Surgery PreOp Assessment PDF

1/2/23 PREOPERATIVE ASSESSMENT PREOPERATIVE EVALUATION OF THE SURGICAL PATIENT; ANESTHESIA BASICS M PA P 5 2 1 E R I N K U N Z , M H S , PA - C OBJECTIVES 1. 2. 3. 4. Describe the history and physical exam components of a pre-operative assessment. Recognize findings in a patient’s medical histor...

1/2/23 PREOPERATIVE ASSESSMENT PREOPERATIVE EVALUATION OF THE SURGICAL PATIENT; ANESTHESIA BASICS M PA P 5 2 1 E R I N K U N Z , M H S , PA - C OBJECTIVES 1. 2. 3. 4. Describe the history and physical exam components of a pre-operative assessment. Recognize findings in a patient’s medical history that may warrant additional work-up for pre-operative clearance. Discuss tools that may assist in preoperative risk assessment and their indications. Describe the impact of the following on the physiologic stress of a surgical patient and special considerations for the perioperative management of each: a. b. c. d. e. f. g. h. Cardiovascular disease Pulmonary disease Renal dysfunction Hepatic dysfunction Diabetes Adrenal insufficiency Pregnancy Extremes of age (elderly and pediatric patients) 5. Discuss the role and importance of informed consent as it relates to surgery. 6. Compare and contrast the techniques, indications, contraindications and potential complications of the following types of anesthesia: a. b. c. General anesthesia Monitored anesthesia care (MAC) Procedural sedation 7. Compare and contrast the techniques, indications, contraindications, and potential complications of the following types of regional anesthesia: a. b. c. Spinal anesthesia Epidural anesthesia Peripheral nerve block FIRST STEP: OBTAIN A MEDICAL HISTORY From the patient, the family, the caregivers, the medical records, outside medical records… use anything that has reliable data! the first step is always to get a GOOD medical history, something that is reliable MEDICAL HISTORY, CONT. • History of Present Illness: – Acuity or chronicity of the illness – Fevers, chills or sweats related to infection? – Weight loss related to tumor? • Past Medical History – Medical conditions, medication list can often help in obtaining a complete history – Prior venous thromboembolism (DVT/PE) – Prolonged bleeding with prior surgeries or minor injuries – Tobacco, alcohol or illicit drug use – Functional status, mobility and exercise tolerance • Past Surgical History – Previous surgery, location of incisions, complications • Past Anesthesia History – History of problems with anesthesia or airway problems Important to know!!! dive deep into their medication history complete medicine lists are very helpful - sometimes calls pharmacy to determine drug list always important to know about their tobacco and drug use - important to know to help the patient when they are in the hospital sometimes physical exam findings can indicate a surgery, if your patient forgot to mention it MEDICAL HISTORY, CONT. • Family History – Problems with anesthesia (malignant hyperthermia) or bleeding or clotting • Social History – Family, friend support, living situation, work situation • Medication and supplement/herbal list – This is absolutely critical to be accurate • Allergies/adverse reactions – To medications and tape, adhesives, preps, etc Social hx - important to know who will be caring for the patient, need to know living situation (are there stairs) important to determine how to care for patient outside of the hospital medications and supplement/herbal list is SO important THE NEXT STEP: PHYSICAL EXAM • Essential part of the patient assessment – Vital signs • Oxygen saturation on room air and BMI can also be useful – General fitness – Exercise tolerance – Cachexia or obesity – with specific interest in recovery and wound healing – Specific findings: • Murmurs, bruits, absent peripheral pulses, adenopathy, skin integrity, incidental masses, hand dominance, neurologic deficits, other unusual findings, airway problems (more on this in a minute) Never underestimate the power of your history and physical exam! 2nd step is the physical exam - is your patient okay to undergo surgical intervention? Will they survive the surgery or the hospital stay? can assess the general fitness by watching the patient walk/move or asking about it THE NEXT STEP: PHYSICAL EXAM – SPECIFICS – THE AIRWAY There is a specific airway exam in pre-operation airway is one of the most important - can this patient be intubated