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Surgery > Pre-op > Flashcards

Pre-op Flashcards

1
Q

How long before surgery should a patient have a pre-operative assessment?

A

2-4 weeks

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2
Q

What classification is used to assess a patient’s airway for potential difficulty in intubation?

A

Mallampati classification

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3
Q

A general structure of pre-operative history (during pre-op assessment)

A
  • HPC - why did the patient first attended ->what procedure is planned
  • PMH - general one, but ask particularly about: CVS, respiratory, endocrine, renal problems
  • Extra questions:
  • women in reproductive age -> pregnancy?
  • Afro-Caribbean origin -> sickle cell anaemia?

Past surgical history: any surgeries before?

  • Past anaesthetic history: have they head anaesthetics before -> any issues -> how they were during recovery -> nausea/vomiting?
  • Drug history: medication and allergies
  • Family History: any adverse reations in surgery? malignant hyperpyrexia/ hypertermia?
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4
Q

Why is it important, in pre-op assessment history to ask about:

  • cardiovascular disease
  • respiratory disease
  • renal disease
  • endocrine disease
A
  • cardiovascular disease (include HTN and exercise tolerance) -> as the risk of acute cardiac events is increased during anaesthesia
  • respiratory disease -> to plan adequate oxygenation and prevent ischaemic events in peri-operative period
  • renal disease:
  • surgical complications increased with renal disease-causing: biochemical imbalance, coagulopathy, anaemia
  • IV contrast or blood loss may worsen renal problems -> therefore careful planning is needed
  • endocrine disease (especially DM and thyroid problems) -> medication requires change in peri-operative period
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5
Q

What (2) examinations should be performed in pre-op assessment?

A
  • General examination -> looking at any obvious pathology in CVS, respiratory, abdominal signs
  • Airway assessment -> to predict difficulties with intubation

*area of procedure could be also examined

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6
Q

ASA grading - simple explanation of each score

A

ASA grade directly co-relates with a grade of post-op complications/ mortality

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7
Q

The choice of pre-op investigations depends on what? (4)

A
  • local guidelines
  • seriousness of procedure
  • age
  • co-morbidities
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8
Q

What blood tests could be done pre-op? And why? (5)

A
  • FBC -> to identify any potential anaemia and thrombocytopaenia -> this needs to be treated before surgery to minimise cardio-vascular compromise
  • U&Es -> to assess renal function; this will allow planning if iV fluids would be administrated
  • LFTs -> to assess liver metabolism and synthesis -> as may require to adjust dosing
  • Clotting screen -> any coagulation problems (e.g. haemophilia, warfarin use) would need to be corrected before the surgery
  • Group and Save (G&S) and crossmatch -> to prepare for blood loss and eventual transfusion
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9
Q

What’s the difference between G&S and crossmatch?

A

G&S -> to define patient’s ABO group and Rh status; it also screens the blood for atypical antibodies

(G&S is recommended if blood loss is not anticipated; done in case if the blood loss would be greater than expected)

Crossmatch -> patient and donor’s blood are physically mixed -> to see if any immune reaction takes place; if it does then the other blood is tried

(crossmatch is done if a blood loss is anticipated; G&S must be done first)

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10
Q

What imaging is often done in pre-op assessment? (4) Justify

A
  • ECG -> done in a person with underlying cardiac problems or if major surgery is planned

it allows to a) identify cardiac pathology b have a baseline picture so we can identify a new onset of post-op cardiac ischaemia)

  • ECHO -> it is considered if a) murmur is identified b) HF or its signs and symptoms c) signs and symptoms of cardiac disease
  • CXR -> it should not be done routinely, on everyone; do if:
  • systemic resp disease and no recent (last one was done >12 months ago) CXR
  • significant smoking history
  • recent travel to TB endemic area
  • new onset of cardio-respiratory signs
  • Spirometry -> if a patient has a chronic lung condition

done to assess baseline in case if post-op complications arise

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11
Q

What other tests are done pre-op? (4) justify

A
  • pregnancy test -> women in reproductive age
  • urinalysis -> not done pre-op routinely; only if evidence of UTI or glycosuria
  • sickle- cell anaemia -> do not do routinely, only if FHx or a person is African/Afro-Carrabiean origin
  • MRSA swab -> swabs from nostril + perineum + other sites -> if MRSA is identified, anti-septic body and hair-wash is given + topical ointment applied to the nostril

