Transcript Patient Evaluation And Assessment

Patient Evaluation
And
Assessment
Practice Guidelines for Sedation
and Analgesia by NonAnesthesiologists
(Special Article)
Anesthesiology
2002;96:1004-17
Guidelines for Patient Evaluation
Clinicians should be familiar with aspects of the
patient’s medical history and how it might alter the
patient’s response to sedation/analgesia
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Abnormalities of the major organ systems
Previous adverse sedation experiences
Drug allergies, current meds, potential drug interactions
Time and nature of last oral intake
Hx tobacco, ETOH, substance use or abuse
Guidelines for Patient Evaluation
Patients should undergo a focused physical
examination
– Vital signs
– Auscultation of heart and lungs sounds
– Evaluation of airway
Laboratory testing guided by patient’s underlying
medical condition and the likelihood that the results
will affect the management of sedation/analgesia
– Confirmed immediately before sedation
Patient Evaluation/Assessment
Patient Selection Overview
– No unevaluated medical problems
– No co-existing medical conditions
– Chronic medical conditions should be well
controlled
– Patient should be an ASA I or II. ASA III if
their medical condition is compensated and well
controlled
Patient Selection Overview…
Evaluate for any undiagnosed medical conditions
Identify patients that may pose a challenge for a
successful sedation
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Severely phobic
Hx drug abuse or tolerance
Moderate/severely mentally challenged
Obesity
Difficult IV access
Difficult airway
Patient Selection Overview…
Age considerations
– No absolute upper/lower age limits provided:
Practitioner appro trained and skilled
Medical status is stable
Adequate post-op care is available
Pediatric and geriatric patients may require
more advanced management techniques
Medical History…
Cornerstone of preoperative
evaluation/assessment
– Must be recorded in record
Obtained through the use of pre-printed
medical screening questionnaire and patient
dialogue interview
– Must correlate all written and verbal findings to
achieve final opinion of medical status
Medical History…
Biographical information
– Name, address, age
Proposed procedures
– Fit of proposed procedures and overall health
assessment
Current state of health
– Note recent acute illnesses
– Evaluate status of known medical problems
Medical History…
Medications
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Current medication usage
Dosing schedule
Last dose
Prior medication usage in the past two years
Allergies
– Note specific allergic reactions, onset, severity,
duration and treatment
FYI….Medications
Bisphosphonates
– Used for the treatment of hypercalcemia
associated with metastasis to bone
Breast
– Multiple myeloma
– Osteoporosis
Mechanism of action
– Osteoclastic inhibition
Medical History…
Prior surgeries and general anesthetics
Prior hospitalizations
Family history
– Health status of parents and siblings
– Family history of anesthetic complications
Social history
– Occupation
– Tobacco, ETOH usage, substance use and abuse (most drug abusers
are liars)
Sexual history
– High risk sexual behavior
– STD’s
Medical History…
Obstetrical history
– Prior pregnancies and deliveries
– Date of last menstrual period
– Note possibility of pregnancy risk
Past medical history
– Prior evaluation, duration and treatment
Review of systems
– Be alert to signs and symptoms of undiagnosed medical
conditions with anesthetic implications
Review of Systems…
General
– Fever, chills, sweating, weakness, fatigue
Skin
– Rash, pigmentation, bruising, scars, nails
Head
– Headache, trauma
– Cranial nerve function
Eyes
– Visual disturbances, glasses, contacts
Review of Systems…
Ears
– Hearing loss, ringing, dizziness
Nose
– Bleeding, obstruction, colds
Mouth
– Besides routine dental evaluation: frequent sore
throat, hoarseness, problems with swallowing
Review of Systems…
Neck
– Pain, stiffness, limitation of motion
– Swelling, lumps, thyroid enlargement
Respiratory system
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Cough, sputum, coughing up blood
Night sweats
Wheezing
Shortness of breath
Pain with breathing
Sleep apnea
COPD…
Disease state characterized by the presence
of airflow obstruction due to;
– Chronic bronchitis
– Emphysema
Most patients have features of both disease
states
14 million Americans
COPD…
Chronic bronchitis—excessive secretion of bronchial mucus;
productive cough >3 months
Emphysema—abnormal permanent enlargement of air spaces
distal to the terminal bronchiole
The only drug shown to alter the natural history of the
disease is O2
– 3 year survival continuous O2 vs. nocturnal O2;
65% vs. 45%
– Ipratropium bromide (anticholinergic)
– Albuterol
– Theophylline
– Corticosteroids
COPD
Chronic Bronchitis
