Transcript ANESTHESIA PREOPERATIVE ASSESSMENT

ANESTHESIA PREOPERATIVE
ASSESSMENT
Jane Belcher, MSNA, CRNA
Why? Why?? Why?????
 The preoperative evaluation of patients helps to identify factors that
increase risk associated with anesthesia and related to the proposed
surgery.
 All of the questions we ask, information we gather from talking with a
patient, help to formulate our plan of anesthesia and what other adjuncts
we may need to consider with each individual patient
Goals
 Optimize patient care, comfort and satisfaction
 Minimize potential morbidity and mortality
 Minimize surgical delays
 Determine appropriate post-op disposition
 Evaluate patients overall health status
 Form an appropriate plan for perianesthesia care and post-op support
 Educate the patient and family
HOW? HOW? HOW?
 Review patient records, including previous anesthetics
 Patient interview
 Focused physical exam
Patient records
 May reveal significant prior complications:
-Malignant hypertension, actual or potential. This is familial
- atypical plasma cholinesterase-leading to prolonged time on ventilator
particularly if not known. This is often a familial trait
-can determine if patient was a difficult airway or how they tolerate
anesthesia
For inpatients: Check progress notes, consults, meds, labs, CT and ECHO
reports
Patient Interview
 Preferably in person, but may initially be over the phone with the purpose of
gaining valuable information, and developing a trusting relationship
 Medical history-may have to ask or just confirm information. Questions must be
direct and systematic. Information gained can direct further testing needed or
type of anesthetic best for the patient.
 Surgical history-may need to know dates, such as cardiac stent placement.
Have there been any complications with any surgery?
 Anesthetic history-note any complications such as PONV, MH, post-op delirium
or difficult airway. Check out vague reports of fevers/seizures, etc with patient or
a direct family member (patient example)
 Drug history: Ask about all OTC as well as herbal products, as well as allergies to
any drugs and the reaction
 Social history-tobacco, alcohol and illicit drugs
Drug history
 Consider the pharmacodynamics of each drug or drug class the patient is
taking and how that may affect the anesthesia or proposed surgery
 Some drugs should be discontinued preoperatively but others should be taken
up to the day of surgery. However, it is not that easy! Why? Some newer drugs
have been added under some old classifications, such as oral anticoagulants
with varying time considerations for discontinuation. It is recommended to keep
a chart handy with these drugs listed and the recommendations
 Other drugs, such as monoamine oxidase inhibitors, oral contraceptives and
herbal supplements, should be stopped 2-6 weeks before elective surgery. What
do we do if someone who takes these needs surgery? Deal with the
consequences! As a perioperative RN you need to familiarize yourself with these
consequences since you too may have to deal with them!
Anticoagulants…it used to be so easy…
When considering this class you have to weigh the risk-benefit analysis for each with the reason the
patient is taking the drug…
Cardiac stents placed less than 1 year need cardiac consult if possible.
BMS: 6 weeks-3 months minimum delay after PCTA
DES: 12+ months delay
ASA-affects platelets, stop at least 7 days (emergency may have to administer platelets or
cofactors). And that is the easy one!
Antiplatelet agents-Reopro (abciximab) wait 48 hours before any neuraxial or nerve procedure.
Others in that class need to hold for 7-8 days
Anticoagulants-Coumadin and Heparin can be reversed if necessary with Vit K or FFP, and
protamine, respectively. Heparin gtt stop 6 hours before surgery and Coumadin 3-5 days
Antifibrinolytics-discontinuation usually not an option because they are given to break up clots
in life saving situations (Massive PE, MI)
Cardiac, antihypertensives and
antiarrythmics
 ACE Inhibitors and angiotensin receptor blockers can cause extreme
hypotension intraoperatively, refractory to the usual vasopressors. These
patients become intravascularly volume depleted. Controversy regarding
continuing to day of surgery (hypotension vs. improved regional blood flow
or increased risk of HTN/a fib).
 Beta blockers are cardiac protective and most often recommend
continued during periop period. Should be initiated at least 1 week before
high risk surgery. Optimize hydration
 Ca+ channel blockers work by producing peripheral vasodilation and have
a negative inotropic effect by slowing sinus and AV conduction. Usually
hypotension well-controlled with phenylephrine
 Antiarrythmics cause cardiac depression and can prolong neuromuscular
blockade. Best not to withhold, but rather stop ACEI if taking concurrently.
 Diuretics-main concern is hypokalemia and hypovolemia with concern of
fatal arrythmias
Hypoglycemic Agents
 Insulin-morning dose withheld and check serum glucose levels
 Oral agents-withhold the day of surgery and avoid dehydration. Monitor
glucose before and after surgery, and if prolonged surgery monitor intraop.
