Pre-op eval: HPI

o ID: Age, gender, presenting condition, surgeryo NPO guidelines

Last PO? Can take meds with sip of water Point is to decrease gastic vol 2 hrs – clear liquids; 4 hrs – breast milk, 6 hrs – light carb meal; 8 hrs

– full meal w/ fat and protein PMH/PSH

o Conditions that affect anesthesia: cards, pulm, GIo Meds (include herbals: gingko, ginseng, garlic – bleeding risk), compliance

Anti-hypertensives are okay, except ACEI/ARB (hypotension) Take cardiac drugs (amiodarone, digoxin, sotalol, etc.) Take hypoglycemics, but stop DOS (esp. metformin) Keep taking insulin, asthma/COPD meds Anticoagulation – risk benefit between bleeding/clot

Continue taking aspirin if stenting Craniotom / spine surgeries – try to take off anticoags Always stop clopidogrel

Herbal/non-vitamins – stop for 7 days prioro Surgeries

Prior surgeries, surgical complications Anesthesia complications (malignant hyperthermia, difficult airway,

post-op n/v) Social history

o Alcohol abuse – last drink? Chronic use increases anesthesia requirements

o Smoking history increases pulm complications (atelectasis, hypoxemia, pneumonia, intubation)

o Drug abuse – cocaine increases risk of CVA, MI, aortic dissection (cancel/delay!)

o LMP for women – pregnancy? ROS

o Identify co-morbid conditions, cover organs Asthma/COPD, GERD, snoring/OSA, liver/kidney disease, bleeding

disorderso Functional status! – 2 flights of stairs?

Vitals – look at these!! Physical Exam A/P

o ID statement, smmaryo Include functional status, cardiac hist, pertinent PMHo Calculate risk calculator

www.surgicalriskcalculator.com Age, ASA status, Cr, functional status, surgery type

ASA Status: 1 – normal healthy 2 – mild systemic disease (well-controlled HTN, asthma, DM2,

pregnancy) 3 – severe systemic disease (poorly controlled HTN, asthma,

DM2; presence of CAD, CKD, hepatitis, PVD, CVA, cancer) 4 – severe systemic disease that is constant threat to life

(ESRD, pulm HTN, critical aortic stenosis) 5 – moribund, not expected to survive without op (abdominal

compartment syndrome, type 1 aortic dissection) 6 – brain-dead, preserving organs for donation

o Common tests: CBC, BMP, Coags, CXR Maybe LFTs, EKG, type & screen Consider in context of functional status

o Plan: type of anesthetic (sedation, regional, general) Monitors: pulse ox, capnography, NIBP, EKG, temp, concentration of

inspired oxygen Possible monitors: A=line, CVP, PA cath, ECHO, precordial Doppler

o Airway Spontaneous, mask, LMA, ETT

Airways considerations: Prior intubations? Difficult? Head and neck pathology

o Prior hx of radiation, surgery, instrumentation, trauma Associated medical conditions

o Pharyngeal pathologyo Arthritis (particularly RA)o OSAo Obesityo Male sex

Physical Exam: Mallampati class

o Class 1: soft palate, facial pillars, uvula fully visibleo Class 2: partial obstruction of uvulao Class 3: only soft palateo Class 4: only hard palate

Oral aperture (adequate? Prominent teeth?) – open mouth wide! Thyromental distance (normal = 6.5 cm, 3 FB)

o Chin to adam’s apple Neck movement – ROM

o Spinal stenosis is limitedo Assess for radicular signs

Jaw subluxation (lip bite test, bottom teeth up front)

o E.g., full jaw subluxation

Steps to induction/intubation Apply monitors Position patient in “sniff” position (or ramp for obesity) Pre-oxygenation

o Increases oxygen reserves (breath FiO2 100% with mask seal, 3 min of tidal vol breathing, 4 vital capacity breaths, Fet02 = 90%)

o Decreased FRC in pregnancy, obesity, old age Induction of anesthesia

o Usual agents: propofol, etomidate, thiopental (not available)o Adjuncts: opioids, benzodiazepineso Neuromuscular blockers

Mask ventilationo Fingers form a “C”o 90% lift the mandible, 10% press mask to face

Direct laryngoscopyo Insert laryngoscope (start on ride side of mouth and sweep the tongue)o Insert until tip is in valleculao When pulling out, lift up and away (do not use as lever!)o Know larynx anatomy: epiglottis, anterior commissure, vocal cords,

arytenoidso Views:

Intubation!o Go slowly!o Confirm placement – visualize it to go through the cords

Chest rise with manual breath (bilateral) Always have to confirm no mainstem intubation Condensation in the ETT