Introduction to history taking, Pre-operative assessment, laboratory testing & chart review.

Question 0

What are some preoperative assessment goals?

Answer 0

1) Optimize care, satisfaction and comfort.
2) Minimize morbidity and mortality.
3) Minimize surgical delays or cancellations.
4) Determine appropriate post-operative disposition.
5) Evaluate health status and determine if any further consultative, diagnostic investigations are needed.
6) Formulate most appropriate anesthetic plan.
7) Optimize communication among members of the surgical and anesthetic teams.
8) Evaluation should be efficient and cost-effective.

Question 1

What the 10 components of Preoperative Evaluation?

Answer 1

1) Patient History (chart review + history taking)
2) Physical Exam
3) Laboratory Testing
4) Medical Consultation
5) ASA Physical Status Class
6) NPO status
7) Formulation Plan
8) Discussion of Plan (educate and decrease anxiety)
9) Informed Consent
10) Documentation

Question 2

What are the 3 main questions answered by the preoperative assessment?

Answer 2

1) Is the patient in optimal health?
2) Could health problems or medications unexpectedly influence perioperative events?
3) Can, or should, the patients physical or mental condition be improved before surgery?

Question 3

Where do you get your pre-op evaluation data?

Answer 3

1. Patient’s medical history (medical record and patient interview)
   
   2. Physical examination
   3. Diagnostic tests (labs, etc.)
   4. Specialist consultation/reports

Question 4

What is the optimal situation for pre-op clinic visit?

Answer 4

1) Optimal Situation = Preoperative Clinic Visit ~ 1 week pre-op
➢Patient interview
➢Physical examination
➢Develop anesthetic plan
➢Promotes patient teaching & anxiety reduction
➢Allows time to schedule appointments with medical consultants and complete required pre-operative diagnostic testing
➢Obtain informed consent prior to operative day

Question 5

Who Requires Early Pre-operative Assessment?

Answer 5

1) Angina, CHF, MI, CAD, poorly controlled HTN
2) COPD/severe asthma, airway abnormalities, home O2 or ventilation
3) IDDM, adrenal disease, active thyroid disease
4) Liver disease, end-stage renal disease
5) Massive obesity, symptomatic GERD
6) Severe kyphosis, spinal cord injury

Question 6

Where should you start gathering data for pre-op evaluation?

Answer 6

From the OR schedule because it can tell you lot about what to expect with the patient.

1) Demographics- name, age, sex
2) Procedure + diagnosis
3) Length of procedure + position
4) Surgeon (s)
5) Type of Anesthesia

Question 7

What items are included in the chart review?

Answer 7

1) Demographics- name, age, sex
2) Diagnosis/ Procedure
3) Surgical Consent
4) Prior H&P (from surgeon or internist)
5) Nursing notes
6) Patient questionnaire
7) Results of Laboratory Tests
8) EKG, PFTS, X-Ray, Etc.
9) Vital Signs
10) Medication List
11) Allergies
12) tobacco and pain score

Question 8

If inpatient, what may be some items to look at in the chart review?

Answer 8

1) Progress Notes
2) Medication Sheets
3) Nursing Notes
4) Old Anesthetic Records
●Complications noted?

Question 9

What are the 6 purposes of the preoperative interview?

Answer 9

1) Obtain pertinent medical history
2) Formulate plan of anesthetic care
3) Obtain informed consent
4) Patient education
5) Improve efficiency, reduce cost of perioperative care
6) Utilize operative experience to motivate patient to more optimal health status

Question 10

What are some consideration when doing the pre-op interview?

Answer 10

1) Introduce anesthesia provider(s) to patient and/or family
2) Confirm pt. ID, diagnosis and procedure (surgical site)
●Open-ended questions
●General to specific
●Organized and systematic
●Layperson terminology
●Individualized
●Control environment (+/- family members present, interpreters, good lighting, respectful, “unrushed”)

Question 11

What are some factors included in the pre-op interview?