for the surgery • The airway is of critical importance when administering anesthesia, so this will be a more details physical exam than typical – ROM of cervical spine Can they extend their neck so you can see the airway? – Thyroid cartilage to mentum distance ideally greater than 6cm – Mouth opening – ideally greater than 3cm – Dentition – noting dentures, loose teeth, appliances or poor dentition remove anything that can be – Jaw protrusion – the ability to protrude the lower incisors past the upper incisors important for a jaw-thrust – Facial hair (mustaches and beards) tape and mask seal – Classification of the airway based on visual inspection – Mallampati score THE NEXT STEP: PHYSICAL EXAM – SPECIFICS – THE AIRWAY, CONT. Mallampati scoring: – Grade I: the soft palate, anterior and posterior tonsillar pillars and uvula are visible, suggesting an easy airway intubation – Grade II: Tonsillar pillars and part of the uvula are obscured by the tongue – Grade III: Only soft palate and hard palate visible – Grade IV: Only the hard palate is visible, suggesting a challenging airway IS THERE A ROUTINE SET OF LABS TESTS FOR ALL PATIENTS? • There is no set of “routine” lab tests in a preoperative patient. – No clinical data to support that this improves outcomes – Unnecessary testing can cause harm and can also lead to further testing – Clinicians must act on abnormal findings – Pediatric patients rarely require testing • Often blood type can be obtained upon induction of anesthesia to avoid unnecessary needle sticks LAB TESTING IN PREOP, CONT. – Complete blood count (CBC) and comprehensive metabolic panel (CMP) as well as an electrocardiogram are often warranted in high-risk patients prior to complex surgery – INR and PTT can be useful in surgeries with a low margin for perioperative bleeding (brain and spinal surgery) neurosurgery, spine surgery, ocular/eye surgery - when there is a small margin of error for bleeding – Pregnancy testing in the immediate pre-op period for all women of childbearing age – Type and screen for patients with high risk of perioperative blood loss – +/- Staphylococcus aureus screening by nasal swab and testing for MRSA • To allow for chlorhexidine bathing and eradication prior to surgery or antibiotic prophylaxis to prevent wound infections especially for high risk patients or a patient that is getting sometime of implant (knee replacement) TOOLS TO ASSIST IN PREOPERATIVE RISK ASSESSMENT The American College of Cardiology and American Heart Association made a preoperative algorithm for cardiovascular assessment prior to noncardiac surgery. This is useful in Pre-Anesthesia Assessments. emergency - go to OR not emergency - continue algorithm ASA CLASSIFICATION SYSTEM The American Society of Anesthesiologists (ASA) classification system stratifies the degree of perioperative risk for patients. The system is basic but serves anesthesiologists and surgeons in predicting tolerability of operations. DATA THAT CAN DRIVE OUTCOME CHANGE • Administrative and financial data sets from chart abstraction can predict risk-adjusted outcomes, but are not particularly specific or robust • A couple of more robust systems of data collection are the Society of Thoracic Surgeons (STS) and the National Surgical Quality Improvement Program (NSQIP) – Collect data up to 30 days post-op to include morbidity and mortality and are abstracted by clinical staff, can much more accurately predict outcomes. – Following data trends hospital groups and systems can reduce their length of stay and outcomes by analyzing the trends and making changes to target problems • Such as VTE prophylaxis, catheter associated UTI, pulmonary complications – Out of NSQIP has come a variety of useful risk calculators Setting aside the obvious physical and emotional side effects of adverse outcomes there are enormous financial implications – as you can imagine this gets hospital administration’s attention WHY DOES THIS MATTER? Serious complications can also decrease long-term survival it is very important for hospital to use data for both administration and fiancial assessments - Well designed preoperative assessment programs that can identify and modify risk factors are invaluable. A patient that undergoes anastheia must have a history and physical exam on file within 30 days SPECIAL CONSIDERATIONS: CARDIOVASCULAR DISEASE • There are usually six independent predictors of cardiac