Preoperative Evaluation 24.pptx

Preoperative Evaluation, Fasting Guidelines and Aspiration  Identify the required components of an Identify anesthetic preoperative assessment and informed consent. Apply the conventions of ASA patient...

Preoperative Evaluation, Fasting Guidelines and Aspiration  Identify the required components of an Identify anesthetic preoperative assessment and informed consent. Apply the conventions of ASA patient Apply classification system to determine preoperative ASA patient status. Discuss the co-morbidities impacting Discuss administration of anesthesia, preoperative Student recommendations and testing. Learning Identify Identify the general classes of drugs that should Outcomes be continued or discontinued before surgery. Define aspiration pneumonitis, identify Define prevention strategies for at risk populations and discuss treatment options. Apply Apply the ASA fasting guidelines and recommendations for preoperative fasting. Preanesthesia evaluation is defined as: Preanesthetic Evaluation “the process of clinical assessment that precedes the delivery of anesthesia care for surgery and for non- surgical procedures.”  To obtain pertinent information regarding the patient’s current and past medical history and to formulate an assessment of the patients' intraoperative risk  Identification and Mitigation of risk is the goal-  optimize patient conditions when possible  obtain additional testing, or specialty consultations  alter the management plan Preanesthetic  Inadequate preoperative planning and incomplete patient preparation are commonly associated with Evaluation anesthetic complications  Preoperative evaluation guides the anesthetic plan  Can decrease surgical morbidity, minimize expensive delays and cancellation on the day of surgery, and increase perioperative efficiency (less complications, shorter hospital stays and lower hospital costs) VIDEO   Optimize patient care, satisfaction, comfort, and convenience  Minimize perioperative morbidity and mortality  Minimize surgical delays or preventable cancellations on the day of surgery Goals of the  Determine appropriate postoperative disposition of the patient Preoperativ  Evaluate the patient’s overall health status, determining which if any preop investigations e Eval and  and consultations are required Formulate a plan for the most appropriate Preparation perianesthetic care and postoperative supportive patient care of the  Communicate patient management issues effectively among care providers Patient  Educate patient regarding surgery, anesthesia, and expected intra-and postoperative care, including postoperative pain treatments, to reduce patient anxiety and increase patient satisfaction  Ensure time efficient and cost effective patient evaluation  Emerged as the most cost effective, and convenient means of patient preparation Preanesthesia Assessment Clinic (PAC) Designed to: Meet or Complete any Obtain medical Improve Promote schedule required Permit patient history; regulatory patient appointments preoperative registration perform compliance & teaching with medical diagnostic physical exam OR efficiency consultants testing Content of the preanesthetic evaluation includes, but is not limited to:  Chart Review  Patient interview  A directed preanesthesia examination  Preoperative tests as indicated  Other consultations as appropriate  Fasting considerations  ASA Classification  Patient preoperative Instructions (NPO, Meds, Tobacco Use)   Provides the basis for and direction of the patient interview and assessment  Should review patient past and current medical records (don’t Chart forget OTC meds) Review prior anesthetic records Review  (airway management issues, past issues with anesthesia such as nausea)  Review patient current chart  OBJECTIVES  Ensure that the goals of the preoperative assessment are met  Provide preoperative education to the Patient patient and family  Obtain written documentation of informed Interview  and witnessed consent Acquaint the patient and family with the --------------- surgical process (decrease stress) -  Evaluate the patient's social situation with MEDICAL HX respect to surgery (support) SURGICAL HX  Motivate the patient to comply with preventive care strategies (ex smoking ANESTHETIC HX cessation) DRUG HX  NOT A COMPREHENSIVE H&P  NPO, signs & symptoms of reflux, allergies, recreational  Obtain information Confirm that relates information to found in anesthetic chart review managemen t of patient Interview: Medical Obtained in an Establish History organized current and problem and systematic illness way   Focused preoperative medical history (review of systems)  Airway  Cardiac Elements of  Pulmonary the  Kidney Preoperativ  Endocrine and metabolic e Medical disease Gastrointestinal History   Musculoskeletal  Coagulation issues  Anatomic issues relevant (airway, regional) Interview: Surgical & Anesthetic History Obtain information about previous surgery and surgical experience Past anesthetic experiences (types of anesthesia) Adverse reactions to anesthetic agents and/or techniques  Interview: Drug History  Should include:  Complete account of all medications taken by the patient and the last time taken. (ARB, GLP-1  Should include herbal medicines  To include: Dose, schedule, and duration  Continue vs. Discontinue  All pertinent drug and contact allergies  Documented responses and reactions Perioperative Management of Medications 1. Antihypertensive medications Continue on the day of surgery, except for ACEIs and ARBs 2. Cardiac medications (e.g., β-blockers, digoxin) Continue on the day of surgery. 