Overview of pre-anesthesia exam

Report
Overview of preanesthesia exam
(PAME)
Becky Ness MPAS, PA-C
MCHS Mankato
Internal Medicine/Nephrology
Objectives
 1) Identify key diagnostic exams for pre-anesthesia
patients
 2) Identify components of Metabolic Equivalents
Exam Testing (METS) and when further evaluation
is needed.
 3) Identify high risk medications and necessary
adjustments in the perioperative period.
Purpose of the PAME
 Identify risks that could complicate a surgery or
result in a poor outcome.
 Provide insight to the surgeon and anesthesia staff
(MD or CRNA) that will require close monitoring
during surgery (i.e. Hx of anesthesia complications,
HTN, apnea etc.)
 Identify potential postsurgical complications that
will need to be monitored (blood clot risk, hx of lung
disorders, cardiac issues, blood sugars, infection
risks)
Key Elements of the PAME
 Surgery details – facility, surgeon, surgery to be performed, type of
anesthesia expected to be used
 HPI – must include pertinent details as they would relate to the planned
procedure (what symptoms are present, duration, other treatments options
tried)
 Hx – surgical, medical, family, and social
 ROS – must include pertinent positives such as: chest pain/SOB with activity,
palpitations, recent fevers/febrile illness, unexplained weight loss/gain.
 Physical
 Appropriate labs / tests
 Recommendations –Risk assessment and management
Surgery Details
 Intended procedure
 Surgeon’s full name
 Location of surgery
 Date of surgery
 Prior surgical infections
 Prior anesthetic complications – anaphylaxis, malignant
hyperthermia, significant intolerance (projectile vomiting,
prolonged arousal time)
History of Present Illness (HPI)
 Symptoms – onset, duration, severity, disability,
aggravating/relieving factors, acute vs. chronic
 Prior treatments – medical, PT/OT, etc..
 Expected benefit from planned surgical procedure –
pain/symptom relief, increased mobility, improved
quality of life
Assess Level of Risk of the
Planned Surgery

Major risk –
 Aortic and other major vascular surgeries, emergent trauma

Intermediate (reported cardiac risk generally 1 to 5 percent)
 Intraperitoneal and intrathoracic surgeries, carotid endarterectomy, Head
and neck surgery, Orthopedic surgery, Prostate surgery

Low (reported cardiac risk generally less than 1 percent)
 Endoscopic, superficial, or cataract procedures, breast or ambulatory
surgery
Adapted from Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA guidelines
on perioperative cardiovascular evaluation and care for non-cardiac surgery: a
report of the American College of Cardiology/American Heart Association
Task Force on Practice Guidelines. Circulation. 2007;116(17):e429
Histories
 Surgical – previous procedures and indications for procedure, especially
those that might impact the intended surgery. Include procedures that
might have required sedations. i.e. wisdom teeth, ear tubes,
colonoscopy/gastroscopy.
 Medical – any significant medical conditions that might impact surgery or
postop recovery – such as asthma/COPD, prolonged periods of lack of
activity, cardiac history, diabetes, autoimmune disease, OSA,
immunosuppression (chronic steroid use)
 Social –smoking, ETOH, levels of stairs in home, family support (if
relevant to the surgery), caffeine use, recreational/IV drug use, physical
activity
 Family – History of anesthesia difficulty, premature cardiac disease,
death during surgery
Review of Systems
 Needed to identify any specific concerns that might complicate the
surgery or require further testing before proceeding
 Chest pain with or without dyspnea – clarify
aggravating/relieving factors, duration of episodes, acute vs.
chronic complaint
 Dyspnea – clarify aggravating/relieving factors, duration,
presence of orthopnea, acute vs. chronic
 Address pertinent positives within HPI or Plan depending on if
further assessment is warranted
Physical Exam
Main components

HEENT – dentition, Mallampati scoring, pupils/scleral appearance

Cardiac –cardiac sounds (+/- murmur), pedal edema, +/- carotid bruit, stability and assess
need for further testing

Pulmonary – auscultations (+/- abnormal sounds or airflow), chest movement, assess need for
further testing or potential complications

Abdominal- assess for organ enlargement, ascites, pain

Skin- rashes (infectious or simply identified to avoid confusion postoperatively), scarring and
etiology

Neuro – define what is functional/ baseline as a reference for any postop changes
Other systems as warranted
Mallampati Scoring
Metabolic Equivalent Testing
A Predictor of Cardiac Function
METs
Activity
1
Sitting quietly at rest.
2
Walking slowly on level ground, eat, dress, toilet, make bed
3-4
Doing light work around the house.
4
Walking on level ground at 4 mph, light housework (dust/dishes),
golf, bowling
4-5
Climbing a flight of stairs, walking up a hill, sex, scrubbing floors,
moving furniture
6
Moderate recreational activity e.g. dancing, doubles tennis,
moderate cycling,
>10
Strenuous sports e.g. singles tennis, basketball, skiing.
Scoring MET
 Patients unable to meet a MET score of 4 are at increased risk for
surgical complications.
 If patient can not meet a MET of 4 additional cardiovascular risk
assessment is warranted – choice of study dependent of patient’s physical
ability and other co-morbid conditions
 Therefore, asking if the patient can walk a flight of stairs or 2 city
block at a brisk pace without chest pain or severe SOB is a good
indicator of cardiac stability

