Pre-op Eval and Meds Flashcards Preview

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Flashcards in Pre-op Eval and Meds Deck (70):
1

ASA Class?

Healthy patient without disease (organic, biochemical, or psychiatric)

ASA Class 1

2

ASA class?

Pt with mild systemic disease (mild asthma, well controlled HTN)
- no impact on daily activity, low likelihood of impact on surgery/anesthesia

ASA Class 2

3

ASA Class?

Significant or severe systemic disease that limits normal activity (CHF class 2, CRD on dialysis)
- impacts daily activity, likely to impact anesthesia/surgery

ASA Class 3

4

ASA class?

Severe disease that is a constant threat to life/requires intensive therapy (acute MI, respiratory failure on mech vent)
- serious limitation of daily activity, major impact on surgery/anesthesia

ASA Class 4

5

ASA Class?

Moribund patient likely to die in next 24 hrs with or without surgery

ASA Class 5

6

ASA Class?

Brain-dead organ donor

ASA Class 6

7

Major steps in eval of cardiac risk for non-cardiac surgery

step 1- urgency of surgery

step 2- active cardiac conditions (acute MI, unstable/severe angina, decompensated CHF, severe valve disase, significant arrhythmia)

step 3- surgical risk/severity

step 4- eval functional capacity in METs

Step 5- eval patient with poor/indeterminate FC needing intermediate risk or vascular surgery
- Clinical predictors help assess risk (CAD, CHF, CVA, DM, renal disease

8

Define active cardiac conditions

acute MI
unstable/severe angina
decompensated CHF
severe valve disase
significant arrhythmia

**all warrant postponing surgery except for life saving emergency

9

What is focus of patient with emergency surgery needed and cardiac history?

1. Periop surveilance (enzymes, EKG, monitoring)

2. Risk reduction (B blocker, statin, pain management)

10

Pt has no active cardiac condition. What do you do if...

1. low risk surgery

1. proceed w/ surgery w/out additional testing

11

Major components of pre-op history

1. prior surgery/anesthesia (any issues?)
2. med allergies
3. current meds
4. heart history and recent cardiac testing
5. smoking/etoh/illicits
6. steroids (for stress dosing)
7. functional capacity (flights of stairs)
8. HTN, DM, pulm disease, bleeding disorders, liver/kidney disease, jaw/neck/back disease, thyroid disease, neuro disease
9. LMP-possibility ofpregnancy
10. dental disease/chipped teeth/loose teeth
11. OSA/snoring

12

Climibing 1-2 flights of stairs = ? METS
walking 1-2 blocks?

5 METS
3 METS

13

Major components of airway exam? 10 major parts

1. Condition of Teeth
2. Incisor eval (length of upper, relationship of upper to lower)
3. ability to protrude mandibular incisors in front of upper
4. tongue size
5. visibility of uvula
6. facial hair
7. compliance of mandibular space
8. thyromental distance w/ maximum head extension
9. length/thickness of neck
10. ROM of neck

14

Define low risk surgery

superficial or endoscopic
cataract surgery
breast surgery
ambulatory surgery

15

For how long should you delay elective surgery after DES? BMS?

DES- 1 year (d/c plavix but continue ASA if possible)
BMS - 1 month

16

When should you stop ASA before intracranial surgery?

7 days before operation

17

Which surgeries have high risk of bleeding in a closed space? (i.e. d/c asa or plavix if at all possible)

- intracranial neurosurg
- intramedullary canal surgery
- posterior eye chamber optho surgery

18

When is echo helpful in evaluating a murmur?

- high risk valve disease (elderly, CAD, rheumatic fever, increased volume overload, pulm disease, cardiomegaly, abnormal EKG)
- if spinal anesthesia is planned

19

Stenotic vs regurgitant valve disease; which is tolerated better intraop?

regurgitant

20

Which patients is it reasonable to eval LV function preoperatively?

1. dyspnea of unknown origin
2. current/previous HF w/ worsening dyspnea/clinical status change in last 12 months without echo

21

Patients that require antibiotic prophyaxis after dental procedure w/ manipulation of gingival tissue/periapical region of teeth/perf of oral mucosa

1. prosthetic cardiac valve
2. previous infect endocarditis
3. congenital heart disease (unrepaired cyanotic, completely repaired congenital w/ prosthetic material/catheter, repaired CHD w/ residual defects)
4. cardiac valvulopathy in transplant patient

22

BP goal (max) to continue w/ surgery in patient with HTN

180/110

23

Patient related factors increasing postop pulm complications (PPC) - grade A only

advanced age
ASA Class > 2
CHF
Functionally dependent
COPD

(others impaired sensorium, OSA, DM, obesity, smoking)

24

Procedure related factors increasing risk of PPC

- AAA repair
- thoracic surgery
- abdominal surgery
- upper abdominal surgery
- neurosurgery
- prolonged surgery
- head and neck surgery
- emergency surgery
vascular surgery
general anesthesia

25

COPD/ asthma patient regimen that can decrease risk of PPC

corticosteroid + inhaled B agonist preop

26

Anesthetic techniques that help reduce PPC

- maximizing airflow (obstructive disease)
- treating infections
- treating heart failure
- lung expansion maneuvers - coughing, deep breathing, IS, PEEP, CPAP

27

Components of STOP-Bang

snoring
tired
observed to stop breathing while sleeping
pressure (HTN)

BMI >35
Age >50
Neck circ >15.7in (40cm)
Gender male?

