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Preoperative Anesthesia Assessment

What are operative concerns with plavix? When does it need to be stopped? needs to stop TEN days of surgery; may need to cancel regional and do general anesthesia instead; do not do spinal if still on Plavix (epidural hematoma)
What chemotherapeutics can affect heart and lungs? Cytoxin and Adriamycin can affect the heart and lungs.
What are anesthesia concerns for a person with a hiatal hernia? • Hiatal hernia – stomach pushes through diaphragm, increases risk of aspiration (reflux), do not use LMA
What is malignant hyperthermia? What is another name for it? (malignant hyperpyrexia): dysfunction of calcium channels, outpouring of Calcium, tachycardia, muscle rigidity (dantrolene), increased temp 40*C, hypermetabolic state, increased Calcium levels
What is atypical plasma cholinesterase deficiency? Anesthetic concerns? plasma cholinesterase is an enzyme that breaks down acetylcholine; deficiency of this enzyme creates prolonged paralysis until the acetylcholine is broken down.
How should those with latex sensitivity be treated? plasma cholinesterase is an enzyme that breaks down acetylcholine; deficiency of this enzyme creates prolonged paralysis until the acetylcholine is broken down.
Who is at risk for latex allergy? spina bifida, urologic reconstructive surgery, health care workers, history of hand eczema, repeated exposure such as balloons or condoms, allergy to some tropical fruits
__ in __ deaths related to smoking in US; responsible for premature and preventable deaths, second hand smoke causes _____deaths per year r/t lung cancer. 1 in 5; 3000
Components of tobacco include _____and ______ and other substances added by tobacco industry nicotine; carbon monoxide
What is nicotine and what does it do to the CV system? • Nicotine is a toxic alkaloid that produces a ganglionic effect in CV system. This manifests itself by increased HR, increased BP, increased myocardial contractility, increased myocardial oxygen consumption, myocardial excitement, and increased PVR
• The effects of smoking are short-lived: preop smoking cessation for at least ______may improve pulmonary mechanics greatly ( incr. ciliary function, decr. Mucous, incr immune function, decr small airway obstruction) 8 weeks
second hand smoke in children causes: : respiratory tract infections, abnormal PFTs, reactive airway problems
periop complications in children exposed to second hand smoke include: laryngospasm, coughing on induction and emergence, post op desaturation.
Patients should stop smoking _____ postop 12 hours
T1/2 of nicotine is _____; CO ______ 40-60 min; 130-190 min
periop complications of alcohol users include: dysrhythmias, infection, ETOH withdrawl – 3-5x more in chronic excessive ETOH users
effects of alcohol use on anesthetic agents include: resistance or tolerance to CNS depressants (hypnotics, opioids, and inhaled anesthetic gases); MAC is increased
Why is there a greater portion of unbound Rx available in alcoholics with hepatic insufficiency? What is an Rx example of this? • If there is hepatic insufficiency, plasma enzyme activity may be reduced; there may be a greater portion of unbound drug available (decreased albumin & protein binding) eg. Thiopental
What are some S&S of (general) drug use? evidence of drug injections, pupil constriction, lymphadenopathy, malnutrition, poor dentition, nasal perforation, sniffs a lot, problems with nose
what S&S will you see with cannabis? tachycardia, labile BP, euphoria
what S&S will you see with cocaine and amphetamines? amphetamines (malnourished, poor dentition from bruxism – involuntary grinding and teeth clenching): both: (HTN, excitement, hallucinations)
what S&S will you see with Hallucinogens (LSD – lysergic acid diethamide-25; PCP, ketamine): dissociative reactions, hallucinations, split personality, paranoia
what are anesthetic considerations for chronic steroid use? Anesthetic considerations for chronic steroid use (6mo – 1yr): preop LFTs, stress dose of steroids may be needed (100 mg IV hydrocortisone) & post op taper may be needed. stress dose not given for steroid use >1 year.
