Anaesthetics

Question 1

Principles of Pre-Operative Care?

Answer 1

Pre-op assessment
Consent
Bloods (including group+save/Crossmatch)
Fasting
Medication Changes
VTE risk assessment
Surgery school (expectations in recovery/associated risks and side effects)

Question 2

History in Pre-op clinic

Answer 2

Pre-op history -

PMH
PSH
Medications
Allergies
Adverse response to anaesthesia or FH of response to anaesthesia
Smoking
Alcohol

Pregnancy / Sickle Cell FH /
Cardio and Resp exam

ASA grade according to the patients health

Question 3

ASA Grades

Answer 3

The American Society of Anesthesiologists (ASA) grading system classifies the physical status of the patient for anaesthesia. Patients are given a grade to describe their current fitness prior to undergoing anaesthesia/surgery:

ASA I – normal healthy patient
ASA II – mild systemic disease
ASA III – severe systemic disease
ASA IV – severe systemic disease that constantly threatens life
ASA V – “moribund” and expected to die without the operation
ASA VI – declared brain-dead and undergoing an organ donation operation
E – this is used for emergency operations

Question 4

Investigations prior to surgery

Answer 4

Bloods:

• FBC/U+E’s/LFTs/Clotting or INR
• Group and Save / Crossmatch
• HbA1C
• ABG

Imaging:

• ECG
• ECHO
• Lung function tests (ex.spriometry etc)

MRSA screening

Question 5

Fasting before an operation typically involves ____ hrs of no food or feeds before and operation.
____ hrs of no fluids

Answer 5

6 hrs no food
2hrs no fluids

Question 6

Medications changes before surgery

Answer 6

Anticoagulants (warfarin can be continued due to rapid reversal with vit.k / DOACs stopped 24-72 hrs before surgery)

Diabetic medications
- Sulfonylureas (glicazide - hypoglycaemia)
- Metformin (lactic acidosis)
- SGLT2 inhibitors (dapaglifozin - DKA)

start **variable rate insulin infusion ** plus **sliding scale ** of glucose / sodium/ potassium for optimal control of electrolytes

Steroids - can cause adrenal suppression

COCP/HRT (stopped 4 weeks previously if oestrogen containing due to increased risk of VTE)

Question 7

VTE prophylaxis at Pre-op

Answer 7

Every patient admitted to hospital should be assessed for their risk of venous thromboembolism (VTE). Surgery, particularly where the patient is likely to be immobilised (e.g., orthopaedic surgery), significantly increases the risk of venous thromboembolism. There are local and national policies on reducing the risk that involve:

Low molecular weight heparin (LMWH) such as enoxaparin

DOACs (e.g., apixaban or rivaroxaban) may be used as an alternative to LMWH

Intermittent pneumatic compression (inflating cuffs around the legs)

Anti-embolic compression stockings

Question 8

Principles of Capacity

Answer 8

Understand Info
Retain it
Weigh up the pros and cons
Communicate their decision

Question 9

Post Operative / Enhanced Recovery

Answer 9

Enhanced recovery aims to get patients back to their pre-operative condition as quickly as possible, by encouraging independence, early mobility and appropriate diet.

There are increased nutritional requirements after the physiological stress of surgery, so sufficient calories are very important.

The aim is to discharge as soon as possible. This leads to better outcomes for the patient.

The principles of enhanced recovery are:

***Good preparation for surgery *(e.g., healthy diet and exercise)

**Minimally invasive surgery **(keyhole or local anaesthetic where possible)

Adequate analgesia

**Good nutritional support ** around surgery

Early return to oral diet and fluid intake

Early mobilisation

**Avoiding drains and NG tubes where possible, early catheter removal
**

Early discharge