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Who does the Preop Eval/Assessment/Anesthetic Care plan?
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*
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What does the Preop Eval Involve?
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
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Besides Medications, Drug allergies, & Cigarettes, alcohol, illicit drugs we ask about previous anesthesia/surgical experiences. Why?
- 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
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What does PQRST in the history of present illness mean? (in Health history section of Pre-anesthesia eval)
Pain/Quality/Radiating/Site?Timing
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What is important to know about Diagnostic Studies?
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
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What Happens after the Anesthetic Plan is Formulated?
- 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”
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Explain Informed consent
- 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
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What are some advantages of a well done pre-op eval?
Establishes a trusting provider-patient relationship
Significantly diminishes patient anxiety
Measurably influences postop recovery & outcomes
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TRUE or FALSE. ASA status is Imprecise,
subjective, inconsistent. ONLY the higher ASA class roughly predicts anesthetic risk
TRUE
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Name the 5 ASA physical status classifications.
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
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Why is an E sometimes added to the end of an ASA classification?
To denote an emergency surgery
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Is there a class 6 ASA?
Organ donor
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How important are the ASA classifications?
In addition to faciltiating communication about the patient, it effects reimbursement for anesthesia services
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What are the general NPO guidelines?
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
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What are the current PEDI fasting guidelines?
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
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Name people at risk for aspiration
- 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
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How does obesity affect our anesthetic plan?
- 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
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20% of care plans are altered due to conditions identified at preop eval (15% of ASA Class 1 & 2 Patients) what are the common condition that result in changes?
GERD, IDDM, Asthma, & potential difficult airway!
This is why it is preferable to see the patient for preop eval before the day of surgery!!!!!
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What are the two general reasons for a preoperative consult?
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
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Deleterious effects of smoking....(two of them anyway)
CO decreases O2 delivery to tissues
Nicotine increases HR & causes peripheral vasoconstriction
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Why is it important to tell your patients to at least quit smoking for a little while before surgery?
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
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When are PFTs useful?
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
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TRUE or FALSE. History, auscultation, & CXR are usually adequate for a safe anesthetic (rather than getting PFTs)
TRUE
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Why would you do a Preoperative Cardiac Evaluation in Patients Undergoing Non-Cardiac Surgery
- 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.
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Obviously we want to know about our patients coagulation status prior to surgery. What kind of questions would you ask?
- 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
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What is the minimal # platelets to prevent surgical bleeding?
50,000/mm3
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What kinds of pre-op questions would we ask a diabetic?
- 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)?
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What is the minimum testing for a pre-op diabetic?
- Glucose
- Electrolytes
- BUN/creatinine
- UA
- EKG
- Optional: ABGs, ketones, osmolarity, Ca2+, PO4-, Mg2+
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What are some considerations for the alcoholic patient
- Multisystem disease
- Increased CNS tolerance to volatile & induction agents
- Perioperative withdrawal/seizures/DTs
- Paradoxical excitation to sedatives & hypnotics
- Peripheral neuropathy/regional anesthesia
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What are our concerns of the cardio and GI systems of an alcoholic patient?
Cardiovascular: HTN & alcoholic cardiomyopathy
GI: gastritis, bleeding, hepatitis, pancreatitis
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TRUE or FALSE? Chronic abuse of alcohol will increase hepatic metabolic activity w/ increased tolerance to LA, sedatives, analgesics, & NMBs
TRUE
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What are your concerns for the alcoholic patient with IMPAIRED LIVER FUNCTION?
INCREASED drug effect, coagulopathy, esophageal varices
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Do alcoholics have metabolic & nutritional abnormalities?
YES. Metabolic & nutritional abnormalities: thiamine deficiency, hypophosphatemia, hypomagnesemia, hypocalcemia
Leukopenia & anemia
Possibly thrombocytopenia w/ predisposition to DIC
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Alcoholic pre-op pt, you ask CAGE questions. What are they?
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
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What are some signs of withdrawal from alcohol?
Signs of early withdrawal: tremor, agitation, confusion, increased HR
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How do you treat a patient with ACUTE alcohol injestion?
- 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
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What labs would you get for a patient who is acutely intoxicated?
ETOH level, drug screen (polysubstance abuse), CBC, electrolytes, glucose, LFTs, coagulation profile, EKG, calcium, phosphorus, magnesium
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What do we do about the patient with an upper respiratory viral infection???
- 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
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What about an URI in pediatrics?
