Patient Evaluation And Assessment

1. Patient EvaluationAndAssessment

2. Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists(Special Article) Anesthesiology 2002;96:1004-17

3. Guidelines for Patient Evaluation • Clinicians should be familiar with aspects of the patient’s medical history and how it might alter the patient’s response to sedation/analgesia • Abnormalities of the major organ systems • Previous adverse sedation experiences • Drug allergies, current meds, potential drug interactions • Time and nature of last oral intake • Hx tobacco, ETOH, substance use or abuse

4. Guidelines for Patient Evaluation • Patients should undergo a focused physical examination • Vital signs • Auscultation of heart and lungs sounds • Evaluation of airway • Laboratory testing guided by patient’s underlying medical condition and the likelihood that the results will affect the management of sedation/analgesia • Confirmed immediately before sedation

5. Patient Evaluation/Assessment • Patient Selection Overview • No unevaluated medical problems • No co-existing medical conditions • Chronic medical conditions should be well controlled • Patient should be an ASA I or II. ASA III if their medical condition is compensated and well controlled

6. Patient Selection Overview… • Evaluate for any undiagnosed medical conditions • Identify patients that may pose a challenge for a successful sedation • Severely phobic • Hx drug abuse or tolerance • Moderate/severely mentally challenged • Obesity • Difficult IV access • Difficult airway

7. Patient Selection Overview… • Age considerations • No absolute upper/lower age limits provided: • Practitioner appro trained and skilled • Medical status is stable • Adequate post-op care is available • Pediatric and geriatric patients may require more advanced management techniques

8. Medical History… • Cornerstone of preoperative evaluation/assessment • Must be recorded in record • Obtained through the use of pre-printed medical screening questionnaire and patient dialogue interview • Must correlate all written and verbal findings to achieve final opinion of medical status

9. Medical History… • Biographical information • Name, address, age • Proposed procedures • Fit of proposed procedures and overall health assessment • Current state of health • Note recent acute illnesses • Evaluate status of known medical problems

10. Medical History… • Medications • Current medication usage • Dosing schedule • Last dose • Prior medication usage in the past two years • Allergies • Note specific allergic reactions, onset, severity, duration and treatment

11. FYI….Medications • Bisphosphonates • Used for the treatment of hypercalcemia associated with metastasis to bone • Breast • Multiple myeloma • Osteoporosis • Mechanism of action • Osteoclastic inhibition

12. Medical History… • Prior surgeries and general anesthetics • Prior hospitalizations • Family history • Health status of parents and siblings • Family history of anesthetic complications • Social history • Occupation • Tobacco, ETOH usage, substance use and abuse (most drug abusers are liars) • Sexual history • High risk sexual behavior • STD’s

13. Medical History… • Obstetrical history • Prior pregnancies and deliveries • Date of last menstrual period • Note possibility of pregnancy risk • Past medical history • Prior evaluation, duration and treatment • Review of systems • Be alert to signs and symptoms of undiagnosed medical conditions with anesthetic implications

14. Review of Systems… • General • Fever, chills, sweating, weakness, fatigue • Skin • Rash, pigmentation, bruising, scars, nails • Head • Headache, trauma • Cranial nerve function • Eyes • Visual disturbances, glasses, contacts

15. Review of Systems… • Ears • Hearing loss, ringing, dizziness • Nose • Bleeding, obstruction, colds • Mouth • Besides routine dental evaluation: frequent sore throat, hoarseness, problems with swallowing

16. Review of Systems… • Neck • Pain, stiffness, limitation of motion • Swelling, lumps, thyroid enlargement • Respiratory system • Cough, sputum, coughing up blood • Night sweats • Wheezing • Shortness of breath • Pain with breathing • Sleep apnea

17. COPD… • Disease state characterized by the presence of airflow obstruction due to; • Chronic bronchitis • Emphysema • Most patients have features of both disease states • 14 million Americans

18. COPD… • Chronic bronchitis—excessive secretion of bronchial mucus; productive cough >3 months • Emphysema—abnormal permanent enlargement of air spaces distal to the terminal bronchiole • The only drug shown to alter the natural history of the disease is O2 • 3 year survival continuous O2 vs. nocturnal O2; 65% vs. 45% • Ipratropium bromide (anticholinergic) • Albuterol • Theophylline • Corticosteroids

19. Chronic Bronchitis Elevated PCO2 Decreased PaO2 Erythrocytosis Blue Bloaters Reduced FEV1 Reduced hypoxia drive Emphysema Normal PCO2 Decreased PaO2 Normal hematocrit Pink Puffers Reduced FEV1 Reduced hypoxia drive COPD

