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Merrittk
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What is the difference between subjective and objective data gathered during a preoperative evaluation?
Subjective data- Judy says: "anything you gather with your senses", interview
Objective- physical exam
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What is the best resource you have to determine the status of the patient's airway and subsequent difficulty of intubation?
Previous anesthesia record
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What are some advantages of a well done preoperative evaluation?
1. Establish a trusting provider-patient relationship
2. Significantly diminishes patient anxiety
3. Measurable influences postoperative recovery and outcomes
4. Limits lawsuits
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What happens after the anesthetic plan is formulated?
INFORMED CONSENT
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Describe Class 1-5 ASA Physical Status Classifications.
- Class 1- health patients, no medical problems
- Class 2-mild systemic disease
- Class 3- severe systemic disease, but not incapacitating
- Class 4- severe systemic disease that is a constant threat to life
- Class 5- not expected to live 24 hours regardless of surgery
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Is there a Class 6 in ASA Physical Status Classifications?
YES!
Indicates an Organ Donor
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What does an E denote if added to the ASA Physical Status Classification?
Emergency Surgery
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What are shortcomings of the ASA classifications?
- Imprecise
- Subjective
- Inconsistent
-Only the higher ASA class roughly predicts anesthetic risk
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Oral preoperative medications can be taken:
up to 1-2 hours before anesthesia with water sips
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What risk factors place a patient at high risk for aspiration?
- -GI Obstruction
- -GERD
- -Gastric banding patients
- -Diabetes
- -Ate solids recently
- -Abdominal distension
- -Pregnancy
- -Depressed consciousness
- -Recent opioid administration
- -Naso-oropharyngeal bleeding
- -Upper GI bleed
- -Airway Trauma
- -Emergency Surgery
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What is a majorly underappreciated comorbidity? (per Judy)
Obesity!
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What are some general characteristics of Obesity?
- -Excess body weight >20% over predicted ideal body weight
- -Higher incidence of DM, HTN, and CV disease
- -Higher incidence of difficult ventilation and intubation
- -Decreased FRC
- -Increased O2 consumption
- -Increased CO2 production
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What patient population that we talked about in class is at risk for RAPID APNEIC DESATURATION?
Obese.
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What is Pickwickian Syndrome?
Obesity Hypoventilation syndrome and obstructive sleep apnea combined- common comorbidity of obesity
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Decision to order lab tests should be driven by:
Patient history
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How long does a patient need to quit smoking before a significant decrease in respiratory morbidity will be seen?
6-8 weeks
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In terms of coagulation status, what question is important to ask the patient in the preoperative assessment?
Have you had an abnormal bleeding or bruising?
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What standardized assessment can be used to evaluate alcoholic patients?
- CAGE
- 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 taken an eye opener in the morning?
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Why is it important to thoroughly evaluate a patient with a cold preoperatively?
- If patient has an upper respiratory viral infection...
- -alters quantity and quality of secretions
- -increases airway reflexes to mechanical, chemical, or irritant stimulation
- -Intraoperative and postoperative bronchospasm, laryngospasm, and hypoxia are common
- -High risk of pulmonary complications at least 2 weeks and maybe even 6-7 weeks after URI
In summary... tell the patient to reschedule.
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If the patient is uncomfortable reporting their weight, what can you do to ease the tension?
Explain the reasoning... weight is how we dose our drugs :)
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When inquiring about family history, what are we looking for? (mainly?)
Any serious problems with anesthesia- specifically incidence of Malignant Hyperthermia
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What is a test dose?
There's no such thing! If patient's are going to have a reaction to a lot of drug, they're still going to react to a little bit of drug. Silly surgeons.
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When inquiring about drug use in patients, why is it important to really assess patient use?
Because we need to provide safe anesthesia! Just make sure the patient knows we're not judging!
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When assessing cardiovascular status, what general question are we trying to answer?
If the patient can handle the stress of surgery.
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If an asthmatic has had an exacerbation in the last 1-2 months, do we need to reschedule a procedure or not?
RESCHEDULE! due to high susceptibility to complications
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What is the Mallampati classification?
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What is the thyromental distance? How is it measured? What result is indicative of a difficult intubation?
Thyromental distance is the distance between the thyroid and the submental area (bottom of the chin).
It's measured using finger-breadths
Anything under 3 finger-breadths is a PROBLEM.
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What is the incisor distance? How is it measured? What result is indicative of a difficult intubation?
Incisor distance is the distance between the top teeth and bottom teeth when patient is asked to open their mouth.
Measured in centimeters.
Anything less than 2.5 centimeters is a PROBLEM.
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What is the Atlantooccipital range of motion? What result is indicative of a difficult intubation?
Basically, asking the patient to move their head back and forth to assess range of motion... ability to touch the chin to the chest and extend the neck to 35 degrees.
If the patient cannot touch their chin to their chest and cannot properly extend their neck there is a PROBLEM
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What is mandibular mobility? How is it measured?
Mandibular mobility is the patient's ability to move their jaw
- Measured with 2 tests:
- 1. Mandibular protrusion test (measured based on relationship between upper teeth and bottom teeth)
- 2. Upper Lip Bite Test- measured based on how close they can get their bottom teeth to their Vermillion line (flesh/lip line)
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What does LEMON stand for?
(this is definitely on the quiz)
- L: Look at the anatomy
- E: Examine airway
- M: Mallampati
- O: Obstructions
- N: Neck Mobility
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What position should the patient be in during the airway assessment ? (ideally)
Sitting up
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How often should the circle check be performed?
EVERY FIVE MINUTES
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What is the difference between Phase 1 and Phase 2 of PACU Care? What are examples of patients in each phase?
Phase 1: Monitoring and staffing rations equivalent to ICU [ex. patient with epidural or spinal (aka neuroaxis regional anesthesia)]
Phase 2: Transition made from intensive observation to stabilization for care on the surgical ward or at home [ex. patient who had a MAC procedure]
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Tell me everything you can about the Aldrete Score.
Important in gauging patient status during PACU care. [where i worked we couldn't discharge a patient from PACU until their score was 9-10]
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What is residual neuromuscular blockade?
- "floppy"
- may have paradoxical chest movement
- unable to sustain head lift or hand grasp
...in extreme case their upper airway may collapse and may obstruct
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Slow ventilation in the PACU causes what?
SLOW ELIMINATION OF VOLATILE AGENT
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True or False:
Past medical history of smoking, asthma, or COPD is important for recognition of patients at increased risk for reactive small airway obstruction.
TRUE!
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What Bill Murray movie accurately describes how your patient will act in PACU?
Groundhogs day.
-Short term memory function can remain unreliable in PACU.
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What is a very common problem in PACU?
PONV- assess for preoperatively and try to identify patients at risk
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