Anesthesia Assessment

Page 3

• Pre-operative Evaluation Goals:

  • Reduce patient risk and morbidity associated with surgery and anesthesia

  • Prepare the patient medically and psychologically

  • Promote efficiency and cost-effectiveness

Page 4

• Pre-operative Evaluation Requirements:

  • The Joint Commission (TJC) and The American Society of Anesthesiologists (ASA) mandate a thorough pre-op evaluation

  • Minimum requirements outlined by TJC and ASA

  • Modification of patient care to enhance outcomes

Page 5

• Benefits of Good Pre-op Evaluation:

  • Reduces surgery costs

  • Lowers cancellation rates

  • Enhances resource utilization in the operating room

Page 6

• Components of Pre-op Eval:

  • Review of medical record

  • History and Physical relevant to surgery

  • Appropriate diagnostic tests and consultations

  • Determination of patient's condition improvement pre-surgery

  • Addressing patient queries and obtaining informed consent

Page 7

• Challenges in Pre-op Evaluation:

  • Limited time for outpatient procedures

  • Fast turnover between cases

  • Limited time to establish rapport and trust with patients

  • Limited time for addressing patient questions

Page 8

• Healthy Patient Approach:

  • Standardization of best practices

  • Basis for formulating anesthetic plan tailored to the patient

  • Forms rated based on Informational Content, Ease of Use, and Ease of Reading

Page 9 & 10

• Classification of Urgency of Surgical Procedures:

  • Emergency, Urgent, Time-Sensitive, Elective categories based on surgery timing and patient stability

Page 11

• Urgency Classifications Considerations:

  • Weighing urgency against patient optimization

  • Implications of urgency on patient condition and care

  • Necessity of neuro and cardiac assessments for planned procedures

Page 13-15

• Quick Overview of Each System:

  • Detailed assessment of various body systems for pre-operative evaluation

Page 16

• PONV Risk Factors:

  • Factors influencing Post-Operative Nausea and Vomiting (PONV) risk

  • Apfel Risk Score for predicting PONV likelihood based on risk factors

Page 17-19

• OTC Medications Impact:

  • Effects of various Over-The-Counter medications on surgical and anesthetic outcomes

Page 20 & 21

• Energy Requirements and Exercise Tolerance:

  • Estimation of energy needs for different activities

  • Exercise tolerance as a crucial predictor of peri-op risk for non-cardiac surgeries

Page 22

• Indications for Further Cardiac Testing:

  • Algorithm-based decision for additional cardiac assessments

  • Consideration of surgery urgency and recent cardiovascular evaluations

Pre-operative Evaluation

Page 23

• Systems Approach for Airway Evaluation

  • Recognize potential difficulty in airway management

  • Review prior anesthesia records

  • Question patients about ability to breathe through their nose

  • Inquire about a diagnosis of obstructive sleep apnea (OSA)

Page 24

• Systems Approach for Airway Evaluation

  • Evaluate oral cavity and dentition

  • Assess thyromental distance

  • Check neck size, tracheal deviation, or masses

  • Evaluate the patient's ability to flex and extend the neck and head

Page 25

• Systems Approach for Airway Evaluation

  • Trauma patients, severe rheumatoid arthritis, or Down's syndrome require thorough C-spine evaluation

  • Symptoms of cord compression may necessitate X-ray examination

Page 26

• Systems Approach for Airway Evaluation

  • Modified Mallampati Airway Classification:

    • Class 1: Full view of soft palate, uvula, tonsillar pillars

    • Class 2: Soft palate and upper portion of uvula

    • Class 3: Soft palate

    • Class 4: Hard palate only

Page 27

• Systems Approach for Lung Evaluation

  • Consider history of tobacco use

  • Assess dyspnea, exercise tolerance, and recent upper respiratory infections

  • Look for stridor

Page 28

• Systems Approach for Lung Evaluation

  • Check for snoring, sleep apnea, and perform a physical exam

  • Evaluate respiratory rate, chest excursion, use of accessory muscles, nail color, breath sounds, and presence of wheezing or crackles

Page 29

• Systems Approach for Lung Evaluation

  • Inquire about history of asthma, last use of a rescue inhaler, and last asthma attack

Page 30

• Systems Approach for Cardiovascular Evaluation

  • Look for signs and symptoms of uncontrolled hypertension and unstable cardiac diseases

  • Assess dyspnea, chest pain, and syncope

Page 31

• Systems Approach for Cardiovascular Evaluation

  • Note racing rhythms, irregular beats, palpitations, and shortness of breath

  • Evaluate the ability to climb stairs

Page 32

• Systems Approach for Cardiovascular Evaluation

  • Consider the presence of unstable angina as a high perioperative risk factor for myocardial infarction

Page 33

• Systems Approach for Cardiovascular Evaluation

  • Take blood pressure and listen for murmurs, abnormal rhythms, or bruits over the carotids

  • Abnormal findings may require further evaluation for stroke risk

Page 34

• Systems Approach for Cardiovascular Evaluation

  • Understand Major Adverse Cardiac Events (M.A.C.E) and associated risks

  • Consider age, history of cardiovascular disease, diabetes, and cerebrovascular disease in assessing M.A.C.E risk

Page 35

• Systems Approach for Cardiovascular Evaluation

  • Use the Revised Cardiac Risk Index (RCRI) to assign perioperative risk based on clinical variables

Page 36

• Systems Approach for Cardiovascular Evaluation

  • Understand high-risk types of surgery and factors contributing to cardiac complications

  • Consider history of ischemic heart disease, congestive heart failure, and other risk factors

