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Year 3 Surgery block > Peri-op & Anaesthesia : Pre-op Assessment > Flashcards

Peri-op & Anaesthesia : Pre-op Assessment Flashcards

1
Q

What is the purpose of the pre-op Assessment

A
  • to identify pt co-morbidites that may lead to complications during the anaesthetic, surgical or post operative period
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2
Q

When does a pre-operative assessment happen?

A

Patients scheduled for elective procedures will generally attend a pre-operative assessment 2-4 weeks before the date of their surgery.

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3
Q

The Pre-op history - what is involved? (headings for now)

A
  • History of the Presenting Complaint
  • Past Medical History
  • Past Surgical History
  • Past Anaesthetic History
  • Drug History
  • Family History
  • Social History
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4
Q

What would you ask about a pts Past medical hx in a pre-op assessment?

A
  • CVD - including HTN
  • Resp disease
  • Renal disease
  • Endocrine - Diabetes and Thyroid disease
  • GORD - aspiration of gastric contents
  • Pregnancy - all women of reproductive age will get a urinary test
  • Sickle Cell disease - could be undiagnosed if country of birth does not have routine screening
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5
Q

Pre-op assessment: You are asking a pt about cardiovascular disease.

What are some good screening questions ?

A
  • Exercise tolerance
    good indicator of cardiovascular fitness ( for major surgery can predict risk of post-op complications / level of care)

Screening questions for undiagnosed disease:
* Exertional chest pain
* syncopal episodes
* orthopnoea

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6
Q

Pre-op assessment: You are asking a pt about their past medical history (respiratory disease.)

Why is adequate oxygenation and ventilation important?

A

Adequate oxygenation and ventilation is essential in reducing the risk of acute ischaemic events in the peri-operative period

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7
Q

Pre-op assessment: You are asking a pt about their past medical history (respiratory disease.)

What are some key questions to ask a pt how might this relate to anaesthetic choices?

A

Ask:
* can the patient lie flat for a prolonged period?
* do they have a chronic cough?
these are key as may preclude spinal anaesthesia

Screen for :
* symptoms and signs of obstructive sleep apnoea (if RF)

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8
Q

What to ask about a pts past surgical hx?

A
  • Has the patient had any previous operations? If so, what, when, and why?
  • If the patient is having a repeat procedure, this can significantly change both the surgical time and ease of operation, and hence influence the anaesthetic technique used
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9
Q

What to ask about a pts Past Anaesthetic History?

A
  • Has the patient had anaesthesia before?
  • If so, for what operation and what type of anaesthesia?
  • Were there any problems?
  • Did the patient experience any post-operative nausea and vomiting?
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10
Q

What to ask about a pts drug hx?

A
  • A full drug history as some medications require stopping or altering prior to surgery.
  • Ask about any known allergies, both drug and non-drug allergies
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11
Q

What to ask about Family history?

A

Most hereditary conditions relating to anaesthesia are extremely rare, (e.g. malignant hyperthermia), it is important to ask about any known family history of problems with anaesthesia

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12
Q

What to ask about Social history?

A
  • smoking history, alcohol intake, and any recreational drug use
  • Language spoken and the need for an interpreter
  • Living situation, anyone at home (may need to stay overnight if no other adult at home), how they will get home etc. Work etc.
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13
Q

What does a pre-op examination involve

A
  1. GENERAL EXAMINATION- highlight any underlying undiagnosed pathology e.g. undiagnosed murmur or signs of HF, resp or GI symptoms.
    * ASA score based on co-morbidities
  2. AIRWAY EXAMINATION- to predict difficulty of airway management e.g. Mallampati score
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14
Q

AR the ASA score (American Society of Anaesthesiologists)

A
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15
Q

Pre-op Bloods: AR (reasons for later)

A
  • FBC
  • U&Es
  • LFTs
  • TFTS (condition specific)
  • HBA1c (condition specific)
  • Clotting screen
  • G&S +/- cross matching
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16
Q

Why do FBC for a pre-op pt?

A
  • Assess for any anaemia or thrombocytopenia, as this may require correction pre-operatively to reduce the risk of cardiovascular events or allow for preparation of blood products
17
Q

Why do U&E’s pre-op?

A
  • assess the baseline renal function
  • help inform fluid management and drug decisions, both for anaesthesia and post-operative analgesia (e.g. morphine is generally avoided in those with CKD)
18
Q

Why do LFTS pre-op?

A
  • assessing liver metabolism and synthesising function
  • useful for peri-operative management; if there is suspicion of liver impairment, LFTs may help direct medication choice and dosing
19
Q

Why do a clotting screen?