complication. The likelihood of major cardiac complications increases incrementally with the number of factors present. – History of ischemic heart disease – History of congestive heart failure (CHF) – History of cerebrovascular disease – High-risk operation, – Preoperative treatment with insulin diabetics – Preoperative serum creatinine greater than 2.0 mg/ dL. renal disease CARDIOVASCULAR DISEASE, CONT. • More recent data has been able to develop risk calculators for a perioperative myocardial infarction (MI) or cardiac arrest. These include: – Type of operation – Dependent functional status do they function on their own? do they need help? – Abnormal creatinine – ASA class – Increasing age made a risk calculate for perioperative MI or cardiac arrest based on their risk factors listed CARDIOVASCULAR DISEASE, CONT. when the risk is high, you will send the patient to cardiology for preoperative optimization (not clearance) • Modify the patient's cardiovascular risks by: – Smoking cessation, – Optimal control of diabetes – Blood pressure control – Fluid status maintenance – Compliance with medical preoperative medications/ medical management cardiology can provide a list of things that the patient will need to do to decrease their risk or optimize their outcome from surgery CARDIOVASCULAR DISEASE, CONT. • Formal cardiac assessment by a cardiologist is recommended when there are risk factors: – The American College of Cardiology (ACC) Foundation and the American Heart Association (AHA) periodically issue joint recommendations about the cardiac evaluation and preparation of patients in advance of noncardiac operations. These guidelines are evidence based, include an explanation of the quality of the data, and provide comprehensive algorithms for the propriety of testing, medications, and revascularization to ensure cardiac fitness for operations. – This is important for preoperative risk but can also address postoperative risks as well. – Non-invasive and invasive tests are only performed when the outcomes will influence patient care. – Preoperative aspirin usage should continue among patients at moderate to high risk for coronary artery disease. – Antiplatelet agents such as clopidogrel should be stopped, but only after discussion with cardiology if the patient has recently undergone coronary artery stent placement. • If a patient has a known necessary surgery upcoming and needs coronary artery stenting, the use of bare metal stents (in lieu of drug eluting stents) is preferred due to the decreased post-stent placement time needed for antiplatelet therapy. SPECIAL CONSIDERATIONS: PULMONARY DISEASE Postoperative pulmonary complications (PPC), such as the development of pneumonia and ventilator dependency, are debilitating and costly. They are associated with prolonged lengths of hospital stay, an increased likelihood of readmission, and increased 30-day mortality. Therefore, it is critical to identify patients at greatest risk for PPC. SPECIAL CONSIDERATIONS: PULMONARY DISEASE, CONT. What are the risks for postop pulmonary complications? • Advanced age • Elevated ASA class • Congestive heart failure • Functional dependence • Known chronic obstructive pulmonary disease (COPD) • Malnutrition • Alcohol abuse • Altered mental status • Smoking – Known association with postoperative pneumonia, SSI, death when compared to nonsmokers or those who have quit smoking • Best risk reduction if patient quits at least 4 weeks prior to surgery SPECIAL CONSIDERATIONS: PULMONARY DISEASE, CONT. • Sleep apnea - should be asked to all patients before anasthea – A simple “STOP BANG” questionnaire can screen patients for sleep apnea. • Snoring • Tired during day • Obstructed breathing pattern during sleep • high blood Pressure • BMI, • Age over 50 years • Neck circumference • male Gender – special considerations for CPAP or BiPAP devices before and after operations. • Post-operative pulmonary toilet – – Coughing, incentive spirometry, walking, deep breathing exercises, head of bed elevated important to do in the post-op setting – All of these can improve length of stay and decrease the risk for post-op pneumonia SPECIAL CONSIDERATIONS: RENAL DYSFUNCTION Patients with renal dysfunction can have delayed drug clearance and this can adversely affect anesthesia. Certain anesthetics should be avoided as they are nephrotoxic and can further renal damage. If patient is already on