Perioperative Medicine Introduction Flashcards
Perioperative medicine - what is it?
“Medical side of surgery”
The pre-operative assessment is an opportunity to identify co-morbidities that may lead to patient complications during the anaesthetic, surgical, or post-operative period. Patients scheduled for elective procedures will generally attend a pre-operative assessment …-… weeks before the date of their surgery.
The pre-operative assessment is an opportunity to identify co-morbidities that may lead to patient complications during the anaesthetic, surgical, or post-operative period. Patients scheduled for elective procedures will generally attend a pre-operative assessment 2-4 weeks before the date of their surgery.
What is the basic structure of a periop pathway?
Pre-op
Intra-op
Post-op
Perioperative pathways (3 pathways)
Elective
Urgent
Emergency
What happens before an emergency op?
Presentation Assessment Investigations Decision Booking Anaesthetists assessment Theatre
Group and Save (G&S) and Cross-Match (X-match) are two tests that are slightly different in their aims:
A G&S determines the patient’s blood group (ABO and RhD) and screens the blood for any atypical antibodies; the process takes around 40 minutes and no blood is issued
A G&S is recommended if blood loss is not anticipated, but blood may be required should there be greater blood loss than expected
A cross-match involves physically mixing the patient’s blood with the donor’s blood, in order to see if any immune reaction takes places; if it does not, the donor blood is issued and can be transfused in to the patient, otherwise alternative blood is trialled
This process also takes ~40 minutes (in addition to the 40 minutes required to G&S the blood, which must be done first), and should be done pre-emptively if blood loss is anticipated
What is a CEPOD list?
Dedicated theatre lists for emergencies during normal working hours were introduced into UK hospitals in the early 1990s as a result of recommendations of the National Confidential Enquiries into Perioperative Deaths (NCEPOD). These lists are commonly known as CEPOD lists.
Key points for urgent surgery
Booked directly with theatres
Emergency list available 24/7
Urgency has to be assessed to confirm order of operating with the CEPOD criteria
There is limited theatre space - robust assessment of urgency and good communication between teams is needed
Surgical teams usually more involved in emergency work up than in elective cases
Pre-op investigations
Communication Blood tests (FBC, U+Es, LFTs, HbA1C/TFTs, clothing, G+S+/-Cross match) Pregnancy tests Sickle cell disease or trait tests Urine tests CXR Echocardiography
Cardiac Investigations pre-op
An ECG is often performed in individuals with a history of cardiovascular disease or for those undergoing major surgery. It can indicate any underlying cardiac pathology and provide a baseline for comparison if there are post-operative concerns for cardiac ischaemia.
An echocardiogram (ECHO) provides very useful information for the anaesthetist as it helps to risk stratify and tailor the intra-operative care of the patient. It may be considered if the person has (1) a heart murmur (2) ECG changes (3) signs or symptoms of heart failure.
For patients with untreated ischaemic heart disease, or symptoms of angina, myocardial perfusion scans are often performed to look for inducible ischaemia.
Respiratory Investigations for pre-op
If a patient has a chronic lung condition e.g. COPD, spirometry may be of use in assessing current baseline and predicting post-operative pulmonary complications in these patients. Patients may also be referred for spirometry if there are symptoms and signs of undiagnosed pulmonary disease.
Plain film chest radiographs (CXR) are less commonly performed routinely pre-operatively and should be used only when necessary
When is a urinalysis indicated pre-op?
Especially for urological procedures, a urinalysis must be performed to assess if there is any evidence or suspicion of ongoing urinary tract infection
Do all patients have an MRSA swab pre-op?
All patients will have swabs taken from the nostril and perineum for MRSA colonisation. If this is isolated, decontamination hair and body wash, along with topical ointment applied to the nostrils, will be given.
Cardiopulmonary Exercise Testing pre-op - when is this indicated?
Cardiopulmonary Exercise Testing
High-risk patients undergoing major surgery may be referred for cardiopulmonary exercise testing (CPET). This usually involves a 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, which can be used to risk-stratify patients for post-operative complications and need for higher level care environments
On all anaesthetic charts, a patient will be given an … grade after their pre-operative assessment, which has been subjectively assessed and based on the criteria below. A patient’s …. grade directly correlates with their risk of post-operative complications and absolute mortality.
On all anaesthetic charts, a patient will be given an American Society of Anaesthesiologists (ASA) grade after their pre-operative assessment, which has been subjectively assessed and based on the criteria below. A patient’s ASA grade directly correlates with their risk of post-operative complications and absolute mortality.
