Transcript Patient Health Education Seminar

Humongous Insurance
PREOPERATIVE EVALUATION
GOALS
• to reduce the morbidity of surgery
• to increase the quality but decrease
the cost of perioperative care
• to return the patient to desirable
functioning as quickly as possible
These goals have been facilitated by a
preoperative meeting
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Meeting specific purposes
1. To obtain patient's medical history and physical and
mental conditions, in order to determine which tests
and consultations are needed
2. Guided by patient choices and the risk factors
uncovered by the medical history, to choose the care
plans to be followed
3. To obtain informed consent
4. To educate the patient about anesthesia,
perioperative care, and pain treatments
5. To make perioperative care more efficient and less
expensive
6. To motivate the patient to more optimal health
3
• preoperative patient conditions
and perioperative optimization of
care are significant predictors of
postoperative morbidity
5
Preoperative evaluation strives to
answer three questions:
1. Is the patient in optimal health?
2. Can, or should, the patient's
physical or mental condition be
improved before surgery?
3. Does the patient have any health
problems or use any medications
that could unexpectedly influence
perioperative events?
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Such an evaluation must include:
• review of hospital chart(s) and prior anesthesia
records
• consultation with the primary care physician
• history-taking
• physical examination
• evaluation of laboratory tests obtained,
ordering of additional laboratory tests
• discussion of perioperative anesthesia plans
with the patient in a way that provides
accurate information and reduces patient
anxiety
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History-taking
The rule of threes
The three aspects of acute history:
• Exercise tolerance
• History of present illness and its
treatments
• When the patient last visited with her
or his primary care physician
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History-taking
The rule of threes
The three aspects of chronic history:
• Medications and causes for their use
and allergies
• Social history including drug, alcohol,
and tobacco use and cessation
• Family history and history of prior
illnesses and operations
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History-taking
The rule of threes
The three aspects of physical examination:
• Airway
• Cardiovascular
• Lung, plus those aspects specific to the
patient's condition or planned procedure,
such as a sensory nerve examination if a
regional block is planned
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History-taking
General items
-
-When did you last have anesthesia?
-Do you have any problems with anesthesia? Have any of your family members had
any problems with anesthesia?
-Do you have allergies?
-What are you allergic to?
-Have you had any blood tests in the last 6 months?
-Have you had a chest x-ray in the last 2 months?
-Have you had an electrocardiogram (ECG) in the last 2 months?
-Has your stool been checked for blood or have you had a colonoscopy, etc., in the
last year?
-Have you been a patient in a hospital, an emergency department, or an outpatient
surgery center in the last 2 years? If so, why? What part of the hospital (for example,
critical care unit)? How long were you there?
-Do you take any medications?
-What medications do you take?
-Do you take any medications not prescribed by your doctor, that you purchase
through the internet or from a shelf at a drugstore, health food store, or grocery
store?
-Do you take any supplements or vitamins or minerals? (These can interact
substantially with perioperative medications.)
-Do you wear contact lenses?
-Do you currently use eye drops prescribed by a doctor?
-When did you have an alcoholic drink?
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-Have you ever had a drinking problem?
History-taking
Cardiovascular Disease
Most important is to determine the patient's
cardiovascular reserve:
The ability to do 4 metabolic equivalents (METs) of
exercise, the equivalent of walking 5 city blocks or
climbing two flights of stairs at a reasonable rate without
having to stop correlates in multiple studies with better
perioperative outcome.
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CONFIDENTIAL
Cardiovascular Disease…
What is the most vigorous activity you've done in the last 3 weeks?
How far have you walked in the last week without stopping?
Can you walk a block without stopping? When did you last do so?
Can you walk 4 blocks without stopping? When did you last do so?
Have you ever awakened and felt short of breath?
Do you become short of breath after climbing a flight of stairs or after walking a short distance?
When did you last climb a flight of stairs?