dialysis, then scheduling surgery to avoid disruptions to dialysis is imperative. need to make sure you schedule their surgery according to when they have dialysis - cannot miss dialysis!!! SPECIAL CONSIDERATIONS: HEPATIC DYSFUNCTION • Patients with liver disease can be high-risk for surgery • The distribution of anesthetic drugs, metabolism of others and elimination of drugs may be altered bleeding with intubation • Portal hypertension and esophageal varices can lead to bleeding and other complications • Often there is concurrent thrombocytopenia, which can cause problems with neuraxial anesthesia administration and increase bleeding at surgical sites. thrombocytopenia —> can have low platelets that means they bleed more easily, mihgt need platelets before surgery SPECIAL CONSIDERATIONS: DIABETES need very tight blood sugar control for diabetic patients • Diabetic patients with elevated postoperative blood glucose levels have a greater chance to have a surgical site infection following cardiac surgery, and greater likelihood of postoperative infection and prolonged hospital stays in patients with noncardiac operations. • The relative risk for surgical site infection seems to be correlated directly with the degree of hyperglycemia. • Preoperative blood glucose and hemoglobin A1c levels are inconsistently associated with adverse outcomes, but clearly preoperative glucose control translates to better postoperative control. • Special considerations for management of preop glucose for fasting prior to surgery: – Often diabetic patients will be scheduled as first cases, to minimize the chance of cases running behind and forcing prolonged NPO since they are on sugar control SPECIAL CONSIDERATIONS: DIABETES, CONT. • Careful consideration for how to manage oral antihyperglycemic medications and insulin. – There are available charts and guides for preoperative medication management. • Management of Type 1 diabetes different than Type 2, using care to continue insulin, but at a lower level while fasting with frequent monitoring. • If patient’s preop blood glucose immediately prior to anesthesia is >300mg/dL then consideration should be made for delaying the case until such time that adequate blood glucose levels can be achieved. SPECIAL CONSIDERATIONS: ADRENAL INSUFFICIENCY • Patients with primary adrenal insufficiency or chronic adrenal suppression from corticosteroid use are at risk with surgery. – Without proper perioperative steroids they are at risk of Addisonian crisis, hemodynamic instability and even death very serious – All patients with primary adrenal insufficiency should have stress dose steroids preoperatively, this can be directed by their endocrinologist – Patients on chronic steroids, especially those on 20mg daily or greater, should also be considered for stress dose steroids – Consider stress dose steroids for high-risk surgeries > lower risk procedures SPECIAL CONSIDERATIONS: PREGNANCY • Risk assessment requires consideration of two patients, the mother and fetus. • The risks include: the risk to the fetus of hypoxemia caused by reduced uterine blood flow, maternal hypotension, excessive maternal mechanical ventilation or maternal hypoxia, or depression of the fetal cardiovascular system or central nervous system by anesthetic agents, exposure to teratogenic drugs, risk of preterm delivery • Algorithms are used to assess need. – Elective surgery should be delayed until postpartum – Essential surgery need to weigh risk/benefits • In the first trimester if there is greater than minimal risk to the mother to wait, then proceed and have perinatology involved • If no or minimal increased risk to the mother, then wait until midgestation – Emergency surgery • Proceed with caution, with informed consent try to avoid operation in the first trimester SPECIAL CONSIDERATIONS: EXTREMES OF AGE • Elderly – Assessing preoperative frailty can be predictive of increased change of falls, worsened mobility, postoperative complications, prolonged hospital stays and discharge to skilled nursing facilities – Physiologic age vs chronologic age – Multiple medical conditions, limited mobility and polypharmacy are all risk factors – Assessing frailty by several different measures can be useful – Real risk for cognitive decline associated with general anesthesia as well as hospital delirium or sundowning – Special preoperative clinics for geriatric patients can improve