Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
96 Cards in this Set
- Front
- Back
|
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.
|
