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What Mallampati class would predict a difficult airway?
Mallampati class 3 or 4
What is the thyromental distance? What value would indicate a difficult airway?
- Distance btw thyroid cart prominence and chin.
- < 3 finger widths = difficult airway
What is the interincisor distance? What value would indicate a difficult airway?
- Distance between top and bottom teeth when open mouth.
- < 2.5 cm = difficult airway
What is the Atlantoocipital ROM?
Ability to bring head to chest and to extend head back to 35 degrees (sniff position)
What is Mandibular mobility?
Ability of patient to move lower jaw, assessed with either Mandibular protrusion test or upper lip bite test.
How is the Mandibular protrusion test performed?
Ask patient to protrude lower incisors anterior to upper incisors, ability to do so is class a
What position should the patient be in when assessing thyromental distance?
Sitting up, looking either forward or to the side
What other factors should be considered when assessing the airway?
- -length of upper incisors (long)
- -shape of palate (narrow)
- -neck length (short)
- -neck girth
- (predictors of more difficult airway)
What's the biggest predictor of a difficult airway?
Past difficult intubation
What does LEMON stand for?
- Airway assessment pneumonic:
- Look at anatomy
- Examine airway
- Neck mobility
T or F, you should ask the patient to say "ahh" when doing the Mallampati classification?
FALSE! This raises the soft palate and does not provide accurate info about the airway.
What structure can you see in a Mallampati 1 airway that isn't seen in classes 2-4?
What's the difference between a Mallampati 2 and 3 classification?
The fauces can be seen in 2, not in 3
What minimum ASA class is a smoker automatically assigned?
What's the most important part of the intraop assessment?
The sweep or circle check. Should be done q5 mins. Points are patient, anesthesia machine, drugs, surgical field (blood loss), IVF, UOP.
What are the two levels of PACU care and what is the difference between the two?
Phase 1- higher intensity care, ICU nurse to patient ratios, required after all regional anesthesia (spinal or epidural)
Phase 2- less intense monitoring, s/p GA pts with stable hemodynamics may go straight here
Who decides what level of PACU care the patient requires?
T or F, all pts require a minimum of 30 mins in PACU?
false, no specific minimum period of time for PACU care
What is the Aldrete score? What are its components?
PACU score to assess readiness for PACU discharge. 5 components, all scored from 0 to 2. Goal = score of 9 or greater to leave PACU.
Activity, Respiration, Circulation, Consciousness, O2 sat
What minimal ASA classification is automatically assigned to morbidly obese patients?
What would make someone an ASA class 2?
mild systemic disease
What would make someone an ASA class 3?
severe systemic disease, but not incapacitating
What would make someone an ASA class 4?
severe systemic disease that is a constant threat to life, ex: ICU pt
What would make someone an ASA class 5?
not expected to live for 24 hours regardless of surgery
What would make someone an ASA class 6?
What respiratory symptoms would lead to cancelling a case in an adult? Would you do the same for a child?
- Fever or purulent secretions in an adult. Would cancel surgery for adult or child.
- -In adults avoid elective procedures with minor cold, however probably wouldn't cancel surgery for a child since they have so many colds each year, it would be near impossible for them to schedule surgery when they're not sick.
T or F, with MAC the patient should be able to maintain their airway and protective reflexes
T, however, everyone has the possibility to LOOSE their airway, hence it is performed by anesthesia
What are limitations to the ASA physical status classification system?
-It's imprecise, subjective, and inconsistent
-Only the higher ASA classes (3+4) roughly predict anesthetic risk
What are general NPO guidelines?
- No solid food for 6-8 hours
- Oral pre-op meds may be taken 1-2 hours prior with a sip of water
What best prevents aspiration?
In what patients would you want to place an NGT pre-op?
Pts with GI obstruction or SBO!
When is a decrease in respiratory morbidity seen after smoking cessation?
After 6-8 weeks
T or F, pre-op PFTs are done routinely for pts with lung disease or smokers?
F! History, auscultation, and CXR are usually adequate
What minimum Plt count is required to prevent surgical bleeding?
Bob takes coumadin, his INR is 2, and is scheduled to have a spinal, ok, right?
NO! No anticoagulants and regional anesthesia.
Antiplatelet meds like ASA or NSAIDs are controversial and need to be discussed with the surgeon
T or F, an acutely intoxicated patient needs no aspiration precautions for his emergency surgery?
F! They should be treated as full stomach
How can we try to prevent PONV?
Ask for potential pre-op to identify at risk pts and take measures to help prevent it.