*it is given pre-op for elective surgery patients (even if the operation would be delayed)

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12
Q

Investigations for day-case patients

A
  • ECG – All patients >70yrs or a history of chest pain, hypertension, or a heart murmur
  • LFT’s – Any alcohol intake over the expected amount
  • U&E’s – All patients >60yrs, currently taking antihypertensives, history of DM or renal problems, or a urine sample >1+ protein
  • Sickle cell test – If Afro Caribbean (and not previously tested)
  • CXR – Any recent pneumonia, to discuss with anaesthetist
  • TFTs – Patients on thyroxine or having thyroid surgery
  • FBC – All patients >60yrs, or history of anaemia, any bleeding disorder, or sickle cell trait

For DM patients, perform a routine HbA1c; if >69mmol then disucss with anaesthetist regarding the need to defer the surgery

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13
Q

What about fluid intake in regards to NBM before most surgeries?

A

Clear fluids up to 2 hours before

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14
Q

Which medication should be stopped earliest before surgery?

A

Clopidogrel

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15
Q

How long before the surgery stop HRT/OCP?

A

4 weeks before

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16
Q

Contraindications to LMWH

A
  • endocrine, neck surgery
  • peptic ulcer disease
  • previous cerebral haemorrhage
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17
Q

What procedure requires phosphate enema in the morning before the operation?

A

Left hemicolectomy

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18
Q

What’s RAPRIOP?

A

It is a mnemonic for pre-op management of a patient

R - reasurrance

A - advice

P- prescription

R - referral

I - investigations

O- Obs

P - patient

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19
Q

Advice regarding fasting before surgery (A in RAPRIOP)

A
  • Stop eating – 6 hours before
  • Stop dairy products (including tea and coffee) – 6 hours before
  • Stop clear fluids – 2 hours before
20
Q

Why do we need to fast before surgery?

A

It is mainly to avoid pulmonary aspiration during peri-operative period

*may cause:

  • pneumonitis -> do to very acidic gastric content
  • aspiration pneumonia -> due to secondary infection following pneumonitis or aspiration of an infected material
21
Q

What are 3 categories of pre-operative drug regimes (in regards to P from RAPRIOP)

A

P - prescriptions

  • prescriptions to stop
  • prescriptions to alter
  • prescriptions to start

*some patient may require bowel preparation and blood productions

22
Q

What are (4) drugs to stop before surgery and when?

A

Memonic CHOW

C - clopidogrel -> stop 7 days before surgery (due to bleeding risk)

*Aspirin and other anticoagulants can be carried out - as minimal effect on surgical bleeding

H - hypoglycaemics -> complicated, another flashcard

O - OCP or HRT-> 4 weeks before surgery (due to DVT risk)

W - Warfarin -> stopped 5 days before the surgery and LMWH started instead

23
Q

What’s the INR target for a patient on Warfarin before surgery?

A

Need to be INR <1.5 an evening before the surgery

if INR is above the target then may need to supplement the patient with PO vitamin K

24
Q

What are drugs to alter before surgery (2)?

A
  • Subcutaneous insulin -> may switch to IV variable rate infusion
  • Long term steroids -> must continue (risk of Addisonian crisis if not) -> If the patient cannot take these orally, switch to IV
25
Q

Conversion rate of predniosolone (PO) to hydrocortisone (IV)

A

conversion rate is 5mg PO prednisolone = 20mg IV hydrocortisone

26
Q

What considerations should be done pre-op for a patient on long - term steroids?

A

Surgery -> metabolic insult and trauma -> activation of HPA -> production of corticosteroids

If a patient is on a long- term steroid therapy -> HPA may be suppressed = risk of acute adrenal failure

Management: give a peri-operative stress dose of corticosteroids

27
Q

(3) drugs that we need to prescribe pre - op

A
  • LMWH -> complete VTE risk assessment on admission, but most of the patient will receive it unless contraindications exist
  • TED stockings -> all patients receive below the knee TED stocking (but contraindicated in vascular surgery patients) *also contraindicated in other instances - on different flashcard
  • Prophylactic antibiotics -> for patients with orthopaedic, GI, vascular surgeries
28
Q

General (in simple terms) management of a patient with T1DM pre-surgically

  • considerations before surgery
  • NBM patient
  • post-op
A

Pt should be put in the morning, at the beginning of the list:

(means they may need to be admitted a night before)

