Pt Assmt Flashcards
(141 cards)
1
Q
Standardization of Best Practices- enhances the process by
A
Basis for formulating best anesthetic plan
Tailored to the patient
2
Q
True Emergency
A
Life, Limb or Organ Saving
surgery <6hours-
3
Q
⭐️
Examples of True Emergency
A
ruptured aortic aneurysm
major trauma to thorax or abdomen
acute increase in ICP
4
Q
Urgent
A
Conditions threaten life, limb or organ; surgery within 6-12 hours
examples: perforated bowel; compound fracture; eye injury
5
Q
Time sensitive
A
Stable but requires intervention
surgery within days-weeks
examples: tendon; nerve injuries; cancer
6
Q
Elective
A
Procedure planned at patient or surgeon convenience
surgery within 1 year- examples: all other procedures that can be planned in advance
7
Q
Preanesthetic Eval Screen
ROS
A
everything on the ppt came from this chart
8
Q
Although not life-threatening, ______ after a previous surgery may be the patient’s most negative and lasting memory.
A
persistent nausea and vomiting
9
Q
⭐️
vomiting after inhalation anesthesia identified four risk factors:
A
female gender
prior motion sickness or postop nausea
nonsmoking,
use of postop opioids
KNOW this chart!
10
Q
Components of the Airway Examination That Suggest Difficult Tracheal Intubation
A
11
Q
⭐️
Know Dat Mallampati!
A
12
Q
standard for assessing the relationship of the tongue size relative to the oral cavity
A
The Mallampati classification
13
Q
⭐️
assessment of the cervical spine is critical for these pts
A
severe rheumatoid arthritis (RA) or Down syndrome
14
Q
Evaluation of the airway involves examination of …
A
oral cavity, including dentition
thyromental distance
neck size
potential tracheal deviation/masses
flex the base of the neck/extend head
15
Q
T/F
POCT slightly high is better than low POCT
A
T
16
Q
Thyroid strom is a differential Dx to ___
A
MH
17
Q
Best Bronchodilating IA
A
Sevo
18
Q
⭐️
Know these OTC drugs
A
Ephedra: (wt. loss) Tachycardia; HTN; increased sympathomimetic effects with others (arrythmia with digoxin and HTN with oxytocin)
Feverfew: (migraines) PLT inhibitor; Increased bleeding risk; rebound H/A with cessation
GBL; BD; & GHB (body building/ wt. loss) Illegal; death; seizures; severe bradycardia; unconsciousness
Garlic: (antioxidant/lowers cholesterol) decreased PLT aggregation
Ozempic- Gastroparesis
19
Q
The Apfel simplified risk score
A
predicts PONV with 0, 1, 2, 3, or 4 risk factors as 10%, 20%, 40%, 60%, and 80%, respectively
20
Q
Apfel scoring for pt w/ no risk factors
A
10% risk
21
Q
Work synergistically to prevent PONV
A
prop
decadron
zofran (5HT3)
22
Q
The presence of ___ has been associated with a high perioperative risk of myocardial infarction (MI)
A
unstable angina
23
Q
The perioperative period is associated with a ___ and surges ___, both of which may exacerbate the underlying process in unstable angina, increasing the risk of acute infarction.
A
hypercoagulable state
in endogenous catecholamines
24
Q
⭐️
Herbal OTC
A
Ginger: (anti-nausea) Potent inhibitor of thromboxane synthetase; Increased bleeding time
Gingko: (blood thinner) Increased bleeding in pts on anti-coags
Ginseng: (energy/ antioxidant) Inhibits PLT aggregation
Goldenseal: (laxative/diuretic) Oxytocic= worsens edema & HTN
Kavakava: (Anxiolytic) potentiates sedatives & hepatotoxicity
Licorice: (Tx of gastric ulcers) HTN; Hypokalemia & edema
St John’s Wort (depression/anxiety) prolongs anesthetic effects
25
Potent inhibitor of thromboxane synthetase; Increased bleeding time
Ginger: (anti-nausea)
26
Gingko
(blood thinner) Increased bleeding in pts on anti-coags
27
Inhibits PLT aggregation
Ginseng: (energy/ antioxidant)
28
potentiates sedatives & hepatotoxicity
Kavakava: (Anxiolytic)
29
Goldenseal
(laxative/diuretic) Oxytocic= worsens edema & HTN
30
(Tx of gastric ulcers) HTN; Hypokalemia & edema
Licorice
31
St John’s Wort
(depression/anxiety) prolongs anesthetic effects
32
Valerian
(anxiolytic/sedative) potentiates sedative effects of anesthesia
33
Vitamin E
(slows aging) Increases bleeding in conjunction with anti-coagulants & anti-thrombin meds
34
Estimated Energy Requirements for Various Activities
35
1 MET
Daily self-care; eat; dress; walk indoors; walk a block or 2 on ground level 2-3mph
36
Climb a flight of stairs or walk up a hill; walk on ground level 4mph; run a short distance; heavy work around the house; participate in moderate activities (golf, bowling, dancing, doubles tennis)
4METs
37
>10METs
Participate in strenuous sports like swimming; singles tennis; football; basketball or skiing
38
⭐️
remains one of the MOST important predictors of Peri-op risk for non-cardiac surgery; also helps define the need for further testing
Exercise tolerance
39
Excellent exercise tolerance (even in patients with stable angina) suggests that...