3. Antidepressants, anxiolytics, and other psychiatric medications Continue on the day of surgery. 4. Thyroid medications Continue on the day of surgery. 5. Oral contraceptive pills Continue on the day of surgery. 6. Eye drops Continue on the day of surgery. 7. Heartburn or reflux medications Continue on the day of surgery. 8. Opioid medications Continue on the day of surgery. 9. Anticonvulsant medications Continue on the day of surgery. 10. Asthma medications Continue on the day of surgery. 11. Corticosteroids (oral and inhaled) Continue on the day of surgery. HPA axis suppression-not making their own corticosteroids so they are relying on PO, if they don’t take we cover with a stress dose). In last 6mo. May be candidate for steroid coverage. Can have crisis postoperative. 12. Statins Continue on the day of surgery. 13. Aspirin Continue aspirin in patients with prior percutaneous coronary intervention, high-grade IHD, and significant CVD. Otherwise, discontinue aspirin 3 days before surgery. Perioperative Management of Medications 14. P2Y 12 inhibitors (e.g., clopidogrel, ticagrelor, prasugrel, ticlopidine) Patients having cataract surgery with topical or general anesthesia do not need to stop taking thienopyridines. If reversal of platelet inhibition is necessary, the time interval for discontinuing these medications before surgery is 5–7 days for clopidogrel, 5–7 days for ticagrelor, 7–10 days for prasugrel, and 10 days for ticlopidine. Do not discontinue P2Y12 inhibitors in patients who have drug-eluting stents until they have completed 6 mo. of dual antiplatelet therapy, unless patients, surgeons, and cardiologists have discussed the risks of discontinuation. The same applies to patients with bare metal stents until they have completed 1 month of dual antiplatelet therapy. 15. Insulin For all patients, discontinue all short-acting (e.g., regular) insulin on the day of surgery (unless insulin is administered by continuous pump). Patients with type 2 diabetes should take none, or up to one half of their dose of long-acting or combination (e.g., 70/30 preparations) insulin, on the day of surgery. Patients with type 1 diabetes should take a small amount (usually one third) of their usual morning long-acting insulin dose on the day of surgery. Patients with an insulin pump should continue their basal rate only. 16. Topical medications (e.g., creams and ointments) Discontinue on the day of surgery. 17. Non-insulin antidiabetic medications Discontinue on the day of surgery (exception: SGLT2 inhibitors should be discontinued 24 hours before elective surgery). Metformin & gluphage Perioperative Management of Medications 18. Diuretics Discontinue on the day of surgery (exception: thiazide diuretics taken for hypertension, which should be continued on the day of surgery). 19. Sildenafil (Viagra) or similar drugs Discontinue 24 h before surgery. 20. COX-2 inhibitors Continue on the day of surgery unless the surgeon is concerned about bone healing. 21. Nonsteroidal anti-inflammatory drugs Discontinue 48 hours before the day of surgery. 22. Warfarin (Coumadin) Discontinue 5 days before surgery, except for patients having cataract surgery without a bulbar block. 23. Monoamine oxidase inhibitors Continue these medications and adjust the anesthesia plan accordingly.  Herb Relevant Pharmacologic Preoperative Common Name Effect Discontinuatio n before surgery Echinacea: purple Activation of cell-mediated No data Clinically coneflower root Ephedra: ma huang immunity Increased HR & BP through At least 24 hours Important direct and indirect sympathomimetic effects Effects and Ginger: Singiber officinale Upper GI tract discomfort, nausea, motion sickness, RA At least 7 days Perioperative Garlic: Allium sativum Inhibition of platelet aggregation At least 7 days concerns of (may be irreversible) Ginko: duck foot tree, Inhibition of platelet-activating At least 36 hours selected maidenhair tree, silver apricot factor herbal Ginseng: american, asian, chinese and korean Lowers blood glucose, inhibition of platelet aggregation (may be At least 7 days medications ginseng Kava: awa, intoxicating irreversible) Sedation anxiolysis At least 24 hours pepper, kawa St John's Wort: amber,, Inhibition of neurotransmitter At least 5 days goat week, hard hay, reuptake, monoamine oxidase hypericum, inhibition is unlikely klamatheweed Valerian: all heal, garden Sedation No data helitrope, vandal root  Interview: Social History  Educate on adverse consequences on substance abuse and how they affect anesthetic care  