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96 Cards in this Set

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What constitutes the Anesthetic Record?
Preanesthetic Evaluation

Intra-anesthetic Record

Postoperative Notes
What are the Goals of the Pre-Anesthetic Phase?
Educate Patient
History and Physical
Order/ review preoperative labs and tests

Choose the plan of care
Determine pre-op medication needs
Obtain informed consent
Motivate patient to follow preventive strategies
Educate Patient [3]
Anesthesia
Perioperative Care
Pain therapy
Choose the plan of care based on [3]
Choose the plan of care
-Guided by patient choice
-Risk factors associated with
Patient history
-Surgical considerations
Clinical and Organizational factors affecting preoperative assessment
Increase outpatient procedures
Third party payers
Organized health plans
No consistent system for risk assessment
Vital Statistics [3]
Gender and Age
Height and Weight (+/- BMI)
Vital Signs
Current Medications
Prescription
-Drug, Dose, Route, Reason
-Over the Counter
Street Drugs
-Amphetamines
-Marijuana
-Cocaine
-Steroids
Social History
Tobacco-Pack years
Alcohol-Ounces per week
Caffeine-Coffees and sodas per day
Drug Allergies
Type of Allergy
Surgical Products
Tape, Betadine, Latex
Food Allergies
Shellfish
Eggs
Tropical foods (ie. Banana, avocado, peach, kiwi, celery, chestnuts)
Surgical History
Surgical Procedure
Type of Anesthesia
Complications of Anesthesia or Surgery
Transfusion history – Rxn?
Family History of Anesthetic Complications
Physical Examination
Direct Evaluation
Heart
Lungs
Airway
Back/Regional site
? Surgical site (may need to be marked by surgeon)
Review of Systems

Review of Systems
AIRWAY {6}

MOST IMPORTANT!!
6 main areas included:
Mallampati classification
Dental examination
Thyromental Distance
Temporomandibular Joint Function
Atlanto-Occipital Joint Function (AS & RA)
“Redundant Tissue”
Significant Airway Findings
Previous Difficult Intubation
Decreased ROM of neck or instability
Facial Trauma/Burn
Swelling/Mass in Trachea
Wheezing/Rhonchi/ low baseline SaO2
Excessive Secretions (CHF, URI, pneum.)
Decreased Jaw ROM
Hoarseness
Bleeding Problems
Nausea/Vomiting
Reflux/ Hiatal Hernia
Poor Mallampati
Large Tongue
Short Thyromental Distance
Overbite
OSA
Mallampati Classification

class 1
Class I
Soft palate
Uvula
Fauces
Anterior & Posterior Tonsillar Pillars
Laryngoscopy
Visualize entire glottis
Mallampati Classification

class 2
Class II
Soft palate
Uvula
Fauces
Laryngoscopy
Posterior commissure
Mallampati Classification

class 3
Class III
Soft palate
Uvular base
Laryngoscopy
Tip of epiglottis
Mallampati Classification

class 4
Class IV
Hard palate only
Laryngoscopy
No glottic structures

Consider Awake Fiberoptic Intubation (AFOI)
Class IV
Hard palate only
Laryngoscopy
No glottic structures

Consider Awake Fiberoptic Intubation (AFOI)
Loose or Missing Teeth
Dentures
Protruding Teeth
Braces/Retainers
Also look for piercings
Thyromental Distance
Neck fully extended
3 Fingerbreadths
Distance from:
Thyromental notch
Lower Mandibular border
Atlanto-occipital Joint Function
How far can they extend their neck
Do they get dizzy?
Necessary for sniffing position
Observe patient performing
Temporomandibular Joint Function
Mouth opening
Effort dependant
Normal at least 4 cm/ 2-3 fingers
Respiratory
Dyspnea

