2) Preoperative Evaluation

when first meeting the patient, what 3 things must you do?

introduce yourself, confirm patient name and DOB, confirm procedure and indication

asking about ________ can give you insight into the patient’s medical history before doing a full review of systems

medications

in a full review of systems, you should ask about the following areas:

allergies, cardiovascular, pulmonary, neurologic, endocrine/renal, GI/hepatic, coagulation, musculoskeletal

after reviewing all systems, it’s important to get a social history about the following 3 areas:

tobacco, alcohol, and drug use

in addition to a review of systems and social history, it’s important to get a history in what other areas?

surgical and anesthetic history, including family history

after all histories are taken, what’s an important thing to ask about that could determine if this surgery will be cancelled?

NPO status

in the event that all history is recorded and NPO status is confirmed, what should you review next?

airway

when reviewing airway, what should you ask about?

any cracked, chipped, or loose teeth

when reviewing airway, what will you ask the patient to do?

lift chin, open mouth, stick out tongue

when reviewing airway, why do you ask the patient to lift their chin?

checking thyro-mental distance

what thyro-mental distance are we happy with?

>3 finger widths

when reviewing airway, why do you ask the patient to open their mouth?

checking distance between incisors

what distance between incisors are we happy with?

>2 finger widths

when reviewing airway, why do you ask the patient to stick out their tongue?

checking mallampati score

define mallampati class I

soft palate, uvula, fauces, pillars

define mallampati class II

soft palate, most of uvula and fauces visible

define mallampati class III

soft palate, base of uvula

define mallampati class IV

hard palate only

after all patient history is taken and airway is assessed, what 2 exams do we perform?

cardiac and pulmonary

in the cardiac exam, what are you listening to?

all 4 heart valves

cardiac exam: 2nd intercostal space, right of sternum listens to what valve?

aortic valve

cardiac exam: 2nd intercostal space, left of sternum listens to what valve?

pulmonary valve

cardiac exam: 5th intercostal space, left of sternum listens to what valve?

tricuspid valve

cardiac exam: 5th intercostal space, midclavicular line listens to what valve?

mitral valve

when performing a pulmonary exam, what’s the minimum expectation for stopping and asking the patient to take a full breath in and out?

at least 3 stops front and back on each lung

what’s the last thing you should ensure before leaving the room?

all patient’s questions have been answered and there’s nothing else they’d like to share

predictors of difficult airway

small mouth opening

reduces neck mobility

short thyromental distance

previous difficult intubation

facial/neck abnormalities

obesity and sleep apnea

what does ASA describe?

patient’s physical condition

fasting interval for clear liquids

2 hours

fasting interval for breast milk

4 hours

fasting interval for infant formula

6 hours

fasting interval for nonhuman milk

6 hours

fasting interval for light meal or toast

6 hours

fasting interval for meal with fat/meat

8 hours

preop medication: anxiolytic

reduce anxiety and sedation; may depress respiration

preop anxiolytics may cause…

respiratory depression

preop medication: opiods

provide analgesia

preop opioids may cause…

respiratory depression, nausea, sedation

preop medication: antiemetics

reduce PONV

preop medication: antacids or acid reducing drugs

reduce acidity or volume of gastric contents

preop medication: anticholingerics

reduce secretions or modify vagal responses

are chronic beta blockers continued before surgery?

yes withdrawal is harmful

are anticoagulants and anti-platelets continued before surgery?

depends on bleeding risk and risk of thrombosis

if a patient has diabetes, what do you need to plan for?

high or low perioperative glucose

are ACE inhibitors and angiotensin receptor blockers continued before surgery?

depends on indication and blood pressure