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Joint Commission

answer

All patients mus receive a preoperative assessment. ASA has standards for Evaluation

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Goals for Preop Eval

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Reduce patient risk and morbidity associate with surgery and coexisting diseases, promote efficiency and reduce costs, prepare the patient medically and psychologically.

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Best Screening Tool

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Most important is to look at previous anesthesia assessment.

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Allergies

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Go over meds and allergies and if allergic may need steriod coverage. Make sure to document the REACTION. Ask about Latex Allergy

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??End Organ Damage

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Htn, Diabetes, Obesity. Assess for end organ failure especially noted in heart, lung, renal, and CVA.

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Exercise Tolerance

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Best determinant of cardiac risk.

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General Medications to take Preop

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Most Meds for Heart and HTN. Possibly start patients on betablocker before case. May be need subacute endocarditis treatment. Asthma and COPD meds Reflux meds Insulin.

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General Medications to hold Preop

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Oral hypoglycemics

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Preop Sedation

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Timing should be carefully planned for optimal effect and avoid delays.

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Allergy to Anesthetic

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Anyone that states them or a family member has a allergy be cautious of malignant hyperthermia.

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Airway Preop Assessment

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Use Mallampati Assessment for difficult intubations. Trauma, Downs syndrome, or rheumatoid arthritis should be assessed for cervical damage before intubation. May need x-rays.

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Pulmonary Preop Assessment

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Tobacco use, SOB, Cough, Wheeze, Stridor, Snoring-Sleep Apnea. Recent Upper Respiratory Infection. Look and listen for respiratory sounds, rate, rhythm, nails, SOB.

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Cardio Preop Assessment

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Most Interested in S/S of uncontrolled HTN, MI, CHF, Valve Disease, Dysrhythmias. Murmur to assess for aortic stenosis, abnormal rhythms or HF.

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Unstable Angina Preop Cardio

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Increase risk of MI Periop. Due to hypercoagulable states, surges of endogenous catecholamines (Epi, Levo, Dopam, etc).

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Mitral Valve Prolapse

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Subacute bacterial endocarditis prophylaxis

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Bruits over Carotids

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Risk for stroke

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Neuro Preop Assessment

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Simply done by watching them answer questions. May need extensive questioning if they have a neuro disease. Always test strength, reflexes and sensation for patients that are having surgery that could change those. Check Previous scans.

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Endocrine Preop Assessment

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Assess for Diabetes, Thyroid, parathyroid, endocrine tumors, and adrenal cortical suppression.

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Goldman Cardiac Risk Index

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High Risk SX. History of Ischemic Heart. CVA. CHF. Preop Tx of Insulin. Creatinine greater than 2. Greater risk with more factors.

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Preop Diabetes

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Autonomic Neuropathy with diabetes is best predictor of Silent CAD and MI. Obtain ECG and evaluate for Q wave. Gastroparesis- give gastrokinetic such as metoclopramide.

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Preop Htn

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Increased risk with left ventricular hypertrophy of MI. Delay Surgery if Diastolic Greater than 110.

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Preop Exercise Tolerance

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Increased risk if cant walk a mile without being SOB. Studies say it is ok if pt can describe exercise tolerance to assess risk for CAD. If high CAD risk or SOB while walking increased risk of hypotension and ischemia.

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Preop Cardiac Morbidity Decrease

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With Beta Adrenergic Blockers.

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Dobutamine

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Given for preop testing for those unable to exercise.

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Preop Echo

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regional wall motion abnormalities at low heart rates increase risk.

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Preop Coronary Angiography

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Best method for Coronary Anatomy. Pts. who have an MI periop is from noncritical stenosis not from the main ones assessed with Angiography.

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Recent Stent Placement

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Should wait at least 3-4 weeks after placement before other surgeries.

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Pulmonary Complications Peri-Op

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Atelectasis Pneumonia Bronchitis Bronchospasm Hypoxemia COPD Respiratory Failure requiring Ventilator Highest risk when patients have thoracic, aortic, or upper abdominal sx.

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General Anesthesia (GA) and Pulmonary Complications

answer

Decreases functional residual capacity Altered diaphragmatic motion leading to V/Q mismatch with shunting and dead space ventilation.

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GA and Pulmonary Microsopic issues

answer

inhibits mucociiliar clearance, increased alveolar capillary permeability, inhibit surfactant, increased nitiric oxide, increased sensitivity of pulmonary vasculature to nurohumoral mediators.

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Pulmonary Function Tests

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Usually prior to lung resection or unexplained Respiratory S/S.

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Oral Medications

answer

60-90 mins before OR.

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IM Medications

answer

30-60 min Before OR.

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Allergy

answer

Absolute contraindication to its use. Rash, Hives, SOB, Pruritis, Anaphylaxis

question

Drug Intolerance

answer

GI complaints or Mental Status Changes

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Smoking History

answer

Stop smoking 12 hrs before. (nicotine effects on CV and carbon monoxide on oxygen carrying capacity is short lived) Higher risk for pneumonia and atelectasis. (to decrease these risks need to quit smoking 4-8 weeks before surgery)

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ETOH

answer

Builds resistance to CNS depressants Long Term- Poor Wound Healing, infection, bleeding, Hepatic Acute Intoxication- May see exagerated response to anesthetic.

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Tolerance

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Decreased in responsiveness to the drug. The drug can't work like it was designed to.