- 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
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Predictors of a difficult airway
- 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
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TRUE or FALSE. Interincisor distance is a fairly good predictor of airway but not as good as neck circumference or thyromental distance
TRUE
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What is the Alantooccipital range of motion?
Ability to touch chin to chest
Ability to extend neck to 35 degrees
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What does this picture show?
Lifting head up alining the pharyngeal-laryngeal axis and 90 degrees to oral airway
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How do you assess for mandibular mobility?
- Mandibular protrusion test
- Upper Lip Bite Test
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Explain the different classes of the mandibular protrusion test
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Besides the multiple tests we do in the pre-op assessment. What are some other considerations for the airway assessment?
- Length of Upper Incisors
- Shape of Palate
- Length of neck
- Girth of neck
- Obesity
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What does LEMON stand for?
(NEED TO KNOW THIS!!!)
- Look at anatomy
- Examine airway
- Mallampati
- Obstructions
- Neck Mobility
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What are some things we monitor for in the OR?
- •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
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What is a circle check?
Pt is 1200, going clockwise around you every 5-15minutes to ensure everything is okay/working correctly. (document VS at least every 5min)
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Describe Phase 1 of PACU
- Monitoring & staffing ratios equivalent to ICU
- After neuroaxis regional anesthesia (RA)
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Describe Phase 2 of PACU
- •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
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How is the sequence of post-op care determined?
by preexisting disease, surgical procedure, & pharmacological implications of periop anesthetic agents
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TRUE or FALSE. A mandatory period of high-intensity care for every postop patient is an obsolete requirement
TRUE
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•On admission to PACU, anesthesia provider gives report to PACU nurse. What do you include?
- •Your report guides the intensity & duration of PACU observations
- •Anesthetic technique
- •Administered agents
- •Type & reversal of neuromuscular blockade
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The PACU RN performs and initial assessment. What is she looking for?
- •Baseline responsiveness
- •Ventilation
- •Pain
- •VS
- •Regression of motor blockade with regional anesthesia
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The Aldrete Score includes what 5 things? (NEED TO KNOW THIS!)
- Activity
- Respiration
- Circulation
- Consciousness
- O2 Saturation
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•Poor respiratory effort is a PACU problem that must be resolved. What are the goals?
•Breathing easily, coughing on command, Oxygenation @ preanesthetic level
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Hemodynamic instability is a PACU problem that must be resolved, what are the goals?
BP within 20% preanesthetic level, stable HR & rhythm
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Attenuated sensorium is a PACU problem that must be resolved, what are the two goals?
Fully awake, MAE voluntarily
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Postoperative pain is a PACU problem that must be resolved, what is the goal?
Pain mgt not requiring continuos intervention
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What is Residual Neuromuscular Blockade?
- •“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
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What are some causes of ventilation problems in the PACU?
- •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
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Negative Pressure Edema is a phenomenon unique to the postextubation period. What are the s/s?
- •Coarse breath sounds
- •Pink, frothy sputum
- •Hypoxia & HTN often precede these physical signs
- •CXR findings: normal-sized heart, alveolar infiltrates
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What causes negative pressure edema in the postextubation period?
- •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
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What is the tx and follow up for negative pressure edema in the post extubation period?
- •Treatment: supportive measures, minimal diuresis
- •Follow-up: extended PACU observation or hospitalization
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What are some frequent, treatable causes of post-op HTN and tachycardia?
•Pain, hypothermia with shivering, bladder distention, essential HTN
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What are some rare causes of post-op HTN and tachycardia
•Hyperthyroidism, pheochromocytoma, MH
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Your post-op patient is HTN and tachycardic, you've ruled out the common treatable causes, what are some other causes?
•Hypoxemia, hypercarbia, fever & its etiologies, anemia, hypoglycemia, tachydysrhythmias, withdrawal, myocardia ischemia, meds, PMH, surgical procedures, intraop events
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What are some causes of post-op hypotension?
•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
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How do you treat post-op hypotension?
- •Must be treated swiftly & aggressively
- •Volume expansion!!!!
- •Then if necessary, vasopressors or inotropes
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What does slow to awaken mean?
- Failure to progress beyond protective airway reflexes & minimal conscious awareness
- May be residual drug effects
- If persists, consider ventilatory, metabolic, & CNS etiologies
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What is the common post-op problem?
PONV
Assess for potential preoperatively by trying to identify at risk patients!!!
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