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Elevated PCO2
Decreased PaO2
Erythrocytosis
Blue Bloaters
Reduced FEV1
Reduced hypoxia drive
Emphysema
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Normal PCO2
Decreased PaO2
Normal hematocrit
Pink Puffers
Reduced FEV1
Reduced hypoxia drive
Asthma
Inflammatory respiratory disease; dyspnea,
coughing, wheezing
– Bronchial spasm, inflammation and mucous hypersecretion
Etiology
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Extrinsic (allergic/atopic)
Intrinsic (nonallergic idiosyncratic)
Drug induced (ASA, NSAID’s)
Exercise induced
Infectious
Asthma
 Classification:
 Intermittent
 Symptoms <2/wk, SABA <2days/wk, Interference with
daily activity: None
 Persistent
 Mild: Symptoms >2 days/wk, SABA >2 days/wk but not
daily, Interference with daily activities: Minor
 Moderate: Symptoms daily, SABA daily, Daily
activities: Some Limitations
 Severe: Symptoms through the day, SABA several
times per day, Activity extremely limited
Asthma
Management: Stepwise approach
Intermittent:
– SABA
Persistent
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Step 2: Low dose ICS
Step 3: Low dose ICS + LABA
Step 4: High dose ICS + LABA
Step 5: High dose ICS + LABA + amalizumab
Step 6: Hight dose ICS + LABA + Oral
corticosteroids + amalizumab
Obstructive Sleep Apnea
Vastly under diagnosed problem
– Suspected that 1:5 adults has at least mild OSA and 1:15
adults has moderate or severe OSA
OSA status indicated by the frequency of apnea
and hypopnea events per hour of sleep (AHI)
Polysomnography results
– AHI cutpoints
5—mild
10—moderate
15—severe
OSA Symptoms
Habitual
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Loud snoring
Nocturnal breathing pauses
Choking
Gasping
Excessive daytime sleepiness
Demographic Correlates of Increased
OSA Prevalence JAMA:291 April 28, 2004
Male sex
Age 40-70 years
Risk Factors
– Body Habitus
Overweight and obesity (“Pickwickian” vs.
“nonpickwickian”)
Large neck girth >/= 17 inches
– Craniofacial and Upper airway abnormalities
Mandibular hypoplasia
Demographic Correlates of Increased
OSA Prevalence
Suspected Risk Factors
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Genetics
Smoking
Menopause
Alcohol use before sleep
Nighttime nasal congestion
Outcomes and/or Comorbid
Conditions
Problems with daytime
functioning
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Daytime sleepiness
Motor vehicle crashes
Psychosocial problems
Decreased cognitive
function
– Reduced quality of life
Cardiovascular and
Cerebrovascular Disease
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Hypertension
Coronary artery disease
Myocardial infarction
Congestive heart failure
Stroke
Diabetes and Metabolic
Syndrome
Consequences of Nocturnal
Hypoxia/Hypercapnia
Carswell, J. Long-Term Effects of Medical Implants, 14,167-176, 2004
Polycythemia
Pulmonary hypertension
Cor pulmonale
Chronic hypercapnia
Morning and nocturnal headache
Left-sided congestive heart failure
Cardiac dysrhythmias
Nocturnal angina
Diurnal systemic hypertension
Risk Factors for Obstructive Sleep
Apnea in Adults
Young et al JAMA April 28, 2004:291 2013-2016
Conclusions
– Under diagnosed
– Associated with diabetes, hypertension, coronary artery
disease, myocardial infarction, congestive heart failure,
and stroke
Due in part to risk factors common to all these conditions and
they may also reflect a role of OSA in the etiology
In one study 83% of patients with resistant hypertension had
unsuspected sleep apnea
Patients with CHF treated with CPAP showed an improvement in
ejection fraction and decreases in systolic blood pressure and
heart rate
Review of Systems…
Heart
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Chest pain
Shortness of breath with exertion or lying down
Swelling in legs or feet
Pounding in chest
Irregular or rapid heartbeats
Heart murmur
High blood pressure
Ischemic Heart Disease
Angina pectoris
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Stable vs. unstable angina
Meds: nitrates, Beta-blockers, Ca-channel blockers, ASA
Surgical intervention
Exercise tolerance
Unstable angina—nothing elective
MI
– < 6 months nothing elective
Sudden cardiac death
– In the absence of MI the largest single cause of death
from coronary atherosclerosis
Congestive Heart Failure…
Diminished functional capacity secondary to cardiac
dysfunction
– Etiology—CAD, HTN, cardiomyopathy,
valvular Dz
Clinical presentation
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Rapid shallow breathing
Inspiratory rales
Increased venous pressure
Systemic venous congestion—distended neck veins, peripheral edema,
weight gain, clubbing of fingers
Medications—ACE, diuretics Digitalis, nitrates vasodialtors
Congestive Heart Failure…
Class I—no limitation of physical activity, no
dyspnea or fatigue
Class II—slight limitation of physical activity.
