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Barry preop eval

Basics preoperative evaulation

What are the Goals of Anesthesia Evaluation? Reduce morbidity/assess riskIncrease quality of anesthesia service, but decrease cost of perioperative careDecrease anxietyObtain informed consentReturn pt to desirable functioning as quickly as possible
3 Questions you should ask in the preop eval? Is the pt in optimal health?Can or should the pt’s physical or mental condition be improved before surgery?Does the pt have any health problems or use any medications that could influence periop events?
An evaluation should include what accepted standard practices of review? Review of hospital chart(s) Review of prior anesthesia recordReview of consultationsH&P, lab results, tests – ordering additional labs and/or testsDiscussion of perioperative anesthesia plansInformed consent – educating pt and reducing anxiety
How long should the eval take? 5-10 min
What was the Ideal World – 1980’s and earlier model of preop eval? preop visit accomplished 1day-2wks prior to Same provide does preop as intraop and postopComplete preop data base with evidence to support the pertinent disease process.
What % of operations are performed on an outpt basis 65%
What is the nature of the current environment Cost-Conscious and Outcome-focused
What standards require pts receive a pre anesthetic evaluation? JCAHOASA/ANA standards
What is a low risk procedure? usually <1% - skin, breast, urologic, and minor ortho, cataract surgery
How are procedures classified in regarding to risk? The rate of morbidity, perioperative MI and/or death was stratified by the type of surgical procedure
What is an intermediate Risk procedure? usually <5% - abdominal (lap chole, intrathoracic, ortho, and carotid
What is a high risk procedure? usually >5% - emergent, aortic and other vascular surgery (AAA, CABG), anticipated prolonged surgical procedures associated with large fluid shifts and/or blood loss
What 5 Items should your preop Assessment include? Identify Patient/Birthdate/MRNProcedure/Surgeon and consentLast oral intakePast Medical/Surgical History(airway assess)
What are the NPO guidelines for :Clear Liquids:Breast Milk:Infant Formula/ non human milkLight mealFried fatty foods clear 2 hoursbreast milk 4 hoursclear liquids 6 hourslight meal 6 hoursfried fatty foods or meat > 8
Is a shellfish/ seafood allergy linked to IV iodine contrast? NO
What is Anaphylaxis? severe life threatening
What is a type 1 Anaphylaxis? mmediate hypersensitivity reaction; IgE mediated release
What is an Anaphylactoid reaction? Is it more or less severe than Anaphylaxis? generalized hives, edema, erythema associated with antigen-antibody process
Are Amide-type local anesthetic reactions common or rare? Rare!
What type of reactions can be seen with Ester-type local anesthetics? Anaphylaxis
What is included in social/substance history AlcoholAmount/typeTobaccoPack yearsCurrent usageIllicitMarijuana, cocaine, amphetamines, anabolic steroids
What questions should be asked regarding medications? PrescriptionNon prescription: vitamins, herbal me
What is the goal regarding pts home medications and anesthesia? maintain the pt’s baseline physiologic status and avoid adverse interactions with anesthesia
What medications should you consider continuing? Antihypertensives - continue all antihypertensive meds, except ACE inhibitors, especially angiotensin II antagonists (AIIAs)AntianginalsAntiarrhythmicsHormone therapy
What is a consideration about anitconvulsants? Alter the hepatic metabolism of many drugs and induce cytochrome P450 enzyme activity
How long can Oral hypoglycemic medications last? may produce hypoglycemia for long as 50 hours after intake?
What do you do if the pt has an insulin pump? ask pt how controlled is diabetes; ask rate; time of surgery; time usually between each meal
What medications should be discontinued before surgery? NSAIDS, ADA, Coumadin, Plavix, Tricyclics/MAOI
How Long should NSAIDS be discontinued before surgery? 7 days
How long should ASA be discontinued before surgery 10-14 days
What are the considerations in discontinuing coumadin/plavix? It is up to the surgeon. PT/INR within 24 hours.
