Electronically Signing Camper Medication Administration Made Easy

Electronically signing camper medication administration

this is dr hessel dictating the podcast for the new anesthesia residence on pre-operative evaluation i have no disclosures you're aware of the reading assignments and i'd like to particularly call attention to the chapter and basics of anesthesia which is really very thorough and i'm mainly going to elaborate on some aspects but i recommend that you read that chapter thoroughly so this is an outline of what we're going to discuss furthermore this topic will be reviewed in additional detail by uh interactive discussion led by dr mccarney next week so one of the most important tasks that you will have is to develop an anesthetic plan for each of your patients it involves assessment of risks assessing the unique characteristics of your patient and understanding the planned surgical procedures to enable you to provide the best possible anesthesia care including the anesthetic technique and monitoring i have provided you with a copy of my suggestions of how you should conduct or plan your anaesthetic plan the key to the development of such a plan is a pre-operative evaluation ideally this is conducted a few days before the procedure in a preoperative or pre-anesthesia clinic and then updated in the immediate pre-operative period in the holding room but the latter may be the first time the patient meets the anesthesiologist finally the most important part of the pre-op evaluation is the history and the physical examination i have submitted provided to you what a document that i call developing an anaesthetic plan and i recommend that you review that in detail so one aspect of the pre-operative evaluation is to assess risk there is a so-called asa american society of anesthesiology physical status and other risk calculators this is the asa physical status it was first adopted in 1962 and it has five categories one is a normal healthy patient two mild systemic disease severe my systemic disease severe systemic disease at a constant threat and class five a morbid patient who's not expected to survive without an operation and a special category of six brain dead organ donors now these are subjective there's much variability among anesthesia providers as to how they classify and often they vary between one class and another it was not designed as a risk calculator but it has been found to be highly associated with progressive risk of morbidity and mortality this slide summarizes some of the characteristics of these various categories and i recommend that you take some time licking these over because they help you define what category you ought to place your patient in notably class one is not influenced by age and although some people will put older patients into class one if they really are healthy perhaps they should stay in class one there are other surgical risk calculators available and one of the best is the american college of society's nissclip surgical risk calculator you can go online in the internet and get this calculator and it will ask you various characteristics of the patient including the operation that's planned and various patient characteristics and then we'll provide you an estimate of mortality and of various complications uh it's updated regularly is very current and i recommend that you use that to give you insight into your patient now let's talk about the components of the pre-op evaluation and they include the history under the history the first part is a detailed description of the patient's present illness and the planned surgical procedure for a beginning for a beginner knowing about the planned surgical procedure and its implications are difficult you can ask your attending other residents but a helpful resource is this textbook that is readily available to you called the anesthesiologist manual for surgical procedures is the latest edition i think it's the ninth edition just came out in the last year or so the second is a history related to coexisting uh diseases and review of systems and we'll go into this a little more detail in a few minutes importantly you need to review allergies not only drug allergies but allergies to other substances that they may be exposed to you need to reviews their habits per se especially for tobacco alcohol other drugs including over-the-counter drugs and herbals very important is knowledge about their exercise tolerance and in the text they talk about metabolic equivalence and how to estimate that you should also take into account their diet and rather they've had weight loss a thorough review of their medications is essential because these have impact on the conduct of your anesthesia drug interactions and clue to what illnesses they have and finally you need to review their prior experience with and complications associated with previous anesthetics and surgery as i mentioned a key component of this is assessment of their medications because of drug interactions and the impact they may have on the conduct of your anesthesia and you must then con consider rather they should continue the medications alter the dosage withhold them or add additional drugs on this i've listed some of the particular drugs that we should be particularly concerned about anticoagulants diabetic drugs corticosteroids contraceptive medications and antidepressants which can have significant interactions with our anesthesia the next key import component of the pre-operative