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Three primary goals of the preop assessment
1.  assess perioperative risk
2.  optimize the patient's medical condition and create anesthesia plan of care
3.  educate the patient
Why assess perioperative risk?
To find pertinent medical history
consultations & appropriate lab testing
Why is it important to educate the patient preoperatively?

(4)
1.  Explain the choise of anesthetics:  MAC/Regional & especially that general anesthesia may need to be a backup.
2.  What to expect peri-operatively
3.  Discuss importance of NPO status
4.  Discuss risks associated with anesthesia in order to obtain informed consent.
Associations regulations on perioperative assessment

(3)
1.  JCAHO:  implied consent if patient is unable to speak, but needs treatment
2.  ASA:  Basic standards for preanesthetic care
3.  AANA:  Scope and Standards for nurse anesthesia practice.
Pre-op Assessment:
ASA Standards:  Standard I

(5)
Standard 1:  Development of anesthetic plan

1.  Review medical record: patient & family with past history of anesthesia issues
2.  Interview and examine the patient
3.  Obtain/review pertinent tests and consults
4.  Determine preop medications
5.  Anesthesiologist follow-up
Pre-op Tests and consults:  Paradigm is changing
65% of patients are now outpatient and do not have the same pre-op testing as they had in the past.
Pre-operative medications related to operation
Rare to order pre-op sedation unless patient is extremely anxious

Antibiotics are ordered by the surgeon & most institutions have a standing order set. 

ABX:  usually in 30-60minutes prior to incision.
Three Nurse Anesthesia Practice Standards

(3)
Standard I:  perform thorough pre-anesthesia assessment.  Ologist usually will see patient ahead of time, yet CRNA should still get a HX

Standard II: Obtain informed consent in patient's language

Standard III:  Formulate patient specific plan of care based on comprehensive patient assessment.
Pre-op Assessment settings

(5)
1.  Inpatient
2.  Anesthesia pre-op eval clinics
3.  Same day admission:  patient comes in the morning or one week prior for assessment
4.  Outpatient:  surgical center or physician office.
5.  Pre-op Telephone assessment
Chart Eval

(3)
Ideally performed prior to the patient interview.  Also decreases patient anxiety because they feel as if you researched their HX.
2.  Provides a basis and direction for the patient interview
3.  Provides a direction for the physical assessment
Pre-op History Summary
Identify the planned procedure
1.  The OR schedule may not accurately reflect the planned procedure
2.  Assess patient's understanding of planned procedure

Systematic review of medical problems:
1.  Current medical problems
2.  Past medical problems.
Chart Review

(7)
1.  Progress Notes
2.  Surgical and anesthesia consent - side & site.  Do not sedate patient until consent is signed and correct.
3.  Consultation Reports/Diagnostic Testing
4.  Laboratory Data
5.  Current Medication Therapy
6.  Nursing Notes
7.  JCAHO universal protocol
Universal Protocol
implemented july 2004

wrong site

wrong procedure

wrong person surgeon

Time out prior to start
Interviewing the patient

(6)
verification of recorded data

establish report with patient

systematic review of history

previous anesthetics , surgery & obstetrical deliveries & adverse reactions

Family history & genetic diseases

cultural diversity:  sensitivity to diverse origins, beliefs, & practices.  Influences patient outcomes.
Medication History

(8)
anticoagulants
antidepressants
benzos
cardiac meds
narcotics
insulin & hypoglycemic meds
pulmonary
nonprescription: otc & herbals
Herbal Drugs affecting Clotting

(7)
chamomile
echinacea
garlic
ginger
ginko
ginseng
Herbal products with CNS stimulant

(3)
ephedra
feverfew
st. john's wort
Herbal Products with Sedative Effects

(2)
Kava
Valerian
Herbal Products with antidepressant effects

(3)
Ephedra
Ginseng
St. john's Wort
Herbal Products Affecting Blood Glucose Levels

(3)
Ephedra
Garlic
Ginseng
Herbal Drugs to Discontinue Prior to Surgery

(7)
Ephedra: 24 hours prior

Garlic:  7 days prior

Ginko:  36 hours prior

Ginseng:  7 days prior

Kava:  24 hours prior

Intoxicating Pepper:  before surgery

St. Johns wort:  5 days prior
Tobacco use complications
Ask patient: number of packs per year

pulmonary and cardiac effects of nicotine

6 times more likely to have pulmonary complications after surgery

Increased C.O. levels (twice as high)

It takes 8 weeks after cessation to see improvement of pulmonary function
Alcohol Use Complications
May have livver issues which affects the metabolism of anesthetics.  May need more anesthetics. (Higher Tolerance)

If they are currently on meds:  they will need less anesthetics.

If patient has liver failure, will need less anesthetics because their body cannot clear. 
Drug Use Complications
If patient is dependent on pain meds, they will need much higher doses.

If they are currently on meds:  they will need less anesthetics.

