pre-op assessment and prep

Question 1

trauma of surgery on patients

Answer 1

stress response
fluid shifts
blood loss
CVS, resp, renal and metabolic stress

Question 2

what is general anaesthesia and what needs to be considered

Answer 2

drug induced reversible coma
CNS, cardiac and resp depression
drug interations

Question 3

what is regional anaesthesia and what needs to be considered

Answer 3

e.g. spinal anaesthetic, epidural
profound sympathectomy
neurological sequelae

Question 4

considerations when anaesthetising a patient

Answer 4

patient - known comorbidities, unknown pathologies
nature of surgery
anaesthetic techniques
post-op care

Question 5

what is the role of an anaesthetist pre-op

Answer 5

assess patient 
identify high risk - peri-op complications and mortality
optimise co-morbidities
minimise risk of morbidity and mortality
inform and support patient 
consent

Question 6

why is doing a full assessment supporting the patient important

Answer 6

reduces: 
anxiety 
delays
cancellations 
complications 
length of stay 
mortality

Question 7

when is a pre-op assessment done

Answer 7

elective planned surgery - 1y care (wks-mths before surgery) , pre-assessment clinic (6-8wks before surgery) - time to improve pre-existing conditions etc

urgent surgery - 2-3 wks, still opportunity for assessment and optimisation

emergency surgery

Question 8

what is involved in the pre-op assessment

Answer 8

hx
examination
investigations

Question 9

hx in pre-op assessment - what do we ask about

Answer 9

known co-morbidities - severity, level of control

unknown co-morbidities - systemic enquiry, clinical examination

ability to withstand stress - exercise tolerance, reason for limitation, cardio-resp disease

D+A - sensitivity or true reaction

prev surgery and anaesthesia - any problems

potential anaesthetic problems

Question 10

examples of potential anaesthetic problems

Answer 10

airway
spine - prev surgery or deformities
reflux - no fasting, intestinal obstruction
obesity
rarities/FHx - hx of family problems w/ anaesthesia - malignant hyperpyrexia, cholinesterase deficiency

Question 11

reasons for investigations in pre-op assessment

Answer 11

detect unknown conditions
diagnose suspected conditions
severity of known disease
establishing a baseline 
detecting complications 
assessing risk 
guiding management 
documenting improvement

Question 12

cardiovascular investigations in pre-op assessment

Answer 12

tests done depend on the patient and the op e.g. fit 20 y/o vs 80y/o

ECG 
exercise tolerance test 
echo 
myocardial perfusion scan
stress echo 
cardiac catheterisation 
CT coronary angiogram

Question 13

resp investigations in pre-op assessment

Answer 13

saturations 
CXR 
ABG
peak flow measurements
FVC/FEV
gas transfer
CT chest

Question 14

things to consider w/ investigations in pre-op assessment

Answer 14

sensitivity and specificity
target those at risk
iatrogenic harm of over-investigating

Question 15

NICE guidelines for investigations required

Answer 15

ASA grade
surgery grade
co-morbidities

investigations are tailored to the specific patients for the specific surgery

Question 16

ASA grading

Answer 16

used to identify how fit and healthy a patient is or how sick they are

1 - otherwise healthy 
2 - mild to moderate systemic disturbance
3 - severe systemic disturbance
4 - life threatening disease
5 - moribound patient
(6 - organ retrieval)

not fully specific for selecting pts w/ underlying/undiagnosed pathology

Question 17

other risk assessment tools

Answer 17

GUPTA perioperative cardiac risk
geriatric sensitive perioperative cardiac risk index
surgical outcome risk tool
american college of surgeons surgical risk calculator
STOP-BANG questionnaire - obstructive sleep apnoea risk
nottingham hip fracture score
P-POSSUM
CR-POSSUM
Q-POSSUM
V-POSSUM
post-op resp failure calculator

Question 18

revised cardiac risk index

Answer 18

point given for each: 
high risk surgery 
ischaemic heart disease
congestive heart failure 
cerebrovascular disease
DM
renal failure

Question 19

exercise tolerance - METS

Answer 19

can you do the following w/o getting SOB:
walk around the house - 2
light housework - 3
walk 100-200m on flat - 4
climb a flight of stairs/walk up a hill - 5
walk on the flat at a brisk pace - 6
play golf, mountain walk, dance - any form of exercise - 7
run a short distance - 8
strenuous exercise or heavy physical work - 9

can be subjective and pts may overestimate their ability

Question 20

cardiopulmonary exercise testing

Answer 20

gold standard for assessing fitness of pts for surgery

requires more equipment, time and trained professionals

measures BCG, BP, o2 consumption

Question 21

link between cardiopulmonary exercise testing and operative risk

Answer 21

anaerobic threshold correlates with risk of peri-op complications and morbidity and mortality

Question 22

conditions to optimise pre-op

Answer 22

HT 
ischaemic heart disease
heart failure 
asthma
COPD
DM
epilepsy

Question 23

lifestyle factors to consider pre-op

Answer 23

smoking - higher risk of resp complications, more chest infections, post-op problems, wound healing
alcohol - post-op infections
obesity
exercise

Question 24

pre-habilitation

Answer 24

improved fitness = improved outcomes
15% reduction in mortality risk per MET
prescribing exercise

Question 25

high risk emergency patients management

Answer 25

informed consent
anaesthetic plan
invasive monitoring 
senior management 
post-op critical care

Question 26

pre-op medication

Answer 26

most continue as normal

esp: inhalers, anti-anginals, anti-epileptics

possible exceptions:
anti-DM (depends on the medication, who controls the DM, time of surgery, type of surgery, how quickly they will be able to eat afterwards etc)
anticoagulants (depends on type of medication and indication)