evaluations of physical examination of course this starts with the blood pressure the pulse and the oxygen saturation an important component that has been neglected in the past is mental status based on your clinical impression but you should also ask the family and their significant others and assess things like instrumental activities of daily life and some are recommending many function tests such as clock drawing we're going to discuss the important airway evaluation is in the next few slides another important aspect is venous and arterial axis an adequate venous line is essential for the safe conduct of anesthesia and this should be investigated prior to going to the operating room and if a line has been placed you need to assess how adequate it is you need to evaluate clinical physical exam as it relates to all of their coexisting diseases that we mentioned before and finally it's important to assess frailty we now know that the presence of frailty doubles or triples the risk of all of the various risk estimates there are multiple indices available in scoring systems and it's beyond our introduction here to go into them but these include activity of daily life muscle strength loss of muscle mass falls etc it is particularly important to assess this in elderly but in patients in all ages especially those with debilitating disease such as cancer one of the most important components of the pre-op evaluation for an anesthesiologist is the airway since we need to manage the airway and problems with airway management are the principal cause of morbidity and mortality associated with anesthesia anticipation and preparation for handling a difficult airway is the key to avoiding these complications and unfortunately it's overlooked by most other practitioners this topic is also reviewed in chapter 16 of your textbook basics of anesthesia on this slide i've summarized some of the factors that are associated with difficult airway management which are in table 13 of basics of anesthesia these are some of the risk factors for difficult mask ventilation and some of the risk factors for a difficult direct laryngoscopy the assessment of the airway starts with the history of prior difficulties review of prior anaesthetic records the physical examination including the general assessment and specific components and finally sometimes specific studies like endoscopy or radiologic studies on this slide i have summarized some of the 12 key components of the airway examination which has been recommended by various organizations and authors not listed but i emphasize here is the condition of the teeth dental injuries are very common after anesthesia and the presence of broken loose or absent teeth can have significant impact on the airway management and so take special care at looking at the teeth and again review this in detail the various components of the airway examination which you must be familiar with one of the most common and popular tests is the malam patty classification this is done by having the patient sit up stick up stick out their tongue but no don't phonate and then you look and see what you can see can you see the uvula can you see the tonsillar pillars can you see the posterior pharynx this is a malin pate view where you can see everything when you can see everything and malin patty 4 where you can't see this the uvula this is the expanded system one two three and four and some have added a class zero when you can actually see the tip of the epiglottis some have added phonation it doesn't seem to improve it and neck extension which seems to make it less sensitive but more specific the melon patty test has been around for about 30 years it's not perfect this was one study that found a sensitivity of about 60 80 a specificity quite low of 50 to 80 and a very poor positive predictive value when it's highly abnormal that's scary but if it's normal it doesn't assure you that they're not going to have a difficulty another popular test is the upper light lip pop bite test you have the patient see if they can cover the upper vermilion line with the lower incisors class 2 is when the lower incisors can touch the upper lip but can't reach the vermilion line and class 3 is when the lower incisors can't touch the upper lip dr khan and his colleagues found this to be quite accurate and better than the melon patty score however another author found this to be not quite as good with a low sensitivity a fairly good specificity but a poor positive predictive value a good negative predictive value but a good negative predictive value now this review article found that no test has an adequate sensitivity and all have substantial false positives they all have a low sensitivity and positive predictive value and poor specificity the bottom line is use all of the tests and still be aware that it could be a difficult error now i'm now going to review the various systems and as i mentioned the text goes over these in great detail and so i'm really going to skim skim over these and give you some highlights in regards to cardiovascular system i'm going to give a podcast on the cardiovascular system in the last week and a lot of this i will go over in more detail furthermore it's very nicely reviewed in chapter 13 and 25 of basics of anesthesia these are some of the aspects that we want to mention preoperative hypertension very common try to determine usual blood pressure this is a problem nowadays because patients are often only seen the first