Tricyclics/MAOI if possible stop 2 weeks prior; or continue but no indirect acting sympathomimetics or demerol
What are excitatory responses seen with tricyclics or MAOIs interactions agitation , headache, hemodynamic instability, fever, rigidity, convulsions, and coma - Thought to be due to excessive central serotoninergic activity – meperidine blocks neuronal uptake of serotonin
What are depressive responses seen with tricyclics or MAOIs interactions respiratory depression, hypotension, and coma as result of MAOI inhibition of hepatic microsomal enzymes and meperidine accumulation
What do you avoid if the pt is on Steroids? Etomidate
What do you do if the pt is If on supplemental steroids for > 1 month give stress dose 100mg on induction, then 50 mg every 6 hours x , or 25mg on induction then total of 100mg over next 24 hours
What is a common adverse effect of Alzheimer’s therapy prolongs suxx
What is a common adverse effect of Lithium? potentiates NMB; check sodium level
What is a common adverse effect of Clonidine? decreases anesthetic requirements
What is a common adverse effect of Aminoglycosides? potentiates NMB
What is a common adverse effect of HIV meds (protease inhibitors end with “vir” potentiate versed
What % of the population uses herbal medications? 80%
What are the most commonly used herbal medications? echinacea, gingko biloba, St. John’s wort, garlic, and ginseng
How long before surgery should herbal medications be discontinued? 2 weeks
What are the uses for Echinacea (echinacea purpura) Prophylaxis and tx of viral, bacterial infections particularly URI
What are the issues with Echinacea (echinacea purpura)? HepatotoxicityPotentiates anabolic steroids, amiodarone, ketoconazole, methotrexateMay decrease effectiveness of corticosteroids, cyclosporineIncreased toxicity of drugs dependent on hepatic metabolism (phenytoin, phenobarbital, rifampin)
What are the uses for Ephedra (Ma Huang)? stimulatory effects (alpha and beta agonist); antitussive
What are the issues with Ephedra (Ma Huang)? Banned by government d/t increased risk of heart attack, stroke, deathLife threatening interaction with MAO inhibitorsIntraop hypotension better treated with phenylephrine than ephedrine
What are the common uses for Garlic (Allium sativum) Lipid lowering, vasodilatory, antihypertensive, antiplatelet, antioxidant, antithrombotic/fibrinolytic qualities
What are the issues with Garlic (Allium sativum)? Inhibition of platelet aggregationIncreased fibrinolyismay increase risk of bleeding
What are the uses for Ginkgo (Gingko biloba)? circulatory stimulant, antioxidant, anti-inflammatory effects; used to treat claudication, tinnitis, vertigo, memory loss, dementia, sexual dysfunction
What are the issues with Ginkgo (Gingko biloba) Inhibition of platelet activating factor may increase risk of bleedingMay decrease effectiveness of anticonvulsants
What are the uses for Ginseng (Panax ginseng)? enhances energy level, anitoxidant, aphrodisiac; lowers blood glucose
What are the issues with Ginseng (Panax ginseng)? Ginseng abuse syndrome: sleepiness, hypertonia, edema; also tachycardia, hypertension with other stimulantsIntraop hypotensionHypoglycemia in diabeticsInhibition of platelet aggregationMay interfere with effect of warfarin
What are the uses for Kava-kava (Piper methysticum)? sedation, anxiolysis; treatment for gonorrhea, skin diseases
What are the issues with Kava-kava (Piper methysticum)? May inhibit norepinephrinePotentiates sedating effects of barbiturates, benzos, alcohol
What are the uses for Saw Palmetto (Serenoa repens)? treatment for BPH
What are issues with Saw Palmetto (Serenoa repens)? Inhibition of 5-α reductaseInhibition of cyclooxygenasemay increase risk of bleeding
What are the uses for st John’s wort (Hypericum perforatum)? depression, anxiety, sleep disorders
What are the issues associated with st John’s wort (Hypericum perforatum) Inhibition of neurotransmitter reuptake may prolong anesthetic effectsInteraction with MAOI’s, SSRI’s
What are the uses for Valerian (Valeriana officinalis)? sedation, anxiety
What are the issues with Valerian (Valeriana officinalis)? May increase sedative effects of anesthetics and prolong anesthesiaAcute withdrawalMay increase anesthetic requirements if long term use
What are the uses for Vitamin E? slows aging process, prevention of stroke and pulmonary emboli, prevention of atherosclerosis, promotion of wound healing
What are the issues with Vitamin E? May increase bleeding
What are some questions you will ask during your neurological assessment? have you ever had a stroke? Do you still have problems or deficits related to your stroke? Weakness, seizures,nerve injuries, mental disorders, Headaches.
