pre operative assessments of patients
DESCRIPTION
PRE OPERATIVE ASSESSMENTS OF PATIENTS. Anthony Nyerges, M.D. Clinical Professor Department of Anesthesiology. PRE OPERATIVE ASSESSMENTS OF PATIENTS. Is the patient in optimum condition for surgery? Stressors of surgery: Cardiac Pulmonary Endocrine Neurological Metabolic. - PowerPoint PPT PresentationTRANSCRIPT
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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 PATIENTSCase Scenario29 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 PATIENTSCase 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