Nengl J Med 1995; 333;1750
Risk Assessments
 Major Cardiac Risks
 Hx of ischemic disease
 CVA
 CHF
 DM
 Renal insufficiency
 Major Pulmonary Risks
• Age > 50, 60, 70, 80
• Chronic Lung Disease
• Asthma
• Smoking
• Heart Failure
• Low Albumin
• High BUN
Cardiac Risk Assessment
 Cardiac Risk Assessment
Multiple tools exist, the most straight forward is
Lee’s Simple Cardiac Risk Index
High risk surgery
1 point
CAD
1 point
CHF
1 point
Hx of CVD
1 point
Insulin therapy for DM
1 point
Pre-op Serum Cr > 2.0
1 point
Score
0-1 =low risk
2 = moderate risk
>=3 high risk
Pulmonary Risk Assessment
Class
 Score
1
Healthy
2
Mild Systemic Disease
3
Severe Systemic Disease - limits
activity, but not incapacitating
4
Incapacitating systemic disease,
which is a constant threat to life
5
Moribund, not expected to survive 24
hrs with or without surgery
o Low Risk –
Class 1 or 2 that is
controlled
o Medium Risk
Class 2 that is not optimally
controlled
o High Risk > = 3
Selecting Perioperative Testing
 Appropriateness is determined by planned surgical
procedure and co-morbid conditions
 Timing of all laboratory studies need to be within
30 days of planned procedure per Medicare Rule
 Testing needs to be correlated with a condition
for billing purposes
 Not every patient NEEDS perioperative testing
beyond the PAME
Common Perioperative Tests
 CBC
+ Appropriate if patient has a history of anemia,
recent infection or there is a potential significant
blood loss.
 BMP (K+ and Cr)
+ Appropriate for diabetics, HTN, Renal disease,
diuretic use, CHF or digoxin use
 INR/PTT
+ If history of coagulopathy or suspicion for one,
currently on anticoagulation or history of liver
disease.
Common testing cont...
 EKG
+ History of DM, Cardiovascular disease, Pulmonary
disease, > than 20pk-yr smoking history, unable to
achieve MET>4, morbid obesity or use of ACE-I,
diuretics or digoxin.
 Chest X-ray
+ History of pulmonary disease, malignancy, radiation
therapy or smoking history > 20 pk-yr.
Medication adjustments
 Meds to continue
Statins
Beta-Blockers (if previously on)
Ca++ channel blockers
Antiarrhythmics
Chronic scheduled pain medications
High dose antidepressants
Anti-epileptics (regardless of indication)
Inhalers
Steroids (may need to consider stress dosing based on indication
for chronic use)
 Long acting insulin (dosing adjustments will be needed based on
blood sugars and diabetes control)

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Medication adjustment cont..
 Meds to hold

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Oral diabetic medications
Rapid acting insulin's
ACE-Inhibitors
Angiotensin receptor blockers
Diuretics
Vitamins (multivitamins within 7 days of surgery)
Mineral supplements
Herbal medications
OTC NSAID’s (stop within 7 days of surgery)
Medication Adjustments Cont...
 Anticoagulants
 Held per provider and surgeon’s discretion based on indication
for use, planned surgical procedure and patient’s
thromboembolic risk
 HIGH risk = bridge prior to procedure, resumption based on
bleeding risk of procedure
 Mitral valve replacement, A-fib with CHA2DS2-VASC>1 or
CVA/TIA within 1 month, VTE within 3 weeks or with other
thromboembolic state (active cancer, APLA, chronic CVD or Pulm
Dz)
 Moderate Risk = bridge prior to procedure, resumption
based on bleeding risk of procedure
 VTE within 6 months, VTE with prior DC of anticoagulation
 Low risk = Very little support for stopping anticoagulation
Pulling it all together
1)This patient is at low/moderate/high risk for cardiac and or pulmonary
complications for this low/moderate/high risk scheduled procedure
2) Labs done today include: List those done; results and further testing/repeat
testing needed prior to surgery.
3)Cardiac: EKG was/was not indicated and results if done, additional testing if
indicated such as stress testing or echocardiography with results.
4) Statement of optimization for planned procedure. Patients are NEVER cleared.
5) Medication recommendations: The patient was counseled about which meds to
hold/adjust prior to surgery these include …
6) Final Recommendations
The patient was instructed to contact the surgeon if any illness or new symptoms
arise between this assessment and the intended surgery. This includes URI
symptoms, fever, or other illness.
Questions???
[email protected]

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