of surgical approach or anesthetic technique
- influence decision to postpone or cancel surgery
- change postop disposition
- establish periop risk profile for communication with other physicians and pt
What non-cardiac surgical procedures or interventions are considered LOW cardiac surgical risk?
- Superficial surgery
- Breast
- Dental
- Endocrine: thyroid
- Eye
- Reconstructive
- Carotid asymptomatic (CEA or CAS)
- Genecology: minor
- Orthopedic: minor
- Urological: minor (TURP)
What non-cardiac surgical procedures or interventions are considered INTERMIEDIATE cardiac surgical risk?
- Intraperitoneal: splenectomy, hiatal hernia repair, cholecystectomy
- Carotid symptomatic (CEA or CAS)
- Peripheral arterial angioplasty
- Endovascular aneurysm repair
- Head/Neck surgery
- Neurological or orthopedic: major (hip/spine surgery)
- Urological or Gynecological: major
- Renal transplant
- Intra-thoracic: non-major
What non-cardiac surgical procedures or interventions are considered HIGH cardiac surgical risk?
- Aortic and major vascular surgery
- Open lower limb revascularization or amputation or thromboembolectomy
- Duodeno-pancreatic surgery
- Liver resection, bile duct surgery
- Oesophagectomy
- Repair or perforated bowel
- Adrenal resection
- Total cystectomy
- Pneumonectomy
- Pulmonary or liver transplant
What six criteria does the Revised Cardiac Risk Index incorporate?
- Presence of ischemic heart disease
- History of HF
- History of cerebrovascular disease
- DM treated with insulin
- Cr level of 2 mg/dL or higher
- Intrathoracic, supra-abdominal or supra-inguinal vascular procedures
*presence of 0, 1, 2, or 3 factors is associated with 0.5%, 1.3%, 4%, and 9% risk of MACE (major adverse cardiovascular events)
What is the purpose of assessing functional capacity?
The ability to achieve a moderate level of activity without symptoms, denoted by a MET score of 4 or more predicts a low risk of perioperative complications
- METs 1 = eating, working at computer, dressing
- METs 5 = climbing 1-2 flights of stairs, dancing, bicycling
- METs 10 = swimming quickly, running or jogging briskly
When might preop consultation be considered?
- Diagnosis, evaluation, and improvement of a new or poorly controlled condition
- Creation of a clinical risk profile that the patient and perioperative team use to make management decisions
When is it recommended to get an Albumin lab preop?
Anasarca
Liver disease
Malnutrition
Malabsorption
When is it recommended to get a CBC preop?
Alcohol abuse Anemia Dyspnea Hepatic or renal disease Malignancy Malnutrition Personal history of bleeding Poor exercise tolerance Recent chemo or radiation therapy
When is it recommended to get Creatinine lab preop?
Renal disease
Poorly controlled DM
Injection of contrast dye during the procedure
When is it recommended to get a Chest x-ray preop?
- Active, acute, or chronic significant pulmonary symptoms such as cough or dyspnea
- Abnormal unexplained physical findings on chest exam
- Decompensated HF
- Malignancy within the thorax
- Radiation therapy to the chest, breasts, lungs, thorax
*extremes of age, smoking, stable COPD, stable cardiac disease, or resolved recent upper respiratory infection should not be considered unequivocal indications
When is it recommended to get an ECG preop?
- Alcohol abuse
- Active cardiac condition (new or worsening chest pain or dyspnea, palpitations, tachycardia, irregular heart bear, unexplained bradycardia, undiagnosed murmur, decompensated HF)
- ICD
- OSA
- Pacemaker
- Pulmonary HTN
- Radiation therapy to chest, breasts, lungs, thorax
- Severe obesity
- Syncope
- Use of amiodarone or digoxin
When is it recommended to get Electrolyte levels preop?
- Alcohol abuse
- CV, hepatic, renal, or thyroid disease (check potassium in ESRD)
- DM
- Malnutrition
- Use of digoxin or diuretics
When is it recommended to get a Glucose level preop?
DM – glucose level determination on day of surgery
Severe obesity
Use of steroids
*maybe get a HgbA1c as well
When is it recommended to get LFT labs preop?
- Alcohol abuse
- Hepatic disease
- Recent hepatitis exposure
- Undiagnosed bleeding disorder
When is it recommended to get a Platelet count preop?
- Alcohol abuse
- Hepatic disease
- Bleeding disorder (person or family history)
- Hematologic malignancy
- Recent chemo or radiation therapy
- Thrombocytopenia
When is it recommended to get a PT and PTT preop?
PT: alcohol abuse, hepatic disease, malnutrition, bleeding disorder, use of warfarin
PTT: bleeding disorder, undiagnosed hypercoagulable state, use of unfractionated heparin
When is it recommended to get TSH, T3, and T4 levels preop?
Goiter
Thyroid disease
Unexplained dyspnea, fatigue, palpitations, tachycardia
When is it recommended to get a pregnancy test preop?
Offer to female patient of childbearing age and for whom the result would alter the patient’s management
When does a preop 12-lead ECG have no benefit?
Class III:
-routine preop resting 12-lead is not useful for asymptomatic pts undergoing low-risk surgical procedures
When can a preop 12-lead ECG be considered?
Class IIb:
-considered for asymptomatic pts without known coronary heart disease, except for those undergoing low-risk surgery
When is a preop 12-lead ECG reasonable?
Class IIa:
-reasonable for pts with known coronary heart disease, significant arrhythmia, PAD, cerebrovascular disease, or other significant structural heart disease, except those undergoing low-risk surgery
When is it recommended to get an Echo and evaluation of LV function preop?
Patients with:
- diastolic murmurs
- continuous murmurs
- late systolic murmurs
- murmurs associated with ejection clicks
- murmurs that radiate to the neck or back
- grade 3 or louder systolic murmurs
LV function:
- pts with dyspnea of unknown origin
- current or previous HF with worsening dyspnea or other change in clinical status if not performed within 12 months
What are the clinical characteristics to consider when deciding to get Pulmonary Function Tests preop?
- Type and invasiveness of the surgical procedure
- Interval from previous evaluation
- Treated or symptomatic asthma
- Symptomatic COPD
- Scoliosis with restrictive function
