Pre-Op Assessment Flashcards
What types of trauma does surgery have in the body?
- Stress response
- Fluid shifts
- Blood loss
- CVS, Resp, renal and metabolic stress
What is general anbaesthesia?
Definition
Drug induced revesible coma that causes depression of the CNS, cardiac and resp systems
What is regional anaesthesia?
Definition
Use of local anesthetics to block sensations of pain from a large area of the body, such as an arm or leg or the abdomen
Causes profound sympathectomy and neurologocial sequale
e.g. spinal anaesthetic, epidural
What is a sympathectomy?
Definition
**Sympathectomy **
A type of minimally-invasive procedure (small incisions of 2–3 inches long, done under general anesthesia) which involves cauterizing (cutting and sealing) a portion of the sympathetic nerve chain that runs down the back inside the chest, parallel to the spine.
What must be concidered prior to surgery?
Factors
- Patient (known co-morbidities, unknown pathologies)
- Nature of surgery
- Anaesthetic techniques
- Post-op care
What are the roles of the anaestheticst in pre-op assessment?
- Assess patient
- Identify high risk of peri-operative complication/morbidity/mortality
- Optimise co-morbidities( to reduce risk of morbidity/mortality)
- Minimise risk
- Inform and support patient decision
- Patient consent
Why is pre-op assessment important?
Reduce:
* Patient anxiety
* Minimise delays and cancellation
* Reduce complications associated with surgery
* Reduce length of stay (reduce cost to NHS, risk of Iatrogenic infection
* Reduce mortality
When is pre-op assessment carried out?
Situation dependent
Elective planned surgery (Months/weeks)
* involvement with primary care in optimising conditions
* Pre-assessment clinic (optimise patient wellbeing prior to operation)
Urgent surgery (weeks)
Emergency surgery (minutes)
Components of pre-op assessment in anaesthetics
Simple List
- History
- Examination
- Investigations
Pre-op assessment in anaesthetics: History
a) Known co-morbidities:
* Severity
* Control
b) Unknown co-mobidities
* Systemic enquiry
* Clinical examination
c) Ability to withstand stress
* Exercise tolerance
* Reason for limintation
* Cardio-respiratory disease
d) Drugs and allergiies
e) Previous surgery and anaesthesia
f) Potential anaestehtic problems:
* Airway/spine/reflux/obesity
* Rareties/FH (malignant hyperpyrexia, cholinesterase deficiency)
Pre-op assessment in anaesthetics: Investigations
Concider:
* Sensitivity and specificity of test(reason for investoagtion)
* Target patients at risk, those that would benefit
* Iatrogenic harm of over-investigation
What are the different types of grading that is used in pre-op assessment of patients?
- ASA grading
- Surgery grade
- Co-morbidities
What system is used to identify how fit a patient is to undergo surgery?
ASA garding
What are the different ASA gardes?
What is ASA1?
Definition
Otherwise healthy patient
e.g. Healthy, non-smoking, no or minimal alcohol use
What is ASA 2
A patient with mild systemic disease
e.g. Current smoker, social alcohol drinker, pregnancy, obesity (30<BMI<40), well-controlled DM/HTN, mild lung disease
What is ASA3?
Patient with severe systemic disease
e.g. Substantive functional limitations; One or more moderate to severe diseases. 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, history (>3 months) of MI, CVA, TIA, or CAD/stents.
What is ASA4?
Patient with severe systemic disease that is a constant threat to life
e.g.
Recent (<3 months) MI, CVA, TIA or CAD/stents, ongoing cardiac ischemia or severe valve dysfunction, severe reduction of ejection fraction, shock, sepsis, DIC, ARD or ESRD not undergoing regularly scheduled dialysis
What is ASA5?
Moribund patient who is not expected to survive without the operation
e.g.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 ASA6?
Declared brain-dead patient whose organs are being removed for donor purposes
What is the revised cardiac risk index?
1 point given for every positive finding in the list
2 or more -> high risk
What is exercise tolerance assessment?
METS (Metabolic Equivalent Test)
Patients managing 5 or more METS (lower morbidaty/mortaluty)
Patients managing less than 5 METS ( increased mobidity/mortality)
Subjective assessment
What is gold standard investigation in peri-operative assessment in assessing fitness of patients for surgery?
Cardiopulmonary exercise testing
Anaerobic threshold correlates with risk of peri-operative complications/moprbidity/mortality
What is the purpose of the per-operative investigations?
What is assessed in termws of patients lifestyle in teh pre-op assessment?
- Smoking (issues with wound healing)
- Alcohol (sig correlation with post-op risk of infection)
- Obesity (losing weight, improves outcomes)
- Exercise (improves outcomes)
- Smokers get automatic refferal to smoking cessation services
What is the purpose of pre-habilitation?
Improved fittness -> improves outcomes
Perscirbing exercise
Study showed 15% reduction in mortality risk per MET
In terms of emergency risk assessment, what is factors are condidered?
- Infomred consent
- Anaesthetic plan (types of drugs)
- Invasive monitoring (aretrial line monitoring)
- Senior management (consultants)
- Post operative critical care
Prior to surgery what medications should be continued?
