Preanesthetic Evaluation

1
Preanesthetic Evaluation
2
Purposes of thePreoperative Evaluation

• Obtain medical history
• Review current physical status
• Order additional tests / consultation
• Answer questions

3
Purposes of thePreoperative Evaluation (cont)

• Reassure patient / allay anxiety
• Order preoperative medications
• Obtain informed consent
• Document the record
• Develop care plan

4
Sources of Information

• Chart review
• Previous hospital records
• Lab / x-ray data
• Consultations
• Patient interview
• Discussion with surgeon

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Medical History

• Review the chart
• Review previous records
• Interview the patient

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The Chart Review

• Demographic Data
• Height / weight
• Vital signs
• Diagnosis

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The Chart Review (cont)

• History and Physical Exam
• Note abnormalities
• Dont assume that all problems are listed

8
The Chart Review (cont)

• Medications
• Routine medications at home
• Meds ordered in hospital
• Lab / x-ray results
• Consultations

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Old Hospital Records

• Available in same institution
• Previous diagnosis
• Previous treatment

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Old Hospital Records (cont)

• Review prior anesthesia record
• Induction doses
• Airway difficulty
• Work-up

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Patient Interview

• First impression is essential
• Look and act professional
• Clearly identify yourself

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Patient Interview (cont)

• Create the environment
• Relaxed yet professional
• Ensure privacy (confidentiality)
• Dismiss extra people

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Patient Interview (cont)

• Allow appropriate amount of time
• Either too long or too short will cause anxiety
• Remain non-judgmental

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Begin the Interview

• Identify yourself
• Start with general questions
• What type of surgery will you have?
• What problems caused you to seek medical help?

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Begin the Interview (cont)

• General questions (cont)
• Have you ever had surgery before?
• Were there any problems?
• Has anyone in your family ever had a problem with
  anesthesia?

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Begin the Interview (cont)

• Proceed to systems review
• Review systems in the same order

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Overall General Health

• How would you rate your overall health?
• Are you being treated for any medical conditions?
• What type of work do you do?

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Overall General Health (cont)

• What is your level of activity?
• Do you have a lifestyle which places you at risk
  for the HIV virus?

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Overall General Health (cont)

• Do you take any drugs, herbs or medications?
• List drugs and dosage
• Identify herbals

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Medication History

• Provides insight into medical problems
• May influence anesthetic plan

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Medication History (cont)

• Gives insight into compliance with directions
• Alerts provider to potential interaction

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Implication of Specific Drugs

• Antihypertensives
• May cause dehydration
• Some will potentiate anesthetics
• Continue on day of surgery

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Specific Drugs (cont)

• Diuretics
• Cause dehydration
• Hypokalemia is common
• Do not give day of surgery

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Specific Drugs (cont)

• Antianginal
• Calcium channel / beta blockers / nitrates
• Give day of surgery

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Specific Drugs (cont)

• Antidysrhythmic
• Generally should be continued
• May have significant side effects
• Do not discontinue without consulting staff

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Specific Drugs (cont)

• Bronchodilators
• Use of aminophylline is controversial
• Volatile agents are bronchodilators
• Aerosolized bronchodilators and corticosteroids
  as needed

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Specific Drugs (cont)

• Insulin
• Tight control expensive and difficult
• Loose control favored at most hospitals

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Specific Drugs (cont)

• Insulin - Loose control (cont)
• A) No insulin / start IV / check glucose
• B) Start IV with dextrose / 1/2 insulin dose /
  check glucose

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Specific Drugs (cont)

• Oral Hypoglycemics
• Usually held on day of surgery
• Compete for plasma binding sites

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Specific Drugs (cont)

• Corticosteroids
• Take detailed history of steroid use
• May need stress dose
• Consult with your staff

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Specific Drugs (cont)

• Thyroid medication
• Thyroxine may be held or given
• Antithyroid drugs should be given

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Specific Drugs (cont)

• Anticonvulsant Drugs
• Should be given
• May induce liver enzymes
• May alter pharmacokinetics of other anesthetic
  drugs

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Specific Drugs (cont)

• Monoamine Oxidase Inhibitors
• Should be discontinued two weeks prior to surgery
• Increases catecholamine stores
• Caution with meperidine

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Specific Drugs (cont)

• Tricyclic antidepressants
• Continue until day of surgery
• Blocks reuptake of norepinephrine
• May cause prolonged sleeping or myocardial
  depression

