2. Preanesthetic Patient Evaluation and Risk Assessment Flashcards by J L

Practice Advisory for Preanesthesia Evaluation: A Report by the American S Anesthesiology

The appointed task force of 12 members were charged to:
1) review ____ evidence
2) obtain expert and public consensus ____
3) create a ____-based assessment of currently available scientific literature and opinion
They concluded that controlled studies for such evaluations were ____.
11% (47 of 6271) of reports identified inadequate or incorrect pre-operative assessment that accounted for 3.1% (197) of adverse events.

published
option
consensus
lacking

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Benefits
• Increases the likelihood of patient and physician ____
• Decreases the likelihood of ____
• Reduces health care ____

satisfaction
adverse events
costs

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Risk Factors

Patient’s ____ status
Non-____, poorly stabilized cardiac and pulmonary
____
Age > ____ years
____ infants
Surgery
____
Type of facility

clinical
non-compensated
obstructive sleep apnea
85
pre-term

anesthesia

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Components
• Evaluation of pertinent medical \_\_\_\_
• Patient \_\_\_\_
• Physical \_\_\_\_
• \_\_\_\_
• \_\_\_\_

records
interview
examination
consultations
consent

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No ____ trials of the clinical impact of performing a preanesthesia medical records review or physical examination were found.
Several studies reported specific perioperative outcomes occurring in patients with specific pre- existing conditions.

controlled

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• In terms of timing of this preanesthetic interview and physical exam
◦ Wouldn’t wanna do this prior to the day of surgery
◦ Ideally want to do this eval ____ days before surgery
◦ The less severe the pt’s disease, the less time you need to allow between the
preanesthetic eval and the actual procedure

several

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Patient Interview
• Abnormalities of the major \_\_\_\_ systems
• Current medications
• Drug \_\_\_\_
• Social history
• \_\_\_\_ history
• Pregnancy
• Previous \_\_\_\_

organ
allergies
family
anesthesia

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Review of cardiovascular system: diseases

____ abnormalities
CAD
Previous ____
Valvular disorders
____
Arrhythmias
____
Previous cardiac surgery

BP
MI
CHF
cardiomyopathy

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Review of cardiovascular system: symptoms

____
Dyspnea
____
Orthopnea
____
Palpitations

angina
syncope
PND

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Goldman Cardiac Risk Index
• 1n 1977, published study1
• Reports \_\_\_\_ outcome
• Does not diagnose \_\_\_\_ disease
• Assign point values to \_\_\_\_ variables
• Predictive value is \_\_\_\_

peri-operative
cardiac
independent
limited

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• Just know there are various points assigned to different parts of the pt’s ____ and
____

history

physical exam

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Incidence of perioperative reinfarction following a myocardial infarction (MI)

Time since MI (months)

0-3
____%

4-6
____%

7-12
____%

13-24
____%

> 24
____%

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Time interval from myocardial infarction (MI) as a predictor of surgical risk

< 6 mos post-MI
____% overall mortality

6-9 mos post-MI
____% overall mortality

> 12 mos post-MI
____% overally mortality

18-22
10
5

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Valvular Disease

• ____ has the highest perioperative morbidity and mortality of all the valvular diseases

aortic stenosis

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• This is a topic that we have to face when we’re doing dentistry on pts and the issue is ____ and prevention of this in pts that have certain things in their history that may predispose them to this after they get some sort of dental procedure that will elicit bleeding, a bacteremia can occur

acute bacterial endocarditis

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• They looked at different antibiotic regimens that have been used and how we’ve changed this over time
• Prior to these latest recommendations, pts were given antibiotics before AND after the procedures
◦ Now we give only ____ hour before the procedure
◦ Eliminated giving them a ____ dose ____ hours after the procedure ◦ That was the major change that took place

1
second
6

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All dental procedures that involve manipulation of gingival tissue or periapical region of teeth or perforation of the oral mucosa

following DO NOT need prophylaxis: routine ____ injections through noninfected tissue, taking dental ____, placement of removable ____ or orthodontic appliances, adjustment of ____ appliances, placement of orthodontic ____, shedding of ____ teeth, and bleeding from ____ to the lips or oral mucosa

anesthetic
radiographs
prosthodontic
orthodontic
brackets
deciduous
trauma

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AHA’s Conclusions

Recommend that most patients no longer need short-term antibiotics as a ____ measure
Risks associated with taking preventive antibiotics outweigh the ____ for most patients
No compelling evidence that antibiotics prior to a surgical procedure prevents ____
Maintenance of optimal oral ____ is more important than prophylactic antibiotics for dental procedures to reduce the risk of infective endocarditis.

preventive
benefits
endocarditis
health

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Who should get prophylactic antibiotics