first time they often have so-called white coast syndrome where the blood pressure is somewhat higher if it is elevated wait for a while wait till the end of the exam and see what it is at the end of the exam and always check the blood pressure in both arms and use the one with the highest pressure to use to monitor the patients in the operating period when they have hypertension you need to check for evidence of organ dysfunction particularly in the heart the brain and the kidneys and then ask yourself is the hypertension under optimal therapy and should surgery be deferred until it's under better control should they be seen by a specialist coronary artery disease is a huge topic a large percent of our patients have coronary heart disease you should start with a search for risk factors remember that the risk of non-cardiac surgery in these patients is influenced by both the degree of coronary artery disease and the magnitude of the surgery you need to assess symptoms compared with their activity if the patient does nothing the fact that they're asymptomatic may mean nothing and of course you want to search out symptoms of angina or angina equivalent dismiss and signs or symptoms of heart failure remember that new onset progressive or severe angina or the presence of acute coronary events are all serious risk factors and deserve deferral of surgery until further evaluation by a cardiologist pay particular attention who have in patients who have had previous coronary interventions and stents these patients need to be seen by a specialist and remember the absence of hemodynamically significant coronary artery stenosis but still have coronary artery disease in other words they have lesions that are less than 50 to 70 percent but are not hemodynamically significant they are still at risk of serious perioperative cardiac events so after evaluation you have to decide do they need further workup is therapy optimized or do you need to defer cardiac surgery until they've had coronary intervention prior to non-cardiac surgery and again consultation with a cardiologist is often indicated and warranted heart failure again a common problem one issue is do they really have heart failure lots of patients carry the diagnosis they're on diuretics or other medicines but all they have is some peripheral edema or do they have pulmonary disease in this regard obtaining a bnt bmp may be helpful then you have to talk about or decide whether this is systolic heart failure or diastolic heart failure is it predominantly right heart failure or left heart failure are they in optimal therapy do they need further consultation and intervention again aortic valve disease the history and physical should provide a clue to the diagnosis and echocardiography is essential for evaluating severity you no longer should guess based on your history of physical history and physical are used to suspect the disease they then need an echocardiogram to determine local presence and severity of the disease in general we proceed with non-cardiac surgery if they have valvular insufficiency and are asymptomatic and if they have stenotic lesions but it's not severe most of these patients require endocarditis prophylaxis which is a topic that you should be familiar with but beyond our presentation this morning and again you need to be familiar with the management of patients with previous prosthetic valves they are still not normal and they need special care and attention congenital heart disease a huge topic in these cases you should always consult a pediatric cardiologist remember that post op patients i should say patients who have post-op for congenital heart disease still are rarely normal they all need endocarditis prophylaxis you need to be a citrus in avoiding venous to systemic air embolism and certain of these patients are particularly high risk those with pulmonary hypertension those who have less than four chambers in their heart those who have cyanosis those who have arrhythmias and those are symptomatic these patients need to be deferred to a specialty hospital or need consultation from specialists in cardiology and pediatric anesthesiology pulmonary hypertension right ventricular failure in the past poorly respected understood and under evaluated these patients are at high risk for perioperative complications clues are on the history i've left out the physical i'm sorry here but certainly there are clues from the physical and from the past medical history on physical jugular venous pulses presence of hepatojugular reflex a pulsatile liver hepatomegaly ascites laboratory studies of evidence of hepatic dysfunction echocardiography if you suspect significant pulmonary hypertension these patients need a cardiology consult and likely a right heart classification and if they're on iv drug therapy especially on infusions for pulmonary hypertension they need specialty management many of our patients nowadays have implanted electronic cardiac electronic devices either pacemakers or cardioverter defibrillators all of these patients likely have significant underlying heart disease they all need special pre-operative evaluation and pair out of management including management and emi the detail is beyond our presentation today but it's something that you will learn and discuss with your attending the pulmonary system is obviously a site of many uh problems in our patients and i would say a third of our patients have significant pulmonary disease the exam as always starts