Are you able to walk up stairs at the same rate as 5 years ago?
Can you climb 2 flights of stairs without stopping? When did you last do so?
Have you ever had a heart attack, or have you ever been treated for a possible heart attack?
Do you have heart problems such as skipped heart beats, angina, or chest pain?
Have you been told that you have a heart murmur or rheumatic fever?
Have you ever been told that you have mitral valve prolapse?
Have you ever had heart or lung surgery?
Do your ankles ever swell?
Are you ever short of breath? When?
Do you ever have chest pains, angina, chest heaviness, or chest tightness?
Do you ever have indigestion that does not occur after overeating?
Have you ever been told by your doctor to exercise or diet to control high blood pressure?
Have you ever been a patient in a critical care unit (cardiac care unit, intensive coronary care unit)?
Have you passed out or nearly passed out in the last year? Why?
Do you sleep with more than one pillow at night? (This question is useful only for men and women
over age 60, as 50% of younger women sleep with two pillows)
Do you currently take water pills or diuretics?
Do you take medication for high blood pressure or medication to prevent high blood pressure?
Do you currently take potassium pills or powder?
Do you currently take anticoagulants or blood-thinning medicine?
Have you ever been told to take, or have you ever been given, antibiotics before routine dental
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work?
Respiratory and Airway Problems
most important consideration regarding the respiratory system is
securing the airway
-Do you wear dentures, a crown, a partial, or a bridge?
-Are any of your teeth loose, cracked, chipped, or capped?
-Have you ever had anesthesia?
-Have you or any blood relative ever had any problems with anesthesia?
-Can you open your mouth fully?
-Do your joints ever click, pop, or hurt?
-Have you ever been treated for a problem of the jaw joint (that is, a temporomandibular joint [TMJ] problem)?
-Have you ever been hoarse for more than 1 month?
-Do you snore, or do others say you snore? (This question proved to be the best predictor of difficult intubation
when our computer-based health history was compared with outcome studies but was not very specific [four of
five patients who answered yes to this question did not have a difficult intubation].)
-Do you ever fall asleep in the daytime? Have you ever had a near-miss car accident because you almost fell
asleep in the daytime? Was this not after a period of intentional sleep deprivation? How often?
-Have you gained weight recently? (A 10% weight gain increases the number of apneic episodes by 30%)
-Have you ever had cancer?
-Have you ever had, or been treated for, arthritis?
-Do you have neck stiffness or problems moving your head?
-Have you ever been told you had diphtheria? (Diphtheria can cause narrowing of the airway.)
The following questions search for lung disease:
-Have you ever had pneumonia? When?
-Have you ever undergone lung surgery?
-Do you have shortness of breath, wheezing, chest pain, bronchitis, asthma, or emphysema?
-Do you cough regularly or frequently?
-Do you cough up mucus (sputum or phlegm)?
-In the last 4 weeks, have you had a fever, chills, cold, or flu?
-Do you smoke or have you ever smoked? When did you stop?
-Do you use spit or chew tobacco?
-Have you ever smoked half a pack or more of cigarettes a day on a regular basis?
-Have you ever smoked a pipe or cigars on a regular basis?
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Hepatic and Gastrointestinal Disease
-Have
you ever been diagnosed as having a hiatus hernia?
-Have you ever had hepatitis, yellow jaundice, liver disease, or malaria?
-Have you ever had gallstones or gallbladder disease?
-Are your stools ever bloody or black and tarry?
-Have you seen bright red blood on your stool or on toilet tissue after
wiping?
-Have your bowel habits changed this year?
-Do you often have diarrhea?
-Have you ever vomited blood or material that looks like coffee grounds in
the last 6 months?
-Do you have frequent nausea or vomiting?
-Have you lost weight this year without trying?
-Has your appetite for food changed in the last year?
-Are you eating the same foods you ate a year ago?
-Have you had heartburn within the last month?
