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Anaesthetics and Genetics > Anaesthetics - Pre-op Assessment > Flashcards

Anaesthetics - Pre-op Assessment Flashcards

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1
Q

what is important to think about in regards to anaesthetics and the elderly?

A

May present with many comorbidities and polypharmacy

Elderly has reduced physiology reserve in most systems

Cognitive decline is something to think about when assessing these patients

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2
Q

what may the trauma of syrgery be?

A
  • Stress response (Anatomical and physiological changes in surgery)
  • Fluid shifts
  • Blood loss
  • Cardiovascular, respiratory, renal and metabolic stress
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3
Q

what are the effects of general anaesthesia?

A
  • Drug induced reversible coma
  • CNS, cardiac and respiratory depression
  • Drug interactions (between anaesthetics and patients durgs)
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4
Q

what deos Regional anaesthesia (e.g. epidural) cause?

A
  • Profound sympathectomy
  • Neurological sequelae
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5
Q

whata re some considerrations in anaesthetics?

A
  • Patient - Known co-morbidities and Unknown pathologies (may not know the patient has these)
  • Nature of surgery (different types of surgery)
  • Anaesthetic techniques
  • Post-op care
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6
Q

what is the role of the anaethatist pre-op?

A
  • Assess
  • Identify high risk (pick out patients that are high risk of perioperative complications, morbidity, mortality)
  • Optimise
  • Minimise risk
  • Inform and support patients decisions
  • Consent
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7
Q

why do a pre-op asessment?

A

Reduces:

  • Anxiety
  • Delays
  • Cancellations
  • Complications
  • Length of stay
  • Mortality
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8
Q

when should you do a pre-op assessment?

A

elective planned surgery - either in primary care or in pre-assessment clinic - gives lots of time to manage conditions prior to surgery

urgert surgery (e.g. for cancer, still have time for assessment)

emergency surgery (e.g. RTA)

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9
Q

what is involved in a pre-op assessment?

A

History

Examination

Investigations

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10
Q

what information needs to be gathered in a pre-op asessment history?

A

• Known co-morbidities:

  • Severity
  • Control (e.g. well controlled asthmatic is different form a bad controlled one)

•Unknown co-morbidities:

  • Systemic enquiry
  • Clinical examination

•Ability of withstand stress (stress of surgery):

  • Exercise tolerance (good way to test it)
  • Reason for limitation
  • Cardio-respiratory disease
  • Drugs and allergies (what is the reaction)
  • Previous surgery and anaesthesia
  • Potential anaesthetic problems
  • Airway
  • Spine
  • Reflux
  • Obesity
  • Rarities / Family history - Malignant hyperpyrexia, Cholinesterase deficiency
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11
Q

what may investigation be used for?

A
  • Detect unknown conditions
  • Diagnose suspected conditions
  • Severity of known disease
  • Establishing a baseline
  • Detecting complications
  • Assessing risk
  • Guiding management
  • Documenting improvement
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12
Q

CVS and respiratory systems are the main ones we are interested to look at as anaesthetists:

what tests could we do to investigate the cardiovascular system?

A

ECG

Exercise tolerance test

Echo

Myocardial perfusion scan

Stress echo

Cardiac catheterisation

CT coronary angiogram

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13
Q

CVS and respiratory systems are the main ones we are interested to look at as anaesthetists:

what tests could we do to investigate the respiratory system?

A

Saturations

ABG

CXR

Peak flow measurements

FVC/FEV

Gas transfer

CT chest

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14
Q

what do you need to think about when choosing an investigation and who is getting them?

A
  • Sensitivity and specificity
  • Target those at risk
  • Iatrogenic harm of over-investigation
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15
Q

What are the NICE guidelines on what we would look for in a patinet when choosing what investigation to use?

A
  • ASA grade
  • Surgery grade
  • Co-morbidities
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16
Q

what are the ASA grades? (Scale we use to see how fit or unwell a patient is)

A

ASA1 - Otherwise healthy patient

ASA2 - Mild to moderate systemic disturbance

ASA3 - Severe systemic disturbance

ASA4 - Life threatening disease

ASA5 - Moribund patient

(ASA6 - Organ retrieval)

17
Q

what are some risk assessment tools?

A

—GUPTA perioperative cardiac risk

—Geriatric sensitive perioperative cardiac risk index

—Surgical outcome risk tool

—American college of surgeons surgical risk calculator

—STOP-BANG questionnaire

—Nottingham hip fracture score

—P-POSSUM

—CR-POSSUM

—Q-POSSUM

—V-POSSUM

Postoperative respiratory failure calculator

Many many more

Each one may look at different things

18
Q

one rik assessment tool we do commonly use along side ASA grading is the cardiac risk index

it is a list of conditions which you get a point ofr each of the things and if you have 2 or more points you are classed as high risk

what are the things on the list?

A
  • High risk surgery
  • Ischaemic heart disease
  • Congestive heart failure
  • Cerebrovascular disease
  • Diabetes
  • Renal failure
19
Q

Exercise tolerance - METs (Metabolic equivalent score)

Subjective as your asking the patient as often overestimate what they can do so they can get the surgery that they want

what are the different MET scores?

A

—Can you do the following activities without getting breathless;

  • Walk around the house - 2 METS
  • Do light housework - 3 METS
  • Walk 100-200 metres on the flat - 4 METS
  • Climb a flight of stairs or walk up a hill - 5 METS
  • Walk on the flat at a brisk pace - 6 METS
  • Play golf, mountain walk dance, or any form of exercise - 7 METS
  • Run a short distance - 8 METS
  • Do either strenuous exercise or heavy physical work - 9 METS
20
Q

what is becoming the gold standard test and can be seen in the picture here?

A

Cardiopulmonary exercise testing

Assess fitness of patient for surgery

21
Q

ultimatley what we are doing this assessment for through history, examinations and investigations is really to see if there is anything that we can optimise

can we improve the situation at all

what things may we be able to optimise?

A

Optimal medical control:

  • Hypertension
  • Ischaemic heart disease
  • Heart failure
  • Asthma
  • COPD
  • Diabetes
  • Epilepsy
22
Q

what lifestyle factors can we alter and look at in the pre-operative clinic?

A

Smoking - respiratory complications and wound healing

Alcohol - risk of infection and septic shock - Cessation of alcohol – no reduction in mortality but reduction in complications (dose dependant)

Obesity (losing weight before surgery improves outcomes)

Exercise (improving the amount the patient exercises improves the outcomes)

23
Q

what is Pre-habilitation?

A

Improved fitness = improved outcomes

15% reduction in mortality risk per MET

Prescribing exercise! (prescribing exercise in peri-operative period to improve chances)

24
Q

what is the process of dealing with a high risk emergency patient?

A

Informed consent

Anaesthetic plan

Invasive monitoring

Senior management

Post operative critical care

25
Q

Pre-op medication - what do we do with the patients medication before surgery?

A

Most continue as normal

some especially have to continue as normal but there is some possible exceptions that may have to stop

26
Q

what medications need ot be conitued?

A

Inhalers

Anti-anginals

Anti-epileptics

27
Q

what medications may not need to be continued during surgery?

A

Anti-diabetic medication (depends what kind, what surgery, how well diabetes is controlled, when is the surgery, etc)

Anticoagulants

28
Q

Summary?

A

Considerations:

  • Patient
  • Surgery
  • Anaesthesia

Pre-op assessment:

  • History
  • Examination
  • —Investigations

Risk assessment

Optimising (optimisation of risk reduction)

Ultimately wanting informed consent form the patient

Anaesthetics and Genetics (15 decks)

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