Fatigue palpitation, dyspnea with routine physical
activity but comfortable at rest
Class III—marked limitation of activity, but
comfortable at rest
Class IV—symptoms present at rest, exacerbated
with physical activity
Hypertension…
Systolic > 140; Diastolic > 90
– Systolic vs Diastolic
Essential vs. Secondary HTN
Stepped-care in treatment
– Step I—single agent (diuretic, B-blocker, ACE, Ca-blocker, A-blocker,
A and B-blockers)
– Step II—increase dosage of first drug or add a second
– Step III—second or third drug and/or diuretic if not already
prescribed
Compensation and stage of treatment
Use of vasoconstrictors?
– NYHA study
Review of Systems…
Vascular system
– Lower extremity pain with exertion
– Leg cramps
– Coldness or change in color of extremities
Mottled
Loss of hair
– Blood clots
– Varicose veins
Review of Systems…
Gastrointestinal
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Chest pain or fullness after eating
Nausea/vomiting
Problems with swallowing
Yellow color to eyes or skin
Abdominal swelling
Liver disease or hepatitis
Review of Systems…
Urinary tract
– Urgent need to urinate
– Kidney disease
– Dialysis
Genitoreproductive
– Females—date of last mensus
– Venereal diseases
Renal Disease…
Patients with chronic renal failure with a GFR
greater than 50% will usually tolerate procedure
well.
Medications: require dose modifications or
contraindicated due to toxicity or are excreted by
the kidney
– Adjust dosages: ASA,APAP, Propoxyphen, PCN,
cephalosporins
– No change necessary with codeine, demerol erythromycin,
cleocin
Anemia
Bleeding disorders
Review of Systems…
Joints
– Pain, redness, warmth, swelling
– Limitations of motion
– Deformities
Lymph nodes
– Enlargement, pain, tenderness
Blood
– Anemia, easy bruising or bleeding, blood
transfusions
Anemia…
Hct < 41% in males and <37 in females
Etiology—increased destruction or decreased
production
History—poor nutrition, acute blood loss,
easy fatigue, ETOH or drug abuse,
transfusion, heavy mensus, chronic disease or
family history
Anemia…
Significant anemia affects the patient’s
ability to maintain oxygenation and blood
volume
A Hct < 30% warrants deferral of an elective
procedure
Sickle cell anemia
Review of Systems…
Endocrine system
– Thyroid enlargement
– Diabetes
Excessive eating, drinking, urination
Type I vs. Type II
Medications and necessary alteration for sedation
– Steroid supplementation
Equivalent Doses of Corticosteroids
Steroid preparation
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Hydrocortisone (cortisol)
Prednisone
Prednisolone
Methylprednisolone
Triamcinolone
Betamethasone
dexamethasone
Equivalent dose (mg)
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20
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0.60
0.75
Steroid Therapy…
Endogenous cortisol; 20mg/d
Patient currently taking or has within the
prior 2 years taken the equivalent of >/= 20
mg/d of cortisol may require supplementation
prior to surgery or anesthesia
Supplementation dependant upon dosage—
usually doubling daily dose day before, day of
and day after
Consult MD
Diabetes Mellitus…
Type II non-insulin dependant—do not pose a
risk if well controlled and compliant
Type I or IDDM
– Procedure dictates the alteration in insulin
Duration of procedure
NPO status
Post-operative intake
Consult with MD
Review of Systems…
Allergies
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Hay fever
Allergic rashes
Asthma
Nonmedication allergies
Psychiatric considerations
– Depression,
– Anxiety
– Family, friend, job problems
Review of Systems…
Nervous system
– Seizures
Date of last seizure
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Fainting
Memory loss
Speech impairment
Cranial nerve function
Motor nerves: paralysis, loss of coordination
Sensory nerves: numbness, tingling, pain
Preanesthetic Physical Evaluation
Focused examination following review of the medical
history
– Risk assessment
– Development of anesthetic plan
Baseline vital signs
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Height and weight
Heart rate
Respiratory rate
