Pre-operative assessment Flashcards
Pre-op consent (inc. capacity)
Makes sure pt understands nature, aims and outcome of surgery
- Ensure right pt gets right surgery
- Assess balance/risk anaesthesia
- Obtained informed consent
Consent to be valid:
Given any time before treatment started. Earlier is better.
Treatment must be understood by pt
Must be given voluntarily
Capacity:
Pt understands, retains, weighs up relevant information, communicate decision
Not fixed, can change to time and decision
Surgical/threatre safety (WHO surgical pause, PPE, M&M)
Surgical pause: before incision made, less then one minute pause of all staff, confirm identity pt, operative site, procedure
Surgical M&M: mortality and morbidity meetings.
Identify adverse outcomes assoc. with medical error, prevent repetition of errors which lead to complications
Diff between G+S, Xmatch?
G and Save
When pt’s blood type identified (ABO, Rhd). No blood issued. Done when blood loss not expected, but may be required
Cross-match
Involves mixing pt’s blood and donor blood to see if an immune reaction takes place. G&S required. Done if blood loss is anticipated.
Common perioperative complications (including pain, nausea & vomiting, pyrexia, oxygen therapy, bleeding, infection, PE)
Pain
Complications: decreaese mobility, ventilation (leading to atelectasis and HAP)
WHO ladder:
Non-opioid anagelsia (NSAIDs, paracetamol) - weak opiates (tramadol, codeine) - strong opiates
Opiates SE: constipation, nausea, itch, resp depression
PCA pump: provides bolus dose of analgesia when pt presses button.
Ad: provides analgesia tailored to pts needs, low risk overdose, record how much given
Disad: prevent pt mobilising, not for pts learning difficulties
N&V
Complications: Anxiety for future surgery, aspiration pneumonia, bleeding, oesophageal rupture
Risk fx: female, previous PONV, use of opioids
Tx: A-E, may need NG if vomiting
Prophylactic: reduce use opiates beforehand, provide prophylactic anti-emetic
Metoclopramide -dop antagonist (unless there is bowel obstruction)
Ondensatron - 5-HT3 receptor antagonist
Cyclizine - H1 receptor antagonist
Haemorrhage Can occur up to 10 days post-op Sx: (haemorrhagic shock): tachy, dizziness, agitation Class 1 <15% blood loss Class 2 15-30 Class 3 30-40 Class 4 >40%
Tx: A-E IV access (large as possible) IV fluids Direct pressure (if visible) Senior rv Blood transfusion Major haemorrhage protocol
Pyrexia Most common cause: infection Day 1-2: respiratory Day 3-5: urinary tract Day 4-6: PE Day 5-7: surgical site infection Anytime: drugs: abx, blood transfusion
Anaesthetic perioperative assessment (e.g. pre-op clinic - ASA grade, airway assessment, assessment of co-morbidities, relevant or necessary investigations)
ASA grade correlates with post-op complications and mortality
I: normal healthy
2: mild systemic disease
3: severe systemic disease
4: systemic disease that is contant threat to life
5: moribund, not expected to survive without op
Drugs:
Aspirin can be continued
Warfarin can be continued in minor surgery. Stop for 3-5d in major surgery. Emergency: vit K+/- FFP, Prothrombin complex
OCP: stop 4 weeks before: major surgery
Digoxin: continue until morning of
Preparation:
NBM >2 pre clear fluids, >6hrs solid food
DVT prophylaxis
Book pre/post XRs
History
Assess history of: MI, diabetes, asthma, HTN
Teeth stable?
Previous anaesthetic? Complications?
Examination Cardioresp exam Neck stable? DVT prophylaxis? Mark side for unilateral surgery
Ix:
FBC (anaemia, thrombocytopenia)
UEs (baselinie kidney function)
BM
Crossmatch: blood type identified and units allocated
Group and Save: blood type identified, held
LFTs (jaundice, alcohol), drug levels (digoxin, lithium)
Clotting studies
CXR (if resp pathology)
ECG (if cardiac pathology)
MRSA swab - nasal+perineum
Airway assessment: Mallampati classification (assess difficulty intubatation) Class 1: soft palate, uvula Class 2: soft palate, major uvula Class 3: soft palate, base of hard Class 4: only hard palate seen