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Specific Drugs (cont)

• Lithium
• Continue until day of surgery
• Muscle relaxant

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Specific Drugs (cont)

• Anti-inflammatory
• Interferes with platelet function
• Surgeon will decide

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Specific Drugs (cont)

• Anticoagulants
• Surgeon will regulate
• Switch to heparin
• Stop 3-4 hours pre-op

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Specific Drugs (cont)

• Antineoplastic agents
• Take a good history
• Look up specific agent

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Specific Drugs (cont)

• Antiglaucoma
• Cholinesterase inhibitors
• Beta blockers

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Specific Drugs (cont)

• Antibiotics
• Be aware of cross sensitivity
• May potentiate muscle relaxants

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Specific Drugs (cont)

• Opioids and Benzodiazepines
• Know time and amount of last dose
• Titrate according to need

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Specific Drugs (cont)

• Recreational drugs
• Remain non-judgmental
• Emphasize safety
• Look for withdrawal symptoms

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Overall General Health (cont)

• Are you allergic to any drugs or medications?
• Side effects are not allergies
• Note drug and type of reaction
• Use extreme caution evaluating prior anaphylaxis

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General Appearance

• Body habitus
• Obvious deformities
• Color (cyanosis / jaundice)
• Does he/she look ill?

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Evaluate the Airway

• Ability to open mouth
• Ability to extend neck
• History of previous head / neck surgery
• Note dentition

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Mouth / Dental Evaluation

• Answer two basic questions
• What is the condition of the teeth?
• Will the patient be difficult to intubate?

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Mouth / Dental Eval. (cont)

• Dental considerations
• Loose teeth
• False teeth
• Bridges / capped teeth
• Poor dental hygiene

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Mouth / Dental Eval. (cont)

• Airway considerations (Wilson)
• Body weight
• Head and neck movement
• Jaw movement
• Receding mandible
• Buck teeth

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Mouth / Dental Eval. (cont)

• Mallampati system
• Sitting position
• Mouth fully open
• Tongue protruding

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Mallampatis Classification

• Class I Class II Class III Class IV

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Evaluate the Airway (cont)

• Assign Mallampatti Classification
• Listen to breath sounds Note findings

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Pulmonary

• Observe character of respiration
• Detailed history
• Acute disease - asthma / bronchitis / pneumonia
• chronic disease - COPD / tuberculosis

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Pulmonary (cont)

• Detailed history (cont)
• Recent URI / sore throat
• Productive cough
• Dyspnea (exertion or resting)
• Sleep apnea

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Pulmonary (cont)

• Detailed history (cont)
• Allergies (hay fever)
• Hoarseness / stridor
• Exercise tolerance

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Asthma

• Get detailed history
• Last episode
• How is it treated?
• Ever hospitalized?

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Asthma (cont)

• Advise of potential risk
• Bronchodilator therapy
• Morning of surgery
• Bring inhaler to O.R.

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Tobacco History

• Signs of COPD
• Productive cough
• Note pack-years
• packs per day times number of years patient has
  smoked

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Circulatory System

• Abnormalities are common
• Problems range from mild hypertension to severe
  ischemic disease

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Circulatory System (cont)

• Look for other risk factors
• Age
• Weight
• Smoking history
• Angina
• Hypercholesterolemia
• Diabetes

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Hypertension

• How long?
• How is it treated?
• Compliance with treatment
• How well is it controlled?
• Note All hypertensive patients are hypovolemic
  until proven otherwise

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Severe Hypertension

• Systolic gt195
• Diastolic gt100
• Delay non-urgent surgery
• Obtain appropriate consult and treatment

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Mild Hypertension

• Systolic lt 165
• Diastolic lt100
• Evaluate other risk factors
• proceed with caution
• obtain appropriate follow-up

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Coronary Artery Disease

• Goal is to determine
• type
• severity
• functional limitation

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Coronary Artery Disease (cont)

• Risk Factors
• age over 45
• obesity
• hypertension
• smoking history
• family history of CAD

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Coronary Artery Disease (cont)

• Risk Factors (cont)
• diabetes
• angina
• prior M.I. or C.H.F.
• dysrhythmias

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Coronary Artery Disease (cont)

• High Risk
• M.I. within past 6 months
• congestive heart failure

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Coronary Artery Disease (cont)

• Exercise Tolerance
• Stair climbing is standard
• two or more flights indicates good reserve
• Assess daily activities