-Are you now being treated, or have you been treated, for ulcer disease?
-Are you currently taking antacids
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History-taking
Bleeding Problems
-Have you ever had a blood problem such as anemia or leukemia?
-Have you ever had a problem with blood clotting?
-Have you ever had a serious bleeding problem?
-Have you received a blood transfusion since 1979?
-Do you use any medications such as aspirin or vitamins such as
vitamin E or supplements such as ginseng or garlic known to
affect blood clotting? How much? How often? When did you last
use such?
-Has a family member or blood relative ever had a serious bleeding
problem?
-Have you ever had prolonged or unusual bleeding from cuts,
nosebleeds, minor bruises, tooth extractions, or surgery?
-Have you ever had excessive bleeding that required blood
transfusion?
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History-taking
Renal Disease
-Have you ever had any kidney problem?
-Have you ever had kidney failure, dialysis, or
kidney infections?
-Have you ever had kidney stones?
-Are you undergoing dialysis for kidney problems?
-Have you had changes in bowel or bladder
function in the last year?
-Has your appetite for food changed in the last
year? (Voluntary avoidance of foods having a
high protein content is a subtle sign of renal
disease.)
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History-taking
Endocrine Disturbances
-Do you wake up at night to urinate? How often?
-Have you ever been told that you have diabetes or sugar diabetes?
-Do you take, or have you taken steroids, cortisone, muscle-building
supplements or steroids, or DHEAs or adrenocorticotropic hormone
(ACTH) in the last year?
-Do you perspire (sweat) much more than others or a great deal every now
and then?
-How often do you have headaches?
-Does your face flush or get red every now and then, even when you are
not exercising
-Have you ever taken medicine (e.g., Synthroid [levothyroxine]) or had
radioactive iodine (131 I) for thyroid disease?
-Do you consistently like the room warmer or colder than your spouse does?
-Do you have muscle cramps or spasma in your legs more than three times
a year?
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History-taking
Neurologic Disease
-Have you ever had a seizure, convulsion, fit, stroke, or paralysis?
-Have you ever been diagnosed as having a tremor?
-Have you ever had migraine headaches?
-Have you ever had nerve injury, multiple sclerosis, or any other
disorder of the nervous system?
-Have you ever had numbness, tingling, or "pins-and-needles" in
your arm or leg that has lasted more than 2 hours?
-Have you taken antidepressant, sedative, tranquilizing, or
antiseizure medications in the last year? Do you take SAM-e
(adenosyl methionine) or St. John's Wort because of feeling
blue? (I might add, if the patient is a woman over age 45 years,
Do you take any medications for hot flashes or for peri- or
postmenopausal symptoms?).
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History-taking
Musculoskeletal Disease
-Have you ever had low back pain?
-Have you been working at your usual job
or doing your normal activities in the last
week?
-Have you taken pain pills or had pain
shots in the last 6 months?
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History-taking
Sensitive Areas of Concern:
possibility of pregnancy, illicit drug use, and the potential for
acquired immunodeficiency syndrome (AIDS)
-Within the last 2 years, have you taken nonprescription drugs, such
as cocaine, crack, heroin, or LSD?
-Have you been exposed to the body fluids (blood, semen, urine, or
saliva) of anyone likely to have the AIDS virus?
-Are you in any of the groups at high risk for AIDS (homosexuals,
bisexuals, hemophiliacs, and those who have had sex with a
prostitute within the last 18 years)?
-Would you like to undergo a test to find out whether you have been
exposed to the AIDS virus?
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The Physical Examination
-Determination of arterial blood pressure in both arms, and in at least one arm 2
minutes after the patient assumes the upright position after lying down.
-Examination of the pulses and of the chest for heaves, thrusts, pulsations,
murmurs, and gallops.
-Examination of the carotid and jugular pulses.