High risk OSA > 3 items yes

28

most common causes of acute dyspnea, testing required preop

COPD - CXR< ABG, PFTs, CT chest (maybe)
asthma - "
CHF - EKG, CXR, echo, BNP, ?stress testing

29

optimal HD time prior to elective procedure

within 24 hrs of surgery, but not immediately before (avoid volume depletion and electrolyte alterations)

30

Major goals of DM management intraoperatively

- prevent hypoglycemia w/ fasting
- prevent major hyperglycemia
- prevent ketosis

31

When should you d/c LMWH pre-procedure w/ high risk bleeding/neuroaxial anesthesia?

12-24 hrs pre procedure

32

How long should you hold warfarin before (except cataract surgery)?

5 doses (allow INR to return to normal). If INR >3, hold longer

33

Which pts should be bridged from warfarin to LMWH/heparin?

pts w/ acute arterial/venous thromboembolism w/in 1 mo before surgery

if surgery cannot be postponed

pts with certain heart valves

pts with high risk hypercoag states

34

Insulin management preop for Type 1/Type 2 DM

- both stop short acting insulin preop

- insulin pumps: continue w/ lowest basal rate (typically PM rate)

- Type 1- take 1/2 to 1/3 of long acting insulin in AM the day of surgery

Type 2- take none or up to 1/2 basal dosing day of surgery

35

Which herbal supplement should NOT be stopped 7 days preop

valerian - CNS depressant that can cause benzo like withdrawal when d/c'ed (needs taper)

36

condition that is contraindication to scopolamine patch 2-4 days pre-op

closed angle glaucoma

37

Antidepressants, antianxiety, psych meds

continue or d/c pre surgery?

continue

38

antihypertensives

continue or d/c pre surgery?

generally continue

**exception- d/c ACEi/ARB 12-24hrs preop if taken only fo rHTN (especially if long procedures, lots of fluid shifts, on multiple anti HTN, procedure w/ dangerous hypotension

39

aspirin

continue or d/c pre surgery?

Continue - known vascular disease, DES risk of thrombosis, surgery w/ serious bleeding consequences, only primary ppx

40

Asthma meds

continue or d/c pre surgery?

continue

41

Methotrexate and no renal failure

continue or d/c pre surgery?

continue

42

Most autoimmune meds (methotrexate + risk RF, enterecept, infliximab, humira)

continue or d/c pre surgery?

d/c, check w/ prescriber

43

OCPs

continue or d/c pre surgery?

continue

44

cardiac meds

continue or d/c pre surgery?

continue

45

Plavix

continue or d/c pre surgery?

Continue- DES < 12 mo, BMS <1mo, befoer cataract surgery

D/c- pts not in above groups

46

COX 2 inhibs, concern for bone healing

continue or d/c pre surgery?

d/c, o/w continue (if no concern)

47

HCTZ, Triamterene

continue or d/c pre surgery?

continue

48

Lasix

continue or d/c pre surgery?

d/c

49

eye trops

continue or d/c pre surgery?

continue

50

estrogen compounds in ocps/cancer therapy

continue or d/c pre surgery?

continue

51

estrogen compounds used to control menopausal symptoms or osteoporosis

continue or d/c pre surgery?

D/C

52

GI reflux meds

continue or d/c pre surgery?

continue

53

Tums

continue or d/c pre surgery?

D/c

54

herbal, non-vitamin supplements

continue or d/c pre surgery?

d/c 7-14 days preop

55

Narcotics for pain/addiction

continue or d/c pre surgery?

continue

56

NSAIDS for pain

continue or d/c pre surgery?

d/c 48 hrs pre op

57

seizure meds

continue or d/c pre surgery?

continue

58

statins

continue or d/c pre surgery?

continue

59

thyroid meds

continue or d/c pre surgery?

continue

60

warfarin, cataract surgery w/out bulbar block

continue (o/w d/c 5 days before surgery)

61

Pt can have fluids/food as desired X hrs before surgery

up to 8 hrs

62

Pt can have light meal (toast, CLD, infant formula, non-human milk) X hrs before surgery

Up 6 hrs

(unless at increased risk for delayed gastric emptying- GERD, DM, obese, pregnant, potential difficult airway, on opiates)

63

Pts can have breast milk up to X hrs before surgery

4 hrs

(unless at increased risk for delayed gastric emptying- GERD, DM, obese, pregnant, potential difficult airway, on opiates)

64

Pts can have clear liquids (water, carbonated bev, sports drink, coffee or tee w/out milk) X hrs before surgery

2 hrs

(unless at increased risk for delayed gastric emptying- GERD, DM, obese, pregnant, potential difficult airway, on opiates)

65

Example of intermediate risk surgeries

-intraperitoneal
-intrathoracic
-CEA
- HENT surgery
- ortho surgery
-prostate surgery

66

vascular surgery/high risk surgery

aortic/major vascular surgery
PVD surgery

67

risks of general anesthesia, occur frequently/minimal impact

oral/dental damage
sore throat
hoarseness
PONV
drowsy/confused
urinary retention

68

risks of general anesthesia that infrequenly occur/are severe

awareness
visual loss
aspiration
organ failure
malignant hyperthremia
drug reactions
failure to wake up/recover
death

69

risks of regional anesthesia that occur frequently/minimal impact

prolonged numbness/weakness
post dural puncture HA
failure of technique

70

risks of regional anesthesia that infrequently occur/are severe

bleeding
infection
nerve damage/paralysis
persistent numbness/weakness
seizures
coma
death