Blood pressure
Temperature
Room air O2 saturation
Preanesthetic Physical Evaluation
Physical habitus
– Significant obesity
Baseline mental status
Evaluation of heart and lungs
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Lung fields
Heart sounds
Murmurs
JVD
Preanesthetic Physical Evaluation
Assess potential IV sites
Skin integrity
Jaundice or pallor
Clubbing of the fingers
Peripheral dependent edema
Airway Evaluation…
Allows for detection and assessment of
abnormalities that may predispose to
difficult airway management and ventilation
during the conscious sedation procedure
– Jaw—micrognathia, retrognathia, trismus,
significant malocclusion
Airway Evaluation…
Mouth
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Decreased interincisal opening (<3 cm)
Edentulous
Protruding incisors
High arched palate
Intraoral structures
– Size of tongue
– Tonsillar hypertrophy
– Nonvisable uvula
Airway Evaluation…
Head and neck
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Short neck
Limited neck extension
C-spine disease or trauma
Tracheal deviation
Dysmorphic facial features
Decreased hyoid-mentalis distance
Less than 3 cm in adult
Airway Evaluation
Mallampati Classification
Able to visualize on
wide mouth opening
Predicted intubation
Easiesthardest
1. Uvula and pharynx
Easiest
2. Partial uvula
3. Hard & soft palate
4. Tongue & hard palate
Hardest
Class I
Class II
Class III
Class IV
Laboratory and Ancillary Testing
Preoperative diagnostic testing should be
ordered when specifically indicated from the
history and physical examinations
ASA states—”no routine laboratory or
diagnostic screening test is necessary for the
preanesthetic evaluation of patients
Medical Risk Assessment (ASA
Physical Status Classification)
Not predictive of outcome but helps the
practitioner determine the overall suitability
of a patient to undergo an outpatient
conscious sedation
ASA classification may aid the clinician in
identifying patients with medical risk factors
that may be a relative contraindication to an
outpatient sedation procedure
ASA Classification…
ASA I: Normal healthy patient
ASA II: Patient with mild systemic disease
that does not interfere with day-to-day
activities
Smoking
ETOH and drug abuse
Mild-moderate controlled HTN
NIDDM
Well controlled asthma
ASA Classification…
ASA III: Patient with moderate— severe
systemic disease that is not incapacitating
but may alter day-to-day activity
Severe labile HTN
IDDM
MI within 6 months
COPD
CHF
ASA Classification…
ASA IV: Patient with severe systemic
disease that is a constant threat to life
ESRD
Liver failure
ASA V: A moribund patient not
expected to survive 24 hours with or
without operation
ASA Classification…
REMEMBER: A patient considered for
outpatient conscious sedation procedures
should be an ASA I or II, although status
III patients are acceptable if their medical
condition is compensated and stable
Medical Consultation…
The patient should not have any medical
conditions that have not been properly
evaluated and assessed
Are there any existing medical conditions
that require further evaluation by internist
or specialist to assist in the medical
management of patient?
Anesthetic Plan…
After appropriate review of medical history
and physical exam an anesthetic plan should
be formulated that balances the realistic
needs and demands of both the patient and
clinician
Be sure to discuss the anesthetic plan with
the patient to answer appropriate questions
and discuss pre-sedation orders
Systemic Changes Associated
with Aging
Anesthetic Correlations
Aging…
Makinodan, Biology of aging. Surgical Care of the Elderly
Chicago, Year Book, 1988
Aging is not a disease
– Certain diseases become more prevalent with increased
age
– Occurs at different rates
– Not confined to the elderly
An inherent progressive impairment of function with
passage of time, which cannot be averted and which
causes individuals to become more vulnerable to
death.
The Aging Population…
As a percentage of the U.S. population
– 4%
– 12%
– 24%
1900
1986
2030
What Changes Are To Be Expected
With Aging?
