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Pre-Op Anesthesia Assessment

Preanesthesia Standards I- perform a thorough/complete assessment II- Obtain informed consent for the planned anesthetic intervention from the patient or legal guardian III- Formulate a patient-specific plan of care
What is the most significant predictor of postop morbidity and mortalitiy? The patient's preoperative condition
Goals of the preop exam *gather information and formulate patient specific plan *minimize perioperative morbidity/mortality by assessing pt health issues *evaluate the patient's health and determine what preop tests or consultations needed *establish a trusting relationship
What general information should you be able to obtain from the medical record? -age -height -weight -surgical consent -admission VS -progress notes and consultation notes -medical treatments and dosages
Important Components of the PreOP interview - History (previous anesthetics, allergies) -Current medical therapy -Physical exam (CV, pulmonary, and airway) -Interpretation of lab data
Previous Adverse Responses Related to Anesthesia -Allergic -Sleep Apnea -Prolonged skeletal muscle paralysis -N/V -Myalagia -Hemorrhage -Postdural Puncture headache -Adverse response in relatives
Family Anesthetic Experiences -most patients are NOT at increased risk even if a family member died under anesthesia -certain inherited conditions are only expressed when exposed to certain anesthetics
Malignant Hyperthermia -rare, life-threatening condition of muscle metabolism -genetic: family members of patient's with MH should be tx as if they also have it -sustained muscle contraction causes massive energy expenditure and hypermetabolic state
Clinical Features of MH -muscle rigidity -masseter spasm -rising etC02 and PaC02 -decrease in Sp02 and Pa02 -Tachypnea -Tachycardia (**1st symptom) -fever (late sign) -metabolic acidosis
The majority of meds are continued preoperatively (T or F) TRUE
Drugs that cause tolerance to anesthetic drugs -ETOH abuse -Benzos
Drugs that exaggerate response to sympathomimetics MAOI and TCA
Latex Allergies -range of reactions possible -Irritant Dermatitis (not ax to latex, usually due to sweating or detergents) -Allergic Contact Dermatitis (reaction to latex or chem additives) -Hypersensitivity Immune System Reaction
Risk factors for Latex Sensitivity -chronic exposure to latex products -spina bifidia -repeated surgical procedures (9+) -known intolerance to latex products (i.e.condoms) -allergy to fruit and tropical fruit (kiwi, peach, advocate) -Intraop anaphylaxis of unknown cause -health care worker
Tobacco Use -smoking rates down to 19% -over 4000 compounds in cigs -Inquire amount smoked and years smoked
Nicotine -sense of relaxation, well-being, and heightened concentration -long term causes release of catecholamines (vasoconstriction) -Incr. Coagulation (sticky/adherent plts, increased viscosity d/t fibrinogen & RBCs stack to form conglomerations
Carbon Monoxide -high affinity for Hgb -bond btw Hgb CO is 250x stronger than O2 -Inhaled CO displaces 02 causing hypoxia
Smoking Effects -small airways in lung narrow and prone to collapse -increase in mucus, decreased ability to clear mucus -excess mucus and inflammation lead to progressive and permanent lunch damage -increased bronchial reactivity/sensitivity
Tobacco Sessation Benefits for Surgery 12-24 hours effects of CO decrease and much of the nicotine is cleared from blood, 48hrs needed for changes in airways reactivity/sensitivity -improvement of secretion and small airways takes 4-8 weeks -after 10 weeks anesthesia risks reduced to nonsmoker
Opiod Abuse effect on anesthetic requirement Acute: decrease Chronic: increased
Barbituate Abuse effect on anesthetic requirement Acute: decreased Chronic: increased
Marijuana use and anesthetic requirment Acute: decreased Chronic: no effect
Amphetamines effect on anesthetic requirement Acute: increased need Chronic: decreased need
Cocaina effect on anesthetic requirement Acute: increase Chronic: no change
Phencylidine (PCP) Acute: decreased Chronic: unknown
Thyromental Distance -distance from thryoid notch to bony point of chin with head extended -7cm (3 fingers) or LESS is assoc w difficult intubation
Standard Lab Testing Age 0-12: none Age 13-49: Hct for females (valid for 1 month), HCG if appropriate Age 50+: Hct, EKG, lytes (labs valid 1 month, EKG 6 months)
Preop Testing for know CV disease -EKG -electrolytes -CXR -cardiology consult
