Pre-Operative

Question 1

Discuss pertinent points on history for anesthesia

Answer 1

Anesthestic Hx
- reaction to previous anesthestics (malignant hyperthermia, plasma cholinesterase deficiency)
- complications during surgery
- difficult intubation
Complete Past Medical Hx and Allergies
Family Hx to Anesthestic

Question 2

Discuss the components of the airway assessment

Answer 2

Facial Features
- BOOTS for difficulty with bag-mask ventilation
Temporomandibular Joint Mobility
- place finger tip at TMJ and ask to open/close mouth
- bite upper lip
Mouth Opening
- normal is 5cm/3 finger breadths
Mouth Features
- edentulous
- loose teeth
Mallampati Score
- 1: whole uvula and pharyngeal pillars visible
- 2: portion of uvula visible
- 3: base of uvula visible
- 4: soft palate and uvula not visible
Thyromental Distance
- normal is 6cm from chin to thyroid cartilage notch
Neck Mobility

Question 3

Discuss features of difficult bag-mask ventilation

Answer 3

BOOTS

• Beard
• Old
• Obese/pregnant
• Toothless
• Sleep apnea

Question 4

Difficult features for difficult intubation

Answer 4

• Obesity
• Poor TMJ mobility
• Small mouth opening
• Large or damaged teeth
• High Mallampati score
• Small thyromental distance
• poor cervical spine ROM

Question 5

Discuss the ASA score

Answer 5

1
- healthy
2
- mild systemic disease with no limitation (controlled hypertension)
3
- severe systemic disease with definite functional limitation (COPD)
4
- severe systemic disease with constant threat to life (unstable angina)
5
- not expected to survive next 24hrs
6
- brain dead
E
- emergency surgery (can add E to above class)

Question 6

Discuss the need for pre-operative fasting

Answer 6

• normally have laryngeal reflex that prevent aspiration but anesthesia abolish reflex increasing risk

Question 7

Discuss high risk features for aspiration

Answer 7

Increased Gastric Content
- intestinal obstruction
- non-fasting state
- medication
- delayed gastric emptying
Lower Esophageal Sphincter Incompetence
- GERD
- Hiatus hernia
- Pregnancy
- Obesity
- Neuromuscular disease
Decreased Laryngeal Reflex
- head injury
- Bulbar palsy

Question 8

Discuss rules for NPO status

Answer 8

• No heavy/fatty meal for >=8hrs
• No light meal for >=6hrs
• No milk or formula for >=6hrs
• No breast milk for >=4hrs
• No clear fluids for >=2hrs

Question 9

Discuss medications to be discontinued pre-operatively

Answer 9

Warfarin
Monoamine Oxidase Inhibitors
Oral hypoglycemics
- stopped morning of surgery
Anti-Depressants
- stopped morning of surgery
Bronchodilators, Insulin, Prednisone
- require dose adjustment on day of surgery

Question 10

Discuss medical management before surgery

Answer 10

Hypertension
- goal to be <180/110 for elective surgery
Coronary Artery Disease
- delay surgery 4-6 weeks following MI due to high risk of re-infarct
- peri-operative beta-blocker for ischemia, high risk surgery for infarct or multiple cardiac risk factors
Diabetes
- monitor blood glucose intra-operatively and treat with dextrose or insulin infusion as necessary
Hyperthyroidism
- monitor for thyroid storm which is treated with beta-blocker
Adrenal Insufficiency
- steroid coverage pre-operative if used within last 6mon for >1week
Asthma
- medications used 1 week pre-operative to achieve good control
COPD
- surgery predispose to atelectasis, bronchospasm, pneumonia, resp failure and need for mechanical ventilation
- optomize pre-op with inhaled agents