with history and physical history of smoking do they have a cough are they short of breath are they producing sputum what is their exercise tolerance are they on drugs and then your lung examination and i always ask the patients for call to cough often they will tell you they have no cough and then when you ask them to cough it's obvious they have a cough and they have terrible sputum and you can examine the sputum grossly and may want to send it for laboratory studies note the effect of position on their ability to breathe and of course their saturation and then based on this you may decide that they need additional testing chest x-ray pulmonary function tests analysis of their sputum blood gases you may decide they need a pulmonary consultation and there's a lot of interest now in prehabilitation of these patients getting them exposed to physiotherapy and training for post-operative pulmonary therapy and studies have shown that in integration of this into their management can reduce the incidence of post-op complications obesity ubiquitous in our patients you know the classification you know the impact on on on how we ventilate the patients drug dosing and all the other things dosing is somewhat complicated and controversial i personally tend to use adjusted body weight these patients all have coexisting disease cardiac failure pulmonary syndromes metabolic syndromes obstructive sleep apnea gastric retention and remember many patients we see are have had bariatric surgery and they present all sorts of problems obstructive sleep apnea again almost ubiquitous uh symptoms you're aware of they are increased risk of all sorts of morbidity they are at increased risk of morbidity and more complications during and after surgery and their risk of obstructive sleep apnea is aggravated for the first first week postoperatively and i always inform the patients um it's usually seen in obese patients but it's also seen in non-obese and you've probably all heard and or maybe use the stop bang screening this is from basics in anesthesia this is stop bang and if the patient answer yes to five or more of these values and then they're at high risk of obstructive sleep apnea and therefore of risk in the peripheral period the neurologic system obviously important you know all about this history and the physical but cognitive function and i've already mentioned this and we know especially in the elderly this is a major problem and is associated with major adverse outcome so you should take more attention to this um especially in this age group by asking the patient about it and asking the family and their significant others you also should conduct somewhat of a formal examination and there are many mental function tests these are advocated but rarely used at the moment but should be according to the experts and more about this in the future but but this is important aspect not to to overlook uh finally there's a risk of deep venous thrombosis and and thromboembolism uh learn about this from your history and from the presence of risk factor and of course take into account anticoagulation therapy what physical activity they've been doing prior to the surgery the gi system can't ignore obvious on this slide the hematopoietic system of which anemia and bleeding risk of particular interest this is rare but something that comes up all the time hit heparin-induced thrombocyte opinion the renal system endocrine diabetes and of course diabetes is ubiquitous learn about it from the history for the patient what medications they're on ideally a hemoglobin a1c although unfortunately in kentucky often the patients don't have these and of course these patients all have renal uh organ system dysfunction or potential for organ system dysfunction which you need to carefully look for i i failed to mention neuropathy on this slide but but that's obviously needs to be added and then other endocrine diseases patients are often on steroids you need to be familiar about the significance there's a section in in miller i mean on basics of anesthesia about what to do about steroids thyroid dysfunction adrenal and rare but something you should be on the lookout for pheochromocytoma i mentioned a special requirement for the elderly this is not only because i'm old but because a lot of your patients are elderly and they have major special problems one is frailty which we'll already mention the second is cognitive function the third is are often malnourished and the fourth this we know about child abuse but we now know elder abuse is unfortunately fairly common and just like in pediatrics you should be on the lookout for evidence of of abuse you should also be on the lookout for elder abuse and we've seen that in a number of patients in our hospital and so be on the lookout then there's a whole issue of laboratory evaluation there's a big ten now a important trend against routine testing and the bottom line is you'd never do a routine test they should always be based on the patient's condition uh your history and physical and the planned procedure and there are many uh detailed chapters and articles about when to do what tasks which are beyond our review today but you'll become familiar with it the cbt is sort of basic not required for most operations but certainly in certain age groups and types of operations again basic metabolic panel in most patients not indicated but based on history physical the plan procedure again a more comprehensive metabolic panel coagulation tests