Early in my education, I often had a difficult time looking at the bigger picture while taking care of patients in the operating room. It is easy to focus attention on skills and exciting surgeries when you are seeing many things for the first time and initially getting involved in airway and line management. One thing that really helped me was to write out anesthetic plans the night before and refine the details as you find out more information the next day when you arrive and have a chance to see the patient. To help you with this further, I have constructed a guide below describing how your setup and plan changes before a case as you learn more details about the specific case and patient. This post is very broad fairly basic. It is designed so that you should be able to understand it very early on in your education. You will learn that things are not always so straight forward and patient co-morbidities are more complex than they are portrayed to be here. However, this is a good starting place. Just be sure to ask yourself as you evaluate your patients in the preoperative area how each detail will impact your management, if at all. Take it step by step and it will being to come more naturally over time. As with many tutorials in this blog, most of the details are in reference to Memorial Hermann-TMC.
When
arriving in the OR in the morning, the first thing I do before heading to my
assigned room is grab a schedule. There are four main things I look at on the
schedule that impact how I set up my room: The procedure being done, the age of
the patient, the gender of the patient, and the weight of the patient (if
listed).
M – Machine
Machine check doesn’t change based on these factors.
S – Suction.
Suction setup doesn’t change based on these factors.
M – Monitors
For each case, I will automatically make sure we have standard ASA monitors BP
cuff, pulse oximeter, and a 5-lead EKG. The other factors may change what else
I have set up.
If the
patient is much older, with possible underlying cardiovascular issues and/or
the procedure listed is known to be invasive with the potential for lots of
blood loss, I will make sure to have an arterial line set up and ready to go.
If it is a
cardiac procedure or the procedure requires monitoring such as SSEP’s that
would impact how much volatile agent we can use, I would consider getting a BIS
in the room to help insure that the patient is not aware during the procedure.
A – Airway
At TMC I will usually have a general airway setup assembled on the anesthesia
machine, but the factors on the schedule will impact what components I add and
what I plan to use.
Is the patient male of female?: This will
generally dictate whether I plan to use a 7.0 or 8.0 ETT. It will also impact
what size oral airway I will plan to use.
What is the
patient’s weight?: This will tell me if the patient is possibly obese and if I
should get a video-scope in the room for intubation. If this is the case, I
like to set up blankets on the bed to get the patient in a proper sniffing
position, as well. Any advantage helps. Also, if it is a large male, I will
consider using a MAC 4, as opposed to the Mac 3.
Does the
procedure relate to a possible neck injury?: If it is imperative that we keep
the patient’s neck stable, I can call for a glidescope or fiber-optic
bronchoscope.
Is the
indicated procedure working in the area of head and neck?: I can determine if I
need to get any oral or nasal RAE tubes for intubation.
Is the
procedure to be completed in the prone position?: If this is the case, I like
to use benzo to help secure the ETT to prevent any dislodgment.
Is it a
short, relatively non-invasive procedure?: I can consider just setting up and
LMA of the appropriate size and plan to let the patient breathe on his or her
own for the duration of the surgery.
Will the bed
be turned 180 degrees for the procedure?: I can determine if I need to get an
accordion for the ETT.
I – IV
I
will always have a standard IV kit set up with a varying sizes of IV’s ranging
from 16-20 gauge. In addition, I will prepare a few other things.
Is the
patient coming from DSU?: If yes, I will not need to spike a bag of LR, since
they will get one in the pre-op area.
Is the
patient coming from ICU and/or is this an invasive procedure with potential for
blood loss?: If this is the case, I will have a hotline spiked and ready to go
to help with fluid resuscitation and to have the potential to give blood.
D – Drugs
Generally, I will set up syringes for Propofol, Lidocaine, Rocuronium, and
Versed, and Fentanyl. It can be difficult to tell from the schedule if you will
need a different set up from this other than if the patient is old enough that
you might not want to give versed.
S- Special
Is it listed
on the schedule that X-ray will be used? If so I’ll grab some lead from the
tech room.
If it is an
invasive procedure or if I know my attending likes it, I will consider getting
some colloid in the room.
