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117 Cards in this Set
- Front
- Back
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Purpose of preop assessment
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Educate pt on
-anesthesia -preriop care (fluids, breathing) -pain meds -dec anxiety (d/t inc catachol) -facillitate recovery |
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Purpose of preop assessment
Purpose |
H&P
Preop labs & tests Plan of care -guided by pt choice -risk factors assoc w/ pt hx, surg considerations |
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Purpose of preop assessment
Purpose |
-Determine preop meds
-Informed consent -motivate pt to follow prevent strategies (quit smoking) |
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Clinical & Org factors affecting preop assess
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inc outpt procedures
3rd party payers (less preop time) No consistnet system for risk assess |
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Sources of information
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chart review
previous hosp records lab/x-ray data consultations pt interview discussion w/ surgeon (listen to their concerns about pt) |
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Chart Review
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medical records
curent inpt records old inpt records (prior OR, vitals) |
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Pt interview
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Privacy
ID yourself as SRNA Ask pt if visitors or family memebers are ok to be in room |
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Vital stats
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gender
age Height weight vitals |
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Current Meds
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Prescription
-drug,dose,route,reason -OTC's (vitamins, herbs) -Street Drugs (amphetamines,pot,coke,roids) |
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Social Hx
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Tabacco (pack/day x yrs)
Alcohol (oz/wk) Caffeine (coffee/pop /day) |
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Drug allg
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Type
Food (shellfish, eggs (dip) Surg products (tape, betadine, latex (pappya) |
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Surg Hx
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Procedure
type of anesthesia complications of anest/surg Transfusion hx (complicate xmatch) Family hx (maliganant hyper,slow wake up, lead pipe syn) |
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Phys exam
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Focused assess (heart,lungs,airway,back,surg site
Review of sys |
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Airway
Possibly most important 5 main areas |
Mallampati class
dental exam thyromental distance TMJ funct Atlanto-occipital jt funct |
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Mallampati class
Class I |
Soft palate
uvula Fauces ant/post tonsillar pillars Laryngoscopy visualize glottis |
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Mallampati Class
Class II |
soft palate
uvula fauces (slight diminished) laryngoscopy (posterior commissure) |
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Mallampati Class
Class III |
soft palate
uvula base laryngoscopy (tip of epiglottis (chords not visualized well) |
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Mallampati Class
Class IV |
hard palate only
Laryngoscopy (no glottic structures) |
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Dentition
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loose missing teeth
dentures protruding teeth braces |
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Thyromental distance
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neck fully ext
-dist from -thyroid notch -lower mandibular border -3 finger breadths (short=anterior) |
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Atlanto-occipital jt funct
(limitation at C1 convexity, anterior airway) |
how far can they ext their neck
-any dizziness -necessary for sniffing pos. -observe pt performing |
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TMJ funct
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mouth opening
effort dependent normal at least 2-3 fingerbreadths (vertical) |
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Respiratory system
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-Dyspnea
Absent w/ mod exertion =no dz -Cough/URI Inc risk: post op pneumonia, reactive airway Genearlly cancel elective 2-6 wks |
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Reason for cancelling d/t cough
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Inc secretions, poss asp
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Swelling of airway d/t cold is ___times more likely to happen with a cold after insturmentation of airway, 2-3 times likely with bag mask
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11 times
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Asthma/RAS
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Hx ER visit, hosp stay
-Triggers -consider PFT -assess wheezing in clinic/preop |
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Asthma
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Review meds/compliance
- inhalers Preop orders Inhalers preop Continue bronchodilators Inhalers to OR w/ pt Hydration (previous night, OR) |
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Smoking
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note pack/yrs
#pack/days/yrs (regardless of quitting) -Counsel pt Can compromise intraop o2 Inc mucous/dec clillary act Inc risk laryngospasm/bronchospasm |
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PFT
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Suspected pulm path
major surg procedure Cardiothoracic, maj abd Assess FVC/FEV1 (note value/% of predicted) Significant abnorm values need more detail tests |
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CV System
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Mortality rate of preop MI 50%
CAD (MI-date,type SS) CHF Angina (stable vs un) ASPVD HTN Exercise tolerance |
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CV testing
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EKG (ST chang, Q wave indict ischemia/injury, reflects window in time, normal in 25-50% of pt w/ CAD
Indicated in pt greater than 45-50yrs |
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Exercise stress
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Eval CAD
Assess myocardial reserve Predictive value <85% predict MHR -25% cardiac comp >85% predict MHR 6% cardiac comp ST dep >1mm + <85% MHR =33% cardiac comp |
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Echo
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noninvasive
reflects mech charct of heart wall motion wall thickening (HTN) valve fx vent funct (estimate) EF |
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Dipyridamole Thallium Scintgraphy
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Assess rev ischemia
Dipryridamole dilates cornary -> thallium is taken up by tissues -Scan at begin, 4hrs -Uptake eval -Pt w/ redist inc intraop risk |
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Coronary angiography
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gold standard
asses individual vessels EF Valve defects |
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Previous MI
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Inc risk for event
Risk approaches gen population >6 mos. |
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Chance of having intraop MI with MI in past 6,3 mos.