A) Before surgery

  • reduce subcutaneous insulin a night before
  • omit morning insulin
  • commence IV variable insulin infusion pump

B) if a patient is NBM

  • give dextrose infusion and check BM every 2 hours

C) Post-op

  • continue until the patient is able to eat and drink
  • overlap IV infusion stopping with SC insulin regimen

-

29
Q

Pre-op management of pt with T2DM

  • if managed with diet only
  • if managed with oral hypoglycaemics
A

A) If T2DM patient is managed by diet and no med - nothing has to be done

B) Oral hypoglycaemics

  • Metformin -> stop on the morning before surgery
  • other hypoglycaemics -> stop 24 hours before the surgery

*insulin IV variable infusion rate is then started + 5% dexterose -> managed as T1DM patient

30
Q

(2) categories of surgeries that require bowel preparation + what to use

A
  • Left hemi-colectomy, sigmoid colectomy, or abdo-peroneal resection: Phosphate enema on the morning of surgery
  • Anterior resection: 2 sachets of picolax (laxative) the day before or phosphate enema on the morning of surgery
31
Q

What does R on (RAPRIOP) reffers to?

A

R - referral

  • consider if ITU or HDU bed will be needed
32
Q

What does last P on RAPRIOP refer to?

A
  • the patient should be fully informed and understand the plan for their care and discharge
  • major surgical patients -> need a follow up appointment in the clinic,
  • day-case surgery -> telephone follow-up from a nurse specialist only or may not require follow-up
33
Q

If a patient has an underlying valvular heart disease what do remember to do before the operation? (3)

A
  • stop Warfarin 3 days before op -> switch to IV Heparin
  • give antibiotic prophylaxis -> to prevent endocarditis
  • do ECHO -> to assess current valvular disease
34
Q

How long (if possible) to wait before the surgery after MI?

A

At least 6 months after MI

35
Q

How long an elective surgery should be deferred for after URTI or LRTI and why?

A

For at least 6 weeks -> this is due to an increased risk of respiratory complications (e.g. secondary infection) if surgery under GA

36
Q

What is pre-op advice for COPD patient? (3)

A
  • stop smoking at least 8 weeks before the surgery
  • optimise the condition with physiotherapy and exercise
  • be admitted a day before the surgery
37
Q

Pre-op considerations of DM person?

A
  • admission 2-3 days before surgery may be needed
  • should be placed first on the theatre list (to minimise risk of uncontrolled BM)
  • sliding scale should be used
38
Q

What’s insulin sliding scale? How to do it?

A

Sliding scale - progressive insulin dose pre-meal and nighttime

  • IV infusion of Actrapid (fast acting insulin) is given against the patient BM
  • mix with normal saline or 5% dextrose

*if patient’s BM is <15 mmol/l -> mix with dexterose

if >15 mmol/l -> mix with normal saline

39
Q

Minor surgery - what to advice for diabetes:

  • type 1
A

Minor surgery and Diabetes Type 1:

  • omit morning insulin dose + commence sliding scale
  • the sliding scale should be running up to the time when the patient is able to eat and drink + normal med regimen is resumed
40
Q

Minor surgery and diabetes mellitus type 2 (on tablets) if:

a) scheduled for morning list
b) scheduled for afternoon liest

A

A) morning list -> omit morning tablets + monitor BM

B) afternoon list -> patient can have a nomal med regime and early breakfast

Pt should be encouraged to eat and drink normally ASAP after the surgery

41
Q

Major surgery and type of diabetes - considerations:

a) Type 1
b) Type 2

A

A) type 1 -> pt should be admitted a day before the surgery and started on sliding scale

B) type 2 -> omit normal meds the night before; sliding scale on the day of the surgery

42
Q
A
43
Q

What peri- operative risks are increased in obesity?

A
  • peri-operative MI
  • arrhythmias
  • HF
  • DVT
  • PE
44
Q

Pt on Warfarin (not with the valvular disease) and pre-op considerations

A
  • admit a day before surgery (usually warfarin is stopped 3 days before)
  • switch to IV heparin infusion

* heparin infusion is stopped 4 hours before the surgery

*patients taking warfarin may be contraindicated for epidural

45
Q

When to stop Aspirin and Clopidogrel before the surgery?

A

stop 5 days before the surgery -> as they interfere with platelet function = risk of bleeding during or after the procedure

Surgery (18 decks)

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