Peri-operative Care Flashcards
Define pre-operative assessment
Establishes patient is fully informed and wishes to undergo procedure
Ensure patient is fit as possible for surgery and anesthetic
Minimises risk of late cancellations by ensuring resources and discharge requirements identified and co-ordinated
Why do we do pre-operative assessment
Reduces morbidity and mortality
Reduces day cancellations
Reduces total bed days
Helps identify at risk patients and gives an opportunity to address those risks
Gives a chance to optimise patients if possible
Helps to avoid predictable complications
Facilitates same day admissions for surgery
Allows timely MRSA screening
Enhances patient safety
Improves outcomes
Complies with 6 P’s = Prior, prep, prevention, pathetically, poor, performance
How does pre-assessment clinic work?
- specially trained nursing staff
- assessed by HCA’s and admin staff
- input from senior/junior surgical/anesthesia doctors
- overseen by consultant anesthetists
- access to phlebotomy, ECG, radiology
- specialist equipment
- one stop service
What happens?
History
Exam
Order tests
Optomise patients
Identify risk
Determine level of post care they need - day case, ITU, overnight
Fully inform patients - e.g. nil by mouth
Hx
PMH Resp CV Exercise tolerance Drugs and allergies Previous general anaesthetic experience
Exam
Airway - difficult? Breathing Circulation - BP, ECG, HR Disability/Drugs and allergies/Social Hx/ Alcohol Exercise tolerance
What tests?
- depends on patient’s co-morbidity (ASA Grade)
- determine grade of surgery (1-4 minor to major+)
- follow national/local guidelines
ASA Grade
To determine patient’s co-morbidities
1 = normal healthy patient
2 = mild systemic disease
3 = severe systemic disease
4 = severe systemic disease which is a constant threat to life
Suffix E added to any grade if emergency case
5 = moribund patient not expected to survive next 24 hours
6 = brain dead
Surgery Grade
1 = minor, excision of lesion of skin, drainage of breast abscess 2 = intermediate, inguinal hernia repair, varicose vein excision, tonsillectomy, knee arthroscopy 3 = major, total abdominal hysterectomy, endoscopic resection of prostate, thyroidectomy 4 = major+, total joint replacement, lung operation, colonic resection, radical neck dissection
NICE Guidelines for routine preoperative tests for elective surgery
Traffic Light System
ASA Grade required
ASA1 = FBC only if major/complex surgery for example
Minor Surgery NICE NG45 Tests Guidelines
Consider ECG and Kidney function for ASA3 or 4 for people at risk of AKI or if no ECG results available for past 12 months
Major Surgery NICE NG45 Test Guidelines
FBC for all patients
Haemostasis consider if ASA3/4 and chronic liver disease/on anticoagnulants/ if clotting status needs to be tested
Kidney function for ASA2,3,4, only for ASA1 if risk of AKI
ECG for ASA2,3,4, only for 1 if none in past 12 months and over 65
Lung function/ABG only if ASA3,4 consider if suspected resp disease
Echocardiogram Guidelines for tests
Consider only if
- heart murmur and cardiac symptoms
OR
- signs/symp of HF
- carry out resting ECG before ordering Echo and discuss findings with anaesthetist
What do you need to inform the patient about?
- nil by mouth
- stopping anitcoagulants = warfarin, antiplatelts
- smoking cessation & chewing gum count as food?
- check consent and provide a date for the operation
How long do patients have to be nil by mouth for?
6 hours for food
4 hours for breast milk
2 hours for clear fluids