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Coronary Artery Disease (cont)

• Angina
• Stable -- Proceed with surgery
• Unstable -- Emergency surgery only
• chest pain at rest
• chest pain with mild exercise
• chest pain that varies in frequency and duration

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Coronary Artery Disease (cont)

• Congestive Heart Failure
• Extremely high risk
• Signs
• night coughing, diaphoresis
• palpitations
• orthopnea

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Coronary Artery Disease (cont)

• Prior myocardial infarction
• Delay elective surgery at least six months
• aggressive monitoring required
• careful selection of anesthetic

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Coronary Artery Disease (cont)

• Valvular Heart Disease
• Each has specific consideration

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Coronary Artery Disease (cont)

• Physical Examination
• Listen to heart and lungs
• Correlate symptoms to ECG

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The Nervous System

• Problems may be central or peripheral
• Thorough history is essential
• Correlate history with physical findings

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Central Nervous System

• Sources of Problems
• Ischemia / Vasospasm
• Embolism / Thrombosis
• Tumor

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Central Nervous System (cont)

• Sources of Problems (cont)
• Aneurysm / Hemorrhage
• Seizures
• Stroke

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Central Nervous System (cont)

• Signs and Symptoms
• Nausea / Vomiting
• Vertigo
• Headache / Visual problems
• Sensory abnormalities
• Motor weakness

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Central Nervous System (cont)

• Signs and Symptoms (cont)
• Hypertension / Bradycardia
• Focal sensory deficit
• Slurred speech
• Confusion / Disorientation
• Coma

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Periphral Neuropathy

• Get neurology consult for new symptoms
• Evaluation essential prior to regional anesthesia

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Peripheral Neuropathy (cont)

• Sources of Problems
• Autonomic dysfunction
• Diabetes
• Drug-induced neuropathy
• Nerve compression

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Peripheral Neuropathy (cont)

• Signs and Symptoms
• Pain
• Increased or decreased Sensation
• Cold intolerance

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Peripheral Neuropathy (cont)

• Signs and Symptoms (cont)
• Weakness / Loss of function
• Cold / Pale extremity
• Diminished reflexes

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Hepatic System

• History of Jaundice or Hepatitis
• Viral hepatitis
• Easily transmitted
• Non-specific symptoms

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Hepatic System (cont)

• Viral Hepatitis (cont)
• Non-specific Symptoms (cont)
• fatigue
• malaise
• vague abdominal pain

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Hepatic System (cont)

• Symptoms of Hepatitis
• Spider nevi
• Ascites
• Generalized tremor
• Cyanosis
• Confusion / Disorientation

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Hepatic System (cont)

• Coexisting Disease
• Obesity / Fatty Liver
• Alcohol abuse
• Multiple blood transfusions
• Recreational drug use
• Dialysis

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Renal System

• Problems may be from urine formation or from
  urine drainage

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Renal System (cont)

• Problems with Urine Drainage
• Chronic cystitis
• Prostatitis
• Renal calculi

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Renal System (cont)

• Acute / Chronic Renal Failure
• Total body disease
• Electrolyte abnormalities
• Coagulation disorders
• Hypervolemic, hypertensive, hyperkalemic

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Renal System (cont)

• Acute / Chronic Failure (cont)
• Get accurate dialysis history
• dialysis schedule
• last dialysis
• Lytes after dialysis

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Gastrointestinal System

• Observe nutritional status
• Obese vs. anorexic
• History of weight gain or loss
• Note electrolytes

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Gastrointestinal System (cont)

• Gastric reflux
• Get accurate history
• Evaluate risk of aspiration

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Gastrointestinal System (cont)

• Gastric reflux (cont)
• Consider gastric prep
• Zantac
• Metoclopramide
• Antacid

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Gastrointestinal System (cont)

• Gastric reflux (cont)
• Rapid sequence induction
• Cricoid pressure

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Gastrointestinal System (cont)

• Emergency / Trauma patient
• Always consider to have full stomach
• Pain will stop gastric motility
• Consider stomach prep
• Rapid sequence induction

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Gastrointestinal System (cont)

• Always check NPO status prior to induction
• 6-8 hours for solids
• 2-3 hours for liquids

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Endocrine System

• Diabetes Mellitus
• Type I -- Insulin dependent
• End organ disease is common
• hypertension
• coronary artery disease
• neuropathy

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Endocrine System (cont)

