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Year 3 - Met3a > Pre-admission Clinic and Pre-operative assessement > Flashcards

Pre-admission Clinic and Pre-operative assessement Flashcards

1
Q

Who comes to the pre-assessment clinic

A
  • people who are going to have elective surgery
  • patient who comes in from a ward
  • patient who comes in from an emergency
  • patient who was an outpatient
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2
Q

Categorise the 4 levels of operation

A
  • immediate
  • urgent
  • expedited
  • elective
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3
Q

What is an immediate operation

A
  • immediate lifesaving or limb or organ saving intervention
  • resuscitation simultaenous with surgical treatment
  • target time ot theatre is within minutes of decision to operate
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4
Q

What is an urgent operation

A
  • Acute onset or deterioration of conditions that threaten life, limb or organ survival
  • fixation of fractures
  • relief of distressing symptoms
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5
Q

What is an expedited operation

A
  • Stable patient requiring early intervention for a condition that is not an immediate threat to life limb or organ survival
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6
Q

What is an elective operation

A
  • Surgical procedure planned or booked in advance of routine admission to hospital
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7
Q

What is the definition of a pre-operative assessment

A
  • pre-operative assessment establishes that the patient is fully informed and wishes to undergo the procedure
  • it ensures that the patient is as fit as possible for the surgery and anaesthetic
  • it minimises the risk of late cancellations by ensuring that all essential resources and discharge requirements are identified and coordinated in advance
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8
Q

Why do we do a pre-operative assessement

A
  • Reduces morbidity & mortality
  • Reduces cancellation on the day
  • Reduces total bed days
  • Helps identify patients at risk and gives an opportunity to address those risks (e.g. plan post-op ITU care)
  • Gives a chance to optimise patients if possible
  • Helps to avoids predictable complications
  • Facilitates same day admissions for surgery
  • Allows timely MRSA screening
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9
Q

What is the rule of 6 Ps

A

Prior preparation prevents pathetically poor performance

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10
Q

How does the pre-assessement clinic work

A
  • Specially trained nursing staff
  • Assisted by HCA’s and administration staff
  • May have input from senior or junior surgical/anaesthesia doctors
  • Overseen by consultant anaesthetists
  • Access to phlebotomy, ECG and radiology services (empowered to order Inx) • Some units may have specialist equipment (e.g CPET)
  • Gold standard: ‘One Stop Service’
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11
Q

What is done in pre assessment

A
  • History
  • Examination
  • Order appropriate tests
  • Optimise patients
  • Identify risk
  • Determine level of post-op care (day case, overnight, ITU)
  • Fully inform patients; e.g. NBM
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12
Q

What is taken in a history in pre assessment

A

• PMHx of: MI, diabetes, HTN, rheumatic fever, epilepsy, jaundice

  • existing illnesses - drugs and allergies
  • be alert to chronic lung diseases, high BP, arrhythmias, and murmurs
  • assess any specific risks e.g. is this patient pregnant
  • is the neck/jae immobile and teeth stable
  • has there been any previous anaesthesia - if so were there any complications such as nausea and DVT
  • family history may be relevant - e.g. in malignant hyperpyrexia, dystrophia myotonic, porphyria, cholinesterase problems and sickle cell disease
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13
Q

What happens in an examination in pre assessment

A
  • ABCDE
  • assess cardiorespiratory system, exercise tolerance
  • is the neck stable for intubation e.g. in arthritis it might not be
  • is VTE prophylaxis needed
  • for unilateral surgery mark the correct arm/leg/kidney
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14
Q

What should you do before administering anaesthetics

A
  1. Determine the patient’s comorbidities – i.e. ASA Grade
  2. Determine the grade of surgery – 1 to 4 (minor to major+)
  3. Follow national or local guidelines, +/- individual advice
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15
Q

What does an ASA grade stand for and what is it used for

A

American Society of Anaesthesiologists’ (ASA) classification of Physical Health is a widely used grading system for preoperative health of the surgical patients,

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16
Q

What are the grades for ASA

A
  • grade 1
  • grade 2
  • grade 3
  • grade 4
  • suffix E
  • ASA 5
  • ASA 6
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17
Q

Describe the ASA grades

A
  • grade 1 = normal health patient - wihtout any clinically important comorbidity and without clinically significant past/present medicial history
  • grade 2 = a patient with mild systemic disease (any alcohol consumption puts you here)
  • grade 3 = a patient with severe systemic disease
  • grade 4 = a patient with severe systemic disease that is a constant threat to life
  • suffix E = Emergency
  • ASA 5 = moribund patient not expected to survive the next 24 hours
  • ASA 6 = brain dead
18
Q

Name the surgery grades

A
  • Grade 1 = minor
  • Grade 2 = intermediate
  • Grade 3 = major
  • Grade 4 = major +
19
Q

give examples of surgery grades

A

Grade 1 = minor
- excision of lesion of skin;drainage of breast abscess

Grade 2 = intermediate
- primary repair of inguinal hernia, excision of varicose veins of leg, tonsillectomy, adenotonsillectomy, knee arthroscopy

Grade 3 = major
- total abdominal hysterectomy; endoscopic resection of prostate, lumbar disectomy, thyroidectomy

Grade 4 = major +
- total joint replacement, lung operations, colonic resection, radical neck dissection

20
Q

How do the NICE guidelines work

A
  • need the ASA grades
  • tests running down the side
  • marks them not routine, consider, and yes
21
Q

Do not routinely offer an

A

Do not routinely offer resting echocardiography before surgery. Consider resting echocardiography if the person has:
- a heart murmur and any cardiac symptom (including breathlessness, pre-syncope, syncope or chest pain) or signs or symptoms of heart failure.

