Pre-Assessment Flashcards
What’s the point in a pre-op assessment?
- An opporunity toidentify co-morbidities that may lead to patient complcations during the anaethetic, surgical or post op period.
When do people get there pr-op assessment?
2-4 weeks
What is ECOG stage 0?
Fully active, able to carry on all pre-disease performance without restriction
What is ECOG grade 1?
Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work
What is ECOG grade 2?
Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours
What is ECOG grade 3?
Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours
What is ECOG grade 4?
Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair
What is ECOG grade 5?
Death
What is ASA score of 1?
Normal, healthy individual
What is an ASA score of 2?
Mild systemic disease - Mild diseases only without substantive functional limitations. Examples include (but not limited to): current smoker, social alcohol drinker, pregnancy, obesity (30 < BMI < 40), well-controlled DM/HTN, mild lung disease
What is an ASA score of 3?
Severe systemic disease - Substantive functional limitations; One or more moderate to severe diseases. Examples include (but not limited to): poorly controlled DM or HTN, COPD, morbid obesity (BMI ≥40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, ESRD undergoing regularly scheduled dialysis, premature infant PCA < 60 weeks, history (>3 months) of MI, CVA, TIA, or CAD/stents.
What is ASA score of 4?
A patient with severe systemic disease that is a constant threat to life - Examples include (but not limited to): recent ( < 3 months) MI, CVA, TIA, or CAD/stents, ongoing cardiac ischemia or severe valve dysfunction, severe reduction of ejection fraction, sepsis, DIC, ARD or ESRD not undergoing regularly scheduled dialysis
What is an ASA score of 5?
A moribund patient who is not expected to survive without the operation - Examples include (but not limited to): ruptured abdominal/thoracic aneurysm, massive trauma, intracranial bleed with mass effect, ischemic bowel in the face of significant cardiac pathology or multiple organ/system dysfunction
What is an ASA score of 6?
A declared brain-dead patient whose organs are being removed for donor purposes
What cardiovascular problems may you want to ask about in the pre-operative assessment?
- IHD
- HF
- HTN
- Valvular disease
- Conduciton defects
- Arrythmias
- PVD/DVT
What are the main surgical grades used to determine the appropriate tests to do pre-operatively?
- Minor
- Intermediate
- Major
- Major plus surgery
What respiratory conditions would you want to screen for in pre-operative assessment?
- COPD
- Asthma
- Infection
- Restrictive lung disease
What criteria need to be met for patients to deemed low risk for surgery?
- No coexisting medical problems
- Have coeisting medical problem that is well controlled and does not impair daily activity
- Do not require/require only baseline investigations
- Have no Hx of anaesthetic difficulties
- Require surgery with minimal complicaiton risk
How would you assess exercise tolerance in pre-op assessment?
- Could you run for a bus?
- How far uphill can you walk?
- How far can you walk on flat?
- Are you able to do shopping?
- How many stairs?
- Able to do housework/take care of yourself?
What other considerations (besides CVS, Resp and exercise tolerance) might you want to investigate/ask about in the pre-op assessment?
- Indegestion/Reflux
- RA
- DM
- Neuromuscular disorders
- Chronic renal failure
- Jaundice - liver dysfunciton
When would you consider doing U+E’s in a patient as part of pre-op assessment?
- Taking drugs - digoxin, diuretics, steroids
- Diabetes
- Renal disease
- Vomiting
- Diarrhoea
When would you consider doing LFT’s in someone for pre-op assessment?
- Hepatic disease
- High alcohol intake
- Metastatic disease
- Evidence of malnutrition
When would you consider doing blood sugars in someone as part of pre-op assessment?
- Diabetes
- Severe PVD
- Long term steroids
When would you consider doing an ECG in someone as part of their pre-op assessment?
- Hypertensive
- IHD
- Cardiac arrythmia
- Diabetes > 40 years old
When would you consider a CXR as part of your pre-op assessment?
- Cardiac/respiratory disease
- Known/suspected malignancy
- Thoracic surgery planned
- Suspected TB
When would you consider doing pulmonary function tests in somoene as part of a pre-operative assessment?
- Symptoms of dyspnoa on mild exertion
- COPD
- Asthma
If a patient was found an pulmonary function tests to be dyspnoeic or cyanosed at rest, or FEV1 < 60%, what additional investigation would you consider?
Arterial blood gas while breathing AIR
When might you consider a coagulation screen in someone for pre-op assessment?
- Anticoagulant therapy
- History of bleeding diathesis
- History of liver disease/jaundice
When might you consider doing a C-spine x-ray in someone as part of their pre-op assessment?
- RA
- Major trauma/surgery to the neck
- Difficult intubation is predicted
What systems would you want to assess pre-operatively in a diabetic patient?
- CVS - HTN, IHD, CVD, MI
- Renal - Kidney disease
- Resp - prone to infections
- Airway - thicking of soft tissues
- GI - delayed gastric empting = prone to reflux
What pre-operative investigations would you consider doing in a diabetic patient?
- Examination - any signs of complications
- HbA1c - 20-48 mmol/mol
- U+E’s
- Blood sugar
- ECG
- CXR
How would you manage a diabetic patient in the pre-operative setting?
- Individualize diabetes management
- Place patient first on list
- Avoid overnight admission if possible
-
If Planned short starvation/miss meal - variable-rate IV insulin infusion
- Try to avoid short starvation
What investigaitons should you consider as part of your pre-operative assessment of someone with asthma?
- How well it is managed
- Document allergies/triggers
- Therapy being used
- PEFR
- Spirometry
- ABG -severe asthma
- ECG
- CXR
What investigations might you consider doing in somoene with COPD as part of your pre-op assessment?
- Spirometry
- ABG - moderate to severe COPD
- ECG
- CXR
How would you optimise COPD patient before surgery?
- Stop smoking - at least 8 weeks before is optimal
- Adjust LAMA/SAMA/LABA/SABA therapy
- Preoperative chest physio
- Pulmonary rehab
How would you evaluate a hypertensive patient pre-operatively?
- Assess whether primary of secondary
- Assess severity
- Asses end-organ involvement
How would you manage hypertension pre-operatively?
- Optimise hypertensive treatment
- Consider deferal of surgery if severe
How would you evaluate somoene with heart failure in pre-op assessment?
- History and examination
- Optimise treatment - symptomatic arrythmias, diuretics etc.
- Consider appropriate investigaitons
What investigations would you consider doing in someone with HF as part of you pre-op assessment?
- Bloods - FBC, U+E’s, LFTs, TFTs, Fasting lipids, glucose
- ECG
- CXR
- TTE - grade impairment
- Consider Cardiac catheterisaiton
What investigations would you consider doing in someone with IHD as part of your pre-operative assessment?
- Grading as per METS criteria
- ECG
- ETT
- MRI perfusion scan
How would you assess/grade exercise tolerance?
What is used to meausure to measure risk of major perioperative cardiav event? List the components
Cardiac risk index
- High risk surgery
- History IHD
- History CCF
- Histor cerebrovascular disease
- DM
- Serum creatinine >180 mEq/l
Whats the 2-4-6 rule?
- 2 hours clear fluids/tea/coffee
- 4 hours breast milk
- 6 hours food