Preop Testing for known Pulmonary disease -ABG -CXR (good for 6 months) -PFT (significant symptoms) -medicine or pulm consult
Preop Tesing for Renal -BUN/Cr -glucose -lytes -PT/PTT -platlets
Preop Testing for Liver Disease -BUN/Cr -Glucose -electrolytes -LFTs -PT/PTT -platlets
Labs for patient on anticoagulant therapy -coags -fibrinogen -platlets -consider hematology consult
Chronic Meds that require preop labs -Diuretics (lytes, BUN/Cr) -Steroids (lytes, glucose) -Digitalis (lytes, Bun.Cr, EKG) -Anti-convulsant: drug levels
When do you order T&S? -major blood loss (>500ml) -Intermediate blood loss (50-500ml) if elderly (>70), significant medical probe, anemia, or required previous transfusion -if patient had transfusion or was pregnant w/in 6 mos
Repeat EKG guidelines for diabetics -Within 1 month if previous EKG abnormal -Within 3 months if previous EKG normal and no symptoms
Repeat EKG guidelines for Non-diabetics -Within 6 months if previous EKG abnormal and no symptoms -Within 1 year if previous EKG normal and no symptoms
Pregnancy Testing Women of reproductive age SHOULD have blood pregnancy test within 38-72 hours of surgery, same day urine test is alternative but less sensitive -Why? anestetics can be teratogenic, risk of abortion, elective surgery should wait until after 1st trimester
Complications of prolonged fasting -Dehydration -Hypoglycemia - Increased Irritability -Thirst -Hunger -Headache
Pulmonary Aspiration #1 cause of anesthesia death, aspiration pneumonitis occurs in1-7:10,000 cases
Patients at risk for Aspiration -GI obstruction, GERD, DM/gastroparesis, pregnancy, abdominal distension (obese, ascites), recent solid food, recent opioid, depressed LOC, airway trauma, nasopharyngeal or upper GI bleed
Critical Values for Aspiration pH < 2.5 and volume >25ml
Aspiration of Acidic Content -immediate aleveolar-capillary breakdown -interstitial edema, intraalveolar hemorrhage, atelectasis, increased airway resistance and hypoxia
Aspiration of Nonacidic Content destroys surfactant, causes alveolar collapse, atelectasis and hypoxia -aspiration of food causes physical obstruction and later inflammatory response -results in alternating areas of atelectasis and hyper expansion, hypoxia, and hypercapnea
Symptoms of Aspiration -can be silent -tachypnea -rales -cough -cyanosis -wheezing -fever (if patient aspirates and within 2 hours no symptoms- full recovery) (75% of pts with symptoms require 02 or ventilation w/in 2 hrs)
Prevention of Aspiration -recognize risk -fasting guidelines -preanesthetic treatment to increase pH and decrease volume -rapid sequence -awake intubations
Fasting Guidelines Clears: 2 hrs Breast Milk: 4 hrs Infant Formula: 6 hrs Light Meal: 6 hrs Heavy Meal: 8 hrs
General Anesthesia A reversible, drug induced coma during which the patient will no perceive or respond to pain. Should include: unconsciousness, amnesia, akinesia, analgesia, and reversibility
MAC anesthesia -administration of sedative and anesthetic drugs producing effects ranging from awake to light sleep -standard of care is the same for MAC as general -Airway management skill is required of the provider giving MAC
Reasons to AVOID regional anesthesia -low platelets -antiplatlet therapy -spinal disease -spinal fracture -sepsis -AS
Reasons for Premedications -Patient Comfort -Decrease gastric pH/volume -decrease airway secretions -decrease risk of PONV -prevent ABX
Factors to Consider when Premedicating -ASA status -Age -Weight -Level of pain/anxiety -Allergies -Hx of drug abuse/use -previous PONV -planned surgical procedure -inpatient or outpatient
PreOp Meds: Benzos -most commonly administered drugs for sedation and anxiety -Versed and Ativan produce anterograde amnesia -can produce excessive sedation in some pts
PreOp Meds: Opiods -use for preop pain control -use if patient requires invasive procedures before surgery -use before insertion of spinal/epidural (non-OB)
PreOp Meds: Antihistamine -prophylaxis against allergic reaction -sedative and antiemetic properties
PreOp Meds: Anticholinergics -used for antisialagogue effect -sedative and amnestic properties (scopolamine) -prevent reflex bradycardia
Why might we give preop steroids? Stress dose given if patient was on steroids prior to surgery
According to SCIP the most common complications after surgery are.. -Surgical site infection and postoperative sepsis, CV complications, Respiratory complications, throboembolic complications
Created by: MegPRN86