Anesthesia Principles and Practice I: Lecture 1 - Preop Primer

Question 1

What are the three big questions to ask and to know before the procedure?

Answer 1

History of anesthesia complications?

Can walk up a flight of stairs without getting short of breath?

When was last time they ate and/or drank?

Question 2

What are the three primary goals of the preoperative period?

Answer 2

Ascertain risk of patient and procedure; Optimize the patient if possible; Develop an anesthetic plan that respects patient wishes, surgical needs, and your skills.

Question 3

What factors influence the anesthetic plan?

Answer 3

Type of anesthesia (general vs regional), airway choice, and surgical positioning.

Question 4

What is the form called that is filled out by Preop RN?

Answer 4

SBAR: Situation, Background, Assessment, Recommendation

Question 5

What key elements are included in the patient history?

Answer 5

Chief complaint, HPI, PMH, PSH, medication and allergy history, previous anesthetic experiences, and physical exam.

Question 6

What makes a patient difficult to interview?

Answer 6

Poor historian, anxiety, language/hearing/visual barriers, disruptive behavior, overly talkative.

Question 7

What CV questions help assess surgical risk?

Answer 7

History of HTN, chest pain, arrhythmias, valve disease, MI, edema, orthopnea, neurological symptoms.

Question 8

What other symptoms might cause you to think there are CV issues?

Answer 8

Swollen hands/feet (CHF); Sleep on multiple pillows (cardiac or GI issues); Random vision loss, limb weakness or dysphasia (CAD, vasospasm, CVA)

Question 9

What is the relationship between CAD and CV complications post noncardiac surgery?

Answer 9

Account for 25-50% of deaths; 5-7% will have perioperative MI; 38-70% mortality intraoperative.

Question 10

Who is at greatest risk of cardiac events under anesthesia with CV complications?

Answer 10

Recent MI, Valvular Heart Disease (Aortic Stenosis probably worst), CHF, unstable angina, Diabetes (neuropathy can cause silent MI).

Question 11

What is the presser of choice for a patient with aortic stenosis?

Answer 11

Phenylephrine (Neosynephrine)

Question 12

What does a MET score of <4 indicate in preop evaluation?

Answer 12

<4 METs indicate increased perioperative cardiac risk.

Question 13

What percentage of perioperative deaths are cardiac-related?

Answer 13

25–50%.

Question 14

What are common CV complications post-op?

Answer 14

MI, pulmonary edema, CHF, thromboembolism.

Question 15

How should high-risk cardiac patients be managed?

Answer 15

Monitor for ischemia, consider revascularization or fixing severe aortic stenosis, optimize CHF, correct anemia and volume status.

Question 16

What are important neuro conditions to note preoperatively?

Answer 16

Stroke, seizures, Parkinson’s, gross motor dysfunction.

Question 17

What are key GU issues to ask about?

Answer 17

ESRD, UTI, dialysis schedule, BPH, kidney stones.

Question 18

What are key GI issues to ask about?

Answer 18

GERD, GI bleeding, Liver disease, Acute abdomen.

Question 19

What to know about infections?

Answer 19

Have they encountered drug resistant infections before.

Question 20

What to consider regarding musculoskeletal and pain?

Answer 20

Acute vs chronic, location, daily opiate use.

Question 21

Why is periop glucose control important?

Answer 21

Prevents infections, cerebral ischemia, endothelial dysfunction, poor wound healing, and poor perfusion.

Question 22

What is the amount of glucose considered hyperglycemia and a risk factor?

Answer 22

GLU > 200 mg/dL

Question 23

What hematologic conditions increase surgical risk?

Answer 23

Bleeding disorders, thrombocytopenia, anticoagulant therapy, liver disease, sickle cell disease.

Question 24

What is the GTPAL system?

Answer 24

Gravity, Term births, Preterm births, Abortions, Living children.

Question 25

What is a G3P2?

Answer 25

3rd pregnancy, two kids already.

Question 26

What questions to ask a pregnant lady?

Answer 26

Pregnancy Induced Hypertension, Gestational Diabetes Mellitus, Hx of Asthma.

Question 27

Can you force a pregnancy test pre-op?

Answer 27

No. It violates patient autonomy.

Question 28

How do recreational drugs affect anesthesia?

Answer 28

Increase anesthetic requirements, complicate IV access, and airway reactivity.

Question 29

Why is antidepressant use relevant to anesthesia?

Answer 29

Potential drug interactions and altered CNS responses.

Question 30

How can anxiety affect anesthetic requirements?

Answer 30

Baseline benzos may increase anesthetic requirements.

Question 31

How can depression affect anesthesia?

Answer 31

Small risk of serotonin syndrome.

Question 32

How can PTSD affect anesthesia?

Answer 32

Can affect induction/emergence.

Question 33

How can bipolar/schizophrenia affect anesthesia?

