How to Preop a Patient

Preop Planning Template

Operation/Patient History:

Positioning: may need extra equipment prone means going to sleep on bed/gurney, proneview, accordion extender, arms out or tucked

Preop Interview/Exam:
Reaction to listed allergy
Airway exam (always) + chronic pain regimen, neuro deficits, bedside echo, anything that might influence your plan and can't find in chart (be specific… not "did you get cardiac clearance")

Positioning

Note position (e.g. prone, lithotomy), arm placement, special equipment like proneview, extenders, or padding.

Plan Overview:

GETA, MAC/Regional, Spinal, Epidural, Combined Spinal/Epidural

Monitors:

standard ASA monitors, A-line, SedLine/BIS, TEE, CVP, PA pressures, cerebral oximetry, Neuromonitoring (EEG, EMG, MEPs, SSEPs, etc)

IV Access:

PIV, central line, PICC

Premedication:

Midazolam, lorazepam, or other anxiolytics as appropriate

Induction:

Standard IV induction, Rapid Sequence Induction (RSI), mask induction

Airway Management:

ETT type and size (standard, oral rae, nasal rae, DLT, bronchial blocker, NIM tube) + laryngoscopy technique (direct Mac/Miller size, glidescope, fiberoptic bronchoscope (FOB)), LMA, native airway + adjuncts (OPA/nasal trumpet)

Maintenance:

inhaled vs TIVA

Emergence/Dispo:

extubate awake, extubate deep, to ICU intubated

Hemodynamics:

rate, rhythm, preload, afterload, contractility

PONV prophylaxis:

Dexamethasone, ondansetron, scopolamine patch, droperidol

Analgesia:

intermittent opioid boluses, opioid infusion, ketamine infusion, intrathecal morphine (ITM)

Fluids/Blood Products:

"Goal directed fluid therapy", maintenance rate, accounting for insensible losses, high blood loss case, belmont

Sample Cases

Simple Laparoscopic Case

RSIRoutine

Operation/Surgeon/Patient Hx: Otherwise healthy 55 year old male (80 kg, BMI 28) with inguinal hernia s/f laparoscopic inguinal hernia repair with Dr. Kind Positioning: supine, arms out Overview: GETA, standard monitors, 1 PIV Monitors: standard IV access: 1 PIV Premed: midazolam (2 mg) Induction: RSI with propofol (2 mg/kg), fentanyl (3 mcg/kg), rocuronium (0.6 mg/kg) Airway: DL, ETT Maintenance: sevoflurane Emergence: extubate awake in OR Hemodynamics: maintain BP within 20% of baseline PONV ppx: dexamethasone, ondansetron Analgesia: fentanyl boluses (0.5 mcg/kg/hr) Fluids/Blood: maintenance 4+2+1 rule ~ 120cc/hr, crystalloid

Complex Abdominal Surgery

A-lineEpiduralHigh Blood Loss

Operation/Surgeon/Patient Hx: 77 year old female with diabetes and ovarian cancer with ascites s/f exploratory laparotomy for tumor debulking with Dr. Smile, on chronic opioids Positioning: supine, arms out Overview: GETA Monitors: standard + arterial line, ABG Q2H, blood glucose Q2H IV access: 2 PIV Premed: none Induction: RSI Airway: ETT, glidescope Maintenance: sevoflurane Emergence: extubate awake in OR Hemodynamics: BP within 20% of baseline PONV ppx: decadron/zofran Analgesia: epidural morphine Fluids/Blood: maintenance + 8-10/cc/kg/hr for insensible losses, blood products as directed by ABG

Complex Spine – Posterior Lumbar Fusion

TIVAProneMEPs

Operation/Surgeon/Patient Hx: 60 year old male with severe lumbar disc degeneration s/f posterior lumbar interbody fusion L1-S1 with Dr. Spine. Hx multiple epidural steroid injections with chronic pain clinic (ESI), cervical DDD, anemia, pacemaker for symptomatic bradycardia Positioning: prone Overview: GETA Monitors: standard + arterial line, MEPs SSEPs by neurophysiology team IV access: 2 PIV Premed: midazolam Induction: standard IV induction Airway: glidescope, ETT Maintenance: propofol gtt Emergence: extubate awake in OR Hemodynamics: MAP > 75 for spinal perfusion, magnet available to put pacemaker in asynchronous mode if interference from electrocautery (bovie) PONV ppx: zofran Analgesia: fentanyl gtt vs methadone Fluids/Blood: maintenance crystalloid, T&S, ?crossmatch depending on anticipated blood loss

Peds – Tonsillectomy

Mask InductionPediatricsDeep Extubation

Operation/Surgeon/Patient Hx: 4 year old male (15 kg) with OSA s/f tonsillectomy with Dr. Kiddo Positioning: supine Overview: GETA Monitors: standard IV access: 1 PIV Premed: oral midazolam Induction: mask induction with nitrous/sevo Airway: oral rae size 4.5, DL with Miller 2 Maintenance: sevo Emergence: extubate deep, precedex PONV ppx: decadron/zofran Analgesia: tylenol/toradol/precedex Fluids/Blood: 20-40 cc/kg bolus crystalloid

CABG Surgery

CardiacCPBTEE

Operation/Surgeon/Patient Hx: 65 year old with HTN, OSA, severe multivessel CAD, diffuse LAD disease on LHC not amenable to DES, on heparin gtt s/f on pump CABG Positioning: supine, arms tucked Overview: GETA Monitors: pre-induction A-line, CVP +/- PAP, TEE, cerebral oximetry, EEG/Sedline IV access: 2 PIV, central venous catheter (IJ) Premed: midazolam Induction: standard IV induction, fentanyl 4-5 mcg/kg, propofol 1 mg/kg, phenylephrine and nitroglycerine gtt started prior to induction Airway: glidescope, ETT Maintenance: isoflurane, propofol during CPB Emergence: to ICU intubated on precedex gtt Hemodynamics: overall goal to reduce myocardial oxygen demand and maintain myocardial oxygen supply Rate - avoid tachycardia to minimize myocardial O2 demand Rhythm - sinus ideal Preload - avoid hypervolemia, reduce LVEDP w nitroglycerin for coronary perfusion Afterload - augment with phenylephrine for CPP Contractility - will likely need augmentation with inotrope to separate from bypass, avoid augmentation if not needed prior to revascularization to avoid increasing myocardial O2 demand PONV ppx: zofran Analgesia: fentanyl boluses Fluids/Blood: albumin, crossmatch for 2 PRBC and 2 FFP

Anesthetic Goals

Remember the pillars of a balanced anesthetic

Amnesia: hypnotic depth
Analgesia: response to stimulus
Akinesia: surgical field immobility

Your anesthetic plan starts with considering what the surgery and patient require in each of these categories

Hemodynamic Planning Tips

Again, consider what the surgery and patient require, and at what time during the operation, you have those goals

Examples

NSGY - often need SBP < 140 to mitigate bleeding intaop and postop
CEA - might need SBP > 170 prior to reperfusion to maintain cerebral perfusion through collaterals, and then SBP < 140 after reperfusion
Cardiac surgeries on CBP - where CTS will cannulate the aorta, SBP goal ~90 to prevent aortic dissection

Think about goals/targets & what agents you plan to use

Rate - beta blockers, anticholinergics, pacemaker
Rhythm - pads on to cardiovert if needed
Preload - augment with volume, euvolemia, venodilators
Afterload - vasopressors
Contractility - inotropes

Positioning

Proneview, padding, circuit extenders
Check arm placement, head/neck alignment
Pressure point protection
Eye protection for prone cases