What are the 4 G anticoagulants? When should they be stopped? garlic, gensing, gingko, ginger. Stop 7 days preop.
ginger anesthetic considerations? serum glucose alterations, CNS depressant
concerns with ephedra? increases HR and BP through direct/indirect sympathomimetic effects; may cause periop hemodynamic instability, MI, stroke, dysrhythmias, & MAOI fatal rxns (extra), *CNS stimulant
what does echinacea do? activation of cell-mediated immunity
What does kava kava do? when should it be stopped? sedation, anxiolysis (d/c 24 hrs preop)
concerns with St. Johns Wart? when should it be stopped? antidepressant, inhibition of neurotransmitter reuptake; induction of CYP enzymes which effects other drug levels; d/c 5 days before surgery.
how is obesity and morbid obesity defined? Defined as having body weight more than 20% in excess of ideal body weight Morbid obesity is 2x ideal body weight.
How do you calculate ideal body weight? Men: 105 lbs + 6 lbs for each inch > 5 ft -Women: 100 lbs + 5 lbs for each ince > 5 ft
How do you calculate BMI and what BMI values are considered overweight, obese, and morbidly obese? BMI = weight (kg) / height (m)^2 BMI 25-29.9 = overweight BMI 30-35 = obese BMI > 35 = morbidly obese
thyromental distance less than ______ is associated with difficult intubation. 7 cm (3 finger breaths)
sternomental distance less than _____ is suggestive of a difficult airway 13.5 cm
what does the interincisor distance measure? The degree of mouth opening, a function of temporomandibular joint
adult should be able to open mouth at least _________between upper and lower incisors 4 cm (2 average finger breadths)
what measurement is most predictive of difficult airway? sternomental distance
describe the sniff position? what is another name for it? Moderate flexion of the neck onto chest and full extension of atlantooccipital joint aligns oral, pharyngeal and laryngeal axis into the McGill, or sniff position. Do not fully extend neck.
What are some limitations to neck extension and what do these disorders do to the larynx? DM, Rheumatoid nodules in airway, cervical arthritis, small C1 gap – pushes larynx anteriorly
ASA 1? healthy, no medical problems
ASA II? mild systemic disease, smoker, or drinker; compliant DM
ASA III? severe systemic disease, but not incapacitating: noncompliant HTN or DM
ASA V? moribund, not expected to live 24 hrs post op
ASA VI? not leaving OR alive, eg. Organ donor
ASA E? E (added after class #): designates emergency surgery, eg. ASA IIE
What are some problems with ASA scoring? current system not explicit enough in its categorization to account for every patient and can result in patient misclassification; over classification is seen when surgical procedure is incorporated into assignment of physical status.
patients with musculoskeletal d/o taking steroids ______ are at risk for adrenal insufficiency. >2 weeks
what is Ankylosing Spondylitis inflammatory arthropathy that causes severely compromised upper airway management of cervical spine, usually in flexion.