-Examination of the chest and auscultation of the bases of the heart for subtle rales
suggestive of congestive heart failure, or for rhonchi, wheezes, and other
sounds indicative of lung disease.
-Observation of the patient's walk for signs of neurologic disease and to assess back
mobility and general health.
-Examination of the eyes for abnormal movement and, along with the skin, for signs
of jaundice, cyanosis, nutritional abnormalities, and dehydration.
-The fingers are checked for clubbing.
-Examination of the airway and mouth for neck mobility, tongue size, oral lesions,
and ease of intubation.
-Functional evaluation of cardiovascular risk by observing vigor and stamina in
walking.
-Examination of the legs for bruising, edema, clubbing, mobility, sensation, and
adequacy of hair growth (or skin texture) as signs of circulatory competence.
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DETECTING DISEASE:
HISTORY, PHYSICAL EXAMINATION, AND CHART
REVIEW VERSUS LABORATORY TESTS
combination of history-taking and physical examination is
the best tool for optimal evaluation of patients and
optimal selection of laboratory tests (i.e., selection of
only those tests that have a greater chance of
benefiting rather than harming the patient).
The problems with ordering batteries of
laboratory tests for all patients:
-laboratory tests are not very good screening devices for disease.
-the subsequent "extra" tests that physicians order as a follow-up of
supposedly abnormal results are costly.
-nonindicated tests often represent additional risk for the patient,
increase medicolegal risk for the physician, and render ORs in
outpatient centers and hospitals inefficient.
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why laboratory tests do not have more
benefit for the perioperative patient?
most abnormalities in asymptomatic patients do not
reflect the presence of disease.
the distribution of results in a population of patient is
gaussian (i.e., normal). The values defining
"abnormal" are set arbitrarily" Therefore, 5% of test
results from patients without disease will be "outside
the hospital reference range."
If one were to order 100 hemoglobin determinations for
a sample of healthy patients, 5% of the results would
be expected to be "abnormal."
Ordering multiple preoperative tests increases the
chances of at least one abnormal result.
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why laboratory tests do not have more
benefit for the perioperative patient?
Assuming that results of tests are independent of one
another, the more tests ordered, the higher the
likelihood of an abnormal result.
For example, if two tests are ordered for a patient
without disease, the chance of both being normal is
0.95 × 0.95 or 0.90. For 20 tests, the chance that all
would be normal would be only 36%. The chance that
at least one result will be abnormal is 64%.
Thus, if one uses more than 13 tests to screen patients
before surgery, one should expect at least one
abnormal test result.
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Preoperative Testing ?!!
Studies show that :
• the history and physical examination are the
best ways to screen for disease
• no harm from omitting all laboratory testing
for ASA I patients
• the history and physical examination dictated
the appropriate laboratory testing
• Laboratory tests can be used to screen for
disease when the patient has appropriate risk
factors and when such tests have proved
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effective
Medicolegal Liability
• "Extra testing"—testing not warranted by findings on a
medical history—does not provide medicolegal
protection against liability
• Studies show that 30% to 95% of all unexpected
abnormalities found on preoperative laboratory tests
are not noted on the chart before surgery
• the failure to pursue an abnormality appropriately
poses a greater risk of medicolegal liability than does
failure to detect that abnormality
• pursuit of unexpected abnormalities in asymptomatic
patients is more likely to harm than benefit such
patients
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Operating Room Schedules
• surgeons find it easier just to order all the tests and
let the anesthesiologist sort them out.
• Surgeons also believe that it is much more efficient
to order batteries of tests than to have an
anesthesiologist, who sees the patient the night
before or the morning of surgery, obtain the tests
on an emergency basis.
• This line of reasoning overlooks the fact that
abnormalities arising from tests performed in the
battery fashion are usually not discovered until the
night before or the morning of surgery, if at all.
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Does Surgical Procedure Influence Laboratory
Test Choice and Requirements?
•Type A procedures are minimally invasive operations.