Cough/URI
-May cancel elective cases for 2-6 weeks
Increased risk for:
-Post-op pneumonia
-Bronchospasm
-2-7x risk for airway “event” in children, 11x if intubated
Asthma/ Reactive Airway Disease
History of ER visits, hospitalization, intubation
Note triggers; environmental or emotional
Consider pulmonary function tests if on steroids
Assess for wheezing pre-op
Asthma
Review medications
Inhalers
Steroid use
Preoperative orders
Inhalers pre-op
Continue bronchodilator am of surgery
Inhalers go to OR/PACU with patient
Smoking
Note pack years
Numbers of packs/day multiplied by years
Counsel patient
Compromises intraoperative oxygenation
Increases mucous/decreases ciliary action
Increase risk for laryngospasm/bronchospasm
Pulmonary Function Testing
Suspected pulmonary pathology
Major surgical procedure
Cardiothoracic
Major Abdominal
Forced Vital Capacity
FEV1
Note value and percent of predicted
Significantly abnormal values need more detailed tests
Cardiovascular System
Mortality rate for perioperative MI – 50%
CAD
MI – date, type, symptoms
CHF
Angina – type, treatment, stable/unstable
Murmur/ Rhythm
ASPVD
HTN
Exercise Tolerance (METS)
Cardiovascular Testing
ECG – electrical activity
ST changes or Q waves indicative of ischemia/injury
Reflects only window of time
Normal in 25-50% patients with CAD
Exercise Stress Test
Evaluate patient with suspected CAD
Assesses hearts myocardial reserve
Predictive Value
<85% predicted MHR= 25% cardiac complication
>85% predicted MHR= 6% cardiac complication
ST depression >1mm + <85% MHR = 33% compl.
Echocardiography
Noninvasive
Reflects mechanical characteristics of heart
Wall motion abnormalities
Wall thickening
Valve function
Ventricular function
Ejection Fraction
Dipyridamole Thallium Scintigraphy
Assesses for reversible ischemia
Dipyridamole administered to dilate coronary arteries followed by thallium
Thallium taken up by tissues
Scan done at beginning and at 4 hours
Uptake evaluated
Patients with redistribution > intraop risk
Coronary Angiography
Gold Standard
Assesses individual vessels for narrowing/ blockage
Ejection fraction
Valvular defects
Previous Myocardial Infarction
Increased risk of myocardial event intra-op
Risk approaches general population after 6 months
Congestive Heart Failure
Most predictive of intraoperative ischemia
Exam: moist rales, orthopnea, tachypnea, jvd, tachycardia
Postpone surgery if possible
If emergency: Pharmacologic measures to optimize cardiac output
Invasive monitoring
Hypertension
Systolic BP > 160
Diastolic BP > 95
Primary / Secondary
Note control/ compliance
Probable ASPVD
Anticipate intraoperative BP fluctuations
Goldman Cardiac Risk Index
Age >70
MI < 6 months
S gallop***
CHF***
JVD
ECG other SR or PAC
PO2 <60 or CO2 >50
HCO3 <20
K+ <3.0
B
UN > 50
Creatinine >3.0
Bedridden
Intraperitoneal/ thoracic/or aortic surgery
Gastrointestinal System
GERD
Continue H2 blockers preoperatively
PUD
Bowel Obstruction
Hepatobiliary System
ETOH abuse
Induction P450 enzymes (paralytics/narcs)
Liver disease – note LFT’s
Acute or chronic
Assess effect of coagulation (PT/PTT if block)
Acute Gallbladder disease (N/V)
Renal System
Chronic renal disease
BUN/Creatinine
Creatinine clearance best measure of renal reserve
Electrolytes
Dialysis (should be done day before surgery)
Hg/Hct
K+ level
Fluid status
Endocrine System
Diabetes
IDDM or NIDDM
History of tendency hypo/hyperglycemia
Insulin or oral antihypoglycemics
Associated microvascular disease
Renal, cardiac, peripheral vascular
Autonomic dysfunction
Diabetic Preoperative Orders
Vary with procedure/ institution
IV D5LR at 125 cc/hr
_ dose intermediate acting insulin
FSBS on admission
Goal: avoid hypo/hyperglycemia
“Tight control” – Barash
Endocrine System
Thyroid Disorders – pt should be euthyroid, continue meds
Hypothyroid
Assess symptoms; cold intolerance, skin manifestations, energy
Hyperthyroid
Airway deviation? May need CT or xray
Adrenocortical Disorders
Hyperadrenocorticism – Cushing’s
Hypoadrenocorticism – Addison’s
Steroid use – for tx asthma, autoimmune dz
Assess for need to supplement during surgery
“Stress dose” steroids
Assess for fluid and electrolyte changes, hypo/hypertension
Obesity
Ideal Body weight/BMI
>20 % ideal body weight = obesity
2x IBW = morbid obesity
Increased risk HTN, NIDDM, CHF, CAD, stroke, cholelithiasis, H/H, OA, PVD, OSA
Need to question about dietary supplements
Amphetamines, antidepressants, Fen/Fen
Neuromuscular System
Arthritis
Degenerative vs. Rheumatoid
Cerbrovascular Disease
History of CVA, TIA
Cervical or Lumbar disc disease
Note parasthesias, sciatica, limits
Scoliosis for regional?
Reproductive System
Females of “childbearing age”
Check hospital/ institution policy
Oral contraceptives may increase risk of deep vein thrombosis
Obstetrical patients
Complications of pregnancy
Complications with delivery in past
Preoperative Testing
If ordered you MUST WAIT FOR RESULT
Consider relevance of each test to anesthesia
Presence of positive finding on H & P
Anticipation of significant changes d/t surgery
High risk population
Preoperative Labs
Hgb/Hct
History of bleeding, bruising, ASA/NSAID use, anticipated high blood loss
PT/PTT
Coumadin/heparin use
Electrolytes
Diuretic use, digoxin, trauma (crush), pre-renal or CRF
BUN/Cr
Diabetes, CRF
CXR
If clinically indicated and results will alter anesthetic mgmt.
K+ levels
When delay vs. replace
If chronic don’t replace, if acute replace
Lowest acceptable K+ level 3.0
If on digoxin lowest K+ can be 3.5
K+ can alter membrane potential
Preoperative Testing
General guidelines
Less than 50 y/o no testing required
Older than 50 ECG and (+/-) CXR
Premenopausal females need H/H, HCG
What is the significance of the ASA Status Classification?
Depicts a pathophysiological baseline for all patients (communicates health status, not risk)
Required, universal standard in anesthesia
Assigned as a result of the initial interview
Provides basis for comparisons of morbidity and mortality
HIGHLY SUBJECTIVE!