What 2 meds are those with musculoskeletal d/o usually on that we need to be concerned about? NSAIDS (bleeding), corticosteroids (may need stress dose of steroids preop to avoid hemodynamic instability)
what will you see in RA patients with cricoarytenoid arthritis? restrictions in vocal cord movement and tracheal stenosis caused by cricoarytenoid arthritis; S&S include hoarseness, stridor, painful speech, dysphagia
What occurs in advanced stages of RA and ankylosing spondylitis? ay see restrictive lung disease, pleural and pericardial effusions, polychondritis, cardiac conduction abnormalities
what GCS score is considered comatose and requires mechanical ventilation? Score < 8 is considered comatose and requires mechanical ventilation support (<7 for Mechanical vent per ppt slides)
Why would be continue corticosteroids periop in those with CNS tumors? reduces CSF or cerebral edema as a result of capillary membrane stabilization
what would we monitor in those taking decadron or solumedrol? blood sugar
what are major cardiac risk factors? • Unstable coronary syndrome • Recent MI • Unstable/severe angina • CHF • High grade AV block (3rd degree) • Symptomatic ventricular arrhythmia • SVTs • Severe valvular disease (AS)
what are intermediate cardiac risk factors? • Mild angina • Prior MI • Compensated or prior CHF • Renal insufficiency
what are minor cardiac risk factors? • Advanced age • Abnormal EKG, or rhythm other than sinus • Low functional capacity (stair climbing) • History of stroke • Uncontrolled systemic HTN
what is orthostatic hypotension? drop in BP by 20%, syncope and dizziness
When would you delay surgery for someone with HTN? Delaying OR only for purpose of BP control may not reduce periop risk – only delay OR for HTN if target-organ damage occurs such as ischemic heart disease, heart failure, or renal failure
what is ischemic heart disease? Insufficient oxygen and nutrition supply (incr demand, decr blood supply)
what are S&S of ischemic heart disease? fatigue, angina, syncope, palpitations, dyspnea
what EKG changes could you see with unstable angina? transient ST and T wave changes without Q wave or enzyme elevation.
should you cancel surgery for stable or unstable angina? If so why and what would you do next? stable angina poses no greater risk of MI periop than in absence of anginal symptoms; Unstable angina has high risk of periop MI; cancel surgery until CV status has been evaluated.tests include CV cath and EST to determine extent of ischemic heart disease
Risk of MI during/after general anesthesia: Overall for general population:__ MI over 6 months ago: _ MI within 3-6 months: _ MI less than 3 months ago: _ Highest period is within ___ of MI If re-infarction occurs, the mortality rate is__ 0.1-0.7%; 6%; 15%; 30%; 30 days; 50%
What CV d/o has highest risk factor of M&M when undergoing non-cardiac surgery? left ventricular dysfunction; ischemic cardiomyopathy are at greatest risk for periop MI
In the presence of CHF, surgery should be postponed until optimal ventricular performance can be achieved; EF ____ by EHCO is associated with greater incidence of postop heart failure and death. <35%
in LV dysfunction, what does you look for to possibly cancel surgery? Look for relevant changes in clinical status: worsening dyspnea, dyspnea of unknown origin
what are S&S of LV dysfunction? Hx of CHF Pulmonary edema; rales, tachypnea Paroxysmal nocturnal dyspnea Resting tachycardia (sympathetic NS stim.) S3 heart sound, gallop Jugular vein distention Peripheral edema CXR showing pulmonary vascular redistribution
What are the most common stenosed or incompetent/regurg valves? aortic, mitral
what is the most common cause of valve disease? rheumatic fever
f. Severe _____ poses greatest risk for noncardiac surgery; has 14x periop sudden cardiac death aortic stenosis
S&S of dysrhythmias include: DOE, angina, syncope, dizziness, palpitations
what preop diagnostic tests are indicated for dysrhythmias? *EKG preop, CXR, preop labs including K+, Mg+, and Rx levels
______ have unifocal PVCs & low periop risk Benign ventricular arrhythmias
_______ is pt has known heart disease and is on anti-arrythmia Rx therapy; “organic heart disease Potentially malignant arrhythmias
_____ is pt has heart disease, hemodynamic compromise, and h/o sudden death in famility; high risk Malignant ventricular arrhythmias:
what are the best leads for monitoring periop ischemia and what portion of the heart does each lead show? f. Use leads II and V in anesthesia: II – posterior inferior wall; V – anterior wall; best leads for monitoring periop ischemia
