Pre-admission Clinic and Pre-operative assessement Flashcards
Who comes to the pre-assessment clinic
- 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
Categorise the 4 levels of operation
- immediate
- urgent
- expedited
- elective
What is an immediate operation
- immediate lifesaving or limb or organ saving intervention
- resuscitation simultaenous with surgical treatment
- target time ot theatre is within minutes of decision to operate
What is an urgent operation
- Acute onset or deterioration of conditions that threaten life, limb or organ survival
- fixation of fractures
- relief of distressing symptoms
What is an expedited operation
- Stable patient requiring early intervention for a condition that is not an immediate threat to life limb or organ survival
What is an elective operation
- Surgical procedure planned or booked in advance of routine admission to hospital
What is the definition of a pre-operative assessment
- 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
Why do we do a pre-operative assessement
- 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
What is the rule of 6 Ps
Prior preparation prevents pathetically poor performance
How does the pre-assessement clinic work
- 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’
What is done in pre assessment
- 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
What is taken in a history in pre assessment
• 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
What happens in an examination in pre assessment
- 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
What should you do before administering anaesthetics
- Determine the patient’s comorbidities – i.e. ASA Grade
- Determine the grade of surgery – 1 to 4 (minor to major+)
- Follow national or local guidelines, +/- individual advice
What does an ASA grade stand for and what is it used for
American Society of Anaesthesiologists’ (ASA) classification of Physical Health is a widely used grading system for preoperative health of the surgical patients,
What are the grades for ASA
- grade 1
- grade 2
- grade 3
- grade 4
- suffix E
- ASA 5
- ASA 6
Describe the ASA grades
- 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
Name the surgery grades
- Grade 1 = minor
- Grade 2 = intermediate
- Grade 3 = major
- Grade 4 = major +
give examples of surgery grades
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
How do the NICE guidelines work
- need the ASA grades
- tests running down the side
- marks them not routine, consider, and yes
Do not routinely offer an
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.
In which case should you offer an echo before surgery
- a heart murmur and any cardiac symptom (including breathlessness, pre-syncope, syncope or chest pain) or signs or symptoms of heart failure
What do you need to inform the patient before surgery
- 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
How do you calculate risk
P-POSSUM
- use physiological parameters and operative parameters
What does the P Possum scale provide
Provides an indication of morbdity and mortality risk
For major surgery you always need a
FBC - for every ASA grade
How do you pre assess an emergency patient
- 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
What investigations do you carry out in a pre-operative assessment
- 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
what specific blood tests might you carry out in a pre operative assessment
- 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
What are the aims of pre-operative assessment
- To provide diagnostic and prognostic information
- to ensure patient understands the nature, aims and expected outcome of the surgery
- to allay anxiety and pain
if you are on anticoagulation what should you avoid pre surgery
- avoid epidural, spinal and regional block
Do you stop taking warfarin before surgery
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)
Do you stop taking warfarin before surgery
– 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
can aspirin be continued in surgery
- Aspirin can usually be continued
What happens to anticonvulsants before surgery
- given as usual pre-op
- post op give drugs IV until able to take orally
how are beta blockers given before surgery
- continue up to and including on the day of surgery as this precludes a labile cardiovascular response
What happens to the contraceptive pill before surgery
- Stop 4 weeks before major/leg surgery
- ensure alternative contraception is used
- restart 2 weeks after surgery
should you continue digoxin before surgery
- continue up to and including the morning of surgery
- check for toxicity - ECG and plasma level
- do potassium and calcium
What preparation should take place before surgery
- 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
What dose of LMWH is given before surgery
- 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
