What are the minimum pre-operative assessment requirements outlined by The Joint Commission (TJC) and The American Society of Anesthesiologists (ASA)?
- Past Medical History
- Physical Status
- Airway Evaluation
- Medication Reconciliation
- Diagnostics
These requirements ensure a thorough pre-op evaluation tailored to individual patients.
What are the goals of the pre-operative evaluation?
- Optimize patient care, satisfaction, comfort & convenience
- Minimize perioperative morbidity and mortality
- Evaluate overall health status
- Optimize preexisting conditions
- Formulate anesthetic plan of care
- Determine postoperative disposition
- Communicate with team members
- Educate patient to reduce anxiety
- Minimize surgical delays and cancellations
- Reduce costs
These goals aim to enhance the overall surgical experience and outcomes.
What are some challenges to evaluation during the pre-operative assessment?
- Impaired normal daily activity
- Conditions requiring assistance or home monitoring
- Recent hospital admission for acute episodes
- Use of medications requiring schedule/dosage modification
These challenges can complicate the assessment process.
Identify conditions that benefit from early preoperative evaluation.
- Respiratory: Asthma, COPD, major airway surgery
- Endocrine: Diabetes, adrenal disorders, active thyroid disease
- Hepatic: Active hepatobiliary disease
- Musculoskeletal: Kyphosis, scoliosis
- Oncologic: Patients receiving chemotherapy
- Gastrointestinal: Obesity, gastroesophageal reflux
Early evaluation can help optimize patient conditions before surgery.
What is the ASA/PS Classification used for?
- To classify patients’ physical status prior to surgery
A good pre-op evaluation can reduce costs, cancellation rates, and increase resource utilization.
Classify the urgency of surgery into four categories.
- EMERGENCY: Life, limb, or organ saving, needed in <6 hours
- URGENT: Threatens life, limb, or organ, needed within 6-12 hours
- TIME SENSITIVE: Stable but requires intervention within days-weeks
- ELECTIVE: Planned at patient or surgeon convenience, within 1 year
Understanding urgency helps in optimizing patient care.
What are the components of the evaluation during pre-operative assessment?
- Identification of patient
- Allergies
- Basic vital signs, height, weight
- Confirmation of diagnosis and procedure
- NPO time
- Review of medical record/advanced directives
- Review of medications
These components ensure a comprehensive assessment.
What are the positive risk factors for PONV (post-operative nausea/vomiting)?
- Female
- Age <50
- History of motion sickness
- Non-smoker
- General anesthesia
- Opioids
- High-risk procedures
Identifying these factors can help in managing PONV risk.
List the OTC medications/supplements that should be held before surgery and their effects.
- Garlic: Increased bleeding, hold 2 weeks
- Ginger: Increased bleeding time, hold 2 weeks
- Ginkgo: Increased bleeding with anti-coagulants, hold 2 weeks
- Ginseng: Inhibits platelet aggregation, hold 1 week
- St John’s Wort: Prolongs anesthetic effects, hold 2 weeks
These supplements can interfere with surgical outcomes.
What is the recommended approach for evaluating patients with diabetes prior to surgery?
- Evaluate 1-2 weeks prior
- Manage glucose pumps and anti-diabetic therapy
- Delay elective surgery to optimize control
- HbA1C <8 for type I, <7 for type II
Proper management of diabetes can decrease peri-operative complications.
What are the long-term effects of diabetes that may impact surgery?
- Microvascular: Retinopathy, neuropathy, nephropathy
- Macrovascular: MI, ischemia, stroke, CAD, CHF, HTN
These effects increase the likelihood of peri-operative complications.
What is the Revised Cardiac Risk Index (RCRI) used for?
- To assess cardiac risk factors prior to surgery
It helps identify patients at higher risk for cardiac complications.
What are the indications for further cardiac consultation?
- High-risk type of surgery
- History of ischemic heart disease
- History of congestive heart failure
- History of cerebrovascular disease
- Pre-operative treatment with insulin
- Pre-operative serum creatinine >2mg/dL
These factors necessitate a more thorough cardiac evaluation.
What is the importance of exercise tolerance in pre-operative assessment?
- Best predictor of risk
- Helps define need for further testing
Exercise tolerance is crucial for assessing peri-operative risk.
What are the symptoms of gastroparesis in diabetic patients?
- Delayed gastric emptying
- Increased risk of aspiration
Gastroparesis can complicate anesthesia management.
What should be balanced to manage hyper and hypoglycemia risks before surgery?
Generally hold Lantus type insulins the night before
Plan for first case of day, BG on arrival.
What are the symptoms of hypoglycemia?
- Glucose tablet
- Clear juice prior to IV
- Glucose may be administered
These measures are critical for managing hypoglycemia in patients.
Should Type I diabetes patients continue basal insulin during fasting?
Yes, continue basal insulin
Hold rapid or short-acting insulin unless treating hyperglycemia.
What should be used for insulin administration prior to surgery?
Patient’s own sliding scale for insulin
This is particularly important for short cases.
What is the role of insulin pumps in surgery?
- Continued for short cases
- Change to IV insulin for major or longer cases
This ensures proper glucose control during surgery.
What can hyperthyroidism increase the risk of during surgery?
Hypermetabolic state of thyroid storm
It is crucial to evaluate for signs and symptoms of hyperthyroidism.
What should be assessed regarding airway management in patients with thyroid masses/goiter?
Evaluate diagnostics and question stridor, respiratory difficulty when supine
Look for evidence of airway narrowing or deviation.
What complications can hypothyroidism lead to?
- Hypothermia
- Hypoglycemia
- Hypoventilation
- Hyponatremia
- Heart failure
Increased susceptibility to anesthesia is also a concern.
What should be checked for parathyroid function?
Calcium level
Assess for signs and symptoms of hypercalcemia.
