Pre-Op Assessment Flashcards
What is the order of the pre op assessment?
History:
Intro + pt understanding
Current health
Medical hx (A CHILD)
Drug hx
Allergies + anaesthetic hx
Family hx
Examination:
General
Hands
Face/neck
Chest
Abdo
Legs
What do you do in the intro to the pre op assessment?
WIPERQ
Details of surgery + indication
Anaesthesia required
Nutritional status
Understanding of NBM status
What aspects of the patient’s current health should be assessed before a surgery
Recent illness
Exercise tolerance
“Do you ever experience SOB, chest pain, or cramping in legs”
Sleep apnoea
What should be covered in the medical history in a pre op assessment?
Open question
REFLUX
Asthma
COPD
Hypertension
IHD/CVD
Liver disease
Diabetes
A CHILD
What medications should be directly screened for in pre op assessment? (5)
1) “blood thinners”,
2) antihypertensives
3) Analgesics
and when they last took them
4) OTC agents
5) steroids
Most drugs are continued on the day of surgery except:
Insulin: for LONG-ACTING, reduce dose by 20% on day of AND day before surgery; for SHORT-ACTING, stop while fasting
Lithium: stop day before
Anticoagulants or antiplatelets: variable sometimes continued
Combined contraceptive pill or HRT: 4 weeks before
K-sparing diuretics: stop on day of surgery
Oral hypoglycaemics: variable according to local policy, generally only altered on the day of surgery
Perindopril and other ACEi: stop on day of surgery
Which psychiatric drugs need special consideration in the pre op period?
MAOi - can have dangerous interactions with certain anaesthetic drugs. If a patient is on a MAOi
Lithium - stop day before and check Li level, LFTs, TFTs
What should happen with herbal medications pre-operatively?
Herbal medications such as St John’s Wort and ephedra should be stopped 2 weeks before surgery.
What should you be aware of perioperatively in patients taking steroids
Patients who take more than 5mg prednisolone daily will need supplementary steroids during the perioperative period.
What should happen with different heparins pre-operatively
Unfractionated heparin is short-acting and normally given via IV infusion. It must be stopped 4 hours before neuraxial block with evidence of a normal APTT.
LMWH is longer acting and administered subcutaneously. Following “prophylactic dose LMWH”, a neuraxial block cannot be performed for 12 hours. Following “treatment dose LMWH”, this is increased to 24 hours.
What should happen with warfarin pre-operatively (3)
For minor superficial surgery (e.g. ophthalmic or minor dental procedures) warfarin may not need to be omitted (however guidelines vary, so always consult local guidance).
For all other surgical interventions, the last dose of warfarin should be given 6 days before the procedure.
Check INR - once INR is <1.5 surgery can go ahead (reduces risk of operative bleeding)
What happens with DOACs pre-operatively?
Rivaroxaban clearance is dependent on dose and renal function:
-> Prophylactic dose with creatinine clearance >30ml/min – 18 hours before neuraxial block.
-> Treatment dose with creatinine clearance >30ml/min – 48 hours before neuraxial block
Dabigatran – wait 48 hours before neuraxial block
Apixaban – wait 48 hours before neuraxial block
What should you ask about after drug history in pre op
Allergies:
- drugs
- plasters
- food (egg, soy, peanut, shellfish)
Anaesthetic hx:
- Airway difficulty
- Malignant hyperthermia
- Anaphylaxis (esp to suxamethonium)
- Post operative nausea and vomiting
- slow to wake up or ICU
What is important in family history in pre op assessment?
- Airway difficulty
- Malignant hyperthermia
- Anaphylaxis (esp to suxamethonium)
- Post operative nausea and vomiting
What is after the family hx in pre op assessment
Social hx:
smoking
alcohol
What do you do after social hx in pre op
Examination
start with General exam
What does the general examination in pre op include (3)
GCS – Eyes, Verbal, Motor (done while examining)
* General appearance (including BMI) – Thin, muscular, generalized/abdominal obesity, cachectic
* Spine check
What do you look at in the hands pre operatively
- Capillary refill,
- Temperature,
- Pulse
What do you look at in the head in the pre op assessment
LEMON
L - look externally (facial trauma, large incisors, beard or moustache, large tongue)
E - evaluate the 3-3-2 rule
3: 3 fingers between upper and lower teeth when mouth open
3: 3 fingers between mandible and hyoid bone
2: 2 fingers between hyoid bone and thyroid cartilage
M - Mallampati score >3
O - obstruction - DENTAL CHECK (loose teeth, caps/crowns/dentures), foreign bodies, inflamed epiglottitis, peritonsillar abscess, trauma)
N - Neck movement (NMJ block) - check flexion and extension + JVP+carotid+trachea
What do you assess in the chest pre operatively?
Cardiac
* Palpates apex beat.
* Checks for ventricular heaves and thrills.
* Percusses back and axilla.
* Auscultates heart sounds, axilla
Pulmonary
* Breath sounds – Decreased sounds, rhonchi, creps, oxygen dependent?
What do you do on the abdo men pre operatively?
- Palpates abdomen (SNT)
- Assesses for organomegaly (hepatosplenomegaly)
- Listens to bowel sounds
What do you do after the abdomen in pre op (3)
Sacrum and legs
* Feels for sacral oedema.
* Assesses calves and legs for DVT.
* Assesses peripheral oedema
What are important investigations to perform pre operatively
Cardio:
□ ECG if over 65/ heart problems
□ Echo
□ Check pacemaker
Respiratory:
□ CXR
□ Spirometry
What are the ASA classifications?
ASA I - ‘normal’ healthy patient
e.g. non-smoking, no or minimal alcohol
ASA II - mild systemic disease
e.g. current smoker, social alcohol, pregnancy, obesity (BMI 30-40)
ASA III - severe systemic disease
e.g. poorly controlled diabetes/HTN, COPD, morbid obesity (BMI > 40), End-Stage Renal Disease (ESRD) undergoing regular dialysis
ASA IV - severe systemic disease that is a constant threat to life
e.g. recent (<3 months) history of MI, sepsis, DIC, ESRD not undergoing regular dialysis
ASA V - moribund, not expected to survive without operation
e.g. ruptured AAA, massive trauma, intra-cranial bleed with mass effect
ASA VI - brain-dead patient, organs being removed for donation
