Pre-anesthesia Evaluation in the Elderly

                                          Module # 5

OBJECTIVES:

            Upon completion the learner will be able to:

1) List the elements of a history necessary for an effective preanesthetic evaluation

2) List the appropriate physical exam elements for an effective preanesthetic evaluation

         3) List the appropriate pre-op testing with indications

         4) List and evaluate patients for major pre-operative risk factors for:

                                    a) Cardiac disease

                                    b) Pulmonary disease

                                    c) Sepsis

                                    d) Renal disease

            5) Clinically assess functional capacity

            6) Demonstrate the ability to:

                                    a) interpret pre-operative testing

                                    b) evaluate mental status

                                    c) assess hydration, oxygenation, nutrition

                                    d) manage polypharmacy

                                    e) counsel the  patient regarding:

                                                - their candidacy for various types of anesthesia.

                                                -anesthetic risk

If you have not reviewed the previous 1–4 modules, please do so before proceeding with this module.

 

                                                                                                THE CASE

You are asked to perform a pre-anesthesia evaluation on a 79 yo Euro-American female who has been in the hospital for cholecystitis for 2 days and has failed medical management.  A cholecystectomy is anticipated. 

HISTORY

Anticipated procedure:   Cholecystectomy… urgent
Proposed as laparoscopic but high likelihood of need to convert to an open procedure

PMHx:

  1. Hypertension x 20 yrs… well controlled
     
  2. CAD:   -past medical history of anterior MI 1999.

                  -hx of “irregular heart beat” during stress echo 5/00

                   (DSE: no ischemia, 50% EF, mild aortic stenosis.)

                  -hx of CHF during an acute illness, presently  compensated

  1. COPD -30 pack yr history of smoking (stopped in 1999)
     
  2. Hypothyroid on replacement therapy
     
  3. Depression

            Surgical Hx.  1) Apply, TAH (Hysterectomy), T&A, hemorrhoid,
                                        cataracts, vein stripping, bladder suspension 1

          
 Allergies:        none

            Medications:
           
Hospital medications
           
(The patient has been taking the following these oral medications with sips of water while an
              inpatient)

                                    Atenolol 25 mg q hs
                                    Albuteral MDI 2 puffs q 4 hrs prn dyspnea
                                    NTG 0.4 mg sl q 5 min prn chest pain
                                    Solumedrol 10 mg q day IV
                                    Levothyroxine 0.15 mg per day
                                    MSO4 1-2 mg IV q 2 hrs prn pain (started in ER)
                                    Tylenol
                                    NTG 0.4 mg sl q 5 min prn chest pain
                       
            Nortriptyline 10 mg q hs

                        Preadmission medications

                                    Atenolol 25 mg q hs
                                    Albuteral MDI 2 puffs q 4 hrs prn dyspnea
                                    NTG 0.4 mg sl q 5 min prn chest pain
                                    Levothyroxine 0.15 mg per day
                                    Prednisone 10 mg q d (x 2 months)
                                    Nortriptyline 10 mg q hs
                                    MSO4 1-2 mg IV q 2 hrs prn pain (started in ER)
                                    Tylenol
                                    Multivitamin q day
                       
            Ca Carbonate/Vit D 500/125 q d.

         Social Hx:  widowed, lives alone, prior smoker (d/c in 1999), no alcohol

Functional status:  does own housework, able to walk 1 flight stairs but with moderate dyspnea often requiring resting, no chest pain.

ROS:  
General: no nutritional problems, weight stable.
HEENT: vision (wears glasses, does not have them with her), normal hearing. Dentition present in poor repair, neck no problems
Cardiorespiratory:  mild dyspnea with walking otherwise negative.
GI: Obese, no heartburn, abdominal pain.
GU:   negative, continent                                            
Endocrine: hypothyroid
MSK: R knee pain, all other joints are fine
Skin: negative 
Neurologic:  negative

  
Question #1
Does the patient have any ACTIVE CARDIAC CONDITIONS?

a) Yes

b) No