Page 37

• Systems Approach for Cardiovascular Evaluation

  • Recognize clinical evidence of heart failure through symptoms like dyspnea, limited exercise tolerance, JVD, and peripheral edema

Page 38

• Systems Approach for Cardiovascular Evaluation

  • Understand the association between diabetes and cardiovascular disease

  • Evaluate pre-op ECG for Q-waves in diabetic patients requiring insulin

Page 39

• Systems Approach for Cardiovascular Evaluation

  • Manage hypertensive disease and its impact on perioperative risk

  • Consider elective surgery delay for elevated blood pressure levels

Page 40

• Cardiovascular Evaluation

  • Importance of surgical procedure in determining morbidity and mortality risks

  • Differentiate between low-risk and high-risk procedures

Page 41

• Cardiovascular Evaluation

  • Importance of exercise tolerance in predicting perioperative risk for non-cardiac surgery

  • Understand implications of stable angina and dyspnea on perioperative risk

Page 42

• Cardiovascular Evaluation

  • Consider timing of non-cardiac surgery after coronary artery stent placement

  • Understand the risks associated with early surgery post-stent placement

Page 43

• Cardiovascular Evaluation

  • Consider implications of AICDs during surgery and review guidelines for management

Page 44

• Cardiovascular Evaluation

  • Understand the risk of re-infarction under general anesthesia post-MI

  • Mortality rate associated with re-infarction under general anesthesia

Page 45

• Pulmonary Disease Evaluation

  • Post-operative pulmonary complications are more common than cardiac complications in non-cardiac surgery

  • Major causes of post-op respiratory failure

Page 46

• Pulmonary Disease Evaluation

  • Limited benefit of pulmonary function testing and chest X-rays in predicting perioperative respiratory complications

  • Association of serum albumin and BUN levels with perioperative pulmonary morbidity

Page 47

• Pulmonary Disease Evaluation

  • High-risk surgeries associated with perioperative pulmonary morbidity

  • Surgeries leading to decreased vital capacity, FRC, and diaphragmatic dysfunction

Page 48

• Pulmonary Disease Evaluation

  • Effects of tobacco on pulmonary function and post-operative complications

  • Recommended duration of smoking cessation before surgery to reduce complications

Pre-operative Evaluation

Pulmonary Disease

• Asthma

  • Assess severity, current status, bronchodilator use, hospitalization frequency, and steroid use

  • Consider stress dose for patients on regular corticosteroids due to adrenal insufficiency

• Obstructive Sleep Apnea (OSA)

  • Characterized by periodic upper airway obstruction during sleep

  • Leads to chronic sleep deprivation, pulmonary hypertension, and right heart failure

  • Patients are susceptible to respiratory depressants, so use judiciously

Endocrine Disease

• Diabetes Mellitus

  • Increased risk for CAD, HTN, CHF, MI, cerebral vascular, peripheral vascular, and renal vascular diseases

  • Leading cause of renal failure requiring dialysis

  • Monitor blood glucose, hgbA1c, lytes, creatinine, and ECG

  • Optimize patients with hgbA1c levels before elective surgery

• Thyroid/Parathyroid Diseases

  • Screen for hyper/hypothyroidism symptoms

  • Hyperparathyroidism leads to hypercalcemia with symptoms like weakness, lethargy, and bone pain

• Adrenal Cortical Suppression

  • Be cautious with long-term steroid users

  • Consider stress dose for patients on steroids within the last 6-12 months

• Renal Disease

  • Assess electrolytes, ensure euvolemia before induction, and be cautious with medications metabolized by the kidneys

• Liver Disease

  • Check coagulation levels before regional anesthesia

  • Consider labs for patients with a history of increased alcohol consumption

Laboratory Test Recommendations

• CBC, Coags, Serum Chemistry

  • Consider for extremes of age, liver/kidney disease, bleeding disorders, malignancy, and type/invasiveness of surgery

• CXR, ECG, Pregnancy Test

  • Use for pulmonary/cardiovascular diseases, clinical findings, unstable conditions, and type/invasiveness of surgery

Decision Making

• Evaluate modifiable risk factors, peri-op risk, and available information before proceeding with surgery

Aspiration Risk

• Factors include emergency surgery, inadequate anesthesia, abdominal pathology, obesity, opiates, neuro deficits, reflux, and hiatal hernia

• Follow fasting times for different types of food and medications to reduce aspiration risk

Patient Interaction

• Greet patients confidently, maintain professionalism, and establish trust

• Conduct pre-anesthetic screening covering diagnosis/procedure, medical history, airway assessment, CNS, infectious diseases, cardiovascular, GI/hepatic, and renal conditions.

Note

Page 72:

• Pre-operative 72 Evaluation

  • Pre-anesthetic Screen

  • Hematology

    • Anemia, coagulopathy, sickle cell, chemo, transfusions

  • Vital Signs

    • NPO status, IV access, invasive monitors, advanced directives

Page 73:

• Pre-operative Evaluation

  • Pre-anesthetic Screen

  • Pulmonary

    • URI, bronchitis, pneumonia, recent cough or cold, asthma

  • Endocrine/Metabolic

    • Diabetes, thyroid, rheumatoid arthritis, steroid use

Page 74:

• Pre-operative Evaluation

  • Pre-anesthetic Screen

  • Importance of quickly relating questions to anesthetic plan

Page 75:

• Pre-operative Assessment

  • ROS/Med HX Physical Exam Anesthesia Plan

  • Reviewed various medical conditions and history for anesthesia planning

Page 76:

• Pre-operative Assessment

  • ROS/Med HX Physical Exam Anesthesia Plan

  • Detailed physical exam findings for airway, cardiovascular, pulmonary, and