____ cardiac valves
A history of ____
Cardiac ____ recipient
Congenital heart disease
____ cyanotic congenital heart disease, including those with palliative shunts and conduits
a completely ____ congenital heart defect with ____ material or device, whether placed by surgery or by catheter, during the first ____ months after the procedure
any repaired congenital heart disease with ____ defect at the site or adjacent to the site of a prosthetic patch or device

prosthetic
endocarditis
transplant

unrepaired
repaired
prosthetic
six
residual

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Antibiotic Regiments

ORAL
Adults: ____
Children: ____

IV/IM
Adults: ____, ____, ____
Children: ____, ____, ____

Pen-allergic
Adults: ____, ____, ____
Children: ____, ____, ____

amoxicillin 2 gm
50 mg/kg

ampicillin 1 gm
cefazolin 1 gm
ceftriaxone 1 gm

50 mg/kg
50 mg/kg
50 mg/kg

clindamycin 600 mg
azithromycin 500 mg
clarithromycin 500 mg

20 mg/kg
15 mg/kg
15 mg/kg

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Review of Respiratory System:
Diseases
 • \_\_\_\_
• COPD
• Recent \_\_\_\_
• Pneumonia
• \_\_\_\_

Study These Flashcards

asthma
URI
cystic fibrosis

Review of Respiratory System:
Symptoms
• \_\_\_\_
• Wheezing
• \_\_\_\_
• Sputum production
• \_\_\_\_

Study These Flashcards

dyspnea
cough
hemoptysis

Postoperative pulmonary complications

____
Pneumonia
Exacerbation of ____ disease
Respiratory failure

Study These Flashcards

atelectasis

chronic

URI and Anesthesia

• Patients with URI should postpone surgery for ____ weeks.

Study These Flashcards

2-3

Smoking and anesthesia: Preoperative abstinence and perioperative morbidity * Determined a ____ within which discontinuing smoking can decrease morbidity and mortality. * Abstinence for ____ weeks improves ciliary function and decreases sputum production

time frame | 4 to 8

Review of Nervous System: Diseases * ____ * TIA * ____ disorder * Multiple sclerosis * ____ disease * Developmental delay * ____ injury

CVA seizure parkinson's spinal cord

``` Review of Nervous System: Symptoms • ____ • Headaches • ____ • Weakness • ____ problems ```

dizziness seizures memory

Neurologic Risk Assessment • 0.7% stroke rate in 735 patients undergoing ____ surgery.7 • Patients with ____ are at high risk of stroke, and their risk may be stratified by clinical scale, ____ imaging, and diffusion magnetic resonance imaging.8 • A history of ____ or ____ is a strong predictor of increased cardiac mortality.8

``` non-cardiac TIA's vessel CVA TIA ```

``` Review of Endocrine System: Diseases • ____ • Thyroid gland dysfunction • ____ gland dysfunction ```

diabetes | adrenal

American Society of Anesthesiology Classification of Physical Status (ASA) * In 1940 - 41, ASA asked a committee of three physicians (Meyer Saklad, M.D., Emery Rovenstine, M.D., and Ivan Taylor, M.D.). * This effort was the first by any medical specialty to stratify ____ for its patients. * Classified patients in relation to their ____ only. * Published in 1963.

risk | physical status

ASA GRADE 1 Status: ____ patient Absolute mortality: ____% 2 Status: ____ systemic disease, or patient over ____ years old Absolute mortality: ____% 3 Status: systemic disease taht causes definite functional ____ on life Absolute mortality: ____% 4 Status: ____ systemic disease that is a constant threat to life Absolute mortality: ____% 5 Status: morbound patient unlikely to survive ____ hours without surgery Absolute mortality: ____%

``` normal healthy 0.1 mild 80 0.2 limitation 1.8 severe 7.8 24 9.4 ```

``` Physical Examination • ____ signs • General inspection • ____ of the heart and lungs • Evaluation of the airway ```

vital | auscultation

Airway Assessment * ____ * Short neck * Limited ____ extension * Decreased thyromental distance * ____ disease or trauma * ____ trauma * Craniofacial syndromes * ____ * Trismus * ____ * Enlarged tonsils

habitus neck cervical spine facial retrognathia tumors

``` Predictors of difficult intubation • Obesity - BMI > ____ • MIO < ____ mm • ____, ____ occlusion • ____ distance ```

``` 30 40 retrognathia class II thyromental ```

Modified Mallampati Classification8 * Standing or sitting ____ * ____ mouth and tongue out * Grouped according to visualized structures • Class1/Grade1= We can see ____, we can see the tonsils, nice open airway, we can see the palatine fossae, the uvula, the soft palate perfectly • Class2/Grade2= Start to see less of an open ____ ◦ Only see part of the uvula, can still see soft palate/palatine fossae • Class3=See less ◦ Don't see ____, we do see the ____ (that's the dotted line) ◦ The ____ is obstructing the uvula • Class4 = don't even see the ____ anymore ◦ All we see if ____ when we look back at those pts

``` upright open everything airway uvula soft palate tongue soft palate hard palate ```

• Mallampati Classes ____ and ____ pose an increased risk of loss of a patent airway during ____ and ____ sedation.

