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What are some regulatory requirements for preop assessment?

  • AAANA standard of care
  • American Society of Anesthesiologies- mandated
  • Center for medicaid and medicare- reimbursement


What are some goals of preoperative evaluation?

  • reduce patient risk and morbidity associated with surgery and anesthesia
  • prepare patient medically and psychologically
  • promote efficiency
  • reduce costs


What are some compoenents of preop evaluation?

  • Pt medical hx (chart review and history taking)
  • physical exam
  • meds/allergies
  • lab testing/dx testing
  • medical consultation (if indicated)
  • ASA-Physical status assignment
  • NPO status
  • formulation of anesthetic plan
  • discussion of plan
  • informed consent
  • documentation


Where are preop evals/assessments conducted?

  • presurgical testing centers - "wave of futre"
  • hospitals
    • or settings
    • critical care unit
    • specialty department
  • OP center


What is the optimal situation for a preop clinic visit?

  • 1 week preop
  • patient interview
  • physical exam
  • develop anesthetic plan
  • promote patient teaching and anxiety reducton
  • allows time to schedule appointments with medicla consultants and complete required preop dx testing
  • obtain informed consent prior to operative day


What typs of conditions wouild require an early preop assessment?

  • angina, CHF, MI, CAD, poorly controlled HTN
  • COPD/severe asthma, airway abnormalities, home O2 or ventilation
  • IDDM, adrenal dx, active thyroid disease
  • liver disease, ESRD
  • Morbid obesity, symptomatic gerd
  • severe kyphosis, SCI


What should be the basis of the preoperative interview?

  • Introduction- title (SRNA, CRNA) role
  • Confirmation- pt ID, dx, procedure (surgical site)
  • Education- type of anesthetic, IV insertion, urinary cath, airway instrumentation, monitors, postop care
  • Establish- trusting relationship


What should be discussed regarding history and medications in preop interview?

  • History
    • ROS
      • CNS
      • Cardiac
      • ENT
      • Pulm
      • Vascular/HTN
      • Endocrine
      • GI/hepatic
      • Renal
      • Hematologic
  • Medications
    • allergies
    • prescription meds
      • DC'ed 
      • taken this AM
    • OTC (ASA, NSAIDS, herbals)


What should be discussed in past surgical history?

  • Complications
  • family history complications
  • obstetrical deliveries


What other areas should be discussed in preop interview?

  • ETOH use
  • Drug abuse
  • tobacco use
  • female- LMP
  • pain
  • NPO status
  • height/weight


What should be examined during the physical exam?

  • General impression, mental status
  • airway- regardless of plan!
  • heart
  • lungs
  • VS
  • Height weight


What are mallampati classifciations?

  • Class I
    • soft palate, fauces, entire uvula, pillars
  • Class II
    • soft palate, fauces, portion of uvula
  • Class III
    • Soft palate, base of uvula
  • Class IV
    • Hard palate only


What are some indicators of a potential difficult airway from physical exam?

  • long upper incisors
  • thyromental distance
    • 2-3 fingers or 6 cm.
    • if >9 cm- hard to align glottic opening
  • interincisor distance
    • 3 cm, 2 fingers
  • atlanto-occipital function
    • 35 degree extension
    • problematic if <23 degree
  • mandibular protrustion test
  • hyomental distance (mandibulohyoid)
    • 2 finger breaths
  • neck circumference
    • male 15-16"
    • women 13-14 "
    • if >17 ", or 40 cm, 5% chance difficult airway


Indicators of difficult mask ventilation?

  • Age >55 years
  • OSA or snoring
  • previous head/neck radiation, sx, trauma
  • lack of teeth
  • a beard
  • BMI >26


What are indicators of difficult DL?

  • Report of difficult intubation, aspiration PNA after intubation, dental or oral truma
  • OSA or snoring
  • previous head/neck radiation, surgery or trauma
  • congenital disease: down syndrome, treacher collins, pierre robin syndrome
  • inflammatory/arthritic disease, RA, ankylosing spondylitis, scleroderma
  • obesity, cervical spine dx or previous sx


What is the prayer sign?

ask patient to bring hands together in front of chest. if knuckles don't lie flat, indication that they've had some collagen deposits and may have problems with neck extension as well

seen in diabetics


Cardiac assessment on physical exam?

  • Heart auscultation
    • Rate
    • Rhythm
    • Murmurs
    • Bruits (carotid)
    • extremity pulses
  • CV
    • bruits
    • extremity pulses
    • extremity edema


Lung physical exam?






What are you observing for on physical exam for neuro/MS system?

  • Extent of neuro exam depends on baseline deficits, disease, or sx procedure
  • Motor- gait, grip strength, ROM, ability to hold arms forward
  • Sensory- distinction of vibration, pain light touch along dermatomes
  • Muscle reflex- deep, superficila and pathologic
  • Cranial nerve abnormalities
  • mental status
  • speech


What would show end target organ damage on ROS, Physical exam, CXR/EKG, labs?

  • ROS- Heart attack, angina, stroke
  • PE- carotid bruit, eye damage
  • CXR/EKG- cardiomegaly, wide QRS, left axid deviation, inverted T waves
  • Labs: elevated BUN/CR, decrease GFR, protein in urine


What is rule for choosing what preoperative testing is needed??

2012 ASA practice advisory for preanesthesia eval states that routine preop tests do not make an important contribution to preanesthetic eval of asymptomatic patient


Preop testing should be selevtively ordered based on:

  • patient medical hx and physicla exam
  • planned sx
  • expected introp blood loss


What does selective preop testing accomplish?

expedites patient care

reduces healthare cost

improves delivery of periop meds


What is sensitivity?

sensitive test is very good at identifying those who have hte disease; true positive

A sensitive test with negative result rules out a disease (SnNOUT)


What is specificity

specific test is good at identifying those without the disease; true negative

A speicifc test with a positive result usually rules in disease--> SpPIN


What determines a minimal invasive sx?

little tissue trauma, minimal blood loss (<500mL)

(ie skin lesion)


What is a moderately invasive surgery?

modest disruption of normla physio

anticipate some blood loss (500-1500 mL)

may need invasive monitors and/or ICU

(ie- inquinal hernia, tonsillectomy, knee arthro)


What is a highly invasive sx?

vascular sx, TURP, TJR, radical neck dissection

signficiant disruption of normal physio

blood loss >1500 mL

commonly require transfusion and ICU care


When might you get a CXR before sx?

  • assessment of periop risk- questionable
    • should not be ordered routinely
  • Decision: based on abnormalities id'ed during preop (ie rales, SOB, intercostal retractions, deviated trachea)
  • Indication: severe COPD, suspected pulmonary edema, PNA, susp mediastinal massess or PE


When should you get a CXR on smokers?

20 pack years or more

pack year= ppd * years smoking