 Remember that diabetes is more than just hypo- or hyperglycemia. Every cell
and organ in the body is affected by this metabolic dysregulation. All can prove
challenging for the perioperative period:
 Increased serum fatty acids (lipolysis) which affects fat soluble drug metabolism
 Decreased protein synthesis leading to muscle wasting
 Dehydration (can lead to thrombus)due to glucose acts as osmotic diuretic
 Autonomic neuropathy: resting tachycardia, orthostatic hypotension, dysrhythmias,
gastroparesis, sudden death syndrome
 Stiff joint syndrome-glucose gets “stuck” in capillaries and joints
Drugs affecting CNS
 Monoamine oxidase inhibitors can cause severe hypertension due to
indirect acting sympathomimetics (ephedrine) due to release of
norepinephrine; untoward effects from Demerol and possibly fentanyl
causing serotonin syndrome. Older MAOIs must be held for two weeks to
avoid these affects.
 Tricyclic antidepressants block alpha activity and can potentiate effects of
epiniephrine and norepinephrine leading to HTN and arrhythmias. However,
discontinuing can lead to cholinergic symptoms, movement disorders and
cardiac dysrhythmias.
 Selective serotonin reuptake inhibitors intraoperatively can cause GI
symptoms, headache and agitation.
 Lithium intraop can cause ventricular arrhythmias, myocarditis, and
atropine-resistant bradycardia. Check serum levels
 Antiparkinsons should be continued to avoid withdrawal symptoms
Allergies
 Drug allergies-note all reactions to
determine if true allergy or an
adverse response to a drug
 Latex- up to 20% of all
intraoperative anaphylactic
reactions are attributed to latex.
 Shellfish allergy should be noted
and patient should be asked
about betadine (used for OR
prep)
 Risk increased in the following:
 Chronic exposure
 Spina bifida, urologic
reconstruction
 Greater than 9 surgeries
 Allergy to tropical fruits
 Intraop anaphylaxis unknown
cause
Social history
 Smoking/tobacco use is the leading cause of preventable premature
death in the U.S.
 Nicotine and CO are just two of thousands of noxious compounds inhaled
from cigarette smoking and second-hand smoke. These cause enough
problems on their own leading to increased oxygen demands and
decreased oxygen transport to all tissues due to CO occupying the
oxygen-binding sites on hemoglobin. These put greater demand on the
cardiovascular system. Stopping for only 12 hours allows the dispersion of
the CO out of the body to decrease these demands. Smokers have greater
mucous production and therefore, greater risk of
laryngospasm/bronchospasm and pulmonary complications.
 These same effects are seen in children exposed to second-hand smoke
Social history…alcohol
 Alcohol use can be classified as the occasional, social drinker, and the
chronic alcoholic
 The former usually does not cause a problem perioperatively
 With the chronic alcoholic it is sometimes difficult to determine the level of
alcohol currently in the system. If the patient is currently inebriated the
anesthesia requirements will be lessened and the risk of aspiration and
withdrawal are increased. Chronic alcoholics who are not currently
inebriated have greater anesthesia requirements due to enzyme tolerance.
 These patients also can have decreased plasma albumin, especially with
hepatic insufficiency. Will see effects from greater circulating
concentrations of some intravenous medications leading to prolonged
reactions to opiates and other CNS depressants.
Social history…illicit drugs
 There has been an increase in the last several years of drug overdose all
over the country. Usually it is discovered the drug used was heroin or crack
cocaine laced with fentanyl or sufentanyl. There has also been a push to
get Narcan available to these folks!
 Cocaine and marijuana, opioids and amphetamines continue to be the
most abused drugs. Perioperatively, marijuana really does not cause much
problem other than
 labile BP and occasional anxiety or panic attacks. Cocaine, however, can
be lethal. Its use can cause tachycardia, arrhythmias, myocardial ischemia,
delirium/hallucinations, enhanced physical strength, tremors, convulsions
and hyperpyrexia…
Illicit drugs….
 Amphetamines used chronically cause poor dentition and involuntary
grinding of the teeth so often the teeth are worn down and black! They are
also most often malnourished. AS I was once told by a patient “you don’t
eat when you do meth and coke”! I didn’t really know that…Symptoms of
acute use can cause some of the same manifestations as cocaine and
make anesthesia much more difficult to manage!
 Opioid abuse is often what leads to the heavier drug use. These patients
tend to be well nourished because appetite is not decreased. Acutely,
these patients will be euphoric, may have respiratory depression,
bradycardia and hypotension and well as slow movement in the GI tract.
Herbal Supplements
 Patients should be questioned about any herbal or over the counter
medications they are taking, the reason and the last dose taken.
 Many herbal supplements have affects on blood clotting, blood glucose,
CNS sedation or stimulation or may interact with psychotropic drugs.
