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PRE OPERATIVE ASSESSMENTS PRE OPERATIVE ASSESSMENTS OF PATIENTSOF PATIENTS
Anthony Nyerges, M.D.
Clinical Professor
Department of Anesthesiology
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PRE OPERATIVE ASSESSMENTS PRE OPERATIVE ASSESSMENTS OF PATIENTSOF PATIENTS
• Is the patient in optimum condition for surgery?
• Stressors of surgery:– Cardiac– Pulmonary– Endocrine– Neurological– Metabolic
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PRE OPERATIVE ASSESSMENTS PRE OPERATIVE ASSESSMENTS OF PATIENTSOF PATIENTS
• AS A CONSULTANT, THE QUESTION
ASKED IS: “FOR THIS PATIENT, ARE THE
MEDICAL CONDITIONS AS GOOD AS
THEY CAN BE?”
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PRE OPERATIVE ASSESSMENTS PRE OPERATIVE ASSESSMENTS OF PATIENTS OF PATIENTS
• Specific recommendations for the situation
at hand:
– Hypotension: use Dobutamine infusion
– Hypertension: use ACE-I, not a CCB
– For post operative ventilation use reverse I: E mode on ventilator
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PRE OPERATIVE ASSESSMENTS PRE OPERATIVE ASSESSMENTS OF PATIENTS OF PATIENTS
• Recommendations such as: “Avoid
hypotension, hypoxemia, hypothermia” are
not useful.
• Recommendations such as “Avoid excess
general anesthetics and narcotics” are not
useful.
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PRE OPERATIVE ASSESSMENTS PRE OPERATIVE ASSESSMENTS OF PATIENTSOF PATIENTS
• Physical examination:
– Venous access issues
– Arterial access: radial, femoral
– Airway / neck for ease of laryngoscopy,
necessity of fiberoptic intubation
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PRE OPERATIVE ASSESSMENTS PRE OPERATIVE ASSESSMENTS OF PATIENTS OF PATIENTS
• Chest for vital capacity effort and baseline breath sounds
• Cardiac murmurs, JVD, baseline pressures
• Regional anatomy: spine
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PRE OPERATIVE ASSESSMENTS PRE OPERATIVE ASSESSMENTS OF PATIENTS OF PATIENTS
• Baseline CBC, Electrolytes, TFT
• Baseline CXR (over 50)
• Basline EKG (over 40)
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PRE OPERATIVE ASSESSMENTS PRE OPERATIVE ASSESSMENTS OF PATIENTSOF PATIENTS
• Specialized cardiac evaluations for compromised
functions:
– Ischemia: Dobutamine stress, nuclear perfusion
(myoview), angiography, TEE for SWMA’s or
valve dysfunction.
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PRE OPERATIVE ASSESSMENTS PRE OPERATIVE ASSESSMENTS OF PATIENTSOF PATIENTS
• Specialized cardiac evaluations for compromised
functions:
– Exercise tolerance / intolerance
– Current medications and historical use pattern;
anticoagulation issues
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PRE OPERATIVE ASSESSMENTS PRE OPERATIVE ASSESSMENTS OF PATIENTSOF PATIENTS
• Specialized pulmonary evaluations:
– Resting ABG for obliterative disease
– PFTs for specific FEF 25-75, DLCO, lung volumes for post-anesthetic implications
– CXR, CT scanning for pulmonary embolism, prior resections, effusions
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PRE OPERATIVE ASSESSMENTS PRE OPERATIVE ASSESSMENTS OF PATIENTSOF PATIENTS
• Neurological evaluations:
– Myogenic dysfunction (post CVA, Hypotonia, Atrophy, NM junction)
– Seizures, LOC, ICP issues
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PRE OPERATIVE ASSESSMENTS PRE OPERATIVE ASSESSMENTS OF PATIENTSOF PATIENTS
• Endocrine Dysfunction:
– Diabetes: brittle control, Hgb A1C, Hx Hyperosmolarity, Lactic Acidosis
– Thyroid crisis: goiter, thyroid storm, low T3 states
– Parathyroid: calcium metabolism on myocardial function, NMJ function
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PRE OPERATIVE ASSESSMENTS PRE OPERATIVE ASSESSMENTS OF PATIENTSOF PATIENTS
• Endocrine Dysfunction:
– Adrenal: Use of intraoperative steroids and wound healing, Hyperglycemia
– Special TPN Issues: Hepatic clearances and myogenic functionality
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PRE OPERATIVE ASSESSMENTS PRE OPERATIVE ASSESSMENTS OF PATIENTS OF PATIENTS