After the
room is set up, I can finally head to the pre-op area to see the patient or to
look up patient information if they are coming directly from their room or the
ICU. This is the point when I can really gather some information and start to
tailor a more specific anesthetic plan to the patient. Each section of the
pre-op sheet will greatly impact our plan. This is usually the order that I
actually go through the pre-op with the patient.
If not in
DSU or pre-op holding and the patient is coming down from ICU, there is a
chance that we will have to go and get the patient. If this is the case, I
would go get a transport monitor from the tech room. I would also grab airway
supplies and some emergency drugs in a large suction bucket to take with me
incase anything happens during transport.
Verify
surgery site- Once confirmed, you want to ensure that you don’t plan to have
any IV’s or monitors that will interfere with the surgery or prep site.
Allergies-
If the patient is allergic to latex or any medications you need to make sure
that it is a true allergy and avoid these things. For medications, this means
finding an alternative to what the patient is allergic to. For example, if the
patient has a PCN allergy, I would consult with the surgeon and plan to avoid
cephalosporins.
NPO Status –
If the patient is deemed to have a full stomach (ate within a 8 hour period, is
diabetic, is pregnant, or has a small bowel obstruction) and we are using a
general anesthetic, the plan will automatically go to a GETA with a rapid
sequence induction to prevent aspiration. This will include cricoid pressure,
suction on hand, and succinylcholine (or rocuronium succ. Is contraindicated –
ie. Elevated potassium levels, muscular dystrophy, recent burns, recent CNS
trauma. It could also be advantageous to give pre-medications such as Pepcid,
Reglan, and Bicitra.
Respiratory-
Recent cough or cold – May be better to postpone the surgery
if it is an elective procedure. If not, be prepared that the patient may have a
reactive airway more prone to laryngospasm and bronchospasm.
Asthma – If
patient has asthma, and hasn’t used their inhaler that day, it may be wise to
get an albuterol inhaler for them to use before heading back to surgery or giving
a small dose of steroids. Keep a close eye on the capnograph waveform to see if
patient has had an attack during airway management.
OSA – If
patient has OSA and is non-compliant with a CPAP machine, they may live at a
higher
PaCO2 than the average person and it may take more to get them to
breathe at the end of surgery. Also, prepare for a potentially difficult bag
mask at the start and end of case, preparing oral and nasal airways as needed.
COPD - People
with COPD are often smokers. Be prepared with suction for lots of secretions.
These patients also live at a higher PaCO2 than the average person so it may be
more difficult to get to breathe on their own at the end of the case. I would
consider trying to limit my narcotics until the patient is breathing on their
own, as to not further depress their respiratory drive.
Cardiovascular
–
HTN – “Keep
them where they live.” If a person normally has an elevated blood pressure, we
want to keep them within 20% of that normal range, not 20% the average person’s
value. This can be particularly important in people with chronic hypertension
as they may have associated cardiovascular co-morbidities.
MI – It is
important to ask what kind of treatments these patients have undergone, if they
are symptomatic, and how recently they had a cardiac workup. If they have been
doing well after their procedure, you may not have to be too concerned. Still may
be advantageous to put in an A-line and induce with Etomidate to keep a tight
control on BP and maintain perfusion to the coronary arteries.
Pacemaker/defibrillator-
Find out what type of implanted device they have and when it was last
interrogated to ensure optimal function. Talk with the surgeon concerning
electro-cautery to ensure patient safety. Make sure to have a magnet in the
room to put the pacer in asynchronous mode or deactivate the defibrillator in
the case of an emergency.
Murmurs/arrhythmias
- Find out if they are on any medications for their arrhythmias and if they are
currently in that arrhythmia. Know how to manage specific arrhythmias –ie keep
a lower heart rate with people in A. fib to allow for adequate filling time of
the atria.
Neurological
–
TIA/CVA – In
patients with TIA or CVA, find out when they have occurred and what
precipitated it. They can be on anti-coagulant drugs that you need to be aware
of and you will need to ensure adequate blood flow to the brain through
maintaining adequate volume status and keep blood pressures from dropping to
low.