in general not recommended for routine operations unless they're clues from the history of physical and but then if you do coagulation tests you they're the basic tests and then various advanced tests that you need to be aware of arterial blood gas indicated certainly in certain patients especially in patients with significant pulmonary disease and the same for pulmonary function tests ecg not generally recommended routinely although many experts recommend that even in asymptomatic males over 55 and asymptomatic females over 65 that they should perhaps have an ecg if they're having at least a major operation uh chest x-rays again depends on the patient a big topic which we'll talk about next in the last week when we talk about cardiac disease is special cardiac testing a lot of interest now in in getting uh bnps and troponins the canadian guidelines strongly recommend these um certainly when they're abnormal they're associated with increased risk um cardiac consultation certainly when in doubt get it and they should be the ones to help you decide if you should do tres testing or need a cardiac cath or echocardiogram that doesn't mean you have to wait for them to order an echo but certainly for stress testing and catheterization that's in purview of the cardiac anesthesiologist now some of the other considerations during your pre-op evaluation i've already mentioned several times the need for consultation about coexisting disease either known or suspected based on your evaluation but remember you're not asking for clearance or how to anesthetize the patient or how to monitor that's your business what you should do instead is ask for specific questions like does the patient have a particular problem that you're worried about does this problem need further testing or evaluation is the patients coexisting disease optimized or do or does the coexisting disease cause special risks or problems or therapy that you need to be aware of another search another consideration is blood products do these patients need blood products ordered preoperatively a third consideration which should start in the pre-op evaluation is perioperative pain management you should discuss this with the patient and finally you need to think about what special equipment or monitoring might be required during their anesthetic care next you have to make recommendations to the patient first pre-hospitalization what should they do about their various medications especially their cardiac medications their various anticoagulants and endocrine drugs what about fasting guidelines and the text goes into the details here but in general uh patients should be strictly npo for all solids uh for eight hours and in certain patients with high risk factors may be even longer clear liquids are allowable up to within two hours and then there's the issue of endocarditis prophylaxis finally on the day of surgery you need to consider rather they need dvt prophylaxis what kind of analgesia they need and also what kind of sedatives or anaemics or anti-aspiration drugs you think they might need finally on the day of surgery if this is the first time the patient sees the anesthesiologist you have to do the complete examination that we just reviewed on the other hand if they've been seen in a pre-op area then all you want to do is see if there have been any changes in their history or physical since they were last seen review their medications and importantly review their oral intake what type of substances do they take how much and when did they take it review any new laboratory studies and finally order any new laboratory studies if you think they are indicated finally the discussion with the patient first is informing the patient about your plans secondly is disclosing their risk risk and getting an informed consent i put in parenthesis here rather these should be written we now have a policy that we should have a written and informed consent signed by the patient there's a lot of controversy how important critical this is the next issue is what should you inform the patient about and there's no simple answer in general the recommendations are to inform them about very common problems and very serious problems but even this is debatable about how much you should inform the patient i personally also all always start with saying there are risks i can go into the details some are minor some are serious even life-threatening if you would like me to go into details i will do so if you'd satisfied i won't others feel quite determined to go into all of these in great detail and you'll have to work out with your in your own practice and with your other attendings how to accomplish this remember to discuss the unique risks associated with procedures that you may be doing such as monitoring or regional anesthesia and finally there's the issue of dnr orders a number of our patients come with dnr orders it is a policy the asa and our hospital that dnr orders are not automatically discontinued when they come to the or and you must review these with the patient or their caregiver to decide exactly what they want you to do and thirdly you must give the patients and their family the opportunity to ask questions and time to answer them and lastly it's your duty to provide comfort to the patient and to the family remember you are first a physician and you are there for the patient you're not a technician to provide anesthesia you're a physician to take care of the patient thank you for your time