outcomes – these are usually multidisciplinary teams including geriatric trained physicians, anesthesiologists, social work, dieticians, etc. do they act their age? younger or older? • Pediatrics – Careful consideration regarding dosing, often weight based, and age based – Preop holding and post-op/PACU care should allow parents or guardians early access – Often inhaled anesthesia is given before IVs are started to avoid unnecessary sticks – Preparing parents/guardians for what to expect is extremely important THE ROLE AND IMPORTANCE OF INFORMED CONSENT • Informed consent is more than just a signed document • This involves a conversation between the surgeon and patient as well as the anesthesiologist – Surgical consent and anesthesia consent are separate and usually obtained by different teams – This should include the exact description of the procedure and the type of anesthesia – The risks, benefits, alternative treatment options – Risk for needing blood transfusions • Patients should be able to understand and agree to the procedure and be legally able to provide consent. If the patient is unable to provide consent, then the patient’s legal proxy or guardian may provide consent. Now let’s step behind the drape. WHAT ARE THE COMMON TYPES OF ANESTHESIA? • General anesthesia • Monitored anesthesia • Procedural sedation • Regional anesthesia – AKA Blocks, etc. when you need the body to be completely still and relaxed (whihch makes the airway floppy so they need intubation) GENERAL ANESTHESIA • General anesthesia is necessary in major operations when complete neuromuscular blockade is necessary and therefore requires securing the airway • Techniques: – In adult patients, there is a dose of propofol, etomidate or ketamine followed by neuromuscular blockage to allow for ease of airway intubation • This is given IV, then the airway is secured by endotracheal tube or laryngeal mask airway (LMA), and inhaled anesthetics begin which may include isoflurane or sevoflurane – In pediatric patients, inhaled agents are often given first, then IVs are placed, and further sedation is given • Indications: – When complete neuromuscular blockade is necessary • i.e. complete stillness of the patient • Contraindications: – Severe cardiac disease or pulmonary disease • i.e when doing elective case on an extremity • Potential complications: – There are many… GENERAL ANESTHESIA, CONT. • The most serious and most common cause of mortality and morbidity is inability to secure the airway • Peripheral nerve damage - The second most common complications from anesthesia from positioning during surgery – Usually temporary, but may be long-lasting • Post-operative nausea and vomiting (PONV) which is more common with general anesthesia over other types, and worse in certain types of surgeries – Preoperative assessment should include risk factors: prior history of PONV, history of motion sickness, need for opiates during or after surgery – Treat with perioperative measures such as ondansetron, scopolamine, reducing other risk factors • Sore throat • Damage to teeth • Dry eyes • Perioperative visual loss – Noted in prolonged spinal surgeries where patient is prone – May be temporary or permanent, partial or total vision loss GENERAL ANESTHESIA, CONT. • And last, but not least… • Awareness under anesthesia – Incredibly rare, with a reported incidence of 0.1-0.2% • Be careful to get a history that this actually occurred during GA and not MAC or procedural sedation – Reassure patients – Use intraoperative vital monitoring and brain wave monitoring • Malignant hyperthermia – Rare, genetically inherited disease characterized by intense muscle contraction related to uncontrolled release of calcium from the sarcoplasmic reticulum and massive increase of intracellular calcium in skeletal muscle due to inability of the calcium to be reabsorbed – Leads to hypermetabolic state with hyperthermia, hypercapnia, tachycardia and metabolic acidosis. – Fatal if not recognized and treated. – Earliest sign is often masseter spasm following administration of succinylcholine during induction – Every operating room should have a malignant hyperthermia protocol – this is a true anesthesia emergency MONITORED ANESTHESIA CARE (MAC) is given by anesthiologist!! • This is a catchall phrase for sedation +/- regional anesthesia that does not require intubation and advanced airway management. • Must be given by an