Preoperative Evaluation of the Patient Flashcards
(41 cards)
The proper pre-op should include all of the following
An interview
A full physical examination
Diagnostics
Scoring of Risk
Plan for anesthesia
FITNESS FOR ANESTHESIA
The clinician must try to avoid any possible complications before they become life threatening
To that end the clinician will see each surgical candidate long before the procedure is scheduled
The very ill patient will often fair poorly under general anesthesia, as well as the surgery
Poor candidate may not always exclude the pt from getting the procedure done
AMERICAN SOCIETY OF ANESTHESIOLOGISTS PHYSICAL STATUS CLASSIFICATION SYSTEM
An E is added to any of the category
*Adding E to any of the above categories denotes an emergency
AMERICAN SOCIETY OF ANESTHESIOLOGISTS PHYSICAL STATUS CLASSIFICATION SYSTEM
ASA 6
Brain Dead
AMERICAN SOCIETY OF ANESTHESIOLOGISTS PHYSICAL STATUS CLASSIFICATION SYSTEM
ASA 5
A moribund pt who is expected to die within 24 hours if they do not get the surgery
Eg.Ruptured AAA, PTE, Increased ICP
AMERICAN SOCIETY OF ANESTHESIOLOGISTS PHYSICAL STATUS CLASSIFICATION SYSTEM
ASA 4
A pt with severe systemic disease that is a constant threat to their life
Eg.CHF, Renal or Hepatic failure, Unstable angina
AMERICAN SOCIETY OF ANESTHESIOLOGISTS PHYSICAL STATUS CLASSIFICATION SYSTEM
ASA 3
A pt. with a severe systemic disease
Eg. Uncontrolled hypertension, DM with vascular issues, previous MI, COPD
AMERICAN SOCIETY OF ANESTHESIOLOGISTS PHYSICAL STATUS CLASSIFICATION SYSTEM
ASA 2
A pt with a mild systemic disease
Eg. Controlled hypertesion, diabetes
AMERICAN SOCIETY OF ANESTHESIOLOGISTS PHYSICAL STATUS CLASSIFICATION SYSTEM
ASA 1
Fit and Healthy Person
ANESTHETIC RISK-Drug Regime
Any drug regimens they are on, may contraindicate certain agents or procedures
Drug therapies will/can interact negatively with the agents used.
This may require cessation of therapies which will further complicate their illness
For all purposes the anesthesiologist will want them to continue their medications going into the surgery
Sometimes when a pt is admitted into the ICU the dr will stop all their drugs and then only add back the drugs that they think are needed and this can be helpful when they are preparing for a surgery
ANESTHETIC RISK-Diseases
Any disease state alters homeostasis and increases the risk of side effects and bad outcomes
Systemic disease will alter uptake, distribution and elimination of the anesthetic agents.
Systemic illness can interfere with anesthetic procedures
Eg. Intubation, monitoring etc.
RISK FACTORS
AGE
The very young and the very old have increased risk of negative outcomes from both surgery and general anesthesia.
Often regular doses are too much and elimination via normal pathways can be less efficient, therefore agents will have prolonged effect.
Recovery can be complicated and drugs hard to reverse.
Ischemic Heart Disease
What Kind of Monitoring Will these Pt Need
These pts will need invasive hemodynamic monitoring, (ie. Swan-Ganz), so circulatory dynamics can be monitored and adjusted.
Ischemic Heart Disease
What Are Some Things You Are Trying To Prevent
Tachycardia, hypertension, LV failure etc. can be avoided with the appropriate therapy.
Ischemic Heart Disease
Drug Therapies
Existing drug therapy needs to be “tuned-up” to ensure optimum therapy and problem avoidance
Ischemic Heart Disease
Pt History and Preoperative Evaulation What Are The Main Things You Are Looking For
Cardiac Reserve
Angina
Prior Myocaridal Infarction
Current Medications
Ischemic Heart Disease
Cardiac Reserve
The work the heart is able to perform beyond that required under the ordinary circumstances of daily life
Limited exercise tolerance in the absence of pulmonary disease is the most striking evidence of decreased cardiac reserve
Ischemic Heart Disease
Angina
Myocardial ischemia caused by an imbalance between myocardial blood supply and oxygen demand
The heart rate and systolic BP at which angina or evidence of ischemia is indicated on the ECG are useful preoperative information
Increased RR is more likely than hypertension to produce sings of ischemia (Tachycardia increases myocardial oxygen demand without increasing coronary perfusion).
Ischemic Heart Disease
Prior Myocardial Infarction
The incidence of a second myocardial infarction in the perioperative setting is related to the time elapsed since the previous infarction. The less time between the previous MI and Sx, the increased risk of another MI. The incidence of perioperative MI does not stabilize at 5-6% until six months after the prior MI
Ischemic Heart Disease
Current Medications
Most likely drugs include B-antagonists, nitrates, Ca2+ channel blockers, ACE inhibitors, statins, diuretics, and platelet inhibitors.
Patients on B-Blockers should be monitored closely throughout the perioperative period
Discontinuation of the above mentioned drugs in the perioperative period can increase risk of perioperative morbidity and mortality and should not be discontinued.
Ischemic Heart Disease
ECG
A preoperative resting 12 lead ECG is recommended
Risk Stratification Vs Risk Reduction
The approach of prescribing various invasive procedures vs careful history taking, assessment and prophylactic medical therapy
PRIMARY HYPERTENSION
Existing drug regimens need to be optimized. Some diuretics can cause hypokalemia, (low serum potassium); weakness, rapid pulse, N&V, peripheral tingling.
Those with uncontrolled hypertension have a greater risk for hypotension during the procedure
Primary Hypertension
Determination of the BP control and review of antihypertensive medications
Medications should be continued throughout the perioperative period
Consider the administration of prophylactic anti-ischemic therapy in (perioperative B-Blockers)
Preoperative treatment should occur because of the incidence of hypotension and the evidence of myocardial ischemia on the ECG during the maintenance of anesthesia is increased in patients who remain hypertensive before the induction of anesthesia