NOT used as a predictor but as a determination of baseline pathophysiological function.
ASA Classification
Class I: Healthy patient
Class II: Mild systemic disease
Class III: Severe systemic disease
Class IV: Severe life threatening systemic disease
Class V: Moribund patient
Class VI: Organ donor patient
E qualifier: Emergency surgery required
ASA examples
2-asthma well control on inhaler
2-htn well controlled
3-htn not well controlled
3-asthma with flareups
3-DM with peripheral neropathy
3-if morbidily obese
5-will die if not going to surgery
Anesthesia Management Options
Communicate available choices

Identify Plan A and Plan B

Nice to know if they absolutely refuse /object an option (you may not be the one conducting the informed consent)
What is the purpose of Informed Consent?
Educates the patient about the events surrounding the procedure to be performed
Based on patient’s right to self-determination

Protects the caregiver from libelous acts.
What is the definition of Informed Consent?
The patient has agreed to undergo
a procedure after receiving a clear
description of the nature of the
procedure, anesthetic options
available, and any potential side-
effects.
Informed Consent
Choice of Technique
Site of surgery
Coexisting disease
Position of operation
Elective or emergency
Age
Patient preference
What anesthetic risks should be disclosed?
Lundquist v Ayerst Laboratories, Inc the court said “the anesthesia provider is not required to inform the patient of every conceivable risk, but only significant risks”
Markarian(1991) you don’t have to site every risk, so as not to unduly alarm the patient.
Risks
Nausea/Vomiting
Airway trauma
Sore throat
Dental Injury
Peripheral Neuropathy
MI/dysrhythmias
Atelectasis
Aspiration
Stroke
Allergic drug reaction
Death
What anesthetic risks should be disclosed?
What are substantial risks? (those inherent in the instrumentation of the mouth, invasive line placement or regional anesthesia)

Accompany risks with measures to minimize harm (use of monitors, drugs…..)

Include rarity of the risk (e.g.. chance of postdural puncture headache < 2%)
What are the elements of Informed Consent? [4]
Disclosure of information – need to make an informed judgment
Comprehension of information – must be understandable, minimize medical jargon
Voluntary – free of coercion or controlling influences. (There are always pressures)
Capacity to Consent – requires a capable decision maker
Who can render Informed Consent?
Persons of legal age
Legal guardians (step-mom/dad)
Emancipated minors (Those under the legal age who are considered legally adult for consent purposes)
Married, widowed or divorced
Patient is a parent
Patient is a member of the armed forces.
Patient is pregnant
Living separate and apart from his or her parent(s) or guardian & managing own finances.
What are special charting concerns with OB anesthesia? [4]
For c-sections note
the following:
Time of Intrauterine incision
Time of birth
Sex of baby
APGAR readings
What is special about DNR in the OR?
AANA ethical guidelines state these orders acknowledge a patient’s right to die with dignity.
Automatic suspension fails to comply with this right.
Raises issue of potential battery.
Clarify all possible scenarios in the perioperative phase and exactly what DNR means. Document discussion and have patient initial/sign.
What is special about the Jehovah Witness patient in the OR?
Clear documentation of the extent to which the patient wishes transfusion of blood or blood products under life threatening situations.
Child – parents need to know transfusion therapy could occur in event of life threatening hemorrhage (via a court order)
Documentation
Standardized consent
Progress Note
-Risks
-Benefits
-Alternatives
Patient Preparation/ Preoperative Medication
Relief of anxiety
Sedation
Amnesia
Analgesia
Antisialogogue
Decrease autonomic response
Reduce gastric volume/ pH
Antiemetic
Reduce anesthetic requirement
Facilitate induction
Allergy prohylaxis
Psychological Preparation
Good counseling = best preop
Explain procedures and sequence
Answer questions
Talk to both patient and family present
Pharmacologic Preparation
Chosen considering individual:
Goals for patient
Knowledge of pharmacologic agents
Preop time available
Desired endpoint
Sedative Hypnotics, Tranquilizers