the myocardium can be stressed without failing
40
poor exercise tolerance
inability to walk four blocks or climb two flights of stairs)
can be an independent risk factor for serious complications
41
Indications for Further Cardiac Testing
(algorithm integrates clinical hx; surgery specific risk & exercise tolerance)
1) Evaluate urgency of Sx & appropriateness of formal pre-evaluation
**2) recent revascularization or CV work up??**
42
Along with the Resp assmt, we should also assess the pts ability to...
ability to breathe through their nose
43
The presence of symptoms of cord compression may require ....
X-ray exam
44
“Metabolic syndrome”
disorder comprising a group of risk factors:
-high blood pressure
-atherogenic dyslipidemia (↑TRG, ↓HDL)
-high fasting glucose
-central obesity
45
Metabolic syndrome has been associated with higher rates of ...
cardiovascular, pulmonary, and renal perioperative events
wound infections
46
Asthma Assmt
History of asthma
Last time use of a rescue inhaler
Last asthma attack
47
unstable cardiac disease
MI
CHF
Valvular disease
arrhythmia
(use cardiac monitor!)
48
A preoperative 12-lead ECG can provide important information about the patient’s heart rhythm as well as (2)
evidence for left ventricular hypertrophy
prior MI
49
ECG
____ in high-risk patients are highly suggestive of a past MI
Abnormal Q waves
50
“silent infarctions”
30% of MIs
NO symptoms
only be detected on screening ECGs,
highest in DM/HTN patients
51
murmur radiating to the carotids
aortic stenosis
52
Abnormal rhythm or gallop
heart failure
53
Presence of Bruits over the carotid
needs further work up for stroke risk
plaque
54
❌
M.A.C.E- Major adverse cardiac events
Low risk procedure= <1% risk of MACE
High risk procedure= >1% risk of MACE
Advanced age = increased risk of MACE and ischemic stroke
Hx of CV disease; DM; Cerebrovascular disease= Elevated risk of MACE
55
pt has DMI and angina
CV risk?
higher for adverse cardiac event
56
⭐️
The Revised Cardiac Risk Index (RCRI)-
assigns peri-op risk using clinical variables
increased risk factors = more complications
57
⭐️
Clinical evidence of heart failure:
Dyspnea
Limited exercise tolerance
Orthopnea
JVD
Crackles
Third heart sound
Peripheral edema
58
Diabetes associated with CV disease
accelerates atherosclerotic disease
higher incidence of silent MI and myocardial ischemia
insulin depdent = RCRI risk factor
pre-op ECG should be evaluated for presence of Q-waves
59
pre-op ECG should be evaluated for
presence of Q-waves
(old MI!)
60
When to treat BP
Treat SBP > 150mmHg
Treat DBP > 90mmHg (in pts 60yrs old or >)
61
Aggressive treatment of BP is associated with...
reduction in long-term MI risk
62
Elective surgery should be delayed for DBP > ___
110mmHg
63
highest incidence of complications
Major open vascular procedures
64
High risk procedures:
major vascular
abdominal
thoracic
orthopedic
65
Which Sx is a/w extremely low incidence of morbidity and mortality
Peripheral procedures
66
Patients with good exercise tolerance that have stable angina suggests that
myocardium can be stressed without failing
67
Patients with dyspnea associated with chest pain during minimal exertion
extensive CAD and greater perioperative risk
68
⭐️
Patients with Coronary Artery Stents
Delay non-cardiac surgery for 14 days after **balloon angioplasty**
Delay non-cardiac surgery for 30 days after **bare metal stent**
69
⭐️
Early surgery after stent placement
adverse cardiac events (incidence of periop death and hemorrhage)
70
⭐️
Delay non-cardiac surgery after drug eluding stents
12 months
71
T/F
Delays after CAD procedures only applies to elective surgeries.