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15% = 6mos
30% = 3mos |
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CHF (use mostly narcotic anesthesia intraop)
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most predictive of intraop isch
Exam- rales,orthopnea,tachypnea,jvd,tachycardia Postpone surg if poss. Emergency: pharm to inc CO Invasive monitor |
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HTN
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SBP >160, DBP >90
-Primary/Secondary -note control/compliance -Possible ASPVD Expect intraop HTN -Consider cancelling to optimize control -If pt takes meds may have to do other measures |
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GI
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GERD (Cont H2, rapid seq)
PUD (caution NG) Bowel obst (don't give reglan) |
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Hepatobillary (inc risk of heapatitis
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ETOH abuse (induct P450)
Inc anesthetic need Live dz (LFT's) Acute/chronic Assess effect on coaguation Aucte GB dz |
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Renal (monitor esp in AAA)
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CRD (BUN/CRT)
Crt clr best measure of renal reserve Elytes HD (H&H, K+, fluid status (perfer not to do surg after HD d/t dec fluid status) |
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Endocrine
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DM- impaired synth, secretion, use of insulin
Hx of hypo/hyper glycemia Microvascular dz assoc (renal, cardiac,pvd, autonomic dysfunct: delay GI empty (GERD, labile BP) |
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DM preop
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IV D5LR 125/hr
1/2 dose of intermediate insulin Blood gluc check on admit avoid-hypo/hyper glycemia Goal of 100mg/dl |
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Endocrine Thyroid
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Euthyroid in OR
Hypo -note cause, tx -assess SS, (cold intol, skin manifest, energy -Thyroid function |
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Endocrine Hyperthyroid
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Continue propylthiouracil & propranolol
airway dev d/t goiter xray neck r/t dev of trachea rev CT scan of thyroid Cancel of hyperthyroid |
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Adrenocrotical Disorders
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Hyperadrenocorticism (Cushings-alklosis,inc fluid)
Hypo- addision's (need steroid 100 solucort pre,post,intra |
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Adrenocrotical Disorders Steroids
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tx for asthma , autoimmune
-may need to supp d/t surg stress -assess fluid & elyte change (hypo/hypertension) |
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Neuromuscular system
Source of problem |
ischemia/vasospasm
embolism/thrombosis tumor aneurysm/hemmorrhage seizure stroke (outcome, weakness, meds) |
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CVD
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Hx CVA, TIA
Cervical or lumbar disc dz -note parethesias, sciatia, limits Arthritis Degen jt vs RA (diff intub w/ RA r/t neck get xray) |
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Reproductive
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Females of childbearing eval for preg
Oral contras (inc risk of DVT) OB Pt's (comp preg, delivery, epidurals, anesthetics) |
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Preop testings
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Consider relevence for each test
Positive finding in H&P Anticipation of significant changes d/t surg High risk population |
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Preop testing
General Guidlines |
older than 50 = EKG, CXR
Premenopause females no preop test <50 HCG, H/H |
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ASA Classification Class I
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Healthy pt
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ASA Classification Class II
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Mild systemic dz (mild htn)
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ASA Classification Class III
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Severe Systemic dz (not incapacitating) (renal failure)
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ASA Classification Class IV (constant threat to life)
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Incapacitating systemic dz (CHF, Mal htn,
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ASA Classification Class V
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Moribund pt (less than 24hrs w/w/o surg will die )
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ASA Classification Class VI
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Organ donor
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ASA Classification Class E
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Emergency qualifier
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Informed consent
Choice of technique |
Site of surg
coexist dz position of operation elective or emeregency Age pt preference |
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Informed consent
Discussion tailored to pts need |
Risks
N/V, Airway (sore throat Dental inj Preiph neurop, cardiac dys/MI Atelectasis, Aspiration Stroke, Allg drug rxn Death |
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Documentation
Progress note |
Standardized consent