Neuropathy –
It is important to find out about preexisting neuropathies and make note of
them in the pre-op chart. In these patients you need to be conscious of
positioning as to not worsen any neuropathy, create new neuropathy, or cause
ischemia. Many neuropathies can originate from the head or neck. If this is the
case, plan accordingly as to get video airway equipment and stabilize the head
and neck during intubation if necessary.
Seizures –
If a patient has a history of seizures, be sure to find out how often they have
them and what medications they are taking. Be prepared with midazolam or
propofol on hand if you need to, at any point, acutely treat a seizure. Also,
many of the medications that people take for epilepsy can increase the
metabolism of paralytics that we give. If needed for the procedure, you may
have to give more than you would to many of your other patients.
Head injury –
Does the patient have an increased ICP from an injury to the head? How is their
mental status at the start of the case? If the patient has an already increased
ICP or is at risk for an aneurism rupture, you need to take proper measures to
ensure that you don’t further increase ICP – keep stimulation minimal during
intubation, limit volatile gases, use positioning to your advantage, use
diuretics in needed, mildly hyperventilate the patient, etc.
Gastrointestinal
–
GERD – If
your patient normally has reflux, you need to find out if it is controlled and
what kind of conditions normally trigger it. It is possible that they are at an
increased risk for aspiration and your anesthetic plan needs to account for
this. This can include things such as pre-medicating with Bicitra, Pepcid, and
Reglan. Also consider doing a rapid sequence induction with cricoid pressure
and starting with the patient in a reverse trendelenburg position.
Hiatal
Hernia – Patients with hiatal hernias are increased risk for reflux and
aspiration. Similar precautions as listed above need to be taken.
Metabolic –
DM – Patients
with DM often have lots of other comorbidities, so be conscious of this. It is
important to check glucose levels and make sure they are in a normal range
before heading back to the OR to improve pot-operative outcomes. Be conscious
of neuropathies and unstable mandibular and alanto-occipital joints when
positioning and do not give drugs that will raise the blood sugar, before you
consider all of the outcomes.
Sickle Cell
– Patients with sickle cell disease have a number of perioperative issues.
Generally, they are poor temperature regulators, poor oxygen carriers, and tend
to be hypercarbic and acidodic. Things we can do you help with this as
anesthesia providers is give plenty of fluid and blood (sometimes
preoperatively), keep a warm temperature in the room, utilize Bair Huggers, and
use higher percent Fi02 if needed.
Thyroid
issues – Whether it be hyper or hypothyroidism, find out if the patient takes a
medication regularly to keep it in control. If they are symptomatic be conscious
of issues such as myxedema coma for hypothyroidism and thyrotoxicosis for
hyperthyroidism and how to treat these (for example giving propranolol as the
first line of defense for thyroid storm). Thyroid goiters can also potentially
lead to difficult airway management. May be beneficial to use video scopes or
fiberoptic bronchoscopes.
Steroid use –
It is important to find out what kind of PO steroids patients are taking, why
they are taking them, and what dose they take it at. If they take them on a daily
basis, it may be wise to give a stress dose of steroids at the start of the
procedure to ensure that their vascular smooth muscle has an adequate response
to endogenous and exogenous vasopressors.
Kidneys –
ESRD – There
are a number of issues that are associated with ESRD patients that we need to
be concerned with. One issue is access. It may be difficult to get IV access,
so we need to make sure that we have as many working IV’s as we need. In
addition we need to find out the patient’s dialysis schedule, when they were
last dialyzed, and what their current volume status is. The amount of fluid
that we can give them greatly depends on this. It is a delicate balance and we
want adequate perfusion, but we don’t want to volume overload them. We will also
need to check their electrolytes and use fluids – NS, Albumin, and PRBCs, as to
not increase the levels of any electrolytes that we don’t want to. Patients may
also be anemic due to lack of erythropoietin production. Finally, many drugs
are partially metabolized and excreted by the kidneys and we want to avoid them
due to adverse or prolonged effects (examples include merperidine and
rocuronium). We need to find alternates to some of these drugs.
Liver –
A number of
drugs are metabolized in the liver and may have a prolonged effect in people
with liver issues. People with liver issues may also have problems with
coagulation and you may anticipate more bleeding during surgical procedures. People
with liver disease may have perfusion issues, various organ comorbidities, and
issues with their lungs. It is important to be aware of all of these.
