preoperative assessment
- complete medical history
- previous anesthetics, operations (and complications), obstetric history and pain history - physical exam
- indicated lab studies or tests
- medical consultations as indicated
Ask patients about the three G’s
- Garlic
- Gingkoo
- Genseng- hypoglycemia, inhibition of platelets aggre
Fasting guidelines
- Clear liquids=2 hours (water, black coffee, pulp free juice, carbonated beverage),
- Break Milk = four hours, infant formula=6 hours
For general physical shape ask…
- can you go up a flight of stairs without any difficulty?
Airway evaluation
- Mallampati classification
- mentohyoid distance (4-6 normal)
- Mouth opening
- Nares
- Dentition
- Airway structions (tonsils, uvula, palates
- Obesity
Asa Classification
-Class I
normal healthy patient
ASA II
a patient with mild systemic disease (no functional limitations)
- smoking
- hypertension
- uncomplicated diabetes
- treated hypothyroidism
- stable asthma
- allergic rhinitis on medcation
- GERD
- Colitis
ASA III
a patient with severe systemic disease
-morbid obesity
-Coronary artery disease (including stent)
-
ASA 4
A patient with severe systemic disease that is a constant threat to life
ASA 5
a moribund patient that is not expected to survive without the operation
If they smoke, and everything else is healthy, what ASA class?
II
ASA class 6
a brain dead patient, organ donor
If the patient has asthma, can we sedate?
Yes, but have them take 2 puffs 15-20 minutes before the procedure. Probably best if they haven’t had a recent attack (within a month or so)
Patient on antidepressants…
rarely sedate
-“you can’t sedate crazy”
Benzodiazepines effect
- Decreased Anxiety
- Sedation
- Anterograde amnesia??
- Muscle relaxation
- Decreased seizure threshold
- Do not cause fatal intoxication in and of themselves
- May produce coma at high doses
- Do not producesurgical anesthesia
- Awareness persists (eyes open)
- Insufficient relaxation
Examples of Benzodiazepines we will use
- Midazolam
- Lorazepam
- Diazepam
- Triazolam
administration of Flumazenil
• 0.2 mg administered over 10-15 seconds; onset 1-2 minutes
-it also reverses Z-drugs
Z-Drugs,
GABA agonists • Zaleplon(Sonata)5and10mgcapsules • Zolpidem (Ambien) 5 and 10 mg tablets • Eszopiclone(Lunesta)1,2and3mgtablets • Zopiclone(Imovane)5and7.5mgtablets • Limiteddurationofaction • Lowriskresidualeffects • Littleeffectdaytimeperformance
First line of defense for a laryngospasm
Positive pressure
-Oxygen is really good for the vocal cords
next line of defense for a laryngospasm
100 mg Lidocaine given by IV
what is a warning sign from laryngospasm?
Stridor sign
-patient struggling to breath
If you have used both Versed and fentanyl and the patient is starting to have some respiratory depression, what should you give and why?
Narcan reverses narcotics (narcotics are more likely to cause respiratory depression),
-If you only used Versed and they are having some Resp Depression, the most important thing to do is give it TIME, other than that you can give flumazenil
if you suspect that a patient aspirated vomit or emesis, what needs to be done?
They MUST have a chest x-ray
If they are hypotensive, what drug should be considered?
ephedrine (about 10 mg, it will need to be diluted)
-and also increase the flow of the saline (you may actually do this first)