Pt dx gen nature of proced risks prospects of succes prog if procedure performed alternative |
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Informed consent
An essential element of safe anesthesia practice Details: |
Clear, concise, communication, primary care strategy, legible doc, risks benefits, consequences if refused, signature of pt
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Preop meds
goals |
Relief of anxiety
sedation, amnesia, analgesia dec secretions, dec autonomic response reduce gastric vol & inc pH |
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Pt Prep/preop meds
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Antiemtic effects
reduction of anesthetic facillitate induction (versed dec amt need of dip ) Allg prophalaxis |
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Psych prep
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Good counseling = best preop
Explain procedures & sequence Answer questions Talk to both pt/family |
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Pharm Prep
Chosen considering pt individualized |
goals
knowledge of pharm agent preop time available desired endpt |
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Sedative hypnotics/tranquilizers
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Versed PO .5mg/kg, IV .5-5mg
Diazepam PO 5-20mg Lorazepam PO/IM 1-4mg (long post op sleep) |
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Opiods
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provide analgesia before induction
-regional anesth -blunts response to endotrach intubation - Morphine IM 5-15mg - Fentanyl IV (needs to be monitored) |
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Anticholinergics
Originally used to decrease secretions assoc w/ inhal anesth Side effects |
CNS tox
-central anticholinergic synd -tx antilerium |
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Properties of Anticholinergics
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Antisalagogue
-for intubation, intraoral procedures, bronchoscopic procedures Scopolamie > Glycopyrolatez > Atropine |
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Properties of Anticholinergics
Sedation & Amnesia |
Scopolamie> >Atropine> glycopyrolate
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Properties of Anticholinergics
Vagolytic action |
Blockade of ACh on SA node
Atropine> Glycopyrolate > Scopolamine |
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Gastric fluic pH & vol
Pts at risk of aspiration |
full stomach
pregnant obese DM GERD Mendelson's syn (asp pneumonitis pH 2.5/ 25ml of contnets |
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Preop fasting
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NPO after MN (controversial)
-studies suggest clrs 2-3 ok -peds pts risk hypovol, hypoglycemia |
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Aspiration prophylaxis
H2 recp antag |
dec gast secretions w/ H+ ion conc
Few side effects multiple dose regimens more effective than single |
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Aspiration prophylaxis
Ranitidine |
More potent, specific, longer acting
Dose IV 50-100mg Duration: 9 hrs Fewer SE than cimetadine |
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Aspiration prophylaxis Famotidine
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H2 recpt antag
IV 20mg every 12 hrs Metabolism: liver Cleared: Renal |
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Aspiration prophylaxis
Antacids |
Neutralize gastric contents
100% effective inc pH >2.5 Give 15-30min prior to induct Nonparticulate Na Citrate .3M No damage to lungs if asp Quick act good for emergency No inc gastric volume |
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Aspiration prophylaxis
Antiemetics |
Droperidol .625mg IV (arrhy)
Metoclopramide inc gastric empty (avoid in bowel obst) Ondansetron 5 HT3 recpt antag (4mg prior to surg, intra, or as rescue for NV |
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Implications for specific drugs
Anti HTN's |
may cause dehydration
some will potentiate anesth continue on day of surg |
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Specific drugs Diuretics SE's
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may cause dehydration
hypokalemia give day of surg |
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Specific drugs Antianginal
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Ca+ ch/ beta blks nitrates
give day of surg |
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Specific drugs Antidysrhythmic
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generally continued
possible SE's Do not D/C w/o consulting |
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Specific drugs Bronchodilators
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use of aminophylline controversial
-volatic agents are bronchodilators -aerosolized bronchodialtors and corticos as needed |
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Specific drugs Insulin
Tight control |
Tight control, expensive, difficut (state of art)
Loose control favored for minor surg Tight control - improve hemodynamics -improve wound healing |
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Specific drugs Insulin
Loose control |
no insulin/start IV/check BG
Start dextrose, give 1/2 dose insulin/ check BG |
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Specific drugs Oral Hypoglycemics
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Hold day of surg
DC metformin 1wk prior to surg (d/t lactic acidosis) |
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Specific drugs Corticosteroids
