PRE OPERATIVE ASSESSMENTS OF PATIENTS

1. PRE OPERATIVE ASSESSMENTS OF PATIENTS Anthony Nyerges, M.D. Clinical Professor Department of Anesthesiology

3. PRE OPERATIVE ASSESSMENTS OF PATIENTS • Is the patient in optimum condition for surgery? • Stressors of surgery: • Cardiac • Pulmonary • Endocrine • Neurological • Metabolic

4. PRE OPERATIVE ASSESSMENTS OF PATIENTS • AS A CONSULTANT, THE QUESTION ASKED IS: “FOR THIS PATIENT, ARE THE MEDICAL CONDITIONS AS GOOD AS THEY CAN BE?”

5. PRE OPERATIVE ASSESSMENTS 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

6. PRE OPERATIVE ASSESSMENTS OF PATIENTS • Recommendations such as: “Avoid hypotension, hypoxemia, hypothermia” are not useful. • Recommendations such as “Avoid excess general anesthetics and narcotics” are not useful.

7. PRE OPERATIVE ASSESSMENTS OF PATIENTS • Physical examination: • Venous access issues • Arterial access: radial, femoral • Airway / neck for ease of laryngoscopy, necessity of fiberoptic intubation

8. PRE OPERATIVE ASSESSMENTS OF PATIENTS • Chest for vital capacity effort and baseline breath sounds • Cardiac murmurs, JVD, baseline pressures • Regional anatomy: spine

9. PRE OPERATIVE ASSESSMENTS OF PATIENTS • Baseline CBC, Electrolytes, TFT • Baseline CXR (over 50) • Basline EKG (over 40)

10. PRE OPERATIVE ASSESSMENTS OF PATIENTS • Specialized cardiac evaluations for compromised functions: • Ischemia: Dobutamine stress, nuclear perfusion (myoview), angiography, TEE for SWMA’s or valve dysfunction.

11. PRE OPERATIVE ASSESSMENTS OF PATIENTS • Specialized cardiac evaluations for compromised functions: • Exercise tolerance / intolerance • Current medications and historical use pattern; anticoagulation issues

12. PRE OPERATIVE ASSESSMENTS OF 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

13. PRE OPERATIVE ASSESSMENTS OF PATIENTS • Neurological evaluations: • Myogenic dysfunction (post CVA, Hypotonia, Atrophy, NM junction) • Seizures, LOC, ICP issues

14. PRE OPERATIVE ASSESSMENTS OF 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

15. PRE OPERATIVE ASSESSMENTS OF PATIENTS • Endocrine Dysfunction: • Adrenal: Use of intraoperative steroids and wound healing, Hyperglycemia • Special TPN Issues: Hepatic clearances and myogenic functionality

16. PRE OPERATIVE ASSESSMENTS OF PATIENTS • Low concentrations of potent inhaled vapors decrease reflexes, diaphragmatic activity • NM antagonists increase nicotinic tone • Sympathetic / parasympathetic “reset” BP control, peristalsis, temperature

17. PRE OPERATIVE ASSESSMENTS OF PATIENTS • Opiate effects on sedation, cough reflex, sympathetic control • LMWH effects on post regional anesthesia

18. PRE OPERATIVE ASSESSMENTS 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

19. PRE OPERATIVE ASSESSMENTS OF PATIENTS • Scheduled for new Ileal conduit diversion • “Anesthesia: Choice”

20. PRE OPERATIVE ASSESSMENTS OF PATIENTS • No PFTs performed • No ABG performed • No evaluation of autonomic dysreflexia • No thyroid functions • No airway exam

21. PRE OPERATIVE ASSESSMENTS OF PATIENTS • Fiberoptic emergency intubation • Hyper / hypotensive crises • Femoral arterial access • “Unanticipated” ICU stay, 3-day intubation, postoperative pulmonary and cardiology consultations

22. PRE OPERATIVE ASSESSMENTS 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

23. PRE OPERATIVE ASSESSMENTS 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

24. PRE OPERATIVE ASSESSMENTS OF PATIENTS • No regional technique possible • Awake arterial line • Central venous cordis sheath • Transfusion 4 units PRBC • Post operative mechanical ventilation (Dynamic Compliance Poor)

25. PRE 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

26. PRE 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

27. PRE OPERATIVE ASSESSMENTS 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

28. PRE OPERATIVE ASSESSMENTS OF PATIENTS • No cranial imaging studies • No workup of hyponatremia • Intraoperative fiberoptic intubation • Intraoperative bronchoscopy • Post operative mechanical ventilation • Recommend CSF puncture and workup