I believe that no laboratory testing is indicated for these
operations, based on preoperative status alone.
•Type B and C procedures are progressively more risky
and invasive. Therefore, often require more preoperative
testing.
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Chest Radiographs
What abnormalities on chest radiographs can
influence management of anesthesia?
•
•
•
•
•
•
•
•
•
•
•
tracheal deviation or compression
mediastinal masses
pulmonary nodules
a solitary lung mass
aortic aneurysm
pulmonary edema
Pneumonia
Atelectasis
new fractures of the vertebrae, ribs, and clavicles
Dextrocardia
cardiomegaly.
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Chest Radiographs
In fact, the risks associated with chest radiographs
probably exceed their possible benefit if the patient
is asymptomatic and less than 75 years of age
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Electrocardiograms
The abnormalities on the ECG that have the potential to
alter management of anesthesia:
• atrial flutter or fibrillation
• first-, second-, and third-degree atrioventricular block
• changes in ST segment suggesting myocardial ischemia or recent
pulmonary embolism
• premature ventricular and atrial contractions, especially those that
are frequent (i.e., greater than 3 per minute)
• left or right ventricular hypertrophy
• short PR interval
• Wolff-Parkinson-White syndrome
• myocardial infarction
• prolonged QT segment
• tall peaked T waves
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Electrocardiograms
• ECGs are indicated for asymptomatic patients
of average risk undergoing type B or C
procedures who are over 40 (men) or 50
(women) years of age.
• one would be justified in obtaining repeat
ECGs prior to elective surgery for above
patients who have recently had an ECG if it is
more than 5 months old or was abnormal.
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Evaluating cardiovascular risk for patients
undergoing noncardiac surgery:
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Hemoglobin, Hematocrit, and
White Blood Cell Counts
Polycythemia:
-Most data confirm that polycythemia is
an independent risk factor for
cardiovascular mortality
-Most physicians arbitrarily do not treat
unless the hemoglobin level is greater
than 16 mg/dL.
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Hemoglobin, Hematocrit, and
White Blood Cell Counts
Anemia
(In the neonatal period)
-recent blood loss
-isoimmunization
-congenital hemolytic anemia
-congenital infection
(in3 to 6 months after birth)
-congenital disorder of hemoglobin
synthesis or structure
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Hemoglobin, Hematocrit, and White Blood
Cell Counts
• No data confirm the hypothesis that preoperative
treatment of moderate or mild normovolemic anemia in
class-A patients decreases perioperative morbidity or
mortality.
• No data exist regarding the possible harm from
abnormal white blood cell counts found preoperatively.
Therefore, the following ranges of "surgically
acceptable values" are arbitrary:
-for hematocrit, 29% to 57% for men and 27% to 54%
for women
-for white blood cell count, 2,400 to 16,000/mm3 for both
men and women.
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Hemoglobin, Hematocrit, and White
Blood Cell Counts
preoperative hematocrit or hemoglobin levels
should be determined for:
• all female surgical patients
• all male surgical patients over 64 years of age who are
undergoing type B or C surgical procedures
Red cell antigen screening would be warranted for all
patients undergoing procedures involving possible
blood loss of more than 2 U/70 kg body weight
(type B and C surgical procedures)
White blood cell counts appear to be rarely, if ever,
justified for asymptomatic patients
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Blood Chemistries, Urinalysis, and Clotting
Studies
Albumin
albumin level was an important predictor of
perioperative morbidity and mortality in every
surgical specialty.
It may therefore be time to add this laboratory
test for patients undergoing surgical class C
procedures, and for patients who have a
physiologic age (RealAge) of over 85 who are
undergoing surgical class B procedures.