• Type I Diabetes (cont)
• End organ disease (cont)
• retinopathy
• nephropathy
• autonomic dysfunction

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Endocrine System (cont)

• Diabetes Mellitus (cont)
• Type II -- Non-insulin dependent
• Onset usually after pregnancy or excessive weight
  gain
• controlled with diet and exercise

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Endocrine System (cont)

• Diabetes Mellitus (cont)
• Goals of Management
• Maintain glucose in 100-250 range
• Provide adequate fluid volume
• Individualize care plan

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Endocrine System (cont)

• Thyroid / Parathyroid Disease
• Hyperthyroidism
• Excessive secretion of T3 and T4

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Endocrine System (cont)

• Hyperthyroidism (cont)
• Signs and Symptoms
• Hypermetabolism
• Exophthalmous
• Elevated T3 and T4

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Endocrine System (cont)

• Hyperthyroidism (cont)
• Treatment
• Propylthiouracil
• Beta blockade

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Endocrine System (cont)

• Hypothyroidism
• Signs and Symptoms
• Hypometabolism
• Low T3 and T4
• May have large tongue
• Treat with synthroid

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Endocrine System (cont)

• Hyperparathyroidism
• Hypercalcemia
• Increased bone resorption
• Reduced renal excretion of calcium

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Endocrine System (cont)

• Hyperparathyroidism (cont)
• Diagnosis
• High serum calcium
• High parathyroid levels
• Patient may be on corticosteroids

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Endocrine System (cont)

• Pheochromocytoma
• Tumor of chromaffin tissue
• Increased production and release of epinephrine
  and norepinephrine

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Endocrine System (cont)

• Pheochromocytoma (cont)
• Signs and symptoms
• Intermittent hypertension
• Headache
• Sweating
• Tachycardia

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Endocrine System (cont)

• Pheochromocytoma (cont)
• Secondary problems
• Hyperglycemia
• Myocarditis
• Cardiomyopathy

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Endocrine System (cont)

• Pheochromocytoma (cont)
• Secondary problems (cont)
• M.I. with CHF
• Hemorrhage into brain or heart

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Endocrine System (cont)

• Pheochromocytoma (cont)
• Diagnosis
• Increased serum epinephrine / norepinephrine
• Increased urine vanillylman-delic acid and
  metanephrine

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Endocrine System (cont)

• Carcinoid Syndrome
• Rare, slow-growing gastrointes-tinal tumor
• Release vasoactive amines and polypeptides

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Endocrine System (cont)

• Carcinoid Syndrome (cont)
• 5-hydroxytryptamine
• Diarrhea
• Abdominal cramps
• Respiratory distress / bronchospasm
• Hypertension

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Endocrine System (cont)

• Histamine and Bradykinin
• Paroxysmal hypotension
• Cutaneous flushing
• Bronchospasm

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Endocrine System (cont)

• Tumor removal
• Metastasis remain
• Relieve obstruction
• Airway
• Bowel
• Major blood vessels

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Endocrine System (cont)

• Adrenal cortical dysfunction
• Secondary to primary disease
• Adrenal cortex tumor
• Pituitary tumor

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Endocrine System (cont)

• Adrenal cortical dysfunction
• Secondary to prolonged steroid therapy
• Scleroderma
• Ulcerative colitis
• Effects may persist up to a year

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Endocrine System (cont)

• Adrenal cortical dysfunction
• Cushings syndrome
• Truncal obesity
• Moon face
• Skin striations
• Easy bruising

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Endocrine System (cont)

• Adrenal cortical dysfunction
• Cushings syndrome (cont)
• Hypertension
• Hypovolemia

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Endocrine System (cont)

• Excess mineralocorticoid (aldosterone) causes
• sodium retention
• potassium depletion
• polyuria
• alkalosis

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Endocrine System (cont)

• Adrenal cortical dysfunction
• Treatment
• Correct fluid volume status
• Correct electrolyte abnormalities
• Administer steroids

121
Hematologic System

• Anemia
• Hemoglobin required for oxygen delivery
• Oxygen supply and demand must match

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Hematologic System (cont)

• Anemia (cont)
• Patients do not want transfusion
• Autologous blood
• Directed donor
• HCT-30 and HGN-10 no longer required

123
Hematologic System (cont)

• Anemia (cont)
• 3 key questions
• What is the cause?
• Is it acute or chronic?
• Will the patient benefit from delay?

