Health Assessment Quiz 1

›In the ideal world, the provider who will administer the anesthesia!!

• In the real world, the patient is often seen ahead of time by a RN or NP or anesthesia provider in a preoperative assessment clinic 
• *Helps to ID patients who may need to cancel or delay surgery so OR runs efficiently*

›Review of the surgical diagnosis, involved organs/systems, & planned procedure

›Interview (subjective data, also ROS)

›Physical exam (objective data)

›Medical record review (current & past)

›All of this determines patient’s physical & mental status

• ›Prior anesthetic experience/family h/o anesthesia problems
• ›   -No problems
•    -›Difficultintubation
•    -›Delayed emergence
•    -MH
•    -›Prolonged neuromuscular blockade    
•        (pseudocholinesterase deficiency)
•    -›PONV
•    -›Awareness-very rare but ask about past experiences

Pain/Quality/Radiating/Site?Timing

›Consider them when diagnosis is questionable following H&P

›Can help establish severity of diagnoses condition

›Can rule out conditions included in the differential

• ›Judicious selection of studies:  
•     ›Sensitivity & specificity
•     Cost-effectiveness, safety, & degree of invasiveness

• ›INFORMED CONSENT!!
• ›Communication of the anesthetic care
• plans…in terms the patient understands!
• ›Discuss all of the following!
•     -›Preop med ”going to give you something to relax you”
•     -›Preop procedures
•     -›Intraop mgt  “I’ll be with you, keep you safe and relax, give oxygen”
•     -›Postop care in the PACU “ what to expect, we’ll take out the breathing tube, take you to the PACU”
•    -›Postop pain mgt “PCA/Epidural”

›

• ›Discuss alternatives (spinal vs GA)
• ›Potential complications
• ›Risks versus benefits
• ›ANSWER THE PATIENT’S QUESTIONS!!
• If you are not the person that will be  administering the anesthetic, inform the person that he/she will have an opportunity to speak again with their own anesthesia provider

›Establishes a trusting provider-patient relationship

›Significantly diminishes patient anxiety

Measurably influences postop recovery & outcomes

TRUE

›Class 1—Healthy patients, no medical problems

›Class 2—Mild systemic disease (smokers)

›Class 3—Severe systemic disease, but not incapacitating

›Class 4—Severe systemic disease that is a constant threat to life

›Class 5—Moribund, not expected to live 24 hours regardless of surgery

›To denote an emergency surgery

›Organ donor

›In addition to faciltiating communication about the patient, it effects reimbursement for anesthesia services

›Adults:

›No solid food for 6-8 hours, most say 8 hours, if no risk of aspiration

›Oral preop meds taken up to 1-2 hours before anesthesia w/ water sips

›Clear liquids up to 2 hours preop in newborns </= 6 months

• ›Solid foods, including milk
•    ›Up to 4 hours preop in newborns </= 6 months
•    ›Up to 6 hours in children 6 months to 3 years
•    ›Up to 8 hours in children > 3 years

• ›GI obstruction (place sump before!!!)
• ›GERD
• ›Diabetes (gastroparesis)
• ›Ate solids recently
• ›Abdominal distention
• ›Pregnancy
• ›Depressed consciousness
• ›Recentopioid administration
• ›Naso-oropharyngeal bleeding
• ›UGI bleed
• ›Airway trauma
• ›Emergency surgery

• ›Diminished ventilation
•   -›Mild VQ mismatch
•   - Pickwickian Syndrome (obesity hypoventilation & OSA)…this may be seen w/ PAH w/ or w/out RV failure!

›So more rapid apneic desaturation!

• ›Increased intra-abdominal pressure w/ HH
• & reflux

›Higher gastric volume & lower pH

›Altered pharmacokinetics

• ›Regional anesthesia more difficult &
• often unsuccessful

›GERD, IDDM, Asthma, & potential difficult airway!

›This is why it is preferable to see the patient for preop eval before the day of surgery!!!!!

