Preop Assessment Flashcards
What are some components of the preop exam?
- o Pts med hx
- o Physical
- o Meds/allergies
- o ASA status
- o Airway assessment
- o Explanation of anesthetic plan.
- o Documentation
- o Consent
- o NPO status
- o Lab testing/diagnostic
What can you obtain from chart review of the patient?
o Demographics
o Dx/sx
o Sx Consent
o Prior H&P
o Nursing notes
o Pts questionnaire
o Results of tests
o EKG/PFT/Xray
o Vitals
o Med list
o Allergies
o OLD ANESTHESIA RECORDS → any complications noted?
What are some medications to d/c prior to sx?
o ACEI- prils
o ARBs – sartans
o Metformin
o Regular Insulin- morning of
§ unless on continuous pump
§ DM 2- none or up to ½ of long acting insulin. D/C short acting
§ DM 1- small amount (1/3) long acting morning of sx
o NSAIDs- 48 hrs
o Aspirin – 7 days
o Warfarin – 5 days
o Clopidogrel- 5 days
o Sildenafil – 48 hrs
o Viagra- 24 hrs
o Topical medications
Who requires early preoperative assesment? When is the ideal time to have that assessment?
1 weeks prior to sx
CV: Angina, CHF, MI, CAD, poorly controlled HTN
Pulm: COPD/severe asthma, airway abnormalities, home O2 or ventilation
Endocrine: IDDM, adrenal disease, active thyroid disease
GI/GU: Liver disease, end-stage renal disease
Metabolic: Morbid obesity, symptomatic GERD
CNS: Severe kyphosis, spinal cord injury
What are some components of preop interview?
- Introduction
- Confirmation- pt ID, dx, procedure (site)
- Education- type of anesthetic, IV insert, urinary cath, airway instrumentation, monitors, post op care
- Establishment
- Open ended questions, general to specific, organized, systematic, individualized, lament terms, controlled environment (+/- family members), interpreters, unrushed
What are some components of an airway assessment?
- Mallampati Classification: PUSH
-
Thyromental distance
- 3fb (6 cm)
- >9 cm–> harder to intubate
- 3fb (6 cm)
- Interincisor distance: 2 fb (3 cm)
-
Atlanto-occipital function: extension
- Normal: 35 degrees
- Problem: < 23 degrees
- Mandibular protrusion test:
-
Hyomental distance
- ~ 2 fb
- Neck circumference
- normal neck:
- Male: 15-16 inches
- Female: 13-14 inches
- > 17 inches (40 cm) → difficult airway (5% chance of difficult area; q cm increased, increase by 1.3%)
- big neck: harder
- normal neck:
-
Prayer sign: collagen linking disorder → concern w/ neck extension
- Knuckle touch (DM pts)
From table
- touch chin to chest
- highly arched palate
What is the predictive value of a test?
SNout – Sensitivity rules OUT→ true negative
SPin- Specificity rules IN
When should you get a CXR?
Assessment of periop risk
Decision: based on abnormalities
Active things happening: SOB, intercostal retractions, deviated trachea, active wheezing, rust colored sputum
Chronic things: Severe COPD, pulm edema, pneumonia, suspected mediastinal masses (deviated trachea)
Recommendations for preop 12 lead EKG?
IIa: reasonable to perform 12-lead → IHD. Significant arrhythmia, PAD, CVD. Significant structural HD (unless low risk procedure)
IIb: Considered 12-lead → asymptomatic pts w/o known coronary heart disease, (except low risk sx)
III: NOT BE PERFORMED → not helpful for asymptomatic pts undergoing low risk procedure
Current recommnedations for NPO status?
o Based on CURRENT ASA guidelines that balance risk factors of fasting with pulmonary aspiration risk
- 2 hours→ clear liquids all patients (Apple juice, Gatorade, no creamer/sugars)
- 4 hours→ breast milk
- 6 hours → formula or solids; light meal
- 8 hours→ heavy meal fried or fatty food
Which patients are prone to aspiration?
Age extreme < 1/ > 70 yo
Ascites
Collagen vascular dx, metabolic disorders (DM, obesity, EDRD, hypothyroid)
HIV- from lipid distribution to neck and abdomen
Hiatal hernia
Esophageal sx
Mechanical obstruction (pyloric stenosis)
Prematurity
Pregnancy
Neuro disorders
Anyone eaten food/nonclear drinks
Trauma
What is an ASA status and how do you determine ASA status on your patient?
- ASA is “to classify the physical condition of the patient requiring anesthesia and surgery”
- ASA is independent of the operative procedure and surgical risk
- focuses mainly on patient’s health
- SUBJECTIVE communication tool used between anesthesia providers
- ASA is independent of the operative procedure and surgical risk
ASA classes:
- I: normal, no systemic dx
- II: mild systemic disease, well controlled, no fx limitations
- Ex: DM w/ controlled BG
- III: severe systemic disease w/ functional limitations
- MI > 3 mo ago
- IV: severe systemic disease that is CONSTANT threat to life
- MI < 3 mo ago
- V: moribund pts, not expected to survive with/without the surgical procedure
- Ex: ruptured aortic aneurysm
- VI: declared brain dead whose organs are being harvested for donation
- E: emergency operation required
How do you determine appropriate fluid requirements intraop?
- MIVF: 4:2:1
- Fluid deficit: NPO x MIVF → divide by 3 → ½ in 1st hr, ¼ 2nd and 3rd hr
- Allowable blood loss: EBL x starting Hct – allowable Hct/ pts Hct
- 3rd space:
- Started in 2nd hr
- Superficial: 1-2 ml/kg
- Minimum: 2-4 ml/kg
- Moderate: 4-6 ml/kg
- Severe: 6-8 ml/kg
- Started in 2nd hr
- 3rd space:
- Blood replacement: start in 2nd hr
What conists of appropraite informed consent for the patient?
- Explanation of planned anesthetic
- Explanation of options available
- R/B
- Pts cooperation
- w/o consent→ ASSULT AND BATTERY
- peds → need guardians
- need witness and pt’s signature
What are predictors for difficult larngoscopy?
- Reports hx of difficult intubation, aspiration pna after intubation, dental or oral truama
- OSA or snoring
- previous head/neck radiation
- congenital dx IE down syndrome
- inflamamtory/arthritic dx- RA, anklyosign spondylitis, scleroderma
- obesit, cervical spine dx or previous sx