True
72
AICDs can be impaired by electromagnetic interference from...
Bovie (cauterization)
could shock the pt!
put a magnet on it
73
Which cardiac device always needs to have magnet on it during cautrztn surgery?
AICD
pacemaker doesn't always need
74
Risk of re-infarction under general anesthesia after previous MI
MI within 3 months or less = 30% incidence
MI within 3-6 months = 15% incidence
MI greater than 6 months = 6% incidence
75
⭐️
IF re-infarction occurs, the mortality rate is
50%!
76
⭐️
T/F
POST-OP RESPIRATORY FAILURE = MAJOR CAUSE OF M&M
lol true
77
Post-operative pulmonary complications occur more frequently than cardiac in patients having ...
non-cardiac surgery
78
T/F
ExTT too early can cause pulm edema
True
pulling against against closed glottis
79
proven to have limited benefit in predicting peri-operative respiratory failure and complications
Pulmonary functions testing (PFT) and chest X-rays (CXR)
80
increases risk of peri-operative pulmonary morbidity
Decreased serum Albumin levels & Increased BUN
81
⭐️
procedures associated with the HIGHEST RISK of peri-operative pulmonary morbidity
Open aortic, thoracic and upper abdominal
82
surgeries associated with a HIGH RISK of peri-operative pulmonary morbidity
Cranial, vascular and neck
83
Smoking effects
Increased carboxyhemoglobin levels
Decreased ciliary function
Increased sputum production
CV stimulation from Nicotine
84
⭐️
amount of time smoking cessation needed to decrease the incidence of post-operative complications
4-8 weeks
85
T/F
Airways of smokers are very reactive
True
don't have them quit the day before pls
86
"stress dose" of inhaler may be helpful in asthmatics that
take regular corticosteroids (d/t renal insuff)
87
Obstructive Sleep Apnea (OSA)
periodic obstruction of upper airway during sleep
88
Obstructive Sleep Apnea (OSA)
clinical effects
chronic sleep deprivation
Chronic pulmonary HTN
RHF
89
⭐️
OSA
considerations for anesthesia
These patients are susceptible to respiratory depressants!
Use judiciously!
90
⭐️
These surgeries lead to decreased vital capacity, FRC, & diaphragmatic dysfunction= hypoxemia and atelectasis
Open aortic, thoracic and upper abdominal
Cranial, vascular and neck
91
⭐️
decreased vital capacity, FRC & diaphragmatic dysfunction leads to
hypoxemia and atelectasis
92
leading cause of renal failure requiring dialysis
DM
93
DM
care considerations
Increased risk for CAD; HTN; CHF & Peri-op MI
Higher incidence of cerebral vascular, peripheral vascular and renal vascular disease
peripheral neuropathies= careful positioning
Gastroparesis= theoretical increased aspiration risk
Stiff joints d/t glycosylation of proteins (could affect airway)
94
⭐️
When to delay a Diabetic pt's elective surgery
A1c above target range (DM1:<7.5% for DM2: <7%),
abnormal electrolytes,
or
ketonuria
95
POCT Goalz
Cardiac surgery= maintain sugar 80-100 mg/dL
non-cardiac surgery= maintain sugar <200mg/dL
(trust the pt, they know their body best)
96
T/F
Hold oral hypoglycemic meds the day of surgery
True
97
Screen for s/sx of hyper/hypothyroidism-
Hypo= hypothermia; hypoglycemia; hypoventilation; hyponatremia & heart failure
Hyper= THYROID STORM- tachycardia; A-fib; CHF; tremor; muscle weakness & anemia
98
⭐️
T/F
enlarged thyroid may create airway difficulty
True
99
Draw which lab for hyperparathyroidism
Ca
100
Thyroid storm
S/S
Diff Dx for MH
101
hyperparathyroidism
S/S
HYPER Ca
weakness
lethargy
headache
insomnia
apathy
bone pain
epigastric pain
102
⭐️
When to stress dose Adrenal cortical suppression pts
if steroids were taken for one month or greater within the last 6-12 months (if more than a minor procedure)
103
Which to use in Renal Dz?