Answer 11

1) Look for co-existing diseases: with a review of systems (CNS/NM, Cardiac, ENT, Pulmonary, Vascular/HTN, Endocrine, GI, Hepatic, Renal, Hematologic)
2) Medications:
●Allergies including Latex, including type of reaction
●Prescriptive – Discontinued for surgery? Taken this AM?
●OTC (ASA, NSAIDS)
●Herbals

Question 12

What are the seven components of the physical exam?

Answer 12

1) General Impression
2) Airway
3) Heart
4) Lungs
5) CNS/PNS
6) Vital signs
7) Surgical site

Question 13

What are the components of the general impression in physical exam?

Answer 13

1) height
2) weight
3) physical features
4) mental status
5) vital signs

Question 14

What are the components of airway assessment in physical exam?

Answer 14

1) Mallampati classification
2) Thyromental distance
3) Head and neck movement
4) Neck circumference
5) Interincisor distance
6) Dentition
7) Relevant craniofacial deformities
➢Looking for predictors of difficult airway management

Question 15

What are some components of Heart/CV assessment included in the physical assessment?

Answer 15

1) Heart-
●Auscultation
•Rate
•Rhythm
•Murmurs
•Bruits (carotid)
•Extremity pulses
2) CV
   Bruits (carotid)
   Extremity pulses
   Extremity edema

Question 16

What are some neurological system components included in the physical exam?

Answer 16

Extent of neuro exam really depends on baseline deficits, disease or surgical procedure

1) Motor – gait, grip strength, ability to hold arms forward, etc.
2) Sensory – distinction of vibration, pain, light touch along dermatomes
3) Muscle reflexes – deep, superficial, and pathologic
4) Cranial nerve abnormalities
5) Mental status
6) Speech

Question 17

What are the musculoskeletal system components including in the physical exam?

Answer 17

Gait, ROM, deficits
➢Obesity
•20% over Ideal Body Weigh
●IBW (m) = 105 lb + 6 lb for each inch > 5 ft.
●IBW (f) = 100 lb + 5 lb for each inch > 5 ft.
•Body Mass Index of 30 – 39.9 kg/m2

➢Vital signs

Question 18

What are goals of preoperative/preprocedure laboratory testing?

Answer 18

1) Reduce anesthetic morbidity.
2) Increase quality of perioperative care
3) Decrease cost of perioperative care
4) Return patient to desirable functioning

Question 19

More Tests the Better, Right? True or false and Why?

Explain.

Answer 19

1) Lab tests NOT good disease screening tools
2) Follow up of “abnormal” results is costly
3) Nonindicated tests increase risks for patients
4) Batteries of tests present medicolegal risk to providers
5) Excessive testing decreases facility efficiency and reduces resources available to care for others

Question 20

What is the litmus test?

Answer 20

1) Will the results of this “test” change my management of this anesthetic?
2) Will the results of this “test” improve this patient’s outcome?

Question 21

How is the type of surgery been done relates to lab test?

Answer 21

1) Minimally Invasive: no need of lab test and EKG
little tissue trauma, minimal blood loss
2) Moderately Invasive: may need lab test because it may change the anesthetic plan
modest disruption of normal physiology
anticipate some blood loss
may need invasive monitors and/or ICU
3) Highly Invasive
significant disruption of normal physiology
commonly require transfusion and ICU care

Question 22

What labs/tests and When?

Answer 22

1) Institutional policy
2) Current expert organization guidelines i.e. ACC/AHA guidelines
3) Anesthesia Provider Judgment
4) Consider – H&H, Chemistry, Coags, LFTS, Renal Function tests, UA, Pregnancy Test, EKG, Chest XRay, Pulmonary Function Tests

Question 23

When should you seek consults?

Answer 23

1) diagnosis, evaluation, and improvement of a new or poorly controlled condition.
2) creation of a clinical risk profile that patient, anesthesiologist, and surgeon use to make management decisions.

3) Controversial
4) Avoid the terms “cleared for surgery” or “cardiac clearance”
5) Ask yourself: Does peri-op management of a patient’s disease process go beyond your comfort level?
●i.e. do you need advice from an expert consultant (endocrine, cardiac, specialist etc.) on the patient’s care that could change or guide your management?