›1.  More info or expertise needed to  establish or quantify a diagnosis that has implications for the anesthetic care plan

›2.  Diagnosis is known but further eval & treatment needed to optimize physical status prior to surgery

›CO decreases O2 delivery to tissues

›Nicotine increases HR & causes peripheral vasoconstriction

›Within 12-24 hours: CO & nicotine levels return to normal

• ›Within 2-3 days: bronchotracheal
• ciliary function improves

›Within 2 weeks: sputum volume decreases to normal levels

›However, no significant decrease in resp morbidity until 6-8 weeks of abstinence

›Useful in patients undergoing lung resection

• ›May be useful in patients undergoing upper abdominal or prolonged or extensive
• procedures

›May predict or monitor patient’s pulmonary response to postop treatment

TRUE

• ›History, physical exam, & EKG help to recognize potentially serious cardiac
• disorders

›Must not only identify the presence of  cardiac disease but also its severity, stability, & prior treatment

›Cardiac risk involves consideration of functional capacity, age, comorbidities, & invasiveness of surgery.

• Always ask about abnormal bleeding or buising!!!
• Medical problems or meds associated w/ increased bleeding
• Family history of excessive bleeding
• Unusual bleeding with prior surgery
• If affirmative response, ask is there epistaxis, hematuria, or menorrhagia

50,000/mm3

• ›Diabetes for how long?
• ›Glycemic control? 
• ›Evidence of CAD or cardiomyopathy, HTN, autonomic neuropathy, CRI, gastroparesis?
• ›Meds, most recent doses, current glucose?
• ›Stiff joint syndrome (neck)?

• ›Glucose
• ›Electrolytes
• ›BUN/creatinine
• ›UA
• ›EKG
• ›Optional: ABGs, ketones, osmolarity, Ca2+, PO4-, Mg2+

• ›Multisystem disease
• ›Increased CNS tolerance to volatile & induction agents
• ›Perioperative withdrawal/seizures/DTs
• ›Paradoxical excitation to sedatives & hypnotics
• ›Peripheral neuropathy/regional anesthesia

›Cardiovascular: HTN & alcoholic  cardiomyopathy

›GI: gastritis, bleeding, hepatitis, pancreatitis

TRUE

INCREASED drug effect, coagulopathy, esophageal varices

›YES. Metabolic & nutritional abnormalities: thiamine deficiency, hypophosphatemia, hypomagnesemia, hypocalcemia

›Leukopenia & anemia

›Possibly thrombocytopenia w/ predisposition to DIC

›C—Do you occasionally cut down on your alcohol intake?

›A—Are you annoyed when people criticize your drinking?

›G—Do you feel guilty at times about your drinking?

E—Do you ever take an ‘eye opener’ in the morning

›Signs of early withdrawal: tremor, agitation, confusion, increased HR

• ›Alcohol on patient’s breath: check ETOH level
•   - If emergent surgery, treat as ‘full stomach’
•   - ›If elective, delay
• ›Dehydrated: inhibition of ADH by ETOH
•   - ›Dehydration + vasodilation from anesthetics = hypotension
• ›Hypothermic
• ›Decreased MAC since already anesthetized!
• ›ETOH synergistic effect w/ cardiorespiratory depressant effects of sedatives & narcotics
• ›Differential diagnoses: acute ETOH intoxication, head injury, metabolic  derangements

›

›

ETOH level, drug screen (polysubstance abuse), CBC, electrolytes, glucose, LFTs, coagulation profile, EKG, calcium, phosphorus, magnesium

• ›Effects of URI:
•    - ›Alters quantity & quality of airway secretions
•   - ›Increases airway reflexes to mechanical, chemical, or irritant stimulation
•   - ›Intraop & postop bronchospasm, laryngospasm, & hypoxia
•   - ›High risk of pulmonary complications at least 2 weeks, & maybe even 6-7 weeks, after URI

• ›Infants at greater risk than older children
• ›Intubation increases risk
• ›Theoretically, recommendation is to avoid anesthesia for several weeks after URI
• ›Clinically, often impossible since children have 5-8 URIs annually
• ›Must distinguish severity & make decision as to proceed or not

• Mallampati Classification:tongue thickness
• Thyromental distance: point from thyroid cartilage to the chin (under 3 fingers)
• Interincisor distance: difference between teeth
• Atlantooccipital range of motion: motion of head back/forth (Down syndrome or Rheumatoid arthritis)
• Mandibular mobility

