1
Q
goals
A
- ensure pt can tolerate anesthetic
- mitigate risk of complications
- reduce pt anxiety/educate pt
2
Q
chart review
A
age
gender
surgical dx
previous hospitalizations
3
Q
past medical history
A
co-existing diseases
4
Q
meds/allergies
A
current meds
vitamins
herbal supplements
allergies
5
Q
past surgical/anesthetic Hx
A
review past anesthetic records
- difficult IV
- difficult airway
- intraoperative hemodynamic instability
- respiratory issues
- PONV
6
Q
Patient interview
A
- systematically question pt about each organ system
- use clinical judgement to det necessary depth of questions related to each organ system
- talk to pt at their education level
- engage at eye level
7
Q
neurologic system
A
- current mental status
- seizures
- cardiovascular accident (CVA)
- stroke
- transient ischemic attack (TIA)
8
Q
cardiac system
A
heart or vascular issues?
- stiff vessels: hypertension
- vessel blockage: CAD
- structural changes: septal defect
- electrical conduction: abnormal
9
Q
coronary artery disease (CAD)
A
plaques build up in coronary arteries
resistance to flow
10
Q
CAD evaluation
A
- any recent episodes of chest pain?
- do you have chest pain while performing activities?
- MET assessment
11
Q
Metabolic Equivalents of Physical Activities
A
> = 4 METs is high risk for cardiovascular event during surgery
12
Q
MET 1
A
eating
working at computer
dressing
13
Q
MET 4
A
raking leaves
gardening
14
Q
MET 5
A
Climbing 1 flight of stairs
dancing
bicycling
15
Q
Revised cardiac risk index
(RCRI)
A
used to estimate pt level of risk for cardiac complications
16
Q
RCRI factors
A
- High-risk surgery
- Ischemic heart disease
- H/O congestive heart failure
- H/O cerebrovascular disease
- diabete mellitus
- creatine >2.0mg/dL
17
Q
High risk surgery
A
intraperitoneal
intrathoracic
supra-inguinal vascular
18
Q
Hypertension evaluation
A
have you been diagnosed w/high blood pressure?
are you on blood pressure meds?
47% of americans
19
Q
normal BP
A
<120/80 mmHg
20
Q
elevated BP
A
120/80 - 129/80 mmHg
21
Q
high BP stage 1
A
130/80 - 139/90 mmHg
22
Q
high BP stage 2
A
> 140/90 mmHg
23
Q
hypertensive crisis
A
> 180/120 mmHg
24
Q
congestive heart failure
A
less than optimal ejection of blood from heart
= less blood to oxygenate tissues
25
CHF evaluation
shortness of breath w/activity?
more fatigued/weaker than normal?
swelling in legs?
persistent cough w/pink phlegm?
weight gain?
26
Valvular disease evaluation
diagnosed w/heart valve problem?
ascultate heart for murmurs
27
common valvular disorders
stenosis
regurgitation
28
stenosis
valve area narrowing restriction to flow
29
regurgitation
valve area does not close properly so blood flows back through valve
30
Atrial Septal Defect /
Ventricular Septal Defect
septum has not formed properly and has a hole
causes pressure changes
impacts blood flow direction in heart
31
Conduction System abnormalities
specialized cardiac cells allow electrical conduction
change conduction = change how heart pumps
32
HR 60-100
normal
33
HR < 60
bradycardia
34
HR > 60
tachycardia
35
bradycardia/tachycardia
may not supply heart w/enough O2
leads to ischemia
36
respiratory system common diseases
obstructive lung disease
restrictive lung disease
cigarette smoking/cessation
obstructive sleep apnea
37
Risk of postoperative pulmonary complications in pts w/respiratory diseases
risk is 1-23% after major surgery
PPC includes:
respiratory infection, resp failure, pleural effusion, atelectasis, pneymothorax, bronchospasm, apsiration pneymonitis
38
obstructive lung disease
asthma
COPD
* cant exhale as much as normal lung
39
dyspnea grade 0
no dyspnea while walking at normal pace
40
dyspnea grade I
short of breath when hurrying up hill
mild
41
dyspnea grade II
slower than contemporaries
moderate
42
dyspnea grade III
stops for breath after 100 yds
severe
43
dyspnea grade IV
dyspnea at rest
very severe
44
Cigarette smoking evaluation
always ask:
last cigarette?
how many years?
how many packs per day?id
45
ideal smoking cessation prior to surgery
6-8 weeks
less than 3-4 weeks doesn't increase or decrease risk
46
ideal timeline to mx smoking cessation post surgery
4 weeks
reduces wound healing complications by 50%
47
obstructive sleep apnea (OSA)
short periods of apnea caused by blockage of air movement in upper airway
2-25% of population
48
Apnea Hypopnea Index
the combined average number of apneas and hypopneas that occur per hour of sleep
level of severity of OSA
49
AHI scoring system
Snoring
Tired
Observed apnea
Pressure (BP high)
BMI > 35
Neck > 16
Gender
50
mild OSA
5-14 AHI
51
moderate OSA
15-29 AHI
52
severe OSA
30+ AHI
53
pulmonary hypotension values
mean pulmonary artery pressure >25mmHg
systolic pulmonary artery pressure >50mmHg
54
pulmonary HTN
increased risk for
- heart failure
- hemodynamic instability
- respiratory failure
- prolonged intubation
55
Endocrine System
- diabetes
- hyperthyroidism: Graves
- hypothyroidism: Hashimotos
- obesity
56
diabetes mellitues
fasting plasma glucose > 126mg/dL
or
HgA1c >= 6.5%
goal: preop sugar < 180 mg/dL
57
insulin guidelines
facility dependent
decrease long acting day prior
no insulin day of
58
obsesity
increases risk of coexisting disease
dosing meds can be challenging
difficult mechanical ventillation
incr risk of postoperative hypoxia
59
ideal body weight male
50+2.3(height-60inches)
60
ideal body weight female
45.5-2.3(height-60inches)
61
BMI
body mass index (kg/m2)
weight / (height*height)
62
obese BMI
30+
63
overweight BMI
25+
64
Gastrointestinal evaluation
GERD
IBD
- Cronhns
- ulcerative colitis
bowel obstructions
peptic ulcers
65
Musculoskeletal
myopathies
- MH
- rhadbomyolosis
myasthenia gravis
hemiplegia (no succ)
66
Oncology
cancer treatment?
avoid dexamethasone?
