PRE OPERATIVE ASSESSMENTS PRE OPERATIVE ASSESSMENTS OF PATIENTSOF PATIENTS

Anthony Nyerges, M.D.

Clinical Professor

Department of Anesthesiology

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

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?”

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

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.

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

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

PRE OPERATIVE ASSESSMENTS PRE OPERATIVE ASSESSMENTS OF PATIENTS OF PATIENTS

• Baseline CBC, Electrolytes, TFT

• Baseline CXR (over 50)

• Basline EKG (over 40)

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.

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

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

PRE OPERATIVE ASSESSMENTS PRE OPERATIVE ASSESSMENTS OF PATIENTSOF PATIENTS

• Neurological evaluations:

– Myogenic dysfunction (post CVA, Hypotonia, Atrophy, NM junction)

– Seizures, LOC, ICP issues

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

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

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

PRE OPERATIVE ASSESSMENTS PRE OPERATIVE ASSESSMENTS OF PATIENTS OF PATIENTS

• Opiate effects on sedation, cough reflex, sympathetic control

• LMWH effects on post regional anesthesia

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

PRE OPERATIVE ASSESSMENTS PRE OPERATIVE ASSESSMENTS OF PATIENTS OF PATIENTS

• Scheduled for new Ileal conduit diversion

• “Anesthesia: Choice”

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

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

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

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

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)

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

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

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

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