TRUE

Ability to touch chin to chest

Ability to extend neck to 35 degrees

Lifting head up alining the pharyngeal-laryngeal axis and 90 degrees to oral airway

• Mandibular protrusion test
• Upper Lip Bite Test

• Length of Upper Incisors
• Shape of Palate
• Length of neck
• Girth of neck
• Obesity

• Look at anatomy
• Examine airway
• Mallampati
• Obstructions
• Neck Mobility

• •Electrocardiography
• •Pulse oximetry
• •Capnography
• •Noninvasive blood pressure
• •Temperature
• •Neuromuscular function
• •EEG/BIS
• •Arterial pressure
• •Central venous pressure
• •Pulmonary artery pressure
• Volume status (fluids, UOP, EBL)
• •Patient positioning
• •Surgical field

Pt is 1200, going clockwise around you every 5-15minutes to ensure everything is okay/working correctly. (document VS at least every 5min)

• Monitoring & staffing ratios equivalent to ICU
• After neuroaxis regional anesthesia (RA)

• •Transition made from intensive observation to stabilization for care on a surgical ward or at home
• •May discharge a patient straight from GA to phase 2 if patient exhibits stable hemodynamics & cognitive functioning
• •Most patients with MAC (monitoring + sedation) or extremity RA

by preexisting disease, surgical procedure, & pharmacological implications of periop anesthetic agents

TRUE

• •Your report guides the intensity & duration of PACU observations
• •Anesthetic technique
• •Administered agents
• •Type & reversal of neuromuscular blockade

• •Baseline responsiveness
• •Ventilation
• •Pain
• •VS
• •Regression of motor blockade with regional anesthesia

• Activity
• Respiration
• Circulation
• Consciousness
• O2 Saturation

•Breathing easily, coughing on command, Oxygenation @ preanesthetic level

BP within 20% preanesthetic level, stable HR & rhythm

Fully awake, MAE voluntarily

Pain mgt not requiring continuos intervention

• •“Floppy”
• •Poorly coordinated w/ ineffective abdominal & intercostal muscle activity
• •C/O restricted breathing & suffocating
• •May be willing to respond to commands
• •Unable to sustain head lift or hand grasp
• •Extreme case---upper airway collapse & respiratory obstruction after extubation
• •Don’t be fooled by TOF 4/4 or spontaneous rhythmic breathing

• •Inadequate reversal of neuromuscular blockade
• •Narcosis
• Interference with Gas Exchange:
• •Residual inhalational anesthesia 
• •Aspiration of gastric contents & reactive airway disease
• •Bronchial foreign body & pneumothorax
• •Supraglottic obstruction
• •Fluid overload

• •Coarse breath sounds
• •Pink, frothy sputum
• •Hypoxia & HTN often precede these physical signs
• •CXR findings: normal-sized heart, alveolar infiltrates

• •Etiology: vigorous ventilatory effort against a partially closed glottis or small ETT
• •Common scenario: rapid emergence in patient that was intoxicated @ intubation
• •Young muscular patients
• •May occur in any patient that experiences some degree of laryngospasm with  extubation
• •Often occurs following narcosis reversal to achieve conditions for extubation

• •Treatment: supportive measures, minimal diuresis
• •Follow-up: extended PACU observation or hospitalization

•Pain, hypothermia with shivering, bladder distention, essential HTN

•Hyperthyroidism, pheochromocytoma, MH

•Hypoxemia, hypercarbia, fever & its etiologies, anemia, hypoglycemia,  tachydysrhythmias, withdrawal, myocardia ischemia, meds, PMH, surgical procedures,  intraop events

•Warming patient & controlling pain in PACU reduces sympathetic tone & redistributes blood volume to periphery

•Effects of surgical blood loss, 3rd spacing, ongoing hemorrhage, & inadequate volume replacement ⇨ hypotension

• •Must be treated swiftly & aggressively
• •Volume expansion!!!!
• •Then if necessary, vasopressors or inotropes

• Failure to progress beyond protective airway reflexes &  minimal conscious awareness
• May be residual drug effects
• If persists, consider ventilatory, metabolic, & CNS etiologies

PONV 

Assess for potential preoperatively by trying to identify at risk patients!!!