Pacemakers can mask toxic effects of: antiarrhythmic Rx, electrolyte disorder, myocardial ischemia and irritability
Exercise stress test (EST): if indicated, (eg. Angina); _____is ominous sign and should get cardiac cath hypotension
what Rx can be given for pharmacologic stress test? adenosine, dipyramidole; dobutamine
what information should you obtain from cardiac cath? # vessel disease and percentage
what is significant stenosis of coronary arteries defined as? Significant stenosis defined as narrowing of coronary artery > 70% or L main artery by > 50%
3 findings that indicate poor ventricular function: 1. Cardiac index < 2.2 2. LVEDP of > 18 mmHg 3. EF < 40%
in those with COPD, when should surgery be postponed? surgery should be postponed in the presence of severe dyspnea, wheezing, pulmonary congestion, or hypercarbia (PCO2 > 50 mmHg)
what are some preop maneuvers to decrease risk fo M&M in those with pulmonary disease? • instructions in respiratory maneuvers • smoking cessation*** • antibiotic treatment • psychological preparations • bronchodilators
abnormally low PO2 values (<60 mmHg) with or without high PCO2 (CO2 retention) often reflects a state of ______ chronic bronchitis
what may you see in CXR of COPD and chronic bronchitis? with COPD you see emphysemic bullae and pulmonary hyperlucency (vascular deficiencies in lung periphery); chronic bronchitis is rarely recognized on CXR
what are PFTs used for in those with COPD confirming the severity of air flow obstruction, and its reversibility with bronchodilators; although not reliable
what is a more reliable predictor of periop morbidity in those with pulmonary disease? Pulse ox
what are postop maneuvers to decr M&M in pulmonary patients? • minimize postop opioids • maximize inspiratory maneuvers (IS, CPT) • early mobilization • heparin therapy (for THA or TKA)
Pertinent information for asthma should include: • frequency of attacks • severity • time interval since last attack • last hospitalization or ER visit • triggers • what works best with an acute episodic attack; MDI?
when should you cancel surgery in someone with asthma? • persistent cough, wheezing or tachypnea on day of surgery – best to reschedule and treat S
in those with asthma, EKG is indicated if ______ is suspected and implies long standing insufficient therapy right ventricular hypertrophy
when is CXR incidacted in asthma? if the patient is suspected of having an acute infiltrative process (PNA, pneumo)
what does spirometric evaluation tell you about asthma patients and at what level should you consider canceling surgery? peak expiratory flow rate; if < 50% of baseline, delay surgery
what are pharmacological considerations for asthmatics the day of surgery? • Should continue medications the day of surgery • Prophylactic B-adrenergic metered dose inhalers • Theophylline PO (therapeutic serum levels are 10-20 mcg/ml) • Stress dose of steroids • Anti-anxiety Rx (psychological triggers are common)
URI in children have 2-7x risk of respiratory adverse effects periop and postop of : bronchospasm, laryngospasm, hypoxemia, atelectasis, croup, stridor.
what are S&S of URI? • Sore throat, inflamed and reddened nasopharyngeal and oropharyngeal mucosa, sneezing, rhinorrhea, muco-purulent nasal secretions, fever, watery eyes, tender eardrums, non-productive cough, WBC > 12,000
what diagnostic tests are done for those with URI? 1. Complete WBC with differential 2. Nasal and throat cultures 3. CXR not indicated if breath sounds are clear; only do CXR if lower respiratory infection is suspected 4. PFTs and ABGs offer little benefit
what hepatotoxic agents are avoided for d/c before surgery? halothane, Tylenol, NSAIDS, ASA, methyldopa, isoniazid, rifampin
what would you see in early stages of hepatobiliary disease? • May be asymptomatic or display symptoms such as malaise, weight loss, abdominal pain, mildly jaundiced, mildly elevated bilirubin levels
what would you see in late stages of hepatobiliary disease? esophageal varices, elevated PT/PTT (coagulopathies), generalized tumors, increased deep tendon reflexes, ascites, spider nevi, hepatosplenomegaly, hepatorenal failure, hepatic encephalopathy