Answer 33

Lithium can prolong NMB and decrease anesthetic requirements.

Question 34

Why is 'NPO after midnight' outdated?

Answer 34

New evidence supports more flexible fasting to improve outcomes.

Question 35

What are the NPO statuses?

Answer 35

Regular meal: 8 hrs; Light meal: 6 hrs; Nonhuman milk: 6 hrs; Breast milk: 4 hrs; Clear liquids: 2 hrs.

Question 36

Why is family history of anesthesia relevant?

Answer 36

To screen for malignant hyperthermia and pseudocholinesterase deficiency.

Question 37

What predicts a difficult airway?

Answer 37

Facial features, limited neck mobility, Mallampati score, etc.

Question 38

What is the ASA Physical Status Classification used for?

Answer 38

To assess and communicate a patient’s preoperative medical condition.

Question 39

Which medications are continued preoperatively?

Answer 39

Beta blockers, calcium channel blockers, bronchodilators.

Question 40

Which medications are typically held pre-op?

Answer 40

ACE inhibitors/ARBs (unless CHF), anticoagulants, oral hypoglycemics.

Question 41

When is ECG recommended pre-op?

Answer 41

Cardiac symptoms, known CAD, or high-risk patients.

Question 42

When are chest X-ray and lung function tests useful?

Answer 42

Only in symptomatic patients or those undergoing major thoracic surgery; ASA 3+4 with known or suspected respiratory disease having a major surgery

Question 43

Who is at risk for pulmonary issues during anesthesia?

Answer 43

Smokers, COPD, age >70, Thoracic or upper abdominal surgery, anesthesia >2 hrs, pneumonia, atelectasis causes (obesity, Trendelenburg, etc.)

Question 44

When to order CBC pre-op?

Answer 44

Suspected active bleeding or anemia.

Question 45

When are coagulation studies needed?

Answer 45

Anticoagulated patients, liver disease, or planned transfusion.

Question 46

What are PT/PTT/INR?

Answer 46

PT = "Play Time" → quick game → extrinsic = fast clotting pathway (also PT monitors Pill = warfarin) PTT = "Perfect Three-Tier" → more steps → intrinsic = slower pathway (also PTT monitors Parenteral = heparin) INR = "Is Normalized Ratio" → just standardizing PT numbers for warfarin.

Question 47

When to consider preop transfusion?

Answer 47

Hb <7 mg/dL; one unit of PRBC should raise 1 mg/dl or HCT 3%

Question 48

When to consider platelet transfusion?

Answer 48

>50,000; 1 x 6 pack of platelets will increase count 30-60,000

Question 49

When is informed consent not required?

Answer 49

In true emergencies with no available proxy.

Question 50

Who can give consent if the patient cannot?

Answer 50

Power of attorney or legal guardian.

Question 51

What is the purpose of premedication?

Answer 51

Reduce anxiety, pain, PONV and anesthetic requirements; ERAS (Enhanced Recovery After Surgery)

Question 52

What are common premeds used preoperatively?

Answer 52

Midazolam, acetaminophen, celecoxib, gabapentin, dexamethasone, ondansetron.

Question 53

What is the drug used to decrease anxiety?

Answer 53

Midazolam (also anterograde amnesia)

Question 54

What are contraindications to PreOp Versed?

Answer 54

Newborn (<1 yo); Elderly (>65 yo); Decreases baseline consciousness; Intracranial pathology; Severe pulmonary disease; Hypovolemia.

Question 55

When do you avoid scopolamine?

Answer 55

Patients over 65 yo.

Question 56

When do you avoid Gabapentin/Pregabalin?

Answer 56

Patients over 65 yo; OSA.

Question 57

Where should the IV be placed pre-op?

Answer 57

Non-dominant, non-surgical side; forearm or hand.

Question 58

What types of anesthesia are available?

Answer 58

General, regional, MAC, peripheral nerve blocks.

Question 59

When is intubation necessary?

Answer 59

Full stomach, long procedures, prone/beach chair position, need for paralysis.

Question 60

When is spinal/epidural anesthesia preferred?

Answer 60

C-sections, orthopedic surgeries, open abdominal/thoracic procedures.

Question 61

What are induction options if IV access is difficult?

Answer 61

Inhalational (kids/disabled), IM ketamine (5 mg/kg = Ketamine Dart).

Question 62

What questions should be answered in your anesthesia plan?

Answer 62

Maintenance meds, pain control, paralytic needs, hemodynamic management.

Question 63

What factors determine post-op disposition?

Answer 63

Oxygen needs, pain control, inpatient vs outpatient, surgery type, and tolerance.

Question 64

What is one MET?

Answer 64

3.5 mL/kg/min.

Question 65

What are the two questionnaires used to evaluate MET?

Answer 65

DASI (Duke Activity Status Index) and MET-REPAIR (MET: Reevaluation for Perioperative cArdIac Risk).