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Hematologic System (cont)

• Anemia (cont)
• Acute blood loss poorly tolerated
• Chronic renal failure
• Anemia and platelet dysfunction
• Tolerate anemia well
• Platelet dysfunction corrected with dialysis

125
Hematologic System (cont)

• Disorder of hemostasis
• Congenital
• Hemophilia
• Acquired
• Thrombocytopenia
• Hepatic dysfunction

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Hematologic System (cont)

• Acquired disorders (cont)
• Platelet dysfunctionBleeding tends to be at
  membranes

127
Hematologic System (cont)

• Disorder of hemostasis (cont)
• Acquired (cont)
• Deficient coagulation factors
• Anticoagulant therapy
• Liver disease
• Bleeding tends to be deep in mucles or joints

128
Musculoskeletal System

• Chronic back pain
• Learn position of comfort
• Relative contraindication to regional
• Get medication history

129
Musculoskeletal System (cont)

• Osteoarthritis (degenerative)
• Chronic back or joint pain
• Symptoms in localized areas
• Get medication history

130
Musculoskeletal System (cont)

• Rheumatoid arthritis (cont)
• May be total body disease
• Neck and larynx
• Myocarditis
• Pleuritis
• Restrictive lung disease

131
Musculoskeletal System (cont)

• Rheumatoid arthritis (cont)
• Medication history
• Aspirin
• Non-steroidal anti-inflammatory drugs
• Steroids

132
Musculoskeletal System (cont)

• Muscular dystrophies
• Most common in children
• Get detailed history
• Look up specific condition
• Associated with higher incidence of M.H.

133
Reproductive System

• Excessive vaginal bleeding may cause anemia
• Suspect pregnancy
• Obtain menstrual history
• Ask about possibility of pregnancy
• Obtain pregnancy test if in doubt

134
Reproductive System (cont)

• Effects of Anesthesia
• Increased spontaneous abortion
• Questionable teratogenesis

135
Obesity

• Common physical finding
• Morbid obesity is a total body disease
• Determine ideal body weight and the body mass
  index

136
Ideal Body Weight

• The Broca Index
• Height in centimeters minus
• 105 for women
• 100 for men
• This gives ideal body weight in kilograms

137
Body Mass Index

• Weight (kg)
• Height (M2)
• Normal 24-26
• Lowest obese weight 30

138
Morbid Obesity

• Twice the ideal body weight
• Physiologic changes
• Altered blood volume
• Increased total volume
• Decreased ml / kg
• Increased O2 demand

139
Morbid Obesity (cont)

• Physiologic changes (cont)
• Increased work of breathing
• Decreased lung volumes
• Decreased pulmonary compliance

140
Morbid Obesity (cont)

• Physiologic changes (cont)
• Hypoventilation / hypoxemia / polycythemia
• Coronary artery disease
• Congestive heart failure
• Fatty liver

141
Morbid Obesity (cont)

• Physiologic changes (cont)
• Diabetes
• Renal insufficiency
• Even the easy things are difficult in the
  morbidly obese patient

142
Laboratory Testing

• Establishes a baseline
• May detect unknown condition
• Yield is very small
• Findings seldom change anesthetic plan

143
Laboratory Testing (cont)

• Follow institutional protocols
• Order tests when indicated
• Hypertension (lytes)
• Digitalis (lytes)
• Diabetes (glucose)

144
Obtaining a Consult

• Coordinate with CRNA and MD staff before ordering
  
• Have a specific indication
• Briefly state history

145
Obtaining a Consult (cont)

• Ask specific questions which you want answered
• Talk directly to the consultant

146
ASA Physical Status

• Developed for statistical studies
• Used to compare outcomes

147
ASA Physical Status (cont)

• Provides quick summary of physical status
• Not meant as risk classification
• Must be assigned to each patient

148
Informed Consent

• Frequently questioned in malpractice cases
• Risks / benefits
• Alternatives
• Answer all questions
• Do not deceive the patient

149
Risks of Anesthesia

• Determine what the patient wants to know - Do not
  needlessly frighten patients
• Start with minor risks
• Proceed to serious risks

150
Risks of Anesthesia (cont)

• Relate risk to physical condition
• Specifically include
• Dental damage
• Aspiration
• Death
• Emphasize safety of monitors

151
Document the Visit

• Complete the evaluation form
• Enter progress notes
• Have patient sign consent
• Write appropriate orders