Cardiovascular
Respiratory
Central Nervous System
Renal
Hepatic
General Changes with Age…
Body Weight
– Age 60
Body weight has peaked
Progressive decrease in weight in remaining years
Composition (net offset)
– Increase in adipose
– Decrease in lean body mass
Cardiovascular Changes
Distensibility of aorta
Mean blood pressure
Left ventricular mass
Systolic BP
Response to catachol’s
Cardiac dysrhythmias
Conduction abnormalities
Coronary blood flow
Maximum heart rate
decrease
normal
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increase
decrease
increase
increase
decrease
decrease
Cardiovascular Changes
Kannel el al: N Engl J Med 311:1144, 1984
Conclusions
– 25% of patients >80 years of age had some manifestations
of coronary artery disease
– 25% of males and 40% of females >75 have hypertension,
primarily isolated systolic hypertension
– The relative low incidence of heart disease in
premenopausal females is lost with menopause
– Mortality from CVD is proportional to systolic blood
pressure and in males also heart rate
– Although mortality from CVD increases with age, it is not
inevitable
Cardiovascular Changes
Stiffening of the aorta
– Even in populations not prone to atherosclerosis
Natural consequence of aging
Elasticity of the thoracic aorta accounts for one-half of the
buffering capacity to the remainder of the vascular tree
Loss of this important buffer results in significant end-organ
damage
– Results in increased pulse wave velocity resulting in
systolic hypertension and progressive left ventricular
hypertrophy
Cardiovascular Changes
Decreased baroreceptor sensitivity
(normotensive and hypertensive)
– Unable to respond to hypotension with usual
compensatory tachycardia
Thus prone to orthostatic hypotension
– Confirmed with a change of 20 mmHg systolic or 10mmHg
diastolic from the sitting to standing readings
Decreased beta adrenergic activity
– Decreased receptor affinity
Cardiovascular Changes
Elderly are prone to bradycardia and dysrhythmias
– Decrease in cardiac pacemaker cells
By age 75 may only have 10-20% of normal cells remaining
Atrophy and fatty infiltration of the conducting tissues
– Interfere with conduction and pacemaker activity
– Degeneration of the Bundle of His and bundle branches
These changes may not be evident in a 12 lead or
rhythm strip, but may necessitate Holter monitoring
Cardiovascular Changes
Reduction in Cardiac Output
– 1% reduction in CO per year starting at age 50
Etiology maybe secondary to lower maximal heart rate
or slower myocardial rate of contraction
Implication being that the elderly have a limited
reserve capacity
Vascular Changes (CAD)
There are histological and compositional changes to the
coronary vasculature with age that increases the likelihood
of CAD
– May not be clinically evident
Framingham study
– 29% males >65 and 45% females >85 had an MI diagnosed solely by Q
waves or changes in R waves
Hertzer (1984 Ann Surg)
– Performed angiograms on patients over the age of 65 with no clinical
signs of CAD
14% truly free of disease
60% found to have significant CAD
– 50% with severe disease warranting bypass grafting or were inoperable
Valvular Changes
Fibrosis and calcification of valves increases
with age
– Aortic
20% of individuals >65 showed some degree of aortic
sclerosis
– Mitral
– Tricuspid
– Pulmonic
Summary of Cardiovascular Changes…
Prevalent and often asymptomatic
– Should assume its presence
Systolic hypertension is not benign in the elderly
Dysrhythmias are to be expected
– Old MI, BBB, conduction defects/blocks, atrial
fib/flutter
Incur greater surgical risk
– Intermittent unifocal PVC’s not associated with
significant surgical/anesthetic risks
Respiratory System Changes
Wahba: Influence of aging on lung function, clinical significance of changes from age twenty. Anesth Analg 62:764; 1983
Bellows
Gas exchange
Control of ventilation
Respiratory System Changes
The bellows become stiffer and less compliant
– Stiffer chest wall secondary to calcifications of
articulations
20% greater effort needed by age 60
– Less muscle strength to expand chest wall
35% reduction by age 65
– Decreased intervertebral spaces
– Decreased elastic recoil
– Vital capacity decreases at a rate of 20 ml/year
Respiratory System Changes
Gas Exchange
– Structural changes reduce gas exchange
Decreased elastic recoil results in trapping, V/P
mismatches, and shunting
– Resultant decreased PaO2
Young/healthy—90-100 mmHg
80 year old—60-70 mmHg
PaO2 = 102 – (0.496 x age)
Decreased elastic recoil may result in closed airway
spaces even during tidal breathing
Respiratory System Changes
Control of ventilation
– Marked differences associated with sleep
Irregular patterns and apnea
Therefore increased incidence of desaturation and
apnea with an anesthetic
– Reduced response to hypoxia and hypercarbia
Much greater fall in oxygen tension to stimulate
ventilation
– 40-70%
– Anesthetic considerations