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Patient Evaluation And Assessment Practice Guidelines for Sedation and Analgesia by NonAnesthesiologists (Special Article) Anesthesiology 2002;96:1004-17 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 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 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 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 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 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 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 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 FYI….Medications Bisphosphonates – Used for the treatment of hypercalcemia associated with metastasis to bone Breast – Multiple myeloma – Osteoporosis Mechanism of action – Osteoclastic inhibition 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 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 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 Review of Systems… Ears – Hearing loss, ringing, dizziness Nose – Bleeding, obstruction, colds Mouth – Besides routine dental evaluation: frequent sore throat, hoarseness, problems with swallowing 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 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 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 COPD 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 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 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 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 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 OSA Symptoms Habitual – – – – – Loud snoring Nocturnal breathing pauses Choking Gasping Excessive daytime sleepiness 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 Demographic Correlates of Increased OSA Prevalence Suspected Risk Factors – – – – – Genetics Smoking Menopause Alcohol use before sleep Nighttime nasal congestion Outcomes and/or Comorbid Conditions 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 Consequences of Nocturnal Hypoxia/Hypercapnia Carswell, 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 Risk Factors for Obstructive Sleep Apnea in Adults Young 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 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 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 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 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 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 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 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 Review of Systems… Urinary tract – Urgent need to urinate – Kidney disease – Dialysis Genitoreproductive – Females—date of last mensus – Venereal diseases 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 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 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 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 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 Equivalent Doses of Corticosteroids Steroid preparation – – – – – – – Hydrocortisone (cortisol) Prednisone Prednisolone Methylprednisolone Triamcinolone Betamethasone dexamethasone Equivalent dose (mg) – – – – – – – 20 5 5 4 4 0.60 0.75 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 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 Review of Systems… Allergies – – – – Hay fever Allergic rashes Asthma Nonmedication allergies Psychiatric considerations – Depression, – Anxiety – Family, friend, job problems 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 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 Preanesthetic Physical Evaluation Physical habitus – Significant obesity Baseline mental status Evaluation of heart and lungs – – – – Lung fields Heart sounds Murmurs JVD Preanesthetic Physical Evaluation Assess potential IV sites Skin integrity Jaundice or pallor Clubbing of the fingers Peripheral dependent edema Airway Evaluation… Allows for detection and assessment of abnormalities that may predispose to difficult airway management and ventilation during the conscious sedation procedure – Jaw—micrognathia, retrognathia, trismus, significant malocclusion Airway Evaluation… Mouth – – – – Decreased interincisal opening (<3 cm) Edentulous Protruding incisors High arched palate Intraoral structures – Size of tongue – Tonsillar hypertrophy – Nonvisable uvula Airway Evaluation… Head and neck – – – – – – Short neck Limited neck extension C-spine disease or trauma Tracheal deviation Dysmorphic facial features Decreased hyoid-mentalis distance Less than 3 cm in adult Airway Evaluation Mallampati Classification Able to visualize on wide mouth opening Predicted intubation Easiesthardest 1. Uvula and pharynx Easiest 2. Partial uvula 3. Hard & soft palate 4. Tongue & hard palate Hardest Class I Class II Class III Class IV Laboratory and Ancillary Testing Preoperative diagnostic testing should be ordered when specifically indicated from the history and physical examinations ASA states—”no routine laboratory or diagnostic screening test is necessary for the preanesthetic evaluation of patients Medical Risk Assessment (ASA Physical Status Classification) Not predictive of outcome but helps the practitioner determine the overall suitability of a patient to undergo an outpatient conscious sedation ASA classification may aid the clinician in identifying patients with medical risk factors that may be a relative contraindication to an outpatient sedation procedure ASA Classification… ASA I: Normal healthy patient ASA II: Patient with mild systemic disease that does not interfere with day-to-day activities Smoking ETOH and drug abuse Mild-moderate controlled HTN NIDDM Well controlled asthma ASA Classification… ASA III: Patient with moderate— severe systemic disease that is not incapacitating but may alter day-to-day activity Severe labile HTN IDDM MI within 6 months COPD CHF ASA Classification… ASA IV: Patient with severe systemic disease that is a constant threat to life ESRD Liver failure ASA V: A moribund patient not expected to survive 24 hours with or without operation ASA Classification… REMEMBER: A patient considered for outpatient conscious sedation procedures should be an ASA I or II, although status III patients are acceptable if their medical condition is compensated and stable Medical Consultation… The patient should not have any medical conditions that have not been properly evaluated and assessed Are there any existing medical conditions that require further evaluation by internist or specialist to assist in the medical management of patient? Anesthetic Plan… After appropriate review of medical history and physical exam an anesthetic plan should be formulated that balances the realistic needs and demands of both the patient and clinician Be sure to discuss the anesthetic plan with the patient to answer appropriate questions and discuss pre-sedation orders Systemic Changes Associated with Aging Anesthetic Correlations Aging… Makinodan, Biology of aging. Surgical Care of the Elderly Chicago, Year Book, 1988 Aging is not a disease – Certain diseases become more prevalent with increased age – Occurs at different rates – Not confined to the elderly An inherent progressive impairment of function with passage of time, which cannot be averted and which causes individuals to become more vulnerable to death. The Aging Population… As a percentage of the U.S. population – 4% – 12% – 24% 1900 1986 2030 What Changes Are To Be Expected With Aging? Cardiovascular Respiratory Central Nervous System Renal Hepatic General Changes with Age… Body Weight – Age 60 Body weight has peaked Progressive decrease in weight in remaining years Composition (net offset) – Increase in adipose – Decrease in lean body mass Cardiovascular Changes Distensibility of aorta Mean blood pressure Left ventricular mass Systolic BP Response to catachol’s Cardiac dysrhythmias Conduction abnormalities Coronary blood flow Maximum heart rate decrease normal increase increase decrease increase increase decrease decrease Cardiovascular Changes Kannel el al: N Engl J Med 311:1144, 1984 Conclusions – 25% of patients >80 years of age had some manifestations of coronary artery disease – 25% of males and 40% of females >75 have hypertension, primarily isolated systolic hypertension – The relative low incidence of heart disease in premenopausal females is lost with menopause – Mortality from CVD is proportional to systolic blood pressure and in males also heart rate – Although mortality from CVD increases with age, it is not inevitable Cardiovascular Changes Stiffening of the aorta – Even in populations not prone to atherosclerosis Natural consequence of aging Elasticity of the thoracic aorta accounts for one-half of the buffering capacity to the remainder of the vascular tree Loss of this important buffer results in significant end-organ damage – Results in increased pulse wave velocity resulting in systolic hypertension and progressive left ventricular hypertrophy Cardiovascular Changes Decreased baroreceptor sensitivity (normotensive and hypertensive) – Unable to respond to hypotension with usual compensatory tachycardia Thus prone to orthostatic hypotension – Confirmed with a change of 20 mmHg systolic or 10mmHg diastolic from the sitting to standing readings Decreased beta adrenergic activity – Decreased receptor affinity Cardiovascular Changes Elderly are prone to bradycardia and dysrhythmias – Decrease in cardiac pacemaker cells By age 75 may only have 10-20% of normal cells remaining Atrophy and fatty infiltration of the conducting tissues – Interfere with conduction and pacemaker activity – Degeneration of the Bundle of His and bundle branches These changes may not be evident in a 12 lead or rhythm strip, but may necessitate Holter monitoring Cardiovascular Changes Reduction in Cardiac Output – 1% reduction in CO per year starting at age 50 Etiology maybe secondary to lower maximal heart rate or slower myocardial rate of contraction Implication being that the elderly have a limited reserve capacity Vascular Changes (CAD) There are histological and compositional changes to the coronary vasculature with age that increases the likelihood of CAD – May not be clinically evident Framingham study – 29% males >65 and 45% females >85 had an MI diagnosed solely by Q waves or changes in R waves Hertzer (1984 Ann Surg) – Performed angiograms on patients over the age of 65 with no clinical signs of CAD 14% truly free of disease 60% found to have significant CAD – 50% with severe disease warranting bypass grafting or were inoperable Valvular Changes Fibrosis and calcification of valves increases with age – Aortic 20% of individuals >65 showed some degree of aortic sclerosis – Mitral – Tricuspid – Pulmonic Summary of Cardiovascular Changes… Prevalent and often asymptomatic – Should assume its presence Systolic hypertension is not benign in the elderly Dysrhythmias are to be expected – Old MI, BBB, conduction defects/blocks, atrial fib/flutter Incur greater surgical risk – Intermittent unifocal PVC’s not associated with significant surgical/anesthetic risks Respiratory System Changes Wahba: Influence of aging on lung function, clinical significance of changes from age twenty. Anesth Analg 62:764; 1983 Bellows Gas exchange Control of ventilation Respiratory System Changes The bellows become stiffer and less compliant – Stiffer chest wall secondary to calcifications of articulations 20% greater effort needed by age 60 – Less muscle strength to expand chest wall 35% reduction by age 65 – Decreased intervertebral spaces – Decreased elastic recoil – Vital capacity decreases at a rate of 20 ml/year Respiratory System Changes Gas Exchange – Structural changes reduce gas exchange Decreased elastic recoil results in trapping, V/P mismatches, and shunting – Resultant decreased PaO2 Young/healthy—90-100 mmHg 80 year old—60-70 mmHg PaO2 = 102 – (0.496 x age) Decreased elastic recoil may result in closed airway spaces even during tidal breathing Respiratory System Changes Control of ventilation – Marked differences associated with sleep Irregular patterns and apnea Therefore increased incidence of desaturation and apnea with an anesthetic – Reduced response to hypoxia and hypercarbia Much greater fall in oxygen tension to stimulate ventilation – 40-70% – Anesthetic considerations
