Pre-operative Assessment Flashcards
(34 cards)
Components of a preoperative assessment
Patient history (chart review); physical exam; laboratory testing; medical consultation;ASA class; NPO status; formulation plan; discussion of plan; informed consent; documentation
Who mandates preoperative assessment?
JCHO; preprocedure and within 48 hours post-procedure
What are the preoperative assessment goals?
Optimize care, minimize morbidity, surgical delays, determine appropriate post operative disposition, evaluate health status, formulate anesthetic care plan, optimize communication among members of the surgical team.
3 main questions answered by the preoperative assessment?
Is the patient in optimal health?
Could health problems or medications unexpectedly influence preoperative events?
Can, or should, the patients physical or mental condition be improved before surgery?
Where do we get the data for the history?
Pt’s medical history (records)
Physical exam
Diagnostic tests
Specialist consultation/reports
What would you prefer to do 1 week pre-op?
Patient interview, physical examination, develop anesthetic plan, promote patient teaching and anxiety reduction, allows time to schedule appointments with medical consultants and diagnostic tests, informed consent early.
Who requires an early preoperative assessment?
Angina, CHG, MI, CAD, poorly controlled HTN, COPD/severe asthma, airway abnormalities, home vent/O2; IDDM, adrenal disease, active thyroid disease, liver disease, ESRD, massive obesity, symptomatic GERD, kyphosis, spinal cord injury
What do you look at during the chart review?
Demographics (age, name, sex); diagnosis/procedure; surgical consent; prior H&P; nursing notes; patient questionnaire; lab tests; EKGs, PFTS, Xray; vitals, medication list; allergies
If inpatient: progress notes, med sheets, nursing notes, anesthetic records
Preoperative interview: 6 purposes
- Obtain pertinent medical history
- Formulate plan of anesthetic care
- Obtain informed consent
- Patient education
- Improve efficiency, reduce cost of perioperative care
- Utilize operative experience to motivate patient to more optimal health
What are the steps of the preoperative interview?
- Introduce anesthesia provider 2. Confirm pt ID, diagnosis, procedure/site (open ended quest., general to specific, organized and systematic, layperson, individualized, control environment). 3. Look for coexisting diseases (review of systems) 4. Medications (allergies, prescriptions, OTC, herbals) 5. Previous anesthetics, exercise tolerance, sleep apneal, ETOH/drug abuse, tobacco, LMP
What are the systems you will review during the preoperative interview while you look for co-existing diseases
CNS/NM; cardiac; ENT;pulmonary; vascular/HTN; Endocrine; GI; Hepatic; Renal; Hematologic
What does your physical assessment of the airway consist of?
Mallampati classification; thyromental distance; head and neck movement; neck circumference, inter incisor distance dentition; craniofacial deformities; predictors of difficult airway management.
What does your physical exam of the heart consist of?
Heart auscultation: rate, rhythm, murmurs, bruits (carotid), extremity pulses
CV: bruits (carotid), extremity pulses, extremity edema
What does your physical exam of the lungs consist of?
Lungs
Inspection, Auscultation, Percussoin, Palpation.
When you listen to lungs, do upper left first, then upper right, then down the back.
What does your physical exam of the neurologic system consist of?
Depends on baseline deficits, disease, or procedures. Motor gait, grip, strength; Sensory: vibration, pain, light touch along dermatomes
Muscle reflexes: deep superficial, pathologic
Cranial nerve abnormalities, mental status, speech
What does your physical exam of the musculoskeletal system?
Gait, ROM
Obesity: 20% over ideal body weight.
BMI= 30-39.9 kg/m2
What is the ideal body weight calculation for males and females?
males= 105 lbs +6lb for each inch >5ft females= 100lbs +5lbs for each inch >5ft
What are the goals of preoperative laboratory testing?
- Reduce anesthetic morbidity
- increase quality of preoperative care
- Decrease the cost of preoperative care
- Return patient to desirable functioning
What are the downsides of doing lab tests?
Lab tests are NOT good disease screening tools
follow up of “abnormal” results is costly
non indicated tests increase risks for patients
batteries of test present medico legal risk to providers
excessive testing decreases facility efficiency
What is the Litmus Test?
- Will the results of this “test” change my management of this anesthetic?
- Will the results of this “test” improve this patient’s outcome?
What are the types of procedures based on invasiveness?
minimally invasive- little tissue trauma, minimal blood loss
moderately invasive- modest disruption of normal physiology, anticipate some blood loss, may need invasive monitors/ICU
highly invasive- significant disruption of normal physiology commonly require transfusion and ICU care
How do you determine what lab tests when?
Institutional policy; ACC/AHA guidelines; anesthesia provider judgement; H/H; chemistry, coags, LFTS, renal function tests, UA; pregnancy; EKG, xray, PFT
Do you need consults?
Controversial; avoid the terms “cleared for surgery”; “cardiac clearance”; does peri-op management of a patient’s disease process go beyond your comfort level? (do you need advice from an expert on the patient’s care that could guide your management?)
What is the definition of ASA status?
“To classify the physical condition of the patient requiring anesthesia and surgery”
- Reflection of pre-operative status
- ASA is independent of the operative procedure and surgical risk
- Subjective communication tool used between anesthesia providers institutions etc.
