Preoperative Anesthetic: Risk Assessment and Management to Form an Anesthesia Plan – Flashcards
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What you're really being asked to do
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-assess risks of anesthesia -assess risks of procedure -manage complicated medical problems -bring all above together to create a plan to best manage the patient while respecting the patients wishes -predict the future based upon: patient, surgeon, anesthesia
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General Approach to Plan
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-ROS, H&P -treatment, directed toward decreasing surgical risk -carry out anesthesia plan -amend plan for: anesthesia/procedural complications
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Risk Evaluation
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overall perioperative mortality = 0.3% Anesthesia induction - 10% Intraoperatively - 35% Postoperatively (48 hours) - 55%
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ASA class 1 48 mortality
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0.07% normal o/w healthy pt
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ASA class 2 48 mortality
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0.24% mild systemic disease with no functional limitations controlled HTN, mild asthma, smoking, controlled DM, obesity
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ASA class 3 48 mortality
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1.4% Moderate to severe systemic disease resulting in some functional limitations Examples: Uncontrolled HTN Prior MI ESRD*** COPD Angina pectoris
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ASA class 4 48 mortality
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7.5% Severe systemic disease that is a constant threat to life and functionally incapacitating Examples: Active CAD with angina Severe valvular stenosis and/or regurgitation Cerebral aneurysm AAA ESRD with multiple systems involved***
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ASA class 5 48 mortality
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8.1% Moribund patient not expected to live 24 hours with or without surgery Examples: Severe trauma Ruptured cerebral aneurysm Septic shock Uterine rupture Aortic dissection
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ASA class E 48 mortality
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doubles risk Emergency surgical procedure Examples: 'Crash' Cesarean section Open fracture Ruptured AAA CHI w/ decompensation NPO status waved for immediate passage to OR
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low risk procedures
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eye surgery, oral surgery, D&C, hysterectomy, herniorrhaphy
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high risk procedures
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craniotomy and cardiovascular
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specific risks
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Pulmonary Cardiac Hematologic Endocrine Thromboembolism prophylaxis
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pulmonary risks
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Complications: Hypoventilation Pneumonia Atelectasis Occur in about a third of patients Accounts for half of perioperative mortality
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Who's at risk for pulmonary complications
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Smokers COPD Obesity Age > 70 Thoracic surgery Upper abdominal surgery Anesthesia > 2 hours
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FEV1 Risk Assessment
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FEV1 > 2L...probably safe FEV1 between 1 and 2L...increased risk FEV1 <1L...high risk
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Pulmonary Risk Management
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Quit smoking Bronchodilator therapy CPT Early treatment of bronchitis Early mobilization
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Cardiac Risks
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Complications: Myocardial Infarction CHF Hypertension 50% fatal, 60% silent Increased mortality post-op day 3
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Who's at risk for cardiac complications
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Recent MI Valvular heart disease CHF Unstable angina Diabetes
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Cardiac Risk Assessment
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Goldman Cardiac Risk-Index for Noncardiac Surgery American College of Cardiology Risk Assessment
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Cardiac Risk Management
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Monitor for perioperative ischemia Repair severe aortic stenosis first Treat CHF aggressively preoperative Postpone non-emergent procedures for at least 6 months after an MI and/or stent placement
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Hematologic Risks
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Complications: thrombo-embolic bleedingEnd
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Who is at risk for hematologic complications
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Polycythemia vera Anemia Thrombocytopenia Anticoagulation Therapy
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Hematologic Risk Assessment
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Hematocrit Platelet count Bleeding time PT/PTT
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Hematologic Risk Management
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Phlebotomy to decrease hct 50,000 Have patients stop anti-platelet therapy for 7 days prior to surgery Bring Coags to normal if possible Transfusion therapy To increase Hg to >7mg/dL 1 unit of PRBC will raise Hb by 1mg/dL or hct by 3% To increase plt to >50, ooo 1 pack of plt will increase by 5-10K
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Endocrine Risks
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Thyroid storm Diabetic complications
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Endocrine Risk Management
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Good control of thyroid function for at least 3 months prior Hold oral hypoglycemics Reduce insulin by half night prior to surgery Test BS prior to surgery and in PACU Give regular insulin PRN
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Thromboembolic Prophylaxis
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Specific to surgery Increased risk: Elderly Obesity Prolonged anesthesia Immobility subq heparin, squeeze legs
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Other Considerations
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Antibiotic prophylaxis -Antibiotics within hour of surgery Herbal medicines -What and when --Stop all with Vitamin E Geriatric patient -Postoperative Cognitive Dysfunction
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Human error accounts for ____ of all incidents
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68%
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___ of cases were related to breathing circuit or ventilator problems
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56%
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Where to start the IV
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non surgical side, non dominant arm flat, non moving surface (back of hand/forearm) start low and work way up
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IV sizes
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large fluid shifts: >18g minimal blood loss, most surgeries = 20g blood products >20g hard stick, 22-24g
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preop planning
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All after the IV is started: Anxiolytics to relieve the patient's induced stress Anti-emetics to reduce PONV Opioids to relieve pain Antibiotic therapy to prevent infections SCIPs protocol MVP protocol Other Topical anesthetics Insulin Surgeon Requests
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Peri-op Planning
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intubation paralyzed - no LMA, use ETT nerve block/regional anesthesia -Spinal (subarachnoid block (SAB)) or epidural, extremity block, digit block pain meds? narcos during/recovery induction agent? maintenance? pain? paralysis? reversal? VS control?
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Pt has asthma
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use Sevoflurane bc bronchodilator not desflurane bc broncho irritant
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Post-op planning
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pt extubated at end of case or stay on vent? O2 delivery to support pt? OAW/NAW? nerve block/regional anesthesia? narcos for PACU? cover nausea
