Fitness for General Anaesthesia

Question 1

What happens in a typical pre-op consultation?

Answer 1

• History
• Examination
• Tests
  
  • Group and save
  • Coagulation
  • U&Es
  • FBCs
  • ECG
  • LFT
• Risk prediction
• Communication (risks, predictable issues, options, questions)
• Decision

Important to check the importance of functional assessment (day to day activities)

Poor pre-op health increases risk of complications

Question 2

What things increase risk of surgery? & specific circumstances

Answer 2

• Smoking (2x risk of all complications)
• Diabetes (2x risk of poor wound healing & infection, 1.5x risk of death)
• COPD (90x risk of postop pulmonary complications, 2x risk of death)
• CKD (approx. 2x risk of infection, CVS & pulmonary complications)
• Frailty (4x risk of death, 2x risk of all complications & discharge not home)
• Cognitive dysfunction (2x risk of delirium & death, delirium more severe)
• Obesity (increased risk of morbidity, not always mortality – obesity paradox)
• Age does not increase risk of complications in many studies but physiological reserve is reduced.
• Anaemia (1.5x risk of morbidity & mortality)

Specific circumstances

• Recent cold (within 2 weeks)
• Recent heart attack (ever, within 1 year, within 6months, within 3 months)
• Recent stroke (within 9 months)
• Allergies

Question 3

How to assess functional capacity?

Answer 3

• History
• Exercise capacity tests
• Cardiopulmonary Exercise Tests (CPET)
• Risk stratification tools
  
  • P-POSSUM
  • Surgical Outcomes Risk Tool (SORT)
  • Surgical Risk Calculator Score (ACS NSQIP)
  • Carlisle Risk Calculator

Question 4

What are METS?

Answer 4

• 1 MET = 3.5 mls 02/KG/min
• amount of oxygen consumed while sitting at rest
• Self –reported effort tolerance

Want at least 4 METS in order to undergo a surgery as means that cells have good oxygen supply

Question 5

What are some exercise capacity tests?

Answer 5

• The incremental shuttle walk test
• The 6 minute walk test (500-600metres walk normal, below 300 means BAD)
• The stair climb test

Question 6

Explain the cardiopulmonary exercise testing (CPET) & what is measured & what are the variables

Answer 6

• 10 minutes on cycle ergometer
• expired gases
• rest, 2 mins unloaded cycling, ramped, recovery phase → (want to find the point where someone produces lactic acid through anaerobic respiration)

What is measured?

• dynamic, non-invasive assessment of the cardiopulmonary system at rest and during exercise
• Cardiovascular variables
  
  • HR, ECG changes, NIBP
• Metabolic gas exchange measurements
  
  • VO2 (how much oxygen the body uses → lower the worse outcome), VCO2 (how much carbon dioxide the body makes), RER (respiratory exchange ratio → normally 0.7 → oxygen to CO2 ratio, if more than 1 means that more CO2 to oxygen meaning that anaerobic respiration)
• Ventilatory measurements
• Work rate

Variables

• Anaerobic threshold (AT)
• VO2 peak
• VE/VCO2

Question 7

What are risk assessment tools when assessing functional capacity?

Answer 7

• P-POSSUM
• Surgical Outcomes Risk Tool(SORT)
• Surgical Risk Calculator Score (ACS NSQIP)
• Carlisle risk calculator

These have limitations as are not representable by the population (e.g. if someone has cystic fibrosis)

Question 8

What is consent? & consent in under 18s

Answer 8

• Voluntary, informed permission by any individual with capacity to any action undertaken.
• Absence of valid consent risk allegations of negligence and / or battery

Extra

• The legal requirements of valid consent reflect the ethical ones: it must be given voluntarily by an appropriately informed patient, who has the capacity to exercise choice.
• Under the Mental health capacity act 5
• Crucial for validity
• 2 stage process
  
  • Is something in the way e.g. disease
  • Understand, recall, weigh up, explain

Under 18’s

• 16-17 year olds
  
  • Assumed to have capacity as an adult
  • Parental responsibility
  • Court if refusal of treatment if would lead to serious harm
• Under 16s
  
  • Gillick competence
  • Parental responsibility
  • Courts
• Emergency
  
  • The minimum to save a life/health
  • Court application

Question 9

What are the 4 pillars of ethics? (with consent)

Answer 9

• Autonomy
• Non-maleficence
• Beneficence
• Justice

Question 10

Explain the Montgomery vs Lanarkshire Health Board (what was found and what are the exceptions)

Answer 10

• No longer Bolam principle (would people of the same qualifications do the same in the same scenario)
• Must provide all ‘material risks’
  
  • ‘’…whether a reasonable person in the patient’s position would be likely to attach significance to it”
• Exceptions
  
  • patient has expressed fixed desire not to know risks
  • discussion of risks would pose serious threat
  • circumstances of necessity, best interest emergency treatment when there is no capacity

Conclusion

• Patients must be informed of,
  
  • Alternative treatments
  • Risk of alternatives
  • Option of not receiving treatment

Question 11

What is shared decision making?

Answer 11

• Collaborative process in which clinicians and patients work together
• Based on clinical evidence and informed preferences
• Acknowledges that there is usually more than one option
• Aim to to find the best choice for the individual patient

Question 12

Why is shared decision making important?

Answer 12

• Embedded in the NHS Long Term Plan’s commitment to individualised care
• Integrated into NHS constitution, GMC guidance, NICE 2021…
• Integral to informed consent
• Montgomery 2015
• Evidence base

Question 13

What is the 3-talk model?

Answer 13

• The three-talk model
  
  • depicts conversational steps, initiated by provider support when introducing options
  • followed by strategies to compare and discuss trade-off
  • before deliberation based on informed preferences

Question 14

What is the BRAN tool?

Answer 14