III IV moderate deep

Preoperative Tests ____ or identification of a disease or disorder that may affect perioperative anesthesia care ____ or assessment of an already known disease, disorder, or medical therapy that may affect perioperative anesthesia care Formulation of specific ____ and alternative for perioperative anesthesia care

discovery verificiation plan

Labs and diagnostic studies * ____ * BMP * ____ studies * LFT’s * ____ * Beta-HCG * ____ * Echocardiogram * ____ test * Cardiac catheterization * ____ duplex * CXR * ____ * ABG

CBC coagulation TFT's ECG stress carotid PFT's

Routine electrocardiographic findings were reported as abnormal in ____% of cases and led to changes in clinical management of ____% of the cases found to be abnormal. • Routine chest x-ray findings were reported as abnormal in ____% of cases (n = 20 studies) and led to changes in clinical management in ____% of the cases found to be abnormal.

7. 0-42.7 9. 1 2.5-60.1 0-51

Pre-anesthesia pregnancy testing for all women patients of childbearing age • ____ or elective • ____ and when to test • ____ to test

mandatory how whom

Pregnancy Testing The incidence of newly diagnosed pregnancies on the day of surgery is ~ ____% The average cost of a urine pregnancy test is ~ $____ and a serum pregnancy test is ~ $____. Serum Beta-hCG is elevated in pregnancy, ____ tumors, testicular cancer, ____, and hepatobiliary tumors. Quantitative serum Beta-hCG levels and pregnancy: 3 weeks since LMP: 5 - 50 mIU/ml 4 weeks since LMP: 5 - 426 mIU/ml 5 weeks since LMP: 18 - 7,340 mIU/ml 6 weeks since LMP: 1,080 - 56,500 mIU/ml 7 – 8 weeks since LMP: 7,650 - 229,000 mIU/ml 9 – 12 weeks since LMP: 25,700 - 288,000 mIU/ml 13 – 16 weeks since LMP: 13,300 - 254,000 mIU/ml 17 – 24 weeks since LMP: 4,060 - 165,400 mIU/ml 25 – 40 weeks since LMP: 3,640 - 117,000 mIU/ml

``` 0.3-2.2 10-15 75 ovarian germ cell teratomas ```

HUP Policy TAKE A LOOK AT THIS!

need an updated slide

Determination of Medical risk Can tolerate the proposed anesthetic both ____ and psychologically More ____ is needed ____ risk is associated with the proposed treatment in the patient’s current physical or emotional state

physically information excessive

Instructions * NPO (____ hours) * ____ of meds * ____ of meds * ____

8 continuation alteration escort

``` Aspiration Risk • ____ • Recent food intake • ____ • Gastroparesis • ____ obstruction ```

obesity GERD GI

Guidelines to reduce risk of pulmonary aspiration No ____ Routine use of gastric stimulants and anti-emetics is ____ Ingested material clear liquids min fasting period: ____ light meal min fasting period: ____

food or drink not recommended 2 hours 6 hours

``` Preoperative medication considerations • ____ • Steroids • ____ • Anticoagulants • Antibiotic ____ • Transfusions ```

diuretics insulin prophylaxis

``` Consent • Discussion about the proposed ____ technique • ____ and risks • Anesthetic ____ • Easily understood ____ ```

anesthetic benefits alternatives language

The following remarks represent a synthesis of the opinion surveys, literature and Task Force consensus: 1. Content of the preanesthesia evaluation includes but is not limited to (1) readily ____ medical records, (2) patient ____, (3) a directed 2. Timing of the preanesthesia evaluation can be guided by considering combinations of surgical ____ and severity of disease, a 3. Routine preoperative tests (i.e., tests intended to dis- cover a disease or disorder in an asymptomatic pa- tient) do ____ make an important contributi 4. Selective preoperative tests (i.e., tests ordered after consideration of specific information obtained from sources such as medical records, patient int 5. Decision-making parameters for specific preopera- tive tests or for the timing of preoperative tests can- not be unequivocally determined

accessible interview invasiveness not

QUIZ QUESTIONS: 1. What cardiac valvular condition is associated with the highest morbidity and mortality? a. ____ 2. T/F: Pts with modified Mallampati 3/4 pose an increased risk to airway problems during anesthesia? a. ____

aortic stenosis | true

2. Preanesthetic Patient Evaluation and Risk Assessment Flashcards

(50 cards)