what is Porphyria? Autosomally inherited lack of functional enzymes active in the synthesis of hemoglobinAvoid barbiturates, diazepam, phenytoin, ergotamine prep, sulfanomides***Adm glucose suppresses ALA synthetase activity and prevents and ablates acute attacks
What is Myasthenia Gravis Destruction or inactivation of postsynaptic acetylcholine receptors leading to reduce number of NMJ sitesUnpredictable reaction to NMBResistant to succ, but lead to phase IISensitive to nondepolarizersGood response to anticholinesterases
What are come cardiovascular questions you would ask the pt.? Do you have high blood pressure, heart disease, or chest pain, rheumatic heart disease, arrhythmias, AICD/Pacer, heart attack or heart failure, circulation issues, CAN YOU CLIMB STAIRS, HOW MANY PILLOWS DO YOU USE?
What is the Stress response of surgery? Blood is diverted from areas of body to head & heart, BP & HR increase – CV system has to be in optimal health
how long is the Perioperative infarction rate is higher after an MI? first 6 months after a previous MI
How long should the pt wait for sx after an MI Due to changes in tx of MI – thrombolytics, PTCASix weeks will allow myocardium to heal - reduces risk of arrhythmias and rupture of ventricular aneurysms.
What are Conditions that could/should be corrected/stable before surgery – (ideally)? Recent MI/severe ICDSevere CHF (rales, an S3 gallop, or JVD)Severe anginaCerebrovascular diseaseHeart rhythm other than sinusChronic renal insufficiencySerum creatinine > 2.0 mg/dL
What do you do if your pt has a pacer or AICD? Demand pacemakers can sense electrocautery therefore will inhibit pacemaker firingConvert to fixed rate or default programMagnet or programming device,contact EPSGrounding pads should be as far from the generator and leads as possible; should use
What about Drug eluting stents (DES) vs bare metal stents? Elective surgery should be delayed if less than 6 months since placement of DESIf emergent, ASA and Plavix should be continued if possible
What pulmonary type questions should you ask on assessment? Do you have a cold,URI, history of asthma, bronchitis, or emphysema, use respiratory inhalers,snore at night? Have you been told you have sleep apnea? Do you use a CPAP ,Have you ever had pneumonia or tuberculosis or been on a vent for resp failure?
What are issues with Obstructive Sleep Apnea OSA pt have 7 x increase in mortalityReview sleep study/Respiratory Distress Index (RDI)RDI > 10 monitored bed overnight vs ICU
What about anesthesia with OSA? Anesthetic agents worsen OSA by decreasing pharyngeal tone and attenuating normal responses to hypoxia and obstructionSupine position worsens OSA, Difficult airway precautionsRegional or local anesthesia when appropriateCPAP in PACU available
What are anesthetic considerations with smoking? Airway ishyperactive,Excessive coughing & bucking, Bronchospasm and rapid desaturation
What about smoking cessation Cessation 24hrs prior to sx? reduces carboxyhgb and may improve oxygenation
Smoking cessation 24hrs to 6 weeks causes? 24hrs – 6 weeks increases incidence of morbidity
Smoking cessation > 6 weeks...? returns oxygenation and mucociliary clearance but not to normal.
What are some postop considerations for smokers? atelectasis, pleural effusions, and pneumoniaPost thoracic/abdominal casesNeed 8 week cessation before drastic reduction of post-op complications
What are some GI questions you should ask on assessment? stomach ulcers or gastritis, hiatal hernia, heartburn or reflux , take any medications or induce vomiting for weight control,regularly use enemas?
what are some issues with Ulcerative colitis, Crohn’s Disease Associated with electrolyte imbalancesDehydrated, malabsorption & malnourishedIf active, could have GI bleeding, GI obstruction, perforation of colon, toxic megacolon
What are problems with Anorexia / Bulemia Malnourished, dehydration, electrolyte imbalances
What are some endocrine questions you should ask on assessment? diabetes or hypoglycemia, insulin or medications to control your blood glucose level, glucose levels well controlled,thyroid problems, goiter, steroids within the past year? how long?
What are some hepatic questions you should ask? ever had liver problems, Does your face flush or get red every now and then, even when you’re not exercising, Do you sweat more than others?
what are intraop considerations with Hyperthyroidism – Thyroid Storm TachycardiaHyperthermiaLabile blood pressure –could be dehydrated and vasodilate during induction
How do you treat issues with hyperthyroidism-thyroid storm Hydration and coolingBeta blockerCorrection of precipitating causeAvoid anticholinergics Avoid ketamine, pancuronium, indirect-acting adrenergic agonist and other drugs that stimulate the SNSIncrease requirements of sedatives
What is often a big allergy issue with Diabetics? DMs who use NPH or protamine zinc insulin are at greater risk of allergic reaction to protamine sulfate
How much will Each cc of D50 raise the blood sugar? will rise BS of a 70kg person 2mg/dl approx.
If the pt is a fragil diabetic, what should you do intraop? Start IV D5W at 1cc/kg/hr mix 50u Reg Insulin in a 250ccNS = 1unit/5cc; start at 5cc/hrAt one hour: check BS then divide by 150 to set insulin drip rate If BS = 300; divide by 150 = 2; therefore insulin drip rate is 2u/hr or 10cc/hr
What is the target blood glucose Target BS = 120-180
What are teh electrolyte considerations with dabetics on insulin infusion? Watch K+, as insulin shifts potassium into the cellAvoid LR, lactate converts to glucose; will see increase glucose levels 24-48hrs. after surgeryNeed at least two functioning IV access
What is Cushing’s? glucocorticoid excess – either from endogenous oversecretion or chronic treatment of glucocorticoids (steroids)Truncal obesity, thin ski, easy bruising
What is Addison’s Disease? Adrenalcortical insufficiency or withdrawal of steroids or suppression of synthesis Hyperaldosteronism – excess of mineralocorticoid hormonesSometimes seen in excess of glucocorticoids
What are some intraop considerations of adrenal diseases? Cause fluid and electrolyte disturbancesFluid retention and hypertensionBlood sugar elevationContinue glucocorticoid or mineralocorticoid replacement therapy
What are problems with liver dysfunction? Coagulation dysfunctionDecrease albuminCardiomyopathyEncephalopathyVariciesDecrease glucose, sodium, potassiumRenal dysfunction
What is a BIG issue with glucose and alcoholics? Giving glucose to a malnourished alcoholic without thiamine will cause irreversible brain damage
is there a signifcant correlation between portal hypertension and mortality? Studies of portal hypertension have shown that mortality can be 50% when preop serum albumin = <3g/dL, serum bilirubin >3mg/dL, and ascites and encephalopathy are present
What do you use extreme caution with on pts with liver dysfunction? Careful with sedatives, narcotics, and drugs metabolized by liverregional vs GA; utilization of blood products intraop – FFP Avoid use of meds than may affect platelet functionASA / NSAIDs
What type of induction should you use on pts with acites? RSI
What is Pheochromocytoma? catecholamine secreting tumor of chromaffin tissueUsually benign and localized in adrenal gland; 20 – 30% are malignant and are extra-adrenal
What are teh cardinal signs of Pheochromocytoma? Paroxysmal headacheHTN – orthostatic hypotensionSweatingPalpitations/tachycardia
What are some anesthetic considerations of Pheochromocytoma? Adequate adrenergic blockade; then betaMonitor volume status; cvp or swan; usually dehydrated Avoid drugs that stimulate SNS, inhibit PNS (pancuronium), or release antihistamine
What is carcinoid syndrome? Tumors - 75% of the time originate in the GI tract – secrete serotonin (5-HT, 5-hydoxytryptamine) , histamine release, elevation of plasma kinins7% of the pt with carcinoid tumors have carcinoid syndrome
How do you treat problems assoc with carinoid syndrome intraop? somatostatin analog :H2 blockers – combination tx H1/H2 (not H1 alone)SteroidsAlpha adrenergic blockersBeta adrenergic blockerVasopressin – for severe hypotension not responsive to somatostatin(will increase pulmonary vascular resistance)
What are some hematological questions you should ask in your interview? your bruise easily, Do you take blood thinners, problems with blood clots, anemia or low blood count, Transfusion history, blood disorders, immunodeficiency virus ?
What types of renal questions should you ask? problems with your kidneys, renal failure, dialysis, problems urinating, if on dialysis where are their shunts?
what are induction considerations for pts post dialysis? Usually dehydrated after dialysis – watch with induction!Prone to CHF, increase K+ levels, platelet dysfx, low HCT
What is Uremia? the end result of renal tubular failure
for pts with nephrotic syndrome and diminished tubular function what do you do? Intense preoperative, intraoperative, and postoperative fluid management
What are the reproducitve questions you should ask in your assessment? When was your last menstrual period? Do you have problems with heavy bleeding Do you take oral contraceptives?Is there any chance that you might be pregnant? Have you ever had PIH? Do you have an STD?
If the women is of child bearing age what should you ALWAYS do? Always check for pregnancy with women/girls of child bearing age
Is there an optimal wating period for sx after pregnancy? All elective surgeries should be held until after delivery; 6 weeks later Cannot be avoided, regional when possible and/or after first trimester
What is linked to congenital anomaliesCleft palate? BZD
women who smoke and take birth control pills are at a greater risk for what? Blood clots
What are some pertinent Musculoskeletal questions you should ask? recent weight loss or weight gain, osteoporosis or arthritis?
What are anesthetics problems associated with Muscular Dystrophy unexpected effects to anesthetic drugs on myocardial function and skeletal muscleCardiac arrest & MHSux avoided – hyperkalemia, rhabdomyolysis, cardiac arrestIncreased risk of aspiration – degeneration of gastrointestinal smooth muscle
What are some anesthetic considerations of Osteoporosis? Limited range of motionIncreased risk of fracture during positioning or movement to and from operating room table
What should be included in your physical exam? Weight / HeightVital SignsPhysical assessmentHEENT AirwayHeartLungsNeurologic ExaminationMusculoskeletal
What should you consider with your airway assessment? Teeth, size of tongueDegree of mouth opening, ROM of neck, Mallampati, size of head and neck,Tracheal Deviation,deviated septum
What problems with a large tongue and disease associated with it? Associated with acromegaly, cretinism, mongolismHard to perform laryngoscopy, or mask ventilate
How do you measure Thyromental Distance The distance, with the neck fully extended, between the thyroid notch and the lower Mandibular border
What are the problems with Rheumatoid arthritis/Ankylosing spondylitis? Restricts ROM of neckRestricts vocal cord movement Tracheal stenosisHistory of difficult intubation
Points on your neuro assessment Assess neurological dysfunctionParalysis or paresthesia,PERRLA, Alertness,Lethargic – avoid drugs that might worsen, Confusion / forgetful
Points on your CV assessment Listen to heart soundsS3 – left ventricular failureJugular Vein DistentionCarotid BruitsPeripheral EdemaExercise tolerance
Points on your respiratory assessment Listen to lung soundsSOB at restUse of accessory musclesProductive coughURIBody HabitusBarrel chest – late manifestation of obstructive lung diseaseObesity – postoperative pulmonary complications
Points on your GI/HEPATIC/RENAL/SKINassessment Assess abdominal girth/ascitesJaundiceBruisingTatoosDiscoloration of skin – esp lower extremities
Points on your MUSCULOSKELETAL assessment ROM limitations
Problems associated with rheumatoid Arthritis Affects joints of larynx – limits vc movement and high incidence of erythema and edema associated with intubationAffects temporomandibular joint
What is the BEST way to screen for disease? a good H&P
why order CBC/Platelet function? If expected to have large blood lossHx of renal disease, anemia, GI bleed, malignancies, bruising
Why order a Chemistry study? Diuretic useRenal diseaseLFT’s for hepatic diseaseDiabetic
Why Order Coags? liver disease, blood thinners, malignancies
Why Order an EKG? Goal is to establish baseline, pick up arrhythmias, blocks, ST changes, MI old or new; working pacemaker
What percent of M.I. are silent? 30% with highest incidence in pts with diabetes and HTN
Who gets an EKG? Protocol of groupMen >45years, female >55yearsHx of CAD, MI, pulm disease, smoker, DMIf big caseIntrathoracic, major abdominal, big vascular case, lot of fluid shifting
What will a CXR show? Detects tracheal stenosis, mediastinal or lung masses, edema, atelectasis, cardiomegly, severe disease, ie hyperinflation
Who gets a CXR? >60 or > 50 yrs if smokerHx of pulm disease, malignancy, radiation therapy
What does a PFT show? Purpose is to determine degree of pulmonary disease; determine response to bronchodilators & help plan lung resectionTo decide whether the removal of lung tissue can be tolerated without compromising pulmonary function
What is the Simplest & most informative PFT? : FEV1 & VCFlow volume loops
What PFT results show increased perioperative risks? FEV1 < 2L; FEV1:FVC < 15cc/kg or max breathing capacity is <50% of predicted value
Who is a PS-1 Healthy patient
Who is a PS-2 Patient with mild systemic disease that results in no functional limitations
Who is a PS-3 Patient with severe systemic disease that results in functional limitations
Who is PS-4 Patient with severe systemic disease that is a constant threat to life
Who is PS-5 Moribund patient not expected to survive without operation
Who is PS-6 Declared brain-dead patient for organ harvest
Who is considered ASA "E" status Any patient for an emergency operation
What are the components of informed consent? Discuss anesthetic choices availableDiscuss risks, benefits, and alternatives of choicesDiscuss potential complications, pain management, and postop careAnswer all questions of all presentPatient, parent, or legal guardian to sign consent
What can delay or cancel a case? Active URINewly “discovered” MI within last 6 monthsNew unstable cardiac rhythmCoagulopathyHypoxiaAdministrative issuesJehovah’s Witness patientEthical procedure coverageAnesthesia provider coverage
What premeds can be used for sedation/anxiety? Versed 1-2.5 mg IVAtivan 0.5-2 mg IV/poValium 2-10 mg IV/poClonidine 0.1-0.3 mg po
What Antiemetics can be used as premeds? Ondansetron 4 mg IVDolasetron 12.5 mg IVDexamethasone 4 mg IV
What is an Anticholinergics that can be used as a premed? Glycopyrrolate 0.1-0.2 mg IV
What meds are used as Pulmonary aspiration prophylaxis Histamine (H2) antagonists < 1hour preop(Tagament, Zantac)Proton pump inhibitors(prilosec/protonix)dopamine receptor antagonist(reglan)Nonparticulate antacids(bicitra)Nonparticulate antacids
Created by: shamus22