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