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Note detailed hx of use
May need stress dose Prednisone >10mg/day >6mos (intra op) |
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Specific drugs
Thyroid |
Thyroxine hold or give
Antithyroids should give |
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Specific drugs Anticonvulsants
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Sould take
May induce liver enzy Alter pharmacokinetics or other anesthetic drugs (inc need of drugs) |
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Specific drugs MAOI's
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DC prior two weeks to surg
(d/t inc catechol stores) -Caution w/ meperidine |
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Specific drugs Tricyclics
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continue until day of surg
blk reuptake of NE May prolong sleep or myocardial depress - exag response to Ephedrine -dec BP -> Neo |
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Specific drugs Lithium
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Cont until day of surg
Muscle relaxant |
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Specific drugs Anti- inflams
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interferes with plt function
surgeon will decide whether to continue |
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Specific drugs Anticoags
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Surgeon will regulate/ may consult anesth
Switch to Heparin Stop 3-4 hr pre-op INR if regional anesth given |
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Specific drugs Antineoplastics
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Take a good hx
look of agents -Bleomycin (O2 tox keep FIO2 below 30%) Adriamycin (heart value) |
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Specific drugs Antiglaucoma
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Cholinesterase inhib
Beta Blkers (makes succholine last longer |
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Specific drugs Antibiotics
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Beaware of cross sens
May potentiate NMB's (Gentamycin) |
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Specific drugs Opiods & Benzo's
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-know last dose
-titrate according to need -If on gtt may need more |
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Specific drugs Recreational drugs
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remain non-judge
emphasize safety look for withdrawl |
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Preanesthesia Doc
Review preop eval if done by another provider |
-Review preop note
-chart -pt exam -agreement w/ assess/pain -documentation of updated counseling |
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Anesthesia Document
What goes on it |
Procedure
Surgeon Monitoring Technique Airway Data from case Remarks |
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Basic checks of OR
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Equipment, gas supply
Drugs, Vitals |
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Monitoring Pt
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Eval of oxygen
-Fio2 -alarms set -document -low flow alarm Pulse ox |
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Continous valuation of adequacy of ventilation
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Auscl breath sounds
Capnography Audible disconnect alarm on vent ID CO2 in exhaled gas after intubation |
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Circulation
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Cont EKG
Document HR/BP Q 5min |
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Pts under General Anesth are monitored by
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auscult of heart sounds
monitoring of intra art BP Ultrasound perph pulse monitoring or pulse plethysmography |
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Drugs & agents used
Amounts given and times given |
Bolus drugs
Infusion drugs |
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Drugs & agents used Amount of controlled drugs
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used
discarded witness |
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Fluids
Note |
Type, amt, times given
Fluids given (time based & totaled) Bld doc by reference # Urine out (time base & total) Bld loss (time base & total) |
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Techniques and monitors used
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list all techniques not implied on record
List all monitors not clearly implied on record - Unusual events time base narrative note action taken |
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Post op status
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doc mental status /LOC
Doc airway & vent status Doc adequacy of pain cont Sensory level & monitor funcntion if regional anesth Vitals, SpO2 |
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Post anesth Doc
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Pt eval on admission to PACU
Pt eval on d/C from PACU Time based record in PACU Vitals LOC |
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Other Documentation
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care given
pain control drugs/fluids blood unusual events or complications |
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Post anesth visit
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Times dates of visits
Pt condition, VS, Pain, food inake if sigmificant Complications of Care Questions answered. |
