Pre-operative assessment Flashcards
Why do we do a pre-operative care/assessment?
Aim: diagnostic & prognostic info
- Ensure right pt gets the right surgery –> (check if signs & symptoms changed)
- Gain informed consent
- Ensure pt understands nature, aims & expected outcome of surgery
- Relieve any anxiety & pain
- Assess risks of anaesthesia & maximise fitness
- Comorbidities? Drugs? Smoker?
- Optimize oxygenation before major surgery - shown to improve outcome
- Check proposed anaesthesia/analgesia with anaesthtist
In pre-op checks what should be considered regarding the CVS?
- exercise tolerance,
- existing illness,
- drugs & allergies
What is something to consider regarding PMHx in a pre-op check?
- MI
- diabetes
- asthma
- HTN
- rheumatic fever
- epilepsy
- jaundice
What things should you consider with FH in a pre-op check?
may be relevant e.g. in malignancy, hyperpyrexia, dystrophia myotonica, porphyria, cholinesterase problems, sickle-cell
What questions should be asked regarding intubation and anaeathesia risk?
specific risks? DVT risk? surgery risk?
- Intubation risk: is neck/jaw immobile & teeth stable
- Anaesthesia risk: ever had before? Complications?
- Specific risks: e.g. pregnancy?
- DVT risk: prophylaxis
- Surgery risk: MARK CORRECT ARM/LEG/KIDNEY IF UNILATERAL
When should contraceptive pill & HRT be stopped before/after major or leg surgery?
- Contraceptive pill & HRT: stop 4wks before major/leg surgery, restart 2wks after
- May be increased risk of DVT/PE
what may antibiotics such as tetracycline & neomycin, as well as lithium do to the body which is relevant for pre-op checks?
- Antibiotics: tetracycline & neomycin may ↑neuromuscular blockade.
- Lithium: get expert help - may potentiate neuromuscular blockage & cause arrhythmias
Which drugs are necessary to check for in pre-op assessment and may cause arrhythmias?
Lithium and tricyclics - may cause arrhythmias
Tricyclics may also enhance adrenaline
while lithium may potentiate neuromuscular blocks
What should be done if on pre-op assessment the pt is on anticoagulants?
- tell surgeon, avoid epidural, spinal & regional blocks
- discuss stopping clopidogrel with cardiologists/neurologists
What should a pre-op patient on beta blockers, anticonvulsants and digoxin do regarding their medications for surgery?
Continue up to and including day of surgery
- check plasma K and Ca for digoxin
- for anticonvulsants give post op IV until able to take orally
What should you be aware of for a patient on diuretics (pre-op assessment)?
beware hypokalaemia, dehydration
What is a simple checklist of pre-op checks?
- Blood tests (inc. G&S
- or crossmatch
- IV cannula
- ECG + CXR
- Drug chart:
- regular medications
- analgesia/anti-emetic
- antibiotics
- -LMWH/heparin
- Compression stockings
- Consent
- Marked site/side
- Anaesthetist informed
- Theatres informed
- Infection risk? e.g. MRSA screen/HIV/HBV/HCV
- NBM - since when?
What questions should be asked regarding a patients drugs?
allergies?
informa anaesthatist about all drugs (e.g. as interactions with the drugs anathetist uses to sedate, muscle relax and painkillers etc)
INCLUDING OTC!
What needs to be done in preparation for surgery?
- Starve pt (NBM >2hrs pre-op for clear fluids & >6hrs for solids)
- Bowl/skin prep needed?
- Prophylactic antibiotics?
- Start DVT prophylaxis as indicated e.g. TED stockings, LWMH 20mg/d SC 2hrs pre-op
- Write up pre-meds, book any peri-operative X-rays or frozen sections, book post-op physio
- If needed catheterize
Pre-op investigations include:
- Bloods:
- FBC
- Sickle-cell screen
- U&E
- LFT
- Clotting
- bHCG
- Investigations:
- CXR
- ECG
What is the purpose of these/indications for patient groups
- FBC
- Exclude infection or anaemia
- Sickle-cell screen
- RFs
- U&E
- >60yrs, cardiac/renal disease, pts on steroids, diuretics, ACEI
- LFT
- Previous/ suspected abnormal liver function, biliary surgery
- Clotting
- Established/ suspected abnormal liver function or clotting disorder
- bHCG
- Women of child bearing age
- CXR
- >60yrs,
- carido-resp disease,
- malignancy, major thoracic/ upper abdo surgery,
- unexplained SOB
- ECG
- >50yrs,
- cardiovascular disease,
- DM,
- smokers
What blood requests should be made for minor day case sugery operations such as carpal tunnel release, lipoma removal?
no request
What blood requests should be made for laparoscopy, appendicectomy, cholecystectomy, hernia repair, simple hysterectomy, liver biopsy, mastectomy, varicose veins, thyroidectomy?
G&S
(blood transfusion e.g. cross match made if over 1 unit of blood loss)
What bloods should be requested for colectomy, hemiarthroplasty, laparotomy, TURP, THR?
cross match
2 units
(blood transfusion e.g. cross match made if over 1 unit of blood loss)
What bloods should be requested for abdominoperineal resection, hepatic/pancreatic surgery?
cross match
4 units
What blood request should be made for aneruysm repair?
cross match
6 units
(blood transfusion e.g. cross match made if over 1 unit of blood loss)
Legally, does consent need to be written?
English law states that any intervention or treatment needs consent
- written consent itself is NOT required by law but it does constitute “good medical practise” in the best interests of the patient and practicioner
- sometimes actions and words can imply valid consent e.g. by simply entering into conversation or holding out an arm,
- –> In these situations your actions and their consequences are understood by the patient as a product of their knowledge, previous interactions with doctors and learning through experience
- sometimes actions and words can imply valid consent e.g. by simply entering into conversation or holding out an arm,
- However if the consequences are not clear and the patient has capacity to give consent you should seek informed written consent as a record of your conversation
What 4 things does consent need to be valid?
- Given any time before the intervention/treatment; earlier better as pt can consider isks, benefits and alternatives
- Consent in an ongoing process throughout pts time with you
- Proposed Rx must be clearly understood by pt
- Benefits, risks (complications), additional procedures, alternative courses of action & their consequences
- Given by a patient who has capacity (can understand, retain & weigh up the necessary information)
- Assessment of capacity must be time & decision-specific
- Given voluntarily
(understand, weigh up, communicate, voluntary and w/capacity)
Who can perform consent?
AKA whos responsibility is consent?
Consent is the responsibility of the doctor undertaking the Ix or Rx
- BUT Task can be delegated to someone:
- suitably trained and qualified
- who has sufficient knowledge of the proposed investigation or treatment, and understands the risks involved
- understands, and agrees to act in accordance with, the GMC guidance
What 3 parts does the WHO surgical safety checklist consist of?
- Sign in (before induction of anaesthesia)
- Time out (before start of surgical intervention)
- Sign out (beofre any member of the team leaves the OR)
NB: the WHO checklist has shown to reduce surgical COMPLICATIONS in MEDCs and in LEDCs it reduces MORTALITY (and comps.?