doses...
Versed
PO: 0.5mg/kg (takes 15 minutes to work!)
IV: 0.5-5mg titrated to effect
Diazepam 5-20 mg PO
Lorazepam PO/IM 1-4 mg
Opioids
Provides analgesia prior to induction
Regional anesthesia
Blunts response to endotracheal intubation
Morphine
Meperidine
Fentanyl
Anticholinergics
Antisialogogue

Sedation and amnesia

Vagolytic action
Antisialogogue
For intubation, intraoral procedures, bronchoscopic procedures
Scopolamine > Glycopyrolate > Atropine
Sedation and amnesia
Scopolamine > Atropine > Glycopyrolate
Vagolytic action
Blocks Ach on SA node

Atropine > Glycopyrolate > Scopolamine
Stabisimus
Stabisimus or other muscle surgeries of the eye may have a dive in HR, so pre-treat with and anticholinergic
Gastric Fluid pH and Volume

Patients at risk for aspiration...

who is considered to have a Full stomach?
Pregnant
Obese
Diabetic
Hiatal hernia
Reflux
Mendelson’s Syndrome
Volume in stomach > 25cc
pH <2.5
Unproved in humans……


Increased risk of aspiration pneumonitits
Preoperative fasting guidelines
NPO after midnight is controversial
Studies show clear liquid 2-3 hrs before surgery ok
Pediatric patients at risk for hypovolemia and hypoglycemia
Preoperative Fasting Guidelines
Adult
8 hours solid food
4-6 hours clear liquid
Pediatric
4 hours formula
3 hours breast milk
2 hours clear liquid
Aspiration Prophylaxis [2]
Anticholinergics
H2 Receptor Antagonist
Decrease gastric secretions with high hydrogen ion concentration
Few side effects
Multiple dose regimens more effective than single dose
Ranitidine
Potent, specific and long acting
Dose: 50-150mg
Duration: 9 hours
Non-particulate Antacids
Neutralize gastric contents
100% effective in increasing gastric pH >2.5
Give 15-30 minutes prior to induction
No damage to lung if aspirated
Continuation of Medications
Cardiac Medications – Continue
Asthma Medications – Continue
Seizure Medications – Continue, check level
Diuretics – usually hold, especially for MAC cases
What should I be concerned about in reference to the law and charting?
It is a legal document and is admissible in court as evidence demonstrating the kind, standard, or quality of care delivered.
Although accurate and complete charting doesn’t prevent complications or potential legal concern, it can minimize discussion concerning the appropriateness of anesthesia management or compliance with standards.
Charting and the Law
Be clear, concise, factual, and objective
Mod amount of emesis vs 200cc
Patient appears upset vs patient crying enroute to OR
Meds given without a clear rationale must be explained (give a response too )
Labetolol 5mg IV for increased BP- patient BP decreased to 110/70)
Don’t refer to incident reports on the chart (not subject to external review)
What are issues concerning manual charting?
Batch Recording

Smoothing
What are the concerns about automated charting?
Liability

Cost

Confidentiality
How can automated charting be used in the future?
Use data bases for:
Large scale studies
Best practices and Clinical Care Guidelines
Equipment issues
Drug utilization
Anesthesia care outcomes
Personnel utilization
Important charting rules...
Anesthetic gases = L/min

Drugs = mg or mcg (not cc’s)

Volatile agents = % (Forane 2%)

Late entries OK – date, time, and signature (don’t squeeze in)

Consistent drug names (generic vs trade)
Reumatoid arthritis on long term steriods? (and ankylosing spondylitis)
preop neck xray
alanto-occipital for?
dizziness=occlusion of blood vessels to brain, especially in CEA (vertebral arteries) look for ‘zingers’ and parasthesias as well with neck extension. Chart ‘head maintained in neutral alignment”
mouth opening less than 2cm?
Nasal or fiberoptic intubation if less than 2 cm.
URI s/s's
Coughing fever, runny nose=URI
increased incidence of laryngospasm?
Increased coughing/sore throat with smoking (discuss post/op implications) increased incidence of laryngospasm.
alantopoccipital evaluation especially with...
especially in ankylosising spondylitis and RA.