anesthesia team and can convert at any time to general anesthesia if necessary. • Commonly given for endoscopy, bronchoscopy, colonoscopy and other minor procedures. PROCEDURAL SEDATION • Procedural sedation may include anxiolytics and pain control but is usually given by non-anesthesia staff. • This is often found in interventional radiology or cardiac catheterization labs where sedation is given by nursing staff under the direction of the interventional physician. • Limited options for sedation and drug use here, as patient must remain conscious enough to maintain their airway. • “Conscious sedation” is a term that is often used, but this can be misleading. Sometimes this refers to procedure sedation and sometimes MAC. Important to clarify which type will be used. REGIONAL ANESTHESIA • Many operations do not require general anesthetic. Procedures below the waist, upper and lower extremities and smaller procedures can often use regional anesthesia without the need for airway manipulation and allows the patient to be conscious. • The advantages include: decreased blood loss, fewer thrombotic complications, less pulmonary complications, shortened hospital stay, ability to be given in outpatient settings • So what is classified as regional anesthesia? – Spinal anesthesia – Epidural anesthesia – Peripheral nerve block spinal versus epidural - the difference in location and time spinal goes to subdural space and gets ICF, epidural does not get ICF SPINAL ANESTHESIA • Techniques: – Sterile prep with patient in lateral position or sitting on OR table – Spinal needle introduced into the subdural space and identified by presence of CSF – Give lidocaine or bupivacaine, depending on the length of need (2 hours vs up to 5 hours) – Patient then laid supine and monitored for proper spread of anesthesia • Hypotension and bradycardia can be induced from sympathetic nerve chain anesthesia • Indications: – Orthopedic procedures below the waist, gynecologic surgery, and cesarean section • Contraindications: – When complete neuromuscular blockade is necessary, head and neck, chest or abdominal surgery • Potential complications: – Hemodynamic instability (as noted above) – Spinal headache (more common in young women) EPIDURAL ANESTHESIA Different from spinal anesthesia by location: the epidural space is between the ligamentum flavum and the dural structures. The subdural space is NOT entered, so no CSF leak potential. Can also be given continuously over the course of days as you place a catheter into the epidural space • Techniques: can give multiple doses since it uses a cath! – Sterile prep with patient in lateral position or sitting on OR table – Needle is placed into the epidural space and catheter passed over the needle – • Test dose given to ensure the needle is not in the subarachnoid space as large volumes of anesthetic there can cause total spinal or high block with cardiovascular collapse this can cause respiratory collapse! can be very dangerous, mother will need to be intubated for many hours until the medication wears Indications: off and they can self breath again! – C-section, midthoracic regional pain control for thoracotomy or abdominal procedures or lower extremity procedures – • • Can be used in concert with general anesthesia Contraindications: – When complete neuromuscular blockade is necessary, head and neck, chest or abdominal surgery – In patients on blood thinners – When spinal hardware or spinal abnormalities make it difficult to place accurately Potential complications: – Misplacement of the catheter into subarachnoid space (need for rapid sequence intubation and GA) – Incomplete block – Slow onset can take a few minutes to have the numbness – Hemodynamic changes – Urinary retention PERIPHERAL NERVE BLOCK • Techniques: – Sterile prep – Injection into the brachial plexus or lumbar plexus or major branches – Catheter can be inserted for continuous blockade for postoperative pain control • Indications: – Procedures on the extremities or for postoperative pain control • Contraindications: – When complete neuromuscular blockade is necessary, head and neck, chest or abdominal surgery – When tourniquets are used, this can compromise the block • Potential complications: – Ineffective, requiring change of anesthetic plan (rare) • Can be given with sedation or with general anesthesia QUESTIONS NOW? Questions later? Email me: Erin Kunz [email protected]