A

Any indication of deranged coagulation such as”
* iatrogenic causes (e.g. warfarin)
* inherited coagulopathies (e.g. haemophilia A/B)
* liver impairment
will need identifying and correcting or managing appropriately in the peri-operative period

20
Q

Compare Group and Save versus Cross-Match

A
21
Q

What investigations might you order for a pt with a history of cardiovascular disease?

A
  • ECG - show underlying pathology, baseline for comparison if post op concerns for cardiac ischaemia
  • ECHO
  • Myocardial perfusion scans (if untreated IHD or symptoms of angina- scans look for inducible ischaemia
22
Q

When might you consider an ECHO for a pt in pre-op assessment (3 reasons)

A

if the person has :
* (1) a heart murmur
* (2) ECG changes
* (3) signs or symptoms of heart failure.

23
Q

What Respiratory investigations might be done?

A

chronic lung conditions e.g. COPD / asthma
* spirometry for baseline
* refer for spirometry if S&S of undiagnosed pulmonary disease
* CXR not commonly performed

24
Q

What are some other tests you might do pre-op?

A
  • Urinalysis - UTI
  • MSA swab from nostril and perineum for MRSA colonisation. Decontamination hair and body wash, along with topical ointment applied to the nostrils, will be given.
  • Cardiopulmonary Exercise Testing (CPET). for high risk pts undergoing major surgery (graded intensity period on a stationary bicycle whilst wearing a mask, as well as ECG monitoring. It provides useful information, such as the VO2max and anaerobic threshold)
25
Q

What information do you need to give pts about food and fluid intake re-op?

A

No solids / dairy products - from 6hrs before surgery
No clear fluids - from 2 hrs before surgery

26
Q

What are some drugs a pt might be on that will need to be stopped pre-surgery

CLUE: CHOW

A

Clopidogrel
* stop 7 days pre op.
* Aspirin and other anti platelets can often be continued as minimal bleeding risk.

Hypoglycaemics
(info in deck on diabetes peri-op care)

Oral contraceptive pill or HRT
* stop 4 weeks pre surgery due to DVT risk. restart at least 2 weeks after surgery when mobile

Warfarin
* stop 5 days prior to surgery due to bleeding risk can replace with LMWH until the night before. If INR still not correct pre surgery vitmain K may be given

27
Q

What drugs may need to be started pre-op?

A

LMWH
* complete VTE risk assessment most patients will recieve this unless contraindicated
* patients undergoing major GI surgery for cancer and lower limb arthroplasty discharged with TED stocking and 28 days prophylatic LMWH

TED stockings
* all aptients but check for contraindications
* some patients with have intermittent pneumatic compression (flowtrons) during the operation may be continued post op i.e. in ITU

Abx prophylaxis
* ortho, vascular, GI surgery common

28
Q

What drugs may need to be altered?

A
  • Subcut insulin - switched to IV variable rate insulin infusion
  • Long term steroids- risk of addisonian crisis if stopped, maybe switched to IV
29
Q

contraindications for TED stockings?

A
  • severe peripheral vascular disease
  • peripheral neuropathy
  • any recent skin graft
  • severe eczema
30
Q

Which patient groups need a coagulation screen (PT, APTT, TT, Fibrinogen) before surgery?

A
  • PMHx of unusual bleeds
  • post surgical or post-dental procedure bleeding
  • unexplained persistent menorrhagia
  • FHx of bleeding disorder
  • Unexplained thrombocytopenia
31
Q

All patients listed for major surgery should have a full blood count pre-operatively.
(Anaemia = Haemoglobin <130g/L (men) or <120g/L (women)
If this is abnormal what do you check next?

A

haematinics such as ferritin, transferrin saturation, B12 and folate should be checked.

32
Q

causes of anaemia

A
  • Iron deficiency (most common)
  • Vitamin B12 or folate deficiency
  • Renal failure
  • Malignancy
  • Menorrhagia
  • Anaemia of chronic disease
  • Drugs e.g. chemotherapy agents
33
Q

Options for pre-op management of anaemia

A
  • Oral iron if >6 weeks until planned surgery
  • IV iron if <6 weeks until planned surgery
  • B12/folate replacement
  • Erythropoiesis‐stimulating agent (ESA) therapy
  • Transfusion if profound anaemia and surgery cannot be delayed
  • liase with GP/specialist to delay surgery
34
Q

Post-operative management of anaemia

A

Transfusion
IV iron
Oral iron

35
Q
A
36
Q
A

Year 3 Surgery block (66 decks)

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