• Low concentrations of potent inhaled vapors decrease reflexes, diaphragmatic activity
• NM antagonists increase nicotinic tone
• Sympathetic / parasympathetic “reset” BP
control, peristalsis, temperature
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PRE OPERATIVE ASSESSMENTS PRE OPERATIVE ASSESSMENTS OF PATIENTS OF PATIENTS
• Opiate effects on sedation, cough reflex, sympathetic control
• LMWH effects on post regional anesthesia
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PRE OPERATIVE ASSESSMENTS PRE OPERATIVE ASSESSMENTS OF PATIENTS OF PATIENTS
• 33 y.o. male C5 quadriplegia x10 years, OSA
syndrome, Hx Ileal conduit, wheelchair dependent
• Revision of tracheostomy in past
• Hx of sweating post prandial
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PRE OPERATIVE ASSESSMENTS PRE OPERATIVE ASSESSMENTS OF PATIENTS OF PATIENTS
• Scheduled for new Ileal conduit diversion
• “Anesthesia: Choice”
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PRE OPERATIVE ASSESSMENTS PRE OPERATIVE ASSESSMENTS OF PATIENTS OF PATIENTS
• No PFTs performed
• No ABG performed
• No evaluation of autonomic dysreflexia
• No thyroid functions
• No airway exam
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PRE OPERATIVE ASSESSMENTS PRE OPERATIVE ASSESSMENTS OF PATIENTS OF PATIENTS
• Fiberoptic emergency intubation
• Hyper / hypotensive crises
• Femoral arterial access
• “Unanticipated” ICU stay, 3-day intubation, postoperative pulmonary and cardiology consultations
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PRE OPERATIVE ASSESSMENTS PRE OPERATIVE ASSESSMENTS OF PATIENTS OF PATIENTS
• 86 y.o. male with mechanical fall: femoral neck fracture
• “VIP” status
• Hx or myocardial infarction s/p stents (3 years ago)
• Hx of A-Fib in past
• Hx diastolic dysfunction of TTE study
• Anticoagulated on coumadin
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PRE OPERATIVE ASSESSMENTS PRE OPERATIVE ASSESSMENTS OF PATIENTS OF PATIENTS
• #1 ECG in EMC yields 1º AVB
• #2 ECG 1 hour later yields new LBBB
• HCT = 32, but dehydrated!
• Mild dyspnea on prior walking
• Surgery wishes to proceed urgently
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PRE OPERATIVE ASSESSMENTS PRE OPERATIVE ASSESSMENTS OF PATIENTS OF PATIENTS
• No regional technique possible
• Awake arterial line
• Central venous cordis sheath
• Transfusion 4 units PRBC
• Post operative mechanical ventilation (Dynamic
Compliance Poor)
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PRE OPERATIVE ASSESSMENTS OF PATIENTSPRE OPERATIVE ASSESSMENTS OF PATIENTS
Case Scenario
29 y.o. male history of aplastic anemia ANC 0.1 on GMCSF followed by hematology oncology awaiting BMTx (XRTx + chemo preconditioning). Now with fibrous cyst of tongue with exfoliation scheduled for hemiglossectomy. Arrives in PTU for surgery:
• No information from Hem-Onc• Case delayed• Post operative wound care• Reverse isolation environment
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PRE OPERATIVE ASSESSMENTS OF PATIENTSPRE OPERATIVE ASSESSMENTS OF PATIENTS
Case Scenario (cont.)
29 y.o. male history of aplastic anemia ANC 0.1 on GMCSF followed by hematology oncology awaiting BMTx (XRTx + chemo preconditioning). Now with fibrous cyst of tongue with exfoliation scheduled for hemiglossectomy. Arrives in PTU for surgery:
• Antibiotic, antiviral, antifungal prophylaxis• Use of nitrous oxide• Postoperative “bone pain” issue-GMCSF vs. operative site• Immune effects of opiates
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PRE OPERATIVE ASSESSMENTS PRE OPERATIVE ASSESSMENTS OF PATIENTS OF PATIENTS
• 63 y.o. Psychologist C1 – C2 fracture
• Admitted 2 ½ weeks
• “Acute” delirium unknown cause
• Chronic alcoholism
• Hyponatremia, anemia, cachexia
• ? R Lobar infiltrate
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PRE OPERATIVE ASSESSMENTS PRE OPERATIVE ASSESSMENTS OF PATIENTS OF PATIENTS
• No cranial imaging studies
• No workup of hyponatremia
• Intraoperative fiberoptic intubation
• Intraoperative bronchoscopy
• Post operative mechanical ventilation
• Recommend CSF puncture and workup