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Flashcards in Intro to Health Assessment Deck (49):
1

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

2

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?

3

Previous surgical hx and family hx we are concerned about

MH, atypical acetylcholinesterase, previous anesthetic complications

4

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)
Dosing schedule
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)

5

What do we want to know about a patient's systemic disease?

Severity
Impact on activities
Current and recent exacerbations
Stability (how well has it been controlled)
Treatments and interventions for the disease

6

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.

7

How long is a typical pre-op assessment

5-15 min

8

___% 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

70%
10%
20-30%

9

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
AANA/ASA standards

10

Components of the pre-op evaluation

Patient history
Physical Assessment
Lab testing and consultation if needed
Assign an ASA Physical Status Class
Formulate a plan
Discuss the plan with the patient
Informed consent
Document

11

This information will be listen on the OR schedule

Demographics (Name, age, sex)
Procedure
Surgeon
Type of anesthesia

12

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?

13

One of the most important things we should review in inpatient charts

Old anesthetic records

14

Optimally, when should a pre-op exam take place?

1 week pre-op clinic visit

15

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

16

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

17

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

18

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)

19

For females during the pre-op assessment, we want to know about their last

menstrual period

20

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?

21

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

22

Does long-term fasting reduce gastric secretions?

Not necessarily

23

NPO guidelines for those who are an aspiration risk

Guidelines don't exist. Up to provider judgement.

24

Patients who are at an aspiration risk

Age extremes (70)
Pregnancy
Ascites (ESLD)
Collagen vascular diseases
Metabolic disorders (DM, obesity, ESRD, hypothyroidism)
Mechanical obstruction (pyloric stenosis)
Prematurity
Neurologic diseases

25

During the surgery we want to keep their BP within

20% of their pre-op value

26

General impression of physical exam

Height/weight
Physical features
Neuro status
Vital Signs

27

Obesity is defined as

20% over ideal body weight
BMI of 30-39.9

28

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

29

Normal neck circumference

Men- 17
Women- 16

30

Order of examination techniques

Inspect, auscultate, percuss, palpate

31

How should we confirm that the patient understands what will be happening?

Have the patient explain the procedure in their own words

32

Bad consequences of ordering too many tests

Costly
You have to follow up on them all
Lab tests are not good disease screening tools
Increased risk for patients undergoing unnecessary testing
Legal implications
Poor allocation of resources

33

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?

34

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?

35

Minimally invasive surgery

Little tissue trauma, minimal blood loss

36

Moderately invasive surgery

Some blood loss anticipated
Moderate disruption of normal physiology
May need invasive monitors or ICU care

37

Highly invasive surgery

Significant disruption in normal physiology
Commonly require transfusion and ICU care

38

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?

39

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

40

ASA Class I

Normal, healthy patient with no systemic disease

41

ASA Class II

Mild to moderate systemic disease, but it is well controlled and there is no functional limitation

42

ASA Class III

Severe systemic disease with functional limitation

43

ASA Class IV

Severe systemic disease that is a constant threat to life (ESLD, current MI, etc)

44

ASA Class V

Moribund patient (about to die) and is not expected to live with or without the surgical procedure (ex- ruptured AAA)

45

ASA Class VI

Braindead patient whose organs are being harvested for donation

46

ASA Class E

Emergency operation required

47

What to think about when formulating the anesthetic plan

Type of anesthesia to be used
Airway
Positioning
Medications
Monitoring needed

48

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)

49

Without consent, surgery and anesthesia is considered this

Assault and battery