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Blood Chemistries, Urinalysis, and Clotting
Studies
blood glucose assays are indicated:
-before type B and C procedures
-for individuals over 75 years of age
40
Blood Chemistries, Urinalysis, and Clotting
Studies
BUN assays are indicated:
•before type B and C procedures
•for patients over 65 years of age
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Clotting Studies
Although partial
thromboplastin
time (PTT) and
prothrombin time
(PT) are useful
tests for screening
patients who have
a history of
bleeding, their
value as screening
tests for
asymptomatic
patients has never
been shown
42
Blood Chemistries, Urinalysis, and Clotting
Studies
the patient taking aspirin:
• Aspirin at a dose of 3 to 10 mg/kg of body weight
daily does not seem to pose a risk of bleeding
• Because the pharmacokinetics of aspirin change when
more than 2 g/70 kg of body weight is consumed daily,
a patient should be evaluated that there is no
appreciable level of acetylsalicyclic acid in the blood for
24 hours before surgery
• The patient should also be evaluated if surgical
hemostasis cannot be ensured or if a regional
procedure into a closed space is planned.
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Tests for HIV, Pregnancy,
Hemoglobinopathies, Malignant
Hyperthermia, and Magnesium Deficiency
• raise ethical questions
• the history is still the best tool for identifying
those who should be tested or those who are
at risk of the condition.
• In the past, no screening test has existed for
susceptibility to malignant hyperthermia
syndrome (MHS) other than a personal or
family history of the condition. Several new
tests are available; none uses genetic testing,
but one is expected to be available shortly.
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Malignant Hyperthermia
It is still too early to predict the usefulness of
these tests as a screening procedure for MHS
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Hypomagnesemia
• is a prevalent laboratory finding in hospitalized
patients.
• Some investigators believe that serum Mg
should be measured routinely in hospitalized
patients because of the high prevalence of
hypomagnesemia coupled with the difficulty of
diagnosing hypomagnesemia on clinical
grounds alone.
• I could not find any data indicating better
perioperative outcome in patients not
undergoing cardiovascular surgery because of
routine detection and correction of
hypomagnesemia. 46
47
Procedure for determining when
pulmonary function tests are warranted
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signs and symptoms of significant liver
disease that warrant the performance of
liver function tests
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The Evolution of Anesthesiology
Health care is in an active state of transformation
and reform.
The next decade will be a transition-rich
environment for consolidations, affiliations, and
improving quality of care.
Will anesthesiology adopt these changes and be
a more vibrant specialty in the future?
Will acceptance or abandonment of such changes
determine the viability of the specialty of
anesthesiology and its value to society in the
future?
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You,
The reader of this chapter,
Have the ability to make
anesthesiology a specialty of the
future or a dinosaur of the past.
The expanding role of the anesthesiologist
beyond the OR has redefined our
specialty for the hospital, our colleagues,
and the community regarding our clinical
expertise, effectiveness, and contribution
to quality patient care.
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The Low Predictive Value of an "Abnormal"
Laboratory Test Result
If the anesthetic management of a patient is
altered because of a test abnormality, that
abnormality should indicate a condition:
(1) that poses a significant risk of preoperative
morbidity that can be lessened by preoperative
treatment.
(2) that cannot be discovered through history-taking
and physical examination.
(3) that is sufficiently prevalent in the population to
justify the risk of performing the follow-up test. To
be cost-efficient, the test should be sufficiently
"sensitive" (have "positivity in disease") and
sufficiently "specific" (have "negativity in health").
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The 2002 ASA Preoperative Testing
Advisory
1. No test, but rather a physician review stating that
"this patient is in optimal shape for daily living" is
usual for patients undergoing minimally invasive
surgery.
2. Evaluation should occur prior to the day of surgery if
the patient is not absolutely healthy or the procedure
is other than "minimally invasive"
3. Certain tests were found to be usual for the most
invasive type of surgery.
4. About 17% of anesthesiologists obtained pregnancy
testing routinely for all women in the potentially
pregnant calendar ages of 11 to 55 years, irrespective
of the patient's statement that "there is no way I
could potentially be pregnant."
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