Drugs:  anabolic steroids, cocaine, heroin, methadone, marijuana
Patient Allergies
Drug Allergy vs. Drug Intolerance:  rash hives, urticaria, tachycardia, dyspnea, GI distubances, Dizziness

Latex allergy will need different room setup and use of non-latex gloves.
Food Allergies / Cross-over Allergies
Latex:  banana, avocado, nuts, kiwi, peaches

Propofol:  soy & eggs
CNS Assessment
Siezures
Tremors
TIA/Stokes
Migraine Headaches
Neuromuscular disease
depression
anxiety
mental disorders
medications will mean tolerance

DOCUMENT:  weakness, paralysis
Cardiac Risk Factors

(6)
High Risk Surgery:  Ex:  AAA
Ischemic Heart Disease
CHF
Verebrovascular disease
IDDM:  Know baseline blood sugar & level of control
Pre-Op creatinine:  >2.0= No Sevo!
Peripheral Nervous System
Numbness
tingling
radicular pain

DOCUMENT!!!
BetaBlockers Peri-operatively
Poise Study:  risk/benefits of betablockers perioperatively

target HR=65
ABCD's of no Beta-Blockers
A:  Asthma
B:  Bradycardia
C:  CHF (faster HR means faster blood flow which helps the cardiac output)
D:  Diabetes, low blood sugar causes tachycardia.  You may not pick up on S&S of low BS if there was a BB given
What is Considered 'A Poor Man's ECHO?'
Can you walk up a flight of stairs without getting SOB.
Does the patient need cardiac clearance?

(7)
1.  HX of Angina?  precipitating factors, duration, & control with medication.

2.  Previous MI.  Symptoms?
Within last 6 months=no surgery
50,000/yr patients have MI on the table.  (40% mortality)

3.  Hypertension requiring meds.  Well controlled?  Evidence of organ damage. 

4.  Heart Failure:  limit fluids with micro gtt

5.  Arrythmia:  type, Afib=anticoagulant

6.  Valvular disease:  replacement, meds, abx

7.  Pace maker/AICD?  May need magnet.
Classification System for Risks Associated with Cardiac History
classes:
I:    0-15
II:   20-30
III:  31+
Reinfarction Rate after surgery
Recent MI within 3 months:  27-37%

Recent MI within 3-6 months:  11-16%

Recent MI after 6 months:  5%
Antibiotic coverage for specified conditions
2007 AHA Guidelines:
1.  artificial valve
2.  HX of IE(endocarditis)
3.  Coronary heart disease
4.  cardiac transplant
Antibiotics used for Pre-op Coverage
Adults:  Ampicillin2g & Gentamycin 1.5mg/kg

Children:  Ampicillin 20mcg/kg & Gentamycin 2mg/kg

Penicillin Allergy:
Adult: Vancomycin 1gm
Children:  Vancomycin 20mg/kg
Assessing Patient Respiratory System

(5)
1.  Acute or chronic disease process
2.  Recent URI
3.  Pneumonia
4.  Tobacco Use
5.  Obstructive sleep apnea
Acute or Chronic Respiratory Disease
*COPD
*Emphysema
*Asthma

*25% of all patients have a pulmonary complication
*5-10% will have adverse respiratory issue post-op
*9-40% increase of repiratory issue post-op with abdominal surgery (the closer the surgery is to the diaphragm, the higher the risk)
Why will a patient be cancelled with an acute URI?
Most cases will be cancelled, but kids will especially because they have an even higher risk for laryngospasm.
What is important to consider if a patient has obstructive sleep apnea?
*They are at a high risk for a difficult intubation & upper respiratory obstruction

* Do not over-sedate
Predicting Post-op respiratory failure

(4)
1.  Type of surgery:
  • AAA
  • Thoracic
  • Neurosurgery
  • upper abdominal
  • periphepheral vascular
2.  Emergency Procedure

3.  Altered labs: low albumin/high BUN

4.  Age extremes:  young/old
Eval for Gastrointestinal System

(7)
1.  Abdominal distention/obstruction
2.  Delayed Gastric Emptying
  • RSI
  • Reglan/bisitra
3.  Hiatal hernia
4.  Mendleson syndrome
5.  reflux:  do they have to sleep upright
6.  PUD/GI bleed
7.  GERD
Hepatobiliary Disease

(3)
1.  Hepatitis
2.  Cirrhosis
3.  Hepatic failure
  • Pre-op
  • coagulopathy
  • may need additional labs, vitK, FFP
Renal Assessment

(6)
Hx of renal insufficiency
  • impacts drug metabolism & excretion
  • elevated K, anemia, elevated electrolytes
  • Elevated K=NO SUCCS!!!
Urinary Tract issues
peripheral neuropathies
BPH
Renal Calculi
Congenital malformations
Endocrine Assessment

(4)
Thyroid disease:  must be euthyroid before proceeding with surgery
Adrenocortical disorders
pituitary diseases
Diabetes:
  • Type I/II
  • Basic management
  • HGA1C
  • Best to have a lower & tighter control
Reproductive System Assessment

(3)
1.  Date of last mentral cycle
2.  Is there a chance you could be pregnant?
3.  May need to do Urine test r/t chance for congenital abnormalities
How to manage a hyperthyroid patient in an emergent OR situation
control sympathetic nervous system
  • Tachycardia
  • diaphoresis
  • tremors
  • TX:  esmolol infusion
  • TX:  pre-op sedatives
Avoid anticholinergics r/t tachyarrythmias & interference with heat regulation.

Pituitary issues may mean the patient needs peri-operative steroid coverage.
Peri-op morbidity in relation to Endocrine diseases
the end-organ effects of endocrine diseases increases peri-op morbidity by 5-10%
Incidence of Diabetes
80-90% of diabetics have type II. 
As patient population becomes more obese, so does the incidence of diabetes
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