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Malignant Hyperthermia- HX

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Rapid onset of extremely high fever with muscle rigidity occurring during the administration of general anesthesia. Early sign is increased CO2 because increase work from cells. Any Temp in family. Ice around them to cool. ICU

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Pseudo Cholinesterase Deficiency- HX

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inherited enzyme abnormality that results in abnormally slow metabolic degradation of exogenous choline ester drugs such as succinylcholine. ICU Ventilator post-op

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Herbal Meds and OR

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Ask to D/C 7 days prior to surgery. 3 G's associated with bleeding- Garlic Ginkco Ginseng

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Latex

answer

20% of intraop anaphylactic reactions. Should be 1st case of day to prevent aeroallergen exposure. At Risk- Many Surgeries, Spina Bifida. Allergy to Tropical Fruit

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Cocaine

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Sympathetic response

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Marijuana

answer

Tachy, HA, Euphoria, Anxiety, Depression

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Opiods

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Parasympathetic response

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Mallampati

answer

Low predictive value for difficult intubation. Best approach is mulifactorial. MP1- easy to intubate MP3-4- Difficult

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Thyromental Distance

answer

TMD Mouth Closed, neck fully extended, measure the distance between prominence of the thyroid carilage and the bony point of the lower mandibular border. Less than 3 fingerbreadths is difficult intubation (pts fingers).

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Interincisor Distance

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Degree the mouth can open.

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Airway Evaluation (AE)

answer

Length of Incisors Relation of maxillary and mandbular incisor during normal jaw closure Relation of maxillary and mandibular incisor during voluntary protrusion or mandible. Interincisor Distance Visibility of Uvula Shape of palate Complicance of mandibular space Thryomental distance Length of neck. Thickness of Neck. Range of Motion.

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Respiratory Assess

answer

Tobacco SOB Cough Wheeze OSA RR, Chest Excursion, accessory muscles, nail color, dyspnea with talking Increased risk of complications depending on surgery. Increases risk when operation is closer to diaphragm. Elective surgery is cancelled with severe SOB, hypercarbia.

question

OSA

answer

Recovery is with head up. Does patient snore loudly enough to hear through a door. Are there observed pauses Wake up and feel choking Daytime sleepiness

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CVS HIGH RISK sx

answer

Emergent Major Aortic or Major Vascular Long SX with large fluid shifts and blood loss

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CVS intermediate risk sx

answer

CEA Head and Neck Orthopedic Prostate Intraperitoneal Intrathoracic

question

CVS low Risk sx

answer

Superficial cataract endo breast

question

Metabolic Equivalent MET Energy Requirement

answer

1 MET- eat, dress, toilet 4- light work dishes/dusting climb a flight of stairs 5-6- heavy work around house 6-8- golf, dance 10+- swimming, basketball If can do 4 or higher than ok for intermediate or low risk sx.

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ACE inhibitor

answer

increased diff. in controlling hypotension in OR.

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Uncontrolled HTN

answer

Labile in OR.

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Ischemic Heart

answer

Insufficient oxygen and nutrient to meet metabolic demand. The longer post MI the less the risk for mortality.

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LV dysnfunction

answer

EF less than 35% > risk for death.

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PE

answer

Bilateral Rales JVD Increased RR Low BP Low Sao2

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Valvular Disease

answer

Aortic Stenosis 14 fold greater incidence of periop death.

question

Pacemaker and AICD

answer

Magnet Consider bipolar Bovie- if surgeon wont suggest short intermittent bursts. BOVIE PAD far from AICD Have interrogated pre and post op

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Musculoskeletal

answer

Osteo, RA, anklyosing spondylitis. ASA or NSAID increase bleeding. May need supplemental steriods to handle stress of surgery because chronic steriods kills adrenal response.

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GI system

answer

N/V/D GERD Hepatitis Pancreatitis

question

Hepatobiliary

answer

increased PT and PTT FFP, Vitamin K, Platelets Risk for hypoglycemia

question

Renal

answer

BUN/Creat may not be accurate. Creat- strong person, BUN- eats lots of protein. Most accurate of renal reserve is creatine clearance HGB low because decreased production of erythropoeitin and fragile RBC's.

question

Dialysis

answer

check K 6-8 hrs prior to case. K >5.5 delay elective sx Check peaked T wave Treat high k with- insulin, calcium, dextrose, bicarb

question

Thyroid

answer

T4 Active form. Propylthiouracil causes agranulocytosis. Continue all drugs. Beta- antagonists are useful. Avoid Anticholinergics.

question

Length of Incisors (AE)

answer

Length of Incisors- LONG COMPARED TO REST OF DENTITION.

question

Relation of maxillary and mandbular incisor during normal jaw closure (AE)

answer

OVERBITE

question

Relation of maxillary and mandibular incisor during voluntary protrusion or mandible (AE)

answer

CANNOT BRING MANDIBULAR ANTERIOR TO MAXILLARY.

question

Interincisor Distance (AE)

answer

LESS THAN 3CM

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Visibility of Uvula (AE)

answer

NOT VISIBLE WHEN TONGUE OUT AND SITTING UP.

question

Shape of palate (AE)

answer

HIGHLY ARCHED OR NARROW

question

Complicance of mandibular space (AE)

answer

STIFF

question

Thryomental distance (AE)

answer

LESS THAN THREE FINGERS

question

Length of neck (AE)

answer

SHORT

question

Thickness of Neck (AE)

answer

Thick

question

Range of motion (AE)

answer

CANNOT TOUCH TIP OF CHIN TO CHEST OR UNABLE TO EXTEND NECK.

Preoperative Assessment and Management Chapter 23 Barash – Flashcards

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