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ACUTE > PRE-OP ASSESSMENT > Flashcards

PRE-OP ASSESSMENT Flashcards

1
Q

What are examples of minor, intermediate and major surgery grades?

A

Minor - excising a skin lesion or draining a breast abscess
Intermediate - repair of inguinal hernia, excising varicose veins, tonsillectomy, knee arthroscopy
Major - total abdominal hysterectomy, thyroidectomy, total joint replacement, colonic resection

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2
Q

What is the ASA grading system?

A

The American Society of Anaesthesiologists classification of physical health - its a subjective assessment of the patient’s overall health

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3
Q

What is ASA1?

A

Normal healthy pt whos a non-smoker and a minimal alcohol drinker at most

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4
Q

What is ASA 2?

A

Pt with mild systemic disease e.g. smoker, social alcohol drinker, pregnancy, BMI 30-40, well controlled DM/hypertension, mild lung disease

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5
Q

What is ASA 3?

A

Pt with severe systemic disease e.g. poorly controlled DM, COPD, BMI >40, alcohol abuse, ESRD, MI >3 months ago

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6
Q

What is ASA 4?

A

Pt with severe systemic disease that is a constant threat to life e.g. recent MI, cerebrovascular accident, cardiac ischaemia, sespsis, ESRD, DIC

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7
Q

What is ASA 5?

A

A moribund pt who is not expected to survive without the operation e.g. ruptured AAA, massive trauma, ischaemic bowel with AF, intracranial bleed with mass effect

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8
Q

What is ASA 6?

A

A brain-dead pt whose organs are being removed for donor purposes

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9
Q

When is ‘E’ used in the ASA grading system?

A

When its an emergency surgery

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10
Q

When are pre-op investigations usually done?

A

2-4 weeks before an elective surgery

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11
Q

What occurs in the pre-op assessment?

A

A history is taken. Anaesthetist specifically asks about PMHx of cardiovascular disease, exercise tolerance, RA, respiratory disease, renal disease, DM, thyroid disease, obstructive sleep apnoea, GORD, pregnancy, sickle cell disease and past surgical/anaesthetics history. A drug and FHx are also important

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12
Q

When should a pt stop smoking before surgery?

A

If you smoke, you have a 1 in 3 risk of post- operative breathing problems. This can be reduced to 1 in 10 if you stop 8 weeks before your op.
Even stopping 72 or 48 hours before an operation can decrease some of the risks.

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13
Q

When will a group & save and a cross-match be needed?

A

A group and save is recommended if blood loss if not anticipated but may be required if there is greater blood loss thanks expected
A cross-match is done if blood loss is anticipated

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14
Q

Pre-op investigations needed for minor surgery?

A

None if ASA 1 and 2
If ASA 3 or 4 then kidney function tests if risk of AKI and ECG if no results available from the past 12 months

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15
Q

Pre-op investigations needed for intermediate surgery?

A

None if ASA 1
If ASA 2 then may need kidney function tests and ECG if any risks
If ASA 3 or more then definitely ECG and kidney function tests. Consider FBC, Coag studies and lung function/ABG

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16
Q

Pre-op investigations needed for major surgery?

A

ASA 1 - FBC. Consider kidney function tests and ECG
ASA 2 - FBC, kidney function tests and ECG
ASA 3 or more - FBC, kidney function tests and ECG. Consider Coag studies and lung function tests/ABG

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17
Q

Which patients get MRSA swabs before surgery?

A

All

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18
Q

When is a pregnancy test indicated before surgery?

A

Always if there is any doubt at all

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19
Q

When is a HbA1c test indicated before surgery?

A

Only if they have diabetes and have not been tested in the last 3 months

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20
Q

When is testing for sickle cell disease before surgery indicated?

A

Not routinely
Only if FHx or suspicion

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21
Q

When are urine dipsticks indicated before surgery?

A

Do not routinely offer urine dipstick tests before surgery.
Consider microscopy and culture of midstream urine sample before surgery if the presence of a
UTI would influence the decision to operate

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22
Q

When is an echocardiogram indicated before surgery?

A

Not routinely!
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 ECG and
discuss the findings with an anaest

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23
Q

What is the mallampati score?