Before ordering the resting echocardiogram, carry out a resting electrocardiogram (ECG) and discuss the findings with an anaesthetist.

22
Q

In which case should you offer an echo before surgery

A
  • a heart murmur and any cardiac symptom (including breathlessness, pre-syncope, syncope or chest pain) or signs or symptoms of heart failure
23
Q

What do you need to inform the patient before surgery

A
  • NBM(nil by mouth) (6 hours food, 4 hours breast milk, 2 hours clear fluids)
  • Stopping anticoagulants (warfarin / anti platelets)
  • Smoking cessation and chewing gum (opinions vary so seek opinions)
  • Check consent, understanding and provide a date if possible
24
Q

How do you calculate risk

A

P-POSSUM

- use physiological parameters and operative parameters

25
Q

What does the P Possum scale provide

A

Provides an indication of morbdity and mortality risk

26
Q

For major surgery you always need a

A

FBC - for every ASA grade

27
Q

How do you pre assess an emergency patient

A
  • Take a full history and examine the patient thoroughly
  • look for undiagnosed co-morbidities and uncontrolled co-morbidities
  • Investigations:usually full set of bloods (and ECG if age>60 or cardio- respiratory disease) as minimum, further tests if time allows.
  • Risk score
  • May need to seek advice from physicians (cardiology, geriatrics etc)
  • Discuss with ananaesthetist early
  • Informed consent
  • Plan post-operative care
28
Q

What investigations do you carry out in a pre-operative assessment

A
  • FBC, U&Es, finger prick blood glucose
  • cross match and group & save - blood type
  • specific blood tests
  • CXR
  • ECG - if older than 55 years or poor exercise tolerance or history of heart disease
  • Echo - if suspicion of poor LV function
  • pulmonary function tests - if known pulmonary disease/obesity
  • lateral cervical spine X-ray - if history of RA, ankylosing spondylitis, Down syndrome
  • MRSA screen
29
Q

what specific blood tests might you carry out in a pre operative assessment

A
  • LFT in jaundice, malignancy or alcohol abuse
  • Amylase in acute abdominal pain
  • Blood glucose if diabetic
  • Drug levels as appropriate
  • Clotting studies if liver or renal disease, DIC, massive blood loss or if on valproate, warfarin, heparin
  • HIV, HBsAg in high-risk patients after counselling
  • Sickle test in those from Africa, West Indies or Mediterranean
  • TFT in those with thyroid disease
30
Q

What are the aims of pre-operative assessment

A
  1. To provide diagnostic and prognostic information
  2. to ensure patient understands the nature, aims and expected outcome of the surgery
  3. to allay anxiety and pain
31
Q

if you are on anticoagulation what should you avoid pre surgery

A
  • avoid epidural, spinal and regional block
32
Q

Do you stop taking warfarin before surgery

A

Minor surgery – can be undertaken without stopping (if INR<3.5 it may be safe to proceed)

Major surgery – stop for 3-5d pre-op; vitK ± FFP or Beriplex® may be needed for emergency reversal of INR; one elective option is conversion to heparin (when re-warfarinizing give LMWH until INR is therapeutic as warfarin is initially prothrombotic)

33
Q

Do you stop taking warfarin before surgery

A

– decision to stop based upon patient’s risk of VTE and bleeding risk associated with procedure

  • No clinically important bleeding risk – can be performed just become next DOAC dose or 18-24h after last dose, and dosing restarted 6h post-op
  • Low bleeding risk procedure – omit DOAC 24h pre-op
  • High bleeding risk procedure – omit DOAC 48h pre-op
34
Q

can aspirin be continued in surgery

A
  • Aspirin can usually be continued
35
Q

What happens to anticonvulsants before surgery

A
  • given as usual pre-op

- post op give drugs IV until able to take orally

36
Q

how are beta blockers given before surgery

A
  • continue up to and including on the day of surgery as this precludes a labile cardiovascular response
37
Q

What happens to the contraceptive pill before surgery

A
  • Stop 4 weeks before major/leg surgery
  • ensure alternative contraception is used
  • restart 2 weeks after surgery
38
Q

should you continue digoxin before surgery

A
  • continue up to and including the morning of surgery
  • check for toxicity - ECG and plasma level
  • do potassium and calcium
39
Q

What preparation should take place before surgery

A
  • starve patient: NBM >2 hours pre-op for clear fluids and >6 hours for solids
  • is any bowel or skin preparation needed, or prophylactic antibiotics
  • Start VTE prophylaxsis - graduated compression stockings, LMWH
  • ensure necessary pre-medications, regular medications, analgesia, anti-emetics, antibiotics are all prescribed
  • book any pre, intra, or post-operative X-rays or frozen sections
  • book post op physio
  • if needed - site IV cannula, catheterise and insert a Ryle’s tube
40
Q

What dose of LMWH is given before surgery

A
  • Moderate risk: 20mg - 2 hour pre-op then 20mg/24 hr
  • high risk(e.g. orthopaedic surgery) - 40mg pre op then 40mg/24hr
  • heparin 5000U SC 2hr pre-op then every 8-12hr SC for 7d or until ambulant

Year 3 - Met3a (43 decks)

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