procedures that usually require min/mod sedation w/few physiological risks - eye surgery - GI endoscopy w/o stenting - dental

procedures associated w/min physiological effect - hernia repair - ENT - IR - GI endoscopy w/stent - cystoscopy

procedures associated w/mod changes in hemodynamics, risk of blood loss - intracranial/spine - gyn/urologic - intra-abdominal w/o bowel resection - intra-thoracic w/o lung resection - cardiac cathertization

procedures w/possible significant effects on hemodynamics/blood loss - colorectal w/bowel resection - kidney transplant - maj joint replacement - open prostatectomy/ cystectomy - maj oncologic surgery

procedures w/maj impacts to hemodynamics, fluid shifts. possible maj blood loss - aortic/cardiac surgery - intra-thoracic lung resection - maj transplant (heart, liver, lung)

Session 10: Pre-Op Interview & Physical Exam Flashcards by Kira Harms

Reasoning Qs

what issues do they currently have?
will they change our anesthetic?
what is the severity of the interference?

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Complete Pre-Op Components (12)

Med/Surg History
Meds/Allergies
Social History
Anesthetic History
DNR
Airway/Physical exam
Lab/Pre-op test results
NPO status
Catch All
ASA Status
Anesthetic Plan
Informed Consent

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Neurological Exam (8)

Seizure
Stroke
Neuromuscular disorders
Aneurysm
Asymptomatic bruit
Parkinsons
Psych disorders
MS

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Alert and Oriented
(A&O status)

overall capacity of brain to know where they are

Alzheimer’s
dementia

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A&Ox1

oriented to person

knows their name
recognizes significant others

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A&Ox2

oriented to person and place

understands where they are

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A&Ox3

Oriented to person, place, time

aware of date, day of week, season

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A&Ox4

oriented to person, place, time, situation

understands/can explain why they are at healthcare facility

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Respiratory Exam

Colds/cough
COPD
Restrictive PD
Asthma
Pulmonary hypertension

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Pediatric URTI Algorithm

can we postpone surgery to minimize risk during upper respiratory infection

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Cardiovascular Exam

(HHIMR)

Hypertension
Heart Failure
Ischemic Heart Disease (METs)
Murmurs/Valvular abnormalities
Rhythm disturbances

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Metabolic Equivalents of Functional Capacity Test

METS
used to asses a pts functional level of exercise
determine risk of intraoperative cardiovascular event

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severe risk of intraoperative cardiovascular event if MET

1 - eating, working at comp
2 - walking down stairs
3 - waking 1-2 blocks
4 - raking leaves, gardening

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Revised Cardiac Risk Index (RCRI)

High risk surgery
Diabetes
Ischemic heart diesease
Congestive heart failure (Hx)
Cerebrovascular disease (Hx)
Creatine >2.0 mg/dL

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High risk surgeries

intraperitoneal (abdomen)
intrathoracic
supra-inguinal vascular

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Very low risk

procedures that usually require min/mod sedation w/few physiological risks

eye surgery
GI endoscopy w/o stenting
dental

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low risk

procedures associated w/min physiological effect

hernia repair
ENT
IR
GI endoscopy w/stent
cystoscopy

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intermediate risk

procedures associated w/mod changes in hemodynamics, risk of blood loss

intracranial/spine
gyn/urologic
intra-abdominal w/o bowel resection
intra-thoracic w/o lung resection
cardiac cathertization

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high risk

procedures w/possible significant effects on hemodynamics/blood loss

colorectal w/bowel resection
kidney transplant
maj joint replacement
open prostatectomy/
cystectomy
maj oncologic surgery

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very high risk

procedures w/maj impacts to hemodynamics, fluid shifts. possible maj blood loss

aortic/cardiac surgery
intra-thoracic lung resection
maj transplant (heart, liver, lung)

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Endocrine Exam

Hypothalamic-Pituitary Disorder
Diabetes mellitus
Thyroid disease
Parathyroid disease
Pheochomocytoma

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Hepatic Exam

Hepatitis
Obstructive Jaundice
Liver failure
Cirrhosis

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Hepatic Disease State Classification

Child-Turcotte-Pugh

Model for End-Stage Liver Disease (MELD)

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MELD score

higher value = worst state of liver disease

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at what MELD score do you see rapid decline?