Tobacco use  chart in pack years  Pack years = Packs per Day multiplied by # of years  A smoking history of more than 20 pack years equates to an increased risk of perioperative complications  Electronic cigarette use (highest use in young adults 18-24 years) Ask in non- judgmental way Constituents of Liquids and aerosols in E-cigarettes Chemical Description Physiologic Impact Nicotine Common nicotine concentrations Sympathomimetic, cardiac, are 0–24 mg vascular, endocrine, and immunologic toxicity Drug-to-drug interactions Propylene glycol Artificial flavoring Carcinogenic Glycerol Artificial flavoring Cardiotoxic, carcinogenic Diacetyl Artificial flavoring Pulmonary toxicity Acrolein, formaldehyde, and Toxic compound generated in Pulmonary and vascular toxicity, acetaldehyde aerosol carcinogenic Heavy metals Contained in e-liquid and aerosol Pulmonary, vascular, and nephrotoxicity Toluene Volatile compound generated in Central nervous system depressant aerosol Interview: Social History  Alcohol intake- AUDIT/CAGE questionnaire  Beware of withdrawal syndrome, increased anesthetic requirements if a chronic user (lower if acutely intoxicated), may have prolonged drug effects due to decreased albumin levels.  Illicit Drug use- THC is much more commonly used, Kratom, Meth, cocaine and amphetamines, Opioids, hallucinogens  APSF Article on Cannabis Perioperative Considerations  AANA Clinical Practice Resource  Synthetic Androgens (anabolic steroids)   COMPLEMENTS HISTORY  MAY DETECT Physical ABNORMALITIES NOT APPARENT FROM Examination HISTORY  HISTORY HELPS FOCUS THE PHYSICAL EXAM Physical Examination  Vital Signs  Evaluation of the airway, heart, lungs & musculoskeletal system (neck ROM, pain)  Baseline mental status, neurologic system to include deficits  Rest of exam directed by history, planned surgery, anesthetic choice  Vascular access  Assessment of the airway should be performed preoperatively in every patient, regardless of the plan of anesthetic management  Airway Evaluation LEMON  Length of upper incisors- Interincisor or intergum distance Look  Condition of the teeth Evaluate  Tongue size Mallampati Obstruction  Presence of heavy facial hair Neck  Thyromental distance- Compliance of the mandibular space  Upper lip bite test-mandibular mobility  Length of the neck  Circumference of the neck  Range of motion of head and neck  Mallampati Airway Classification- Visibility of the uvula Nagelhout Table 20.4 Co-morbidities Impacting Administration of Anesthesia: Musculoskeletal  OBESITY  Defined as compared to ideal body weight.  Ideal Body Weight (IBW) (know how to calculate)  Males= 105 lbs + 6 lbs for each inch > 5 ft  Females= 100 lbs + 5 lbs for each inch > 5 ft  Obesity- body weight 20% in excess of IBW  Morbidly obese- body weight twice the ideal body weight  BMI= weight in kg/(height in meters)2 (don’t have to calculate)**  Increased risk for cardiopulmonary aberrations, sleep-disordered breathing and abnormal airway issues (Nagelhout Box 20.8)  OSA- polysomnography (sleep study) testing is gold standard for diagnosis (STOP-BANG questionaire)  Ankylosing Spondylitis (narrowing and constriction of spinal cord-inflammatory and autoimmune) and Rheumatoid Arthritis  Features include decreased mobility, chronic pain and inflammation, possible difficult airway and cardiopulmonary aberrations in advanced stages  Pharmaceutical considerations (Table 20.5 and table 20.6) (don’t’ need to know med details) Co-morbidities Impacting Administration of Anesthesia: Neurologic  Dysfunction of CNS or peripheral nervous system should be assessed and documented preoperatively o Evaluate for any deficiencies in musculoskeletal, sensory, muscle reflexes, cranial nerve abnormalities, mental status and speech pattern concerns. o Dosing of intraoperative anesthetics can be affected  Seizure disorder o Assess medication compliance, and stability of disease Co-morbidities Impacting Administration of Anesthesia: Cardiovascular  Preanesthesia evaluation for cardiovascular risk:  Pre-existing disease (HTN, ischemic heart disease, valvular disease, arrhythmias, conduction abnormalities)  Disease severity, stability and prior treatment  Nagelhout Box 20.12- conditions which should undergo eval and treatment before noncardiac surgery  Comorbid conditions  DM, PVD, pumonary disease, obesity  Nagelhout Table 20.8- comparison of RCRI, American College of Surgeons NSQIP MICA, and ACS NSQIP Surgical Risk Calculator  Surgical procedure  Nagelhout Box 20.11-surgical risk estimates Co-morbidities Impacting Administration of Anesthesia: Cardiovascular  Hypertension  Controlled vs Uncontrolled (establish this with patient)  Associated organ damage from uncontrolled longstanding HTN?  Increased risk for perioperative instability and myocardial ischemia  Ischemic Heart Disease  Angina- stable vs unstable  *Unstable angina is associated with highest risk of perioperative MI*  Nagelhout Table 20.10- NYHA Functional Classification of CV Disability; Table 20.11- Myocardial Injury and infarction  Heart failure  Preserved (>50%) vs Reduced EF (