Recommendations for specific surgery and ASA grades:
ASA 1 ASA 2 ASA 3 ASA 4 - define each
I - A normal healthy patient
2 - A patient with mild systemic disease
3 - A patient with severe systemic disease
4 - A patient with severe systemic disease that is a constant threat to life
Post operative nausea & vomiting - how is this managed?
This is a relatively common side effect of general anaesthesia. It is important to ask about this and if the patient is concerned, to reassure them that there are specific steps that can be taken to reduce the chance of it happening. These steps include using regional anaesthesia where possible, use of more than one antiemetic and use of TIVA (total intravenous anaesthesia).
Difficult airway pre-op - how is this managed?
It is important to ask patients about this and also review old anaesthetic charts to see if airway management has been an issue and if so what approach worked and what didn’t. Patients who have difficult airways may have an alert in the notes and also carry around a card to give to healthcare professionals.
Mallampati score: This is arguably the most recognized and most performed test for preoperative airway assessment.
… score: This is arguably the most recognized and most performed test for preoperative airway assessment.
Mallampati score: This is arguably the most recognized and most performed test for preoperative airway assessment.
Pre-op assessment for elective patient pathway
Nurse led proforma
Aimed at identifying any co-existing medical problems
Routine investigations, dependent on the type of surgery planned
Screening
Discussion about peri-op period - Starvation guidelines (Food 6 hours, drink 2 hours), anaesthetic, DVT/PE prevention
Elective patient pathway - day case vs inpatient
Day cases usually within 24 hours
Inpatient cases - may stay if bleeding, pain, high risk
AAGBI - what are these guidelines?
Association of Anaesthetists of Great Britain and Ireland
Patient needs to meet criteria for discharge…
Pain and nausea under control
Maintaining oral intake
Mobilising
Discharge summary completed
Malignant hyperthermia - what is this?
Malignant hyperthermia is a severe reaction to certain drugs used for anesthesia. This severe reaction typically includes a dangerously high body temperature, rigid muscles or spasms, a rapid heart rate, and other symptoms. Without prompt treatment, the complications caused by malignant hyperthermia can be fatal.
Suxamethomium apnoea - What is it?
Suxamethonium (succinylcholine) is a drug used in anaesthesia to produce relaxation of the muscles (paralysis). It is normally broken down very rapidly in the body by a substance
in the blood, an enzyme called plasma cholinesterase. The effects of suxamethonium normally wear off within a few minutes.
SA occurs when there are abnormalities in this enzyme and the body has difficulties in breaking down this drug. This means the muscles will stay relaxed (paralysed) for longer than expected
It is important to ask about family history of any adverse reactions to anaesthesia particularly for patients who have not had anaesthetics in the past. Patients should be asked about a family history of … apnoea or malignant ….
It is important to ask about family history of any adverse reactions to anaesthesia particularly for patients who have not had anaesthetics in the past. Patients should be asked about a family history of suxamethonium apnoea or malignant hyperthermia.
Gastrointestinal system pre-op. What is important to ask about?
Gastro-oesophageal reflux disease: This is important in regards to airway management. It is important to find out if it is well controlled or not by asking how often this affects the patient, what triggers it (e.g. certain foods or lying flat), whether does acidic fluid or food actually come up into the mouth and how bad has it been recently. Patients may be on a proton pump inhibitor or H2 receptor antagonists, if they are, make sure they have had their regular dose.
Bowel obstruction: Patients with bowel obstruction should have an NG tube placed and fully aspirated prior to induction of general anaesthesia.
What GI condition is really important in regards to airway management?
Gastro-oesophageal reflux disease: This is important in regards to airway management. It is important to find out if it is well controlled or not by asking how often this affects the patient, what triggers it (e.g. certain foods or lying flat), whether does acidic fluid or food actually come up into the mouth and how bad has it been recently. Patients may be on a proton pump inhibitor or H2 receptor antagonists, if they are, make sure they have had their regular dose.
Patients with … obstruction should have an NG tube placed and fully aspirated prior to induction of general anaesthesia.
Patients with bowel obstruction should have an NG tube placed and fully aspirated prior to induction of general anaesthesia.
In women of childbearing age - what do we ask pre-operatively? (2)
If of childbearing age ask if they could be pregnant (informed consent is required for pregnancy tests). Ask if they are on any hormonal therapies which has increased associated DVT/PE risk (e.g. combined oral contraceptive pill, HRT).