Medications – It is essential to find out what medications
they are normally on and if their medical issues are normally pretty well
controlled. It is also crucial to find out what medications they have recently
taken (that morning, the night before, earlier that week). The following can
impact our anesthetic plan.
Chronic pain medications – Pain management can be
potentially difficult in these patients and require increased amounts of pain
medication. It helps to find out the frequency and amount of what they take to
determine if this might be needed.
Diuretics – Used to control BP, they can sometimes have an
effect on electrolytes. Be sure to check labs and get anything in order that
might be necessary.
ACE inhibitors and ARBs – These BP meds can mess with a
patient’s electrolyte levels and also make keeping up blood pressures
increasingly difficult in the OR. We may need to give more fluids and use
stronger, direct acting vasopressors.
Anti-epileptics – In these patients, we may need to give
increased amounts of muscle relaxant in order to keep them paralyzed throughout
the procedure. It is also important to find out when they last took the medication.
On occasion, you will need to give a dose in the OR.
ASA- If the patient has kept taking ASA within a 7 day
period, they may have issues with coagulation. It is possible that you can
cancel the surgery but if not, keep an eye on blood loss and be sure to
communicate with your surgeon throughout the procedure.
Inulin/DM meds – It is important to check glucose levels
regardless of when they took their medication but this should give you a better
idea of where it will be and if you need to take measures to control it (ie
giving insulin)
Steroids – Patients that take steroids on a regular basis
may need a stress dose of steroids in order to keep management on their BP.
Social History-
Alcohol – If the patient has a history of chronic alcohol
use, be conscious of associated liver issues. Also, they may have a higher
tolerance and require larger doses of anesthetics. If they are acutely
intoxicated, they will need less.
Smoking – Smoking can lead to a number of respiratory
issues, as discussed above in the COPD section.
Illicit drugs – Certain illicit drugs can impact the effect
of agents that we give as anesthesia providers. Be conscious of this and find
alternatives. For example, in cocaine users, ephedrine will not be as effective
because of depleted NE stores.
Surgical History – If
during past surgeries, does the patient have history of:
PONV – Consider scopolamine patch, numerous IV anti-emetics
(Zofran, Decadron, phenergen, etc). Also consider limiting opioids and running
a TIVA instead of using a full MAC of volatile agents.
MH – If patient or family has history of MH, we need to
avoid volatiles and Succinylcholine. This means flushing the anesthesia machine
and planning to run a TIVA. If paralytic is needed, stick to Rocuronium or
others.
Surgeries that impact the airway – Has the patient been
trached before or had surgery that might impact the airway and make for a
difficult mask or intubation. Be prepared for the difficult airway algorithm.
Severe issues with pain control- Explore options with long
acting narcotics or talking with the block to team to see if there is a
possibility for them to work on post-op pain control.
Labs – Part of the anesthetic plan can be deciding what labs
to get and then deciding what to do once you have a chance to view those
values.
CHEM 7 – These values will let you know how the patient’s
electrolyte levels and balances are, as well as giving an idea of kidney
function. These values will let you if it is safe to go into surgery, if you
can anticipate cardiac arrhythmias, if you should use specific drugs, and if
you should use specific types of fluids (ie NS over LR).
Coags. – These values can give you insight to liver
function, how much the patient might bleed during surgery, and if you should
run further tests, such as a TEG, in order to know which blood products would
be appropriate to give during surgery.
H and H – Low H and H values can let you know if your
patient is optimized for surgery or if you may need to type and screen, type
and cross, or even have some blood available in the room.
Tests - Similarly to
labs, part of the anesthetic plan is deciding what type of tests to run on a
patient and then making decisions based on the results you find.
CXR – Can let you know the current state of respiratory
issues of patients and follow the plan as listed above in the respiratory
section. Can also let you know of any masses that might hinder your management
of airway and patient ventilation.
EKG & echo – Good to check these in older patients,
patients undergoing stressful surgeries, and patients with previous cardiac
issues. Will let you know the current state of their heart and how to proceed
according to the cardiac section listed above.
All of these
components are combined to create an anesthetic plan that is specific to each
patient and each surgery.