Perioperative Concerns Regarding Certain Herbal
Supplements
Herbal Uses
Concerns Periop
Discontinue
Echinacea
Immunity
Increase hepatotoxicity
2 weeks
Ephedra
weight loss
Arrythmias; HR/BP/Stroke
24 hours
Garlic
HTN;
Risk of bleeding
7 days
Hyperlipidemia
Ginger
Anti-inflammatory; Risk of bleeding
2 weeks
Anti-emetic
Gingko
Improve blood flow
Risk bleeding
Ginseng
Mood enhancer
Kava
Sedative;anxiolytic Reduce anesthesia
Bleeding;hypoglycemic
36 hours
7 days
24 hours
requirements
St Johns
Antidepressant
Serotonergic crisis
5 days
Wort
Valerian
Anxiolytic;hypnotic Reduce anesthesia
requirements
2 weeks
What are we looking for?
Patient Focused Physical Exam:
Airway
 Airway assessment should be performed on every patient no matter what
the anesthetic plan! You never know when a planned MAC could turn into
an emergency intubation.
 Anesthesia providers DO NOT LIKE SURPRISES!!!! At least not when it comes
to the airway, or other aspects of the physical exam.
 In a matter of about 30 seconds we assess 5 areas on each patient that
would let us know almost 99.9% of the time whether we might have a
difficult time with the airway!
 We also know there are certain conditions that are associated with difficult
airway management
 The lungs should be auscultated just prior to patient going to OR and any
abnormalities addressed
Tests to predict a difficult airway
 Mallampati classification-examines the tongue size relative to the oral
cavity, and the airway is classified based on visible structures.
 Thyromental distance is the straight distance from the end of the lower
mandible to the thyroid cartilage. If it is less than 7cm, or about 3 adult
fingerbreadths, a difficult laryngoscopy can be predicted.
 Interincisor distance shows the degree the mouth can open and the
functionability of the temporomandibular joint. Less than 4cm, or 2
fingerbreadths indicates a difficult laryngoscopy.
 Head/Neck movement indicates the ability to place patient in “sniffing”
position
 Mandibular mobility is demonstrated by having the patient jut out the lower
jaw and indicates ease of inserting and moving the laryngoscope.
 Dentition with documentation of missing, loose or previously damaged
teeth
Focused PE: Cardiac
 As well as cardiac history, the anesthesia provider should listen carefully to
the heart rhythm noting any irregularities and make note of the EKG in
appropriate patients keeping in mind the patients cardiac history, if any.
 One question we always ask patients is regarding exercise tolerance to
show severity of disease. Depending on the patient, we may ask if they are
active (walking/work, etc) or we may just ask “do you get SOB walking to
the bathroom in your home”? A positive answer to that question is very
concerning.
 Has the patient had an ECHO/stress test/surgery/stents???
 What risk factors can lead to cancellation?
Cardiac conditions that need evaluation
and/or treatment prior to noncardiac
surgery
(adapted from European Society of Anaesthesiology)
 Unstable or severe angina; MI within last 30 days
 Symptomatic heart blocks/failure, or newly diagnosed arrhythmias,
bradycardia or tachycardia. Ventricular function should be evaluated in
pt. with dyspnea and current or prior failure-prominent CV risk factor
 Severe valvular disease: aortic valve <1cm squared or symptomatic or
symptomatic mitral stenosis
 Factors that warrant further investigation: (considering type surgery)
 H/O ischemic heart disease
 H/O CVA
 IDDM or renal failure
 High risk surgeries for cardiac: aortic, major and peripheral vascular surgeries
Obesity…another risk factor
 Morbid obesity is defined as twice the ideal body weight.
 IBW: Male=105 lb + 6 lbs for each inch >5 ft
 Female= 100 lb + 5 lb for each inch >5 ft
 Obese patients are at risk of complications from multiple co-morbidities, even if
none are diagnosed or obviously displayed:
 CAD, cardiomyopathy, HTN, thromboembolic events
 Cellulitis, panniculitis, venous stasis ulcers
 Fatty liver, diabetes, hormonal imbalances
 GI problems like GERD, hiatal hernia
 Many malignancies are directly related to obesity
 Musculoskeletal and genitourinary
 COPD, OSA, restrictive and reactive airway diseases, pulm HTN
Every organ, every system is affected
 Providers do have to consider what effects anesthesia will have on every
system and integrate information from all avenues: chart review, patient
interview, diagnostic tests, and physical exam
 Is the liver functioning well enough to metabolize? Is the renal system
working properly so drugs can be excreted and metabolized in appropriate
fashion?
 Diabetes, thyroid conditions and other metabolic conditions can affect
how patients respond to anesthesia.
ASA Physical Classification
 ASA I
No organic, physical, biochemical or psychiatric disturbance
 Healthy patient
 ASA II Mild to moderate systemic disturbance
 Smoking, HTN, obesity, DM, anemia, age extreme
 ASA IIISevere systemic disturbance
 Heart or pulm disease limiting activity, DM with vascular conditions, previous MI
 ASA IV
Severe systemic condition(s) that are life-threatening
 Renal failure, CHF, persistant angina
 ASA VMoribund patient, not expected to live
 Ruptured AAA, Trauma
 ASA VI
Organ donor
 Class E
Emergency surgery, i.e: healthy post-partum requiring surgery for bleeding