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Preop Lecture 1-16 Flashcards

Pre-op

1
Q

What are 3 anesthesia related complications?

A

Malignant hyperthermia
Hx of difficult airway
Pseudocholinesterase deficiency

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2
Q

What considerations do we have to have for someone who has a Hx of MH or Pseudocholinesterase deficiency?

A

-No volatile anesthetics

-No depolarizing muscle relaxants (Succs)
You can give Rocuronium, propofol, fentanyl, precedex

-Remove vaporizers, replace circuit, reservoir bag, and CO2 absorber & flush machine

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3
Q

What is Pseudocholinesterase deficiency?

A

A genetic disorder where you tay paralyzed for an extended period of time.

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4
Q

Ancef has a low cross reaction with _____

A

PCN

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5
Q

What medication causes angioedema?

A

lisinopril

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6
Q

Why is illicit drug use/ETOH important when obtaining Hx?

A

May need more or less of the anesthetic

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7
Q

How does smoking affect coming out of anesthesia?

A

May have a harder time coming out because excessive coughing

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8
Q

T/F: if there’s a difficult airway, you can intubate awake

A

T

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9
Q

BMI =

A

[wt (kg)] / [height (m)]2

or

[703 x wt (lbs)] / [height (in)]2

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10
Q

Describe the BMI chart

A

For adults over 20
Underweight: < 18.5
Normal: 18.5 - 24.9
Overweight: 25.0 - 29.9
Obese: >30.0

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11
Q

BMI does not account for ________

A

muscle

Muscle is heavier than fat

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12
Q

How do seizure medications affect NMB?

A

Decrease DOA

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13
Q

What is the acronym for emergent physical examination questions?

A

AMPLE

Allergies
Medications
Past medical history
Last eaten meal
Events leading up to the need for surgery

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14
Q

In an emergency situation, what do we always assume? Why?

A

They have a full stomach

SNS fight/flight response causes decreased GI motility

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15
Q

What does my airway examination consist of?

A

MITFRD

Mallampati classification
Inter-incisors gap
Thyromental distance
Forward movement of the mandible
Range of cervical spine motion
Document loose/chipped teeth

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16
Q

What is Mallampati classification and how do you assess?

A

Related to tongue size to visualize the oropharyngeal

Have them sit up straight with tongue out (no phonation)

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17
Q

What is Inter-incisors gap and how do you assess?

A

Space between the top and bottom teeth

Have patient open their mouth

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18
Q

What is Thyromental distance and how do you assess?

A

It is a space between your mandible and your thyroid that assesses your mandible space and ease of tongue displacement

Have them fully extend their neck and measure from the tip of the mandible to the upper broader thyroid cartilage

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19
Q

T/F: we can still move the mandible with a C-collar

A

F

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20
Q

What are considerations we should have if we see tracheal deviation?

A

pneumothorax/mass
-may ultrasound/CT scan
-glidescope to intubate

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21
Q

_______________ complications account for almost half of preoperative mortalities

A

Cardiovascular

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22
Q

A murmur around the neck could mean….

A

severe aortic stenosis

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23
Q

What are comorbities common in smokers?

