Pre-operative

Question 1

summarise NICE guidelines on preoperative investigations

Answer 1

• SCD/ trait tests (not routine, speak w team if in family)
• HbA1c (people w diabetes, 3< months since last test)
• Pregnancy tests
• MSU dipstick test - if infection –> decision to operate
• ECG (if heart murmur + any cardiac symptom: SOB/(pre-)syncope/chest pain OR signs/symptoms of heart failure.

Question 2

summarise common peri-operative risk scoring systems

Answer 2

ASA
POSSUM

ASA 1 - normal healthy patient
minor surg.: no routine tests
intermediate: no routine tests
major: **FBC, **ECG (65+ yrs if 1yr< last test), **Kidney function (if risk of AKI),

ASA 2 - mild systemic disease (no loss in functional capacity)

minor: no routine tests
intermediate: **ECG (CVD/diabetes/renal co-morbs) , **Kidney function (if risk of AKI)
major: **FBC, **ECG, **Kidney function

ASA 3 - severe systemic disease (loss of functioning)
ASA 4 - severe systemic disease that is a constant threat to life
minor: **kidney function (risk of AKI), **ECG (no results> 1yr)
intermediate: ** FBC (CVD/renal symptoms), **Haemostasis (chronic liver disease + change anticoagulants), **Kidney function, **ECG, **ABG + LF (if suspected lung disease)
major: “”” except always **FBC

ASA 5: Moribund patient. Unlikely to survive 24 hrs, with/ without treatment
Postscript E indicates emergency surgery

Question 3

criteria for the suitability of patients for day stay surgery

Answer 3

social factors

• adult escorting home
• 24hours carer post-operative

medical factors
- functional status as determined at pre-anaesthetic
assessment (not ASA status, BMI, age, etc)
- just not unstable medical conditions
- Obstructive Sleep Apnoea not contra-indicated absolutely

surgical factors

• no risk of post-operative complications e.g. haemmorhage, CVS instability
• post-operative symptoms must manageable w LA/oral meds
• surgery should not prevent eating within few hours of surgery
• mobile - if not venous thromboembolism prophylaxis

Question 4

What is pre-op care?

Answer 4

preparation

assessment (physical + psychological)

Question 5

what are the objectives of pre-op assessment

Answer 5

explaining procedures
risks
aftercare
Informed decisions
Identifying co-existing medical conditions (w urgency of op)
improvable factors –> fit as possible (smoking, alcohol, nutrition + exercise)
Identify high risk of perioperative complications
–> postoperative care
discharge planning.
variables that provide prognostic info
preop anaesthetic history + assessment (airway assessment, previous anaesthesia + adverse reactions)

Question 6

e.g. of each grade of surgery (1-4)

Answer 6

Grade 1: Minor procedures e.g diagnostic endoscopy, breast biopsy
Grade 2: Inguinal hernia repair, varicose veins adenotonsillectomy, knee arthroscopy
Grade 3: Total abdominal hysterectomy, TURP, lumbar discectomy, thyroidectomy
Grade 4: Major procedures, e.g. total joint, artery reconstruction, colonic resection, radical neck dissection

Question 7

what are common conditions that affect pre-op care?

Answer 7

Ischaemic heart 
Congestive cardiac 
Chronic respiratory 
Diabetes 
Liver or kidney

Question 8

peri-operative management of medical co-morbidities, e.g diabetes mellitus,

Answer 8

intermediate surgery: if ASA 2
**ECG

always
**HbA1c (if no test in 3 months)

Question 9

peri-operative management of medical co-morbidities, e.g hypertension,

Answer 9

???

G+S?

Question 10

peri-operative management of medical co-morbidities, e.g ischaemic heart disease,

Answer 10

Revised cardiac risk index (RCRI)
1procedure-relatedrisk factor: 
- intrathoracic surg/ intra-abdominalsurg/suprainguinal vascular surg
5patient-related
- Ischaemic heart disease
- Congestive heart failure
- History ofstrokeorTIA
- Creatinine> 2.0 mg/dL
- Insulin-dependentdiabetes mellitus
1 functional capacity-related: 
- breathlessness and/or havechest painwhile climbing a flight of stairs, walking on level ground at4 km/hr, or performing heavy work around the house

1) Bloods:
FBC, U&E, LFT, Coagulation Screen, G&S

2) ECG:
baseline (comparison for post-op complications)
- only when: 1+ RCRI & 65yrs+/COPD/Peripheral vascular disease/Arrhythmias

3) CXR
- head + neck,thorax,upper abdomen surg
- Clinical features and/or a history cardiac / pulmonary disease (e.g.,COPD,congestive heart failure)
- > 60 years
- ASA score > 2Hypoalbuminemia
- Emergencies
- Prolonged surgeries (> 3 hours)

4) Echo
- worsening/new onset cardiac symptoms (e.g.,dyspnea,chest pain,syncope)
- moderate or severe valvular regurgitation / stenosis w no echo in past 1 yr

Question 11

peri-operative management of medical co-morbidities, e.g asthma,

Answer 11

BRONCHIAL asthma

• • Pulmonary function tests
• if none in past 1 yr

Question 12

peri-operative management of medical co-morbidities, e.g chronic obstructive pulmonary disease (COPD)

Answer 12

• • Pulmonary function tests

- if none in past 1 yr

Question 13

peri-operative management of medical co-morbidities, e.g patients on anti-coagulant medications

Answer 13

intermediate surgery: if ASA 3/4

• *clotting screen
• *Change anti-coagulants if necessary

Question 14

peri-operative management of medical co-morbidities, e.g sickle cell disease

Answer 14

sickle cell genotype

frequency of crisis + date of patient’s last crisis
average length of hospital stay during painful crisis
known triggers
baseline level of activity
baseline opioid use

G+S?
steady-state Hb + Hct
reticulocyte count
WBC count
as well as history of blood transfusions.