Question 24

What can you tell me about the ASA Status?

Answer 24

“To classify the physical condition of the patient requiring anesthesia and surgery.”

1) Reflection of Pre-operative status
2) ASA is independent of the operative procedure and surgical risk
3) Subjective communication tool used between anesthesia providers institutions etc.

Question 25

What is ASA class I?

Answer 25

normal, healthy patient; no systemic disease, no organic biochemical or psychiatric disease. it exclude the very young and the very old.

Question 26

What is ASA class II?

Answer 26

mild to moderate systemic disease, well controlled, no functional limitation. Ex mild Asthma, or well controlled HTN, no impact on daily activity, DM, smoking as long as it has not progress to chronic effects of Pulm disease, pregnancy, mild obese.

Question 27

What is ASA class III?

Answer 27

severe systemic disease, functional limitation. Ex: renal failure on HD, class 2 CHF or control CHF, old MI, poorly control HTN, morbid obesity, significant impact on daily activity.

Question 28

What is ASA class IV?

Answer 28

severe systemic disease that is a constant threat to life. possible risk of death, unstable angina, symptomatic COPD, CHF, liver and kidney failure, Acute MI, resp Failure requiring mechanical ventilation

Question 29

What ASA class V?

Answer 29

moribund patient, not expected to survive with or without the surgical procedure. Ex : multi organ failure, Sepsis, hemodynamic unstability, bleeding and poorly control coagulapathy

Question 30

What is ASA class VI?

Answer 30

patient declared brain dead whose organs are being harvested for donation.

Question 31

What is ASA class E?

Answer 31

Emergency operation required.

Question 32

What is the current ASA guidelines on NPO Status prior to surgery?

Answer 32

Based on CURRENT ASA guidelines that balance risk factors of fasting with pulmonary aspiration risk

➢2 hours for clear liquids all patients
➢4 hours breast milk
➢6 hours formula or solids; light meal
➢8 hours heavy meal fried or fatty food, gum and candy

Follow your institutions policy however!
* note: some clinicians remain skeptical and use more conservative guidelines NPO 6-8 hours etc.

Question 33

What type of patients are considered an aspiration risk?

Answer 33

1) Age extremes 70 yr
2) Ascites (ESLD)
3) Collagen vascular disease, metabolic disorders (DM, obesity, ESRD, hypothryoid)
4) Hiatal Hernia/GERD/Esophageal surgery
5) Mechanical obstruction (pyloric stenosis)
6) Prematurity
7) Pregnancy
8) Neurologic diseases

Question 34

What factors are included in the formulation of anesthetic plan?

Answer 34

1) Type of Anesthesia
2) Drugs
3) Monitors
4) Airway
5) Positioning
6) Intraoperative monitoring
7) Postoperative care

Question 35

What are the information the patient requires from an Anesthesia Professional?

Answer 35

1) Discuss choices of anesthetic technique (consent) Verbal & Written consent
2) Explain IV catheter
3) Describe use of local anesthetics, medications, fluids
4) Discuss airway management plan
5) Explain monitors- placement, purpose
6) Discuss postoperative recovery
7) Discuss pain management plan

Explain process of transport to OR; Possible outcomes- sore throat, blood transfusion, facial swelling, nasal packing, etc.

Question 36

What are some items included when confirming schedule with the OR team?

Answer 36

1) Time, length procedure
2) Anatomical location
3) Position
4) Xray needed?
5) Additional medications needed?
6) Procedure (s)
7) OR table position

Question 37

What should be included in the pre-op check list?

Answer 37

1) IV/Fluid status
2) Pre-medication
3) Anesthetic Plan
4) Labwork- results, labwork needed?
5) EKG, CXR, needed?- use old for comparison
6) Blood products?-availability & need
7) Need for inhaler, steroid coverage, antibiotics, aspiration prophylaxis?

Question 38

What should be included in the documentation of pre-op evaluation?

Answer 38

1) H&P (review of systems)
2) Informed consent
3) NPO status
4) Medications
5) Allergies
6) ASA Physical Status Class
7) Pre-operative Vital Signs
8) Labs, tests, and consults