A

This assesses access and the degree to which the oropharynx can be visualized
Score of 1-4 is given

1 - complete visualisation of soft palate
2 - complete visualisation of the uvula
3 - visualisation of only the base of the uvula
4 - soft palate not visible at all

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24
Q

What is cardiopulmonary exercise testing?

A

This is a measurement of the cardiovascular and the respiratory system during exercise to assess a pt’s exercise capacity
This helps assess the risk of surgery and determine any appropriate pre-op and post-op care

Uses an ergometer and an ECG, VO2, VCO2, oxygen sats and BP is taken

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25
Q

What is prehabilitation?

A

These are simple steps a pt can do to be at their fittest before surgery which helps avoid complications
Includes improving diet, normal body weight, increasing activity levels, stopping smoking, cutting down on alcohol

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26
Q

How can alcohol consumption affect anaesthetics?

A

Chronic alcohol use can increase the dose requirements for a GA due to enzyme induction
Also associated with higher post-op complications

27
Q

What are the fasting guidelines?

A

No food or non-clear liquids for at least 6 hours before surgery
No clear fluids in the 2 hours before surgery (although sip til send is being trialled)

28
Q

Whats the purpose of the fasting guidelines?

A

To prevent aspiration pneumonitis and pneumonia which are major causes of morbidity and mortality

29
Q

Why is malnutrition an important factor for surgery?

A

If a pt has malnutrition they are at increased risk of post-op complications as the surgery causes physiological stress due to the hypermetabolic state and catabolic response

30
Q

How are patients screened for malnutrition?

A

Using the MUST score

31
Q

What are the methods of feeding a malnutritioned pt?

A

Oral nutritional supplements - if unable to eat sufficient calories
NGT - if unable to take sufficient calories orally or dysfunctional swallow
Gastrostomy feeding (PEG)- if oesophagus blocked or dysfunctional
Jejunostomy - if stomach inaccessible or outflow obstruction
Parenteral nutrition - if jejunum inaccessible or intestinal failure

32
Q

How do you manage pt with diabetes on insulin who have good glycaemic control?

A

If a minor procedure: Adjust insulin regimen
If requires a long fasting period of >1 missed meal or diabetes is poorly controlled - variable rate IV insulin infusion

33
Q

Potential complications of poorly managed diabetes during surgery?

A

• undetected hypoglycaemia whilst a patient is under a general anaesthetic.
• Diabetic patients have increased risk of wound & respiratory infections
• increased risk of post-operative acute kidney injury
• increased length of hospital stay

34
Q

When should variable rate IV insulin infusion be used for pts with diabetes usually controlled with oral antidiabetic drugs?

A

If >1 meal will be missed during fasting
If pts have poor glycaemic control
If there is any risk to renal injury e.g. eGFR <60 or contrast used

35
Q

How should metformin be adjusted around the time of surgery?

A

Day prior to admission - take as normal
Day of surgery - take as normal unless normally take 3 times a day and then miss lunchtime dose

36
Q

How should sulfonylureas be adjusted around the time of surgery?

A

Day prior to admission - take as normal
Day of surgery if morning op - if taken OD then omit this dose. If BD then omit the morning dose of that day
Day of surgery if afternoon op - if taken OD omit that dose. If taken BD then omit both doses

37
Q

How should gliptins (DD4 inhibitors) be adjusted around the time of surgery?

A

Take as normal

38
Q

How should GLP-1 analogues (-tides) be adjusted around the time of surgery?

A

Take as normal

39
Q

How should SGLT2 inhibitors be adjusted around the time of surgery?

A

Day prior to admission - take as normal
Omit on day of surgery

40
Q

How should Once daily insulins be adjusted around the time of surgery?

A

Reduce dose by 20% day before and day of surgery

41
Q

How should twice daily biphasic or ultra-long acting insulins be adjusted around the time of surgery?

A

Halve the usual morning dose on the day of surgery

42
Q

Which anti-diabetic drugs have a risk of hypoglycaemia when fasting for surgery?

A

Sulphonylureas - check BM hourly!

43
Q

Why should SGLT2 inhibitors be omitted on the day of surgery and not restarted until pt is stable?

A

Their use during periods of dehydration/acute illness is associated with an increased risk of developing DKA

44
Q

Why should metformin be adjusted around time of surgery in some cases?

