Pre op assessm and mx

Question 1

Aims

Answer 1

Confirm and explain procedure
Improve risk facs
Anticip probs and get right facils
Informed consent
Optimise prep- prophylaxis and pre med
Dr pt rel

Question 2

Process

Answer 2

Hx incl anaes hx
Exam- heart, lung, mouth, airway. Gen eg anaem, cyanosis, clubbing, jaund, oedema, LNs.
Ix
Pre op prep- drugs. premed eg anxiolytics, Na citrate reduce asp. Fluids. Bloods. Starvat 6hr particulates, 2hr clear fluid. DVT prophylxais. GS and x match. Book bed.

Question 3

Airway

Answer 3

Appearance neck, face, maxilla, mandib
Mallampati score- amnt soft palate and uvula you can see
Jaw movem
Head ext, flex
Teeth and OP
Neck soft tiss eg radio, surg to oes larynx VC
Recent chest and C spine XR
Alt- fibre optic intubation, can be awake

Question 4

ASA

Answer 4

1- norm
2- mild sys dis, func norm
3- mod/sev sys dis, reduc func
4- sev sys dis, v reduc func, const threat to life
5- moribund, will die in 24hr if no surg
E- emergency

Question 5

Ix

Answer 5

Urine
ECG
FBC, UE, Cr, coag
Sickle
Preg
CXR
Glucose

Question 6

NBM

Answer 6

Stop eating 6hr
Dairy products 6 hours
Clear fluid 2hr

Question 7

CHOW drugs to stop

Answer 7

Clopidogrel- 7d. Asp and dipyridamole can contin.
Hypoglycaemics
OCP and HRT- 4wk
Warfarin- 5d. May have bridging LMWH. INR need to be under 1.5. 1-5mg PO K may be req.

Question 8

drugs to alter

Answer 8

Subcutaneous insulin- can switch to IV variable infusion.

LT steroids- must contin as risk addissonian crisis if stop. Switch to IV if req.

Question 9

drugs to start

Answer 9

LMWH- VTE ass. Most pts get dalteparin unless CI, neck or endoc surg. Major GI CA or jnt repl ops req TEDS on disch and 28d LMWH.
TEDs- below knee teds for all except vascular surg and CIs. CI eg sev OVD, periph neurop, recent skin graft, sev eczema.
AB- for ortho, vasc and GI surg.

Question 10

DM periop mx

Answer 10

T1- reduce SC insulin night before, omit SC morning of and start IV variable infus (syringe driver 49.5ml saline with 50U actrapid)- sliding scale. While NBM give 5% dextrose 125ml/hr, check bm ev 2hr. Once can eat and drink then start to overlap IV with their old SC regimen.
T2- stop metformin the morning of, stop others 24 hr before. Put on IV variable infus with 5% dextrose.

Question 11

Bowel prep

Laxtative or enema

Answer 11

Rare used if renal or cardiac dis, or eld/immobile.
Phosphate enema morning of for- L hemi, sigm colectomy, APR
Picolax the day before or phosphate enema in morn of for- ant resec.

Question 12

high bleed risk, get blood ready

Answer 12

GI
HPB
Vascular
Gynae
Ortho

Question 13

AB prophylaxis

2hr pre op if req

Answer 13

Metronidazole plus Cephalosporins eg cefuroxime is a common regime.
Also gent plus metronidazole can be used.
Co amox
None given for lap w/o mucosa breach, hernia, standard lap chole
Lap chole high risk, biliary, UGI- co amox. Or cefuroxime or gent if CI.
Appendicectomy- co amox. Or cef plus metronidazole, or gent plus metron.
Vasc surg- co amox. Or cef plus metron.
High risk MRA- add gent to any of above.