67
Hepatic
liver failure
- changes drug metabolism
- risk for esophageal varices
68
Kidney disease
end-stage renal disease
- renal excretion of meds is slowed
69
Common allergies
antibiotics
- penicillin
- cephalosporin
foods
-seafood
- bananas/kiwi
- egg (propofol)
latex
- spina bifida/myelemeningocele
aspirin/NSAIDS
70
Social history
alcohol use
smoking
drugs
71
Family history of anesthesia
malignant hyperthermia
psuedocholinesterase deficiency
72
malignant hyperthermia
ryanodine receptor mutation
- increases metabolic output
life threatening response to volatile anesthetics
73
psuedocholinesterase deficiency
prolonged response to drugs metabolized by pseudocholinesterase
succinycholine
mivacurium
74
ASA 1
normal pt
75
ASA2
pt w/mild systemic disease
76
ASA 3
pt w/severe systemic disease
77
ASA 4
pt w/severe systemic disease that is a constant threat to their life
78
ASA 5
moribund pt who is not expected to survive w/o surgery
79
ASA 6
brain dead pt for organ donation
80
ASA E modifier
ie. ASA3E
pt when an emergency procedure is required
81
Vitamin K antagonists
Warfarin
stop 5 days prior
briding therapy of LMW heparin for mod/high risk VTE
82
Direct Oral anticoagulatnts
low bleeding risk - 24 hrs
mod bleeding risk - 48 hrs
high bleeding risk - 72 hrsh
83
home medications
continue most regularly schedule meds through the morning of surgery
84
home meds you might need to change prior to surgery
anticoagulants
oral hypoglycemics
monoamine oxidase inhibitors
ACE inhibitors
non-prescription meds
85
physical exam overview
airway assessment
lung auscultation
cardiac auscultation
additional considerations
86
difficult mask ventilation
Obese
Bearded
Elderly
Snorers/OSA
Edentulous
Hx of neck radiation
large neck curcumference
male
mallampati III/IV
airway mass/tumor
87
airway assessment options
mouth opening/jaw protraction
loose/problematic dentition
neck range of motion
neck anatomy
mallampati
88
mallampati class 1
soft palate
fauces
uvula
pillars
89
class 2
soft pallate
fauces
uvula
90
class 3
soft palate uvula
91
class 4
hard palate only
92
thyromental distance
pt fully extends neck
distance from chin to thyroid notch
3 finger breadth
(6.5cm)
* potential space into which tongue will be displaced during DL
93
mouth opening
<3finger width opening (3cm)
94
mandibular protrusion Class A
lower incisor protruded anterior to upper incisors
95
mandibular protrustion class B
lower incisor protruded edge to edge w/ upper incisors
96
mandibular protrusion class C
lower incisor cant be protrude edge to edge
* predictaive of difficult intubation
97
Conditions associated w/difficult airway
pierre robin
mucopolysaccharidoses
treacher collins
trisomy 21
beckwith-weidemann
aperts
goldenhar
klippel-feil
98
respiratory exam
auscultation of lung
work of breathing
body habitus
99
physical exam
check for:
infection
scars
musculoskeletal deformity`
100
ECG
5 lead std
asymptomatic pt-low risk will not get pre-op ECG
pts w/known CAD , arrythmia reasonable to get ECG
101
Cardiac cath
procedure used to diagnose and treat certain cardiovascular conditions
long thin tube inserted into artery or vein in groin, neck, or amr and threaded through blood vessels to heart
102
pulmonary function test
spirometry
- Forced vital capacity (80-120%)
- force expiratory vol (80-120%)
plethysmography
- ful lung function tests
- FRC (75-120%)
- RV (75-120%)
- lung CO2 diffusion capacity (60-120%
103
renal kidney function
cr clearance
- wast from catabolism of muscle
normal male: 0.74-1.3
normal female: 0.6 - 1.1
104
renal - BUN
6-24 mg/dL
105
radiology tests
Chest Xray
MRI
CT
Carotid ultrasound
106
BMP (Chem 7)
Na+
Cl-
BUN
K
CO2
Cr
Glu
107
CBC
WBC
Hgb
Hct
PLT
108
Coagulation studies
PTT
PT
INR
109
informed consent
competence - ability to understand, retain, and use info
unmedicated
reasonable person std
110
Na+
135-145 mEq/L
111
K+
3.5-5 mmol/L
112
Cl-
96-106 mEq/L
113
CO2
23-29 mEq/L
114
BUN
7-20 mg/dL
115
Cr
male: 0.74-1.3 mg/dL
female: 0.6-1.1 mg/dL
116
Glu
60-100 mg/dL
preDM: 100-126 mg/dL
117
Hgb
male: 13-16 g/dL
female: 11.5-15 g/dL
118
Hct
male: 45%
female: 39%
119
WBC
4.5-11 x109/L
120
Plt
150000-450000/microL
121
PT
11-13.5sec
122
PTT
25-35 sec
123
INR
0.8 - 1.1
Sp: Intro to Anes
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