A

Vascular disease
Cancer
Kidney issues

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24
Q

T/F: OSA is always correlated to body structure

A

F

Skinny people have OSA

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25
When can you put someone under anesthesia with an active URI?
emergent situation only.
26
How do we control BGS in the OR?
IV only we will only bring it down slight to help with wound healing if it is profoundly high. Finger stick in preop & 30 mins after insulin given
27
Why is it better for the BGS to be high than low when giving anesthesia?
You cannot tell if a sugar is too low under anesthesia bc all of the S/S are masked by the anesthesia.
28
What is Pheochromocytoma?
A endocrine disorder: catecholamine secreting tumor Tx: Alpha blocker S/S: Pt will feel belly pain ultrasound: see something sitting on top of kidney BP: elevated after anesthesia
29
Thyroid and adrenal disorders can have _______ imbalances
electrolyte
30
T/F: anesthetic agents tend to decrease GFR
T
31
What are two ways to treat contrast induced neuropathy?
Hydrate Dialyze
32
How does liver disease affect anesthesia?
It impacts the drug metabolism and pharmacokinetics Anesthetics might have exaggerated effects impatience with advanced liver disease
33
What is the number one malignancy in the USA?
Alcoholism
34
Hematological disorders include:
Anemia Sickle Cell G6PD Coagulopathies
35
What consideration should I have for someone with sickle cell disease?
**Consult Hematologist** -Incompatibilities with blood -May need to come in the night before to get transfused -not having anything to eat or drink for the Sx--> dehydrated--> clumping of sickles --> pain
36
What does smoking do to your hemoglobin?
Artificially increases it
37
Neurological diseases include:
Cerebrovascular disease Seizure disorder Multiple sclerosis Aneurysm AV malformation Parkinson's disease Neuromuscular junction disorder Neuromuscular dystrophy and myopathy
38
__________, a Parkinson's medication, causes problems with anesthetics
Levodopa
39
What are some considerations with multiple sclerosis?
muscle weakness --> Harder time regaining muscle function & easier to loss muscle function -don't use full dose -consider local/regional instead of NMB
40
Musculoskeletal & connective tissue disorders include:
Rheumatoid arthritis Ankylosing spondylitis Systemic lupus erythematosus Reynaud phenomenon
41
What is ankylosing spondylitis? Where is it concerning at?
Hardening tissue that becomes brittle Concerning in the neck
42
What is Reynaud's phenomenon? What consideration should I have with this?
Constriction and vasospasms in the extremities -use caution with vasoconstrictors -pulse ox, not may not work on extremities (may have to put somewhere else like forehead) -decrease perfusion
43
What consideration do we have with transplant patients?
Always consult with the transplant doctor and transplant center first, they may want to have the surgery there if the outcome might be better -usually taking steroids -vagus nerve severed --> won't respond to neostigtme
44
What was the court case that helped established informed consent?
**Salgo vs Trustees of Leland Stanford Hospital** 1959 - California Stated the procedure left him paralyzed, and he wasn't informed of the risks
45
Most DNR's are _______ during Sx. But you should know your facilities policy.
Suspended
46
How does nutritional status play a part in anesthetics?
malnutrition --> decreased albumin --> decreased anesthesia working
47
When do we need to d/c tube feeds? what other options do we have?
prone or supine flat dophoff
48
Define Frailty
A state of increase vulnerability to physiological stressors
49
What are my high risk surgical procedures?
>5% Aortic and major vascular Peripheral vascular
50
What are my intermediate risk procedures?
1-5% Intra-abdominal surgery Intrathoracic surgery Carotid endarterectomy Head/neck surgery
51
What are my low risk surgery procedures?
Ambulatory surgery Breast surgery Endoscopic procedures Cataract surgery Skin surgery Urologic surgery Orthopedic surgery
52
Based on the Revised Cardiac Risk Index (RCRI), what components increase risk for major cardiac events after surgery?How do you score this?
-High risk surgery -ischemic heart disease -Hx of congestive heart failure -Hx of cerebral vascular disease -DM requiring insulin -creatinine greater than 2 **Each is worth 1 point** Risk or major cardiac event 0 = 0.4% 1 = 1.0% 2 = 2.4% 3 or more = 5.4%
53
What does functional capacity do?
-Assesses cardiopulmonary fitness -estimates patient's risk for a major postop morbidity or mortality -assesses preoperative risk
54
With functional capacity, what is considered a good METs score?
>4 METs
55
How do we normally test functional capacity?
METs score of 5: Climbing 1 flight of stairs
56
What are the times for urgency of surgeries?
Emergent: 30 minutes - 6 hours Urgent: 6 to 24 hours Time sensitive: 1 to 6 weeks
57
What is the Preop Cardiac risk assessment algorithm?
Step 1. Emergency --> Sx Step 2. Active cardiac conditions: ACS decompensated HF significant arrhythmia severe valvular disease --> Postpone until eval/Tx Step 3. Estimate risk using RCRI --> less than 2 --> Sx Step 4. Assessed functional capacity --> greater than 4 --> Sx Step 5. Assess whether testing will impact care. Step 6. Proceed to Sx or consider alternative strategies.
58
Describe ASA I
A normal healthy patient Non-smoking Minimal or no alcohol use
59
Describe ASA II
A pt w/ mild systemic disease w/o substantial functional limitations Current smoker Social alcohol drinker Pregnant person Obesity (BMI between 30-40) Well controlled DM/HTN Mild lung disease
60
Describe ASA III
A pt with severe systemic disease and substantial functional limitations Poorly controlled DM/HTN COPD morbid obesity (BMI >40) Active hepatitis Alcohol dependence/abuse Pacemaker Moderate reduction in EF ESRD with dialysis Premature infant postconceptual age <60 weeks Hx of MI/CVA/TI/CAD/stents (>3 months) **where disability starts**
61
Describe ASA IV
A pt with severe systemic disease that is a constant threat to life MI/CVA/TIA/CAd/stents (< 3 months) Ongoing cardiac ischemia Severe valve dysfunction Severe reduction in EF Sepsis DIC ARDS ESRD without dialysis
62
Describe ASA V
A moribund pt who is not expected to survive without surgery Ruptured abdominal/thoracic aneurysm Massive trauma Intracranial bleed with mass effect Ischemic bowel in the face of significant cardiac pathology Multiple organ/system dysfunction
63
Describe ASA VI
A declared brain dead pt whose organs are being removed for donor purposes **THIS IS ALWAYS AN EMERGENT CASE**
64
What is in a CBC? Who needs one drawn?
Hgb/Hct/Plt/WBC Hx of increased bleeding Hematologic disorders Anticoagulant therapy Poor nutritional status ASA-pt 3/4: intermediate risk procedures All patients undergoing major procedures (ASA 5)
65
What is renal function testing under? Who needs one drawn?
Chemistry panel ASA-pts3/4: intermediate risk procedures ASA-pts2/3/4/5: major procedures
66
How much does Succs raise K?
0.5
67
How can we give K?
CVC: 20-40 meq/hr peripheral: 10-20meq/hr Can give PO at the same time as IV
68
Who needs coag labs?
pts with identified coagulopathies during preop known bleeding disorders Chronic hepatic (liver) disease Anticoagulant use ASA-pt 3/4: intermediate, major, complex surgical procedures
69
Decadron________ glucose levels
increases
70
Who needs a serum glucose and A1c lab?
Known DM Obesity (BMI >50) Cerebral vascular/intracranial disease Steroid history
71
Who needs a urinalysis?
Suspected urosepsis Hip replacement surgery Unexplained fever or chills
72
How does Suggamdex affect birth control?
Inactivates it for about a week NEED TO INFORM PT TO USE DIFFERENT METHOD OF BIRTH CONTROL
73
Who needs an ECG?
Ischemic heart disease HTN DM HF Chest pain Palpitations Abnormal valve murmurs Dips on exertion Syncope Arrhythmias Known IHD PAD CVD Significant structural heart disease undergoing intermediate or high risk procedures ASA pt 3/4: intermediate risk procedures ASA pt 2/3/4: major high risk procedures
74
Who needs a chest x-ray?
Based on abnormalities identified in preop Advanced COPD Bollous lung disease Pulmonary edema Pneumonia Mediastinal masses Tracheal deviation Rales **if patient cannot tell you, you might need x-ray to identify**

Assessment (22 decks)

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