Nimbex
Roc
Nimbex
104
Liver Dz
drug binding is affected by
decreased plasma proteins
105
Liver Dz pt needs regional anesthesia. What should we do first?
Obtain coags
(also do this for ETOH Hx)
106
When to draw coags
liver or kidney disease; bleeding disorder; anticoagulant use; chemotherapy
107
Serum chem (glucose, lytes, renal & liver function)
when to draw
liver or kidney disease; DM; CNS disease; Endocrine disorder; Elderly; Malnutrition; type & invasiveness of surgery
108
When to draw CBC
extremes of age; liver or kidney disease; anticoagulant use; bleeding; hematologic disorders; malignancy; type & invasiveness of surgery
109
T/F
ECG is ordered in pts with pulmonary tests.
True
110
T/F
Patients can refuse a preop pregnancy test.
True
the anesthesia provider can ALSO refuse to do that case
111
Which pts get pregnancy test
all women of childbearing age
112
The decision to go forward with surgery-
Are risk factors modifiable?
Will delaying the procedure add to peri-op risk or morbidity?
What can we do peri-op to decrease risk?
Do we have enough information to make an informed decision?
113
T/F
Emergency surgeries are all considered full stomach
True
114
Aspiration Risk:
115
NPO times
116
Bicitra
Increases gastric pH in 100% of the cases it is used – Highly effective antacid
117
Famotidine
Increases gastric pH
118
Reglan
Increases gastric emptying
(obese; pregnant; diabetics; trauma & emergency surgery)
119
T/F
Advanced directives are part of the pre op eval.
True (in ppt slide 72)
120
Innervation of larynx
121
Structures of larynx
122
Preop eval
Renal Dz
Assess electrolytes
Make patient euvolemic prior to induction (likely dry if hemodialysis recently)
Be mindful of meds metabolized by kidneys
123
Adrenocortical Suppression
S/S
Be suspicious of those on long term steroid use
(Cushing’s- moon face; skin striation; truncal obesity & HTN)
124
periop experience comes with increased serum glucose d/t ....
stress (cortisol and catecholamine release)
125
Glycemic control
benefits
decreases:
morbidity
infection rate
stroke incident
+improves wound healing
126
T/F
continue insulin @ full dose of insulin for DM.
Continue insulin (consider half dose)
127
“prayer sign”
DM
unable to completely oppose their hands (with no space between) = changes in other joints = potentially **impacting airway manipulation**
128
Malam. Score
if pt cant open mouth
automatic 4
129
When can we perform elective noncardiac surgery after stent placement?
-**elective noncardiac** surgery may be **considered after 6 months**
(surgery benefits vs stent thrombosis and myocardial ischemia)
-**after drug-eluting stents: 12 months**
130
A patient with CHF is an ASA _
4
131
T/F
Unstable angina = ASA 3
False
Stable angina = ASA 3
132
ASA class?
Mild-to-moderate systemic disease that is well controlled and causes no organ dysfunction or functional limitation (e.g., treated hypertension)
2
133
For patients using inhaled steroids, they should be administered regularly, starting at least ___ prior to surgery for optimal effectiveness.
48 hours
134
T/F
DM patients are more susceptible to positioning injuries both during and after surgery
true
134
Preop assmt interventions for DM
blood glucose
hemoglobin A1c
serum electrolytes
creatinine
ECG
134
Systems Approach
CV goal
identify clinical risk and need of pre-op cardiac testing
134
Forms are Rated using 3 Categories:
Informational Content
Ease of Use
Ease of Reading
135
Pre-op Eval required components
Review medical record
H&P (pertinent to Sx)
diagnostic tests
Pre-op consultations
Can pt condition be improved by Sx?
Answer all questions
Obtain Informed Consent
136
What happens when we place a magnet over an ICD?
PACEMAKER fxn unaffected
BUT
electromagnetic interference still possible
most often causes bradycardia
(depends on pacer)
best option: reprogram to asynchronous mode
137
To avoid electromagnet interference, it's best to put the pacemaker into __ mode
asynchronous mode
138
When to place magnet over ICD
if Sx above umbilucus & using cuatery
