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Barry preop eval
Basics preoperative evaulation
| Question | Answer |
|---|---|
| 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 fibrinolyismay 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 cyclooxygenasemay 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 |
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shamus22
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