15+ MELD

Gastro-Intestinal Exam

Heartburn/GERD Bowel obstruction NPO guidelines

Clear liquids

2 hrs

breast milk

4 hrsi

infant formula

6 hrs

nonhuman milk

6 hrs

light meal

6 hrs

light meal includes

carb and clear liquid

heavy meal

8 hrs

heavy meal inclused

fat and protein

Renal Exam

Chronic Kidney disease Chronic renal failure Acute renal failure Fistula/PD catheter/HD catheter End Stage Renal Disease (ESRD)

Musculo-Skeletal Exam

Lupus Anklosing spondylitis Rheumatoid arthritis Sclerosis (systemic) Scoliosis Marfans Ehlers-Danlos

Hematological Exam (STTAPHV)

Sickle Cell Thrombocytopenia Thrombocytosis Anemia Polycythemia Hemophilias Von Willebrands

Medication Interview

allergies prescriptions OTC Herbal supps

Prescrptions/OTC questions

how much? last dose?

Social History Interview

Smoking Drinking Illicit drugs

Smoking Qs?

do you smoke? how much? how many years?

pack year

1.5 packs a day for 18 years = 1.5 x 18 = 27 pack year smoker

Drinking Qs?

do you drink? how much? what type? (12oz beer = 1.5oz liquor = 5oz wine)

Illicit Drugs

depressants hallucinogens stimulatns

depressants

alcohol benzodiazepines cannibis GHB ketamine opioids

hallucinogens

cannabis LSD ketamine psilocybin PCP

stimulant

amphetamines caffeine cocaine ecstasy nicotine

inhalants

volatile solvents aerosols gases nitrites

performace enhancing drugs

anabolic steroids peptides hormones

Past anesthetic history

unusual familial death w/anesthesia? PONV adverse outcomes **keep open ended

DNR wishes

most often DNR suspended for anesthesia varying levels: no compressions no shocks no intubation/sustained intubation

Airway Exam

mallampati score thyromental distance mouth opening neck mobility dentition

Dentition exam

loose chipped veneers crowns implants grills

heart auscultation

aortic area pulmonic area erbs pt tricuspid area mitral area

aortic

right side of sternum 2nd intercostal space

pulmonic

left side of sternum 2nd intercostal space

tricuspid

left side of sternum 4th intercostal space

mitral

left side of sternum 5th intercostal space

erbs pt

left side of sternum 3rd intercostal space

lung auscultation

bronchial bronchovesicular vesicular

auscultation

technique perfomed to listen to internal sounds of the body - heart lungs bowel

bell

low-pitched sounds (heart murmers)

diaphragm

normal high-pitched sounds abnromal sounds

broncial

loud high pitched sounds around the trachea

bronchovesicular

medium pitched sounds 1st and 2nd intercostal space by sternum

vesicular

soft low pitched sounds entirety of lung fields

abnormal lung sounds

diminished lung sounds adventitious breath sounds

cracklets

abnormally closing airways during inspiration/expiration CHF or excessive fluid on lungs

wheezes

narrowing of airways leading to obstruction manifestation of asthma exacerbation

auscultation big picture

wheezes or crackles? cardiac valvular sounds that cannot be explained by previous echo?

manual bp measurement

korotkoff sounds sound of the blood when the cuff occludes and partially occludes in an artery

BP measurement

size cuff according

too small cuff

overestimate systolic

too large cuff

underestimate systolic

cuff bladder

extend 50% round extremity

cuff width

20-50% greater than the extremity diameter

pulse check

access can be limited to ensure we are adequately perfusing heart/brain

PEA

pulses electrical activity of heart

potential for blood loss (labs)

CBC Type and Screen +/- cross

potential for electrolyte disturbances (labs)

BMP specific assay

coagulation ? (labs)

coag screen TEG P2y12

Pre-Op vitals

arrythmia hypoxic respiratory distress vital signs

1 kg

2.2 lbs

1 lb

0.45 kg

Catch All Phrase

"is there anything else you see a physician/doctor for that we did not cover?" last change to bring anything else to light

ASA Status

determine overall phsyical aspects of Pt

ASA1

healthy pt no systemic issues

ASA2

mild to moderate systemic cause by surgica need or pathological process well controlled by meds

ASA3

severe disease limits activity

ASA4

severe disease constant threat to life

ASA5

moribund pt will not survive w/o surgery w/in 12 hrs

ASA 6

brain dead organ donation

ASA E modifier

added to any classification to denote emergency status

Session 10: Pre-Op Interview & Physical Exam Flashcards

(93 cards)