A

As its renally excreted any renal impairment may lead to accumulation and lactic acidosis during surgery

45
Q

What is Lee’s revised cardiac risk index (LRCRI)

A

The most commonly used risk score for the development of cardiac complications after major non-cardiac operations
It includes the following predictors: high-risk surgery, IHD, Fx of CHF, cerebrovascular disease, insulin therapy, Pre-Operative Cr>176. Each of these is 1 point and then 4 classes are formed:
Class 1- 0 points
Class 2- 1 point
Class 3- 2 points
Class 4- 3 points or more

46
Q

What risk score is used for postop pulmonary complications?

A

ARIS-CAT

47
Q

What is the ARISCAT score?

A

This predicts the risk of postoperative pulmonary complications including respiratory failure

48
Q

What % of patients who develop post-operative pulmonary complications will die with 30 days of major surgery?

A

20%

49
Q

What score can estimate morbidity and mortality for general surgery pts?

A

POSSUM: physiological and operative severity score for the enumeration of mortality and morbidity

50
Q

What can estimate the 30 day mortality after emergency bowel surgery?

A

NELA calculator: the National Emergency Laparotomy Audity Calculator

51
Q

What is the Surgical Outcome RIsk Tool (SORT)?

A

A risk tool for predicting the 30 day mortality in non-cardiac, non-neurological input surgery

52
Q

What is the ACS NSQIP surgical risk calculator?

A

The American College of Surgeons National Surgical QIP - a universal surgical risk calculator to predict 14 different outcomes within 30 days of surgery

53
Q

What should be given post operatively to patients with adrenal insufficiency?

A

Hydrocortisone “stress dose” to avoid adrenal crisis

54
Q

Do you have to stop aspirin in surgery?

A

Often discontinued 7-10 days before surgery due to bleeding risk
Some cases it is continued e.g. angina with very high thrombotic risk

55
Q

Do TCAs need to be stopped before surgery?

A

Not necessarily but…
Be aware of increased risk of arrhythmias, hypotension and interacting with vasopressors drugs

56
Q

Should combined hormonal contraceptives be stopped for surgery?

A

Yes at least 4 weeks prior to any major elective surgery, any surgery involving legs or pelvis and any surgery that involves prolonged immobilisation of a lower limb
(Provide an alternative method of contraception)

57
Q

When can combined hormonal contraception be started after surgery?

A

2 weeks after full mobilisation

58
Q

Should lithium be stopped for surgery?

A

Yes - 24 hours before any major surgery
If minor surgery it may not be necessary but carefully monitor electrolytes and fluids q

59
Q

Do K+ sparing diuretics need to be stopped for surgery?

A

Often yes in the morning of due to risk of hyperkalaemia

60
Q

Do ACEi and ARBs need to be stopped for surgery?

A

Yes often 24 hours before surgery de to risk of severe hypotension after induction

61
Q

What scoring system is often used to measure frailty?

A

The Rockwood Frailty score

62
Q

Outline the Rockwood Frailty score?

A

1 - very fit - pt is active, energetic, motivated and commonly exercise. Amongst the fittest for their age
2 - well. No active disease but less fit than category 1. Often exercise
3 - managing well. Medical problems are well controlled but not regularly active beyond routine walking
4 - vulnerable. Symptoms limit activities but not dependant on others for daily help
5 - mildly frail - slowing, need help in high order ADLs. Impairs shopping, walking outside alone, meal prep and housework
6 - moderately frail - pt needs help with all outside activities and with keeping hte house. May need help with climbing stairs, bathing, dressing
7 - severely frail - completely dependant for personal care. Stable and not high risk of dying within 6 months
8 - very severely frail - completely dependant and approaching end of life. Could not recover even from a minor illness
9 - terminally ill - life expectancy <6 months

63
Q

What is the ERAS society?

A

This is the Enhanced recovery after surgery society
They aim to improve perioperative care and improve recovery

It is divided in 3 stages:
Pre-op - pt education on surgery, making sure pt is as healthy as possible, optimising medical maabgement and optimal pre-op fasting guidelines
Intra-op - use of multimodal and opioid-sparing analgesia, use of n&v prophylaxis, use of minimally invasive surgery, goal-directed fluid therapy regime
Post-op - adequate pain control, early oral intake, optimising nutrition, MDT follow up

ACUTE (18 decks)

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