Flashcards in Intro to Health Assessment Deck (49):
What are the goals of performing a pre-op assessment?
Formulate the most appropriate anesthetic plan
Minimize morbidity and mortality
Evaluate health status- determine if further tests or consults are needed before surgery
Optimize care, satisfaction, and comfort
Minimizing surgical delays or cancellations
Determine post-op disposition
Optimize communications between members of the surgical and anesthetic teams
What are the three main questions answered by the pre-op assessment?
1) Is the patient in optimal health?
2) Can, or should, the patient's mental or physical condition be improved before surgery?
3) Does the patient have any health problems or use any medications that could unexpectedly influence perioperative events?
Previous surgical hx and family hx we are concerned about
MH, atypical acetylcholinesterase, previous anesthetic complications
Medication history we are concerned about
MAOIs, anticoagulants, vaso-active meds, diuretics (may have lyte abnormalities), steroids (we may need to give a stress dose)
Supplements/herbals (may interact with meds, alter bleeding, etc)
Substance abuse (smoking, ETOH, illegal drugs)
Allergies (make sure it's an actual allergy!)
We also want to know if they take any OTC meds, and if any of their meds were discontinued for sx and when they were last taken)
What do we want to know about a patient's systemic disease?
Impact on activities
Current and recent exacerbations
Stability (how well has it been controlled)
Treatments and interventions for the disease
Important test for many women to have before surgery
If there is any chance a woman is pregnant, she should have a pregnancy test. Drugs affect the fetus the most during the first trimester, and at this point many women don't know they're pregnant yet.
How long is a typical pre-op assessment
___% of all surgeries are outpatient
___% of all surgeries are in surgeon's offices
___% of all surgeries are AM admissions
___% of all surgeries are on inpatients admitted before the day of surgery
Universal practice guidelines
Are based on current evidence and research
Continuous quality improvement and national patient safety goals
Need to meet CMS and JCo requirements
Components of the pre-op evaluation
Lab testing and consultation if needed
Assign an ASA Physical Status Class
Formulate a plan
Discuss the plan with the patient
This information will be listen on the OR schedule
Demographics (Name, age, sex)
Type of anesthesia
What should you confirm with the OR team?
Length of the procedure
Anatomical location and procedure being done
Positioning the OR table and the patient
Need an x-ray?
One of the most important things we should review in inpatient charts
Old anesthetic records
Optimally, when should a pre-op exam take place?
1 week pre-op clinic visit
Why is doing the pre-op clinic visit one week prior to surgery good?
You can do the assessment, and formulate the plan, tell the patient the plan, and get consent out of the way early.
Also, this way the patient has time to complete any pre-op tests or consults prior to surgery
An early pre-op assessment if REQUIRED for these patients
Cardiac: Angina, CHF, MI, CAD, poorly controlled HTN
Resp: Severe asthma, home O2 or ventilation, airway abnormalities
Endocrine: IDDM, active thyroid diseases
Other: Liver disease, ESRD, massive obesity, symptomatic GERD, severe kyphosis, and spinal cord injury
6 Purposes of the Pre-op interview
1) Get medical history
2) Formulate an anesthetic plan
3) Educate the patient
4) Obtain consent
5) Improve efficiency of care and reduce cost
6) Encourage and motivate the patient to achieve a more optimal health status
Tips on how to effectively obtain the patient's medical history during the pre-op interview
1) Organized and systematic
2) Confirm findings from the chart review
3) Use open-ended questions (from general to more specific questions)
4) Use layperson terminology
5) Individualize the interview
6) Optimize the environment (quiet environment, not rushed, +/- family members, lighting, interpreters present, etc)
For females during the pre-op assessment, we want to know about their last
Examples of cardiac questions to ask
Exercise tolerance (How far can you walk or how many flights of stairs can you climb without tiring?)
Any chest pain? When did you last have it? How long does it last? What were you doing when it happened? Are you taking NTG? How frequently?
Ever have an MI? Heart surgery?
So you see a cardiologist? Ever have a stress test? EKG? Cardiac meds?
ASA NPO Guidelines
2 hours for clear liquids
4 hours for breast milk
6 hours for formula or a light meal (nothing greasy)
8 hours for a heavy meal or fatty food, gum, and candy
Does long-term fasting reduce gastric secretions?
NPO guidelines for those who are an aspiration risk
Guidelines don't exist. Up to provider judgement.
Patients who are at an aspiration risk
Age extremes (70)
Collagen vascular diseases
Metabolic disorders (DM, obesity, ESRD, hypothyroidism)
Mechanical obstruction (pyloric stenosis)
During the surgery we want to keep their BP within
20% of their pre-op value
General impression of physical exam
Obesity is defined as
20% over ideal body weight
BMI of 30-39.9
Formula for ideal body weight for men and women
Men: 105lb + 6lb per inch over 5 feet
Women: 100 + 5lb per inch over 5 feet
Normal neck circumference
Order of examination techniques
Inspect, auscultate, percuss, palpate
How should we confirm that the patient understands what will be happening?
Have the patient explain the procedure in their own words
Bad consequences of ordering too many tests
You have to follow up on them all
Lab tests are not good disease screening tools
Increased risk for patients undergoing unnecessary testing
Poor allocation of resources
2 questions to ask to determine if a test is necessary
1) Will the outcome of the test affect my anesthetic management?
2) Will the results of the test improve the patient's ultimate outcome?
Sensitivity vs specificity of a test
Sensitivity- how sensitive the test is to detecting the disease if it is present
Specificity- if you don't have the disease, will the test accurately determine that you don't have it?
Minimally invasive surgery
Little tissue trauma, minimal blood loss
Moderately invasive surgery
Some blood loss anticipated
Moderate disruption of normal physiology
May need invasive monitors or ICU care
Highly invasive surgery
Significant disruption in normal physiology
Commonly require transfusion and ICU care
How can we determine if we need a consult?
Ask yourself this question "Does peri-op management of this patient's disease process go above my comfort level?"
- Basically, do we need extra guidance from an expert on how to care for this patient and manage their care?
What does the ASA Physical Status evaluate?
This classifies the physical condition of the patient who will be undergoing anesthesia and surgery
- It reflects pre-op health status
- The assessment is INDEPENDENT of the operation and surgical risk (it's just their baseline overall health status)
- This tool is subjective, but is used to communicate patient condition between anesthesia providers and institutions
ASA Class I
Normal, healthy patient with no systemic disease
ASA Class II
Mild to moderate systemic disease, but it is well controlled and there is no functional limitation
ASA Class III
Severe systemic disease with functional limitation
ASA Class IV
Severe systemic disease that is a constant threat to life (ESLD, current MI, etc)
ASA Class V
Moribund patient (about to die) and is not expected to live with or without the surgical procedure (ex- ruptured AAA)
ASA Class VI
Braindead patient whose organs are being harvested for donation
ASA Class E
Emergency operation required
What to think about when formulating the anesthetic plan
Type of anesthesia to be used
What do we as anesthesia providers need to discuss with our patients?
Our choice of anesthetic technique
Explain their IV
Describe our use of fluids, medications, and local anesthetics
How we will manage their airway
The types of monitors we will be using to make sure they are safe and where they will be placed
The process of transport to the OR
What will happen when they wake up (airway, pain relief, location, etc)
Possible outcomes (swelling, sore throat, nasal packing, blood transfusion, etc)