o Preop coagulopathies are corrected with:. phytonadione (Aquamephyton), FFP, cryoprecipitate
• ______are common measures of hepatocellular enzymes that are also distributed throughout cells of the heart, lungs, kidney, skeletal muscles, so increases in their serum concentration is not always indicative of hepatobiliary disease AST, SGOT, ALT, SGPT
• In biliary obstruction or irritation, ______enzymes may be released from cells of the bile ducts. alkaline phosphatase (AP)
• Increases in AP serum concentrations of these enzymes may facilitate the differentiation of hepatic dysfunction caused by ______vs. that caused by _____ parenchymal disease ; cholestasis
• Cholestatic liver disease can be confirmed by high serum levels of ______ conjugated (direct) bilirubin
what is the most reliable determination of liver dysfunction and why? Serum PT is most reliable determination of liver dysfunction; reflects the ability of the damaged liver to synthesize clotting factors
what is not apparent for several days after acute hepatocellular insult and why? • Hypoalbuminemia is not apparent for several days after acute hepatocellular insult (has longer T1/2 than PT)
Evidence of RI may not be apparent until at least ___of nephrons are not functional. 70%
true measurement of GFR is: creatinine clearance or 24 hr urine
how is creatinine clearance calculated? Creatinine clearance: GFR (ml/min) = UV / P U – urinary concentration of creatinine (mg/dl) V – volume of urine (ml/min) P – plasma concentration of creatinine (mg/dl)
what GFR values indicate mild renal dysfunction and renal failure? GFR of 50-80 = mild renal dysfunction GFR < 10 = renal failure
For individuals 60-70 years old, there is a ___ decline in nephron mass; GFR declines __ per year from 30 to 80 years of age. 30%, 1%
what does the preop assessment of a pt in chronic renal failure focus on? • *focus on fluid overload and e-lyte imbalance (incr weight gain, JVD, peripheral and periorbital edema, bibasilar rales); • Preop labs: K+ within 6-8 hrs of surgery
what are causes of chronic anemia in chronic renal failure patients and what is a typical hgb level? Hgb levels of 5-8 mg/dl are not unusual for patients with chronic renal failure; causes of chronic anemia may be due to a decrease in renal erythropoietin production and enhanced fragility of the RBCs in the presence of urea (uremia)
what should you consider a blood transfusion preop? if extreme fatigue/pallor, persistent tachycardia, limited exercise tolerance
why do coagulopathies occur in patients with chronic renal failure? decr platelet adhesiveness secondary to chronic state of metabolic academia (HD may be used)
what should you generally look for in patients with endocrine disorders? Look for end organ effects; M&M rates are 5-10x greater in DM patient with renal and autonomic NS involvement
Type 1 DM: most prone to : episodes of hypoglycemia, ketoacidosis, and severe end organ insufficiency (microvascular changes, diabetic retinopathy, cataract formation), and somatic and autonomic insufficiency (orthostatic hypotension, bradycardia, gastroparesis) and nephropathy
Death in DM is usually d/t : complications of atherosclerosis (MI, stroke)
what consult is usually placed for all DM patients and why? • Cardiology consult (every diabetic has cardiac involvement so much treat them as if they are a cardiac patient even though asymptomatic); EST and EKG obtained
Increased T3 and T4 levels are seen in conditions such as ... Graves disease, toxic goiter, thyroid carcinoma, and pituitary tumors that oversecrete TSH
what Rx would you avoid in someone with hyperthyroidism? anticholinergics (cause tachycardia)
what are primary and secondary reasons for hypothyroidism? what 2 diseases does hypothyroidism include? Includes chronic thyroiditis and Hashimoto’s disease (autoimmune) - tissues are exposed to decr amounts of T3 and T4 . This may be due to destruction of or hypofunction of thyroid gland (primary); or may be due to decreased TSH production (secondary).
what are S&S of hyperaldosteronism? HTN with hypokalemia (<3), sodium and water retention, metabolic alkalosis
what are some indications for a CXR? o Previous abnormal CXR o History of malignancy o History of pulmonary infection o History of +PPD or TB o History of CHF o History of prematurity o OSA o Symptomatic or debilitating asthma
ASA IV severe systemic disease that is a constant threat to their life
Created by: rwilson