20. Asthma • Inflammatory respiratory disease; dyspnea, coughing, wheezing • Bronchial spasm, inflammation and mucous hypersecretion • Etiology • Extrinsic (allergic/atopic) • Intrinsic (nonallergic idiosyncratic) • Drug induced (ASA, NSAID’s) • Exercise induced • Infectious

21. Asthma • Classification: • Intermittent • Symptoms <2/wk, SABA <2days/wk, Interference with daily activity: None • Persistent • Mild: Symptoms >2 days/wk, SABA >2 days/wk but not daily, Interference with daily activities: Minor • Moderate: Symptoms daily, SABA daily, Daily activities: Some Limitations • Severe: Symptoms through the day, SABA several times per day, Activity extremely limited

22. Asthma • Management: Stepwise approach • Intermittent: • SABA • Persistent • Step 2: Low dose ICS • Step 3: Low dose ICS + LABA • Step 4: High dose ICS + LABA • Step 5: High dose ICS + LABA + amalizumab • Step 6: Hight dose ICS + LABA + Oral corticosteroids + amalizumab

23. Obstructive Sleep Apnea • Vastly under diagnosed problem • Suspected that 1:5 adults has at least mild OSA and 1:15 adults has moderate or severe OSA • OSA status indicated by the frequency of apnea and hypopnea events per hour of sleep (AHI) • Polysomnography results • AHI cutpoints • 5—mild • 10—moderate • 15—severe

24. OSA Symptoms • Habitual • Loud snoring • Nocturnal breathing pauses • Choking • Gasping • Excessive daytime sleepiness

25. Demographic Correlates of Increased OSA Prevalence JAMA:291 April 28, 2004 • Male sex • Age 40-70 years • Risk Factors • Body Habitus • Overweight and obesity (“Pickwickian” vs. “nonpickwickian”) • Large neck girth >/= 17 inches • Craniofacial and Upper airway abnormalities • Mandibular hypoplasia

26. Demographic Correlates of Increased OSA Prevalence • Suspected Risk Factors • Genetics • Smoking • Menopause • Alcohol use before sleep • Nighttime nasal congestion

27. Problems with daytime functioning Daytime sleepiness Motor vehicle crashes Psychosocial problems Decreased cognitive function Reduced quality of life Cardiovascular and Cerebrovascular Disease Hypertension Coronary artery disease Myocardial infarction Congestive heart failure Stroke Diabetes and Metabolic Syndrome Outcomes and/or Comorbid Conditions

28. Consequences of Nocturnal Hypoxia/HypercapniaCarswell, J. Long-Term Effects of Medical Implants, 14,167-176, 2004 • Polycythemia • Pulmonary hypertension • Cor pulmonale • Chronic hypercapnia • Morning and nocturnal headache • Left-sided congestive heart failure • Cardiac dysrhythmias • Nocturnal angina • Diurnal systemic hypertension

29. Risk Factors for Obstructive Sleep Apnea in AdultsYoung et al JAMA April 28, 2004:291 2013-2016 • Conclusions • Under diagnosed • Associated with diabetes, hypertension, coronary artery disease, myocardial infarction, congestive heart failure, and stroke • Due in part to risk factors common to all these conditions and they may also reflect a role of OSA in the etiology • In one study 83% of patients with resistant hypertension had unsuspected sleep apnea • Patients with CHF treated with CPAP showed an improvement in ejection fraction and decreases in systolic blood pressure and heart rate

30. Review of Systems… • Heart • Chest pain • Shortness of breath with exertion or lying down • Swelling in legs or feet • Pounding in chest • Irregular or rapid heartbeats • Heart murmur • High blood pressure

31. Ischemic Heart Disease • Angina pectoris • Stable vs. unstable angina • Meds: nitrates, Beta-blockers, Ca-channel blockers, ASA • Surgical intervention • Exercise tolerance • Unstable angina—nothing elective • MI • < 6 months nothing elective • Sudden cardiac death • In the absence of MI the largest single cause of death from coronary atherosclerosis

32. Congestive Heart Failure… • Diminished functional capacity secondary to cardiac dysfunction • Etiology—CAD, HTN, cardiomyopathy, valvular Dz • Clinical presentation • Rapid shallow breathing • Inspiratory rales • Increased venous pressure • Systemic venous congestion—distended neck veins, peripheral edema, weight gain, clubbing of fingers • Medications—ACE, diuretics Digitalis, nitrates vasodialtors

33. Congestive Heart Failure… • Class I—no limitation of physical activity, no dyspnea or fatigue • Class II—slight limitation of physical activity. Fatigue palpitation, dyspnea with routine physical activity but comfortable at rest • Class III—marked limitation of activity, but comfortable at rest • Class IV—symptoms present at rest, exacerbated with physical activity

34. Hypertension… • Systolic > 140; Diastolic > 90 • Systolic vs Diastolic • Essential vs. Secondary HTN • Stepped-care in treatment • Step I—single agent (diuretic, B-blocker, ACE, Ca-blocker, A-blocker, A and B-blockers) • Step II—increase dosage of first drug or add a second • Step III—second or third drug and/or diuretic if not already prescribed • Compensation and stage of treatment • Use of vasoconstrictors? • NYHA study

35. Review of Systems… • Vascular system • Lower extremity pain with exertion • Leg cramps • Coldness or change in color of extremities • Mottled • Loss of hair • Blood clots • Varicose veins

36. Review of Systems… • Gastrointestinal • Chest pain or fullness after eating • Nausea/vomiting • Problems with swallowing • Yellow color to eyes or skin • Abdominal swelling • Liver disease or hepatitis

37. Review of Systems… • Urinary tract • Urgent need to urinate • Kidney disease • Dialysis • Genitoreproductive • Females—date of last mensus • Venereal diseases

38. Renal Disease… • Patients with chronic renal failure with a GFR greater than 50% will usually tolerate procedure well. • Medications: require dose modifications or contraindicated due to toxicity or are excreted by the kidney • Adjust dosages: ASA,APAP, Propoxyphen, PCN, cephalosporins • No change necessary with codeine, demerol erythromycin, cleocin • Anemia • Bleeding disorders

39. Review of Systems… • Joints • Pain, redness, warmth, swelling • Limitations of motion • Deformities • Lymph nodes • Enlargement, pain, tenderness • Blood • Anemia, easy bruising or bleeding, blood transfusions

40. Anemia… • Hct < 41% in males and <37 in females • Etiology—increased destruction or decreased production • History—poor nutrition, acute blood loss, easy fatigue, ETOH or drug abuse, transfusion, heavy mensus, chronic disease or family history

41. Anemia… • Significant anemia affects the patient’s ability to maintain oxygenation and blood volume • A Hct < 30% warrants deferral of an elective procedure • Sickle cell anemia

42. Review of Systems… • Endocrine system • Thyroid enlargement • Diabetes • Excessive eating, drinking, urination • Type I vs. Type II • Medications and necessary alteration for sedation • Steroid supplementation

43. Steroid preparation Hydrocortisone (cortisol) Prednisone Prednisolone Methylprednisolone Triamcinolone Betamethasone dexamethasone Equivalent dose (mg) 20 5 5 4 4 0.60 0.75 Equivalent Doses of Corticosteroids

44. Steroid Therapy… • Endogenous cortisol; 20mg/d • Patient currently taking or has within the prior 2 years taken the equivalent of >/= 20 mg/d of cortisol may require supplementation prior to surgery or anesthesia • Supplementation dependant upon dosage—usually doubling daily dose day before, day of and day after • Consult MD

45. Diabetes Mellitus… • Type II non-insulin dependant—do not pose a risk if well controlled and compliant • Type I or IDDM • Procedure dictates the alteration in insulin • Duration of procedure • NPO status • Post-operative intake • Consult with MD

46. Review of Systems… • Allergies • Hay fever • Allergic rashes • Asthma • Nonmedication allergies • Psychiatric considerations • Depression, • Anxiety • Family, friend, job problems

47. Review of Systems… • Nervous system • Seizures • Date of last seizure • Fainting • Memory loss • Speech impairment • Cranial nerve function • Motor nerves: paralysis, loss of coordination • Sensory nerves: numbness, tingling, pain

48. Preanesthetic Physical Evaluation • Focused examination following review of the medical history • Risk assessment • Development of anesthetic plan • Baseline vital signs • Height and weight • Heart rate • Respiratory rate • Blood pressure • Temperature • Room air O2 saturation

49. Preanesthetic Physical Evaluation • Physical habitus • Significant obesity • Baseline mental status • Evaluation of heart and lungs • Lung fields • Heart sounds • Murmurs • JVD

50. Preanesthetic Physical Evaluation • Assess potential IV sites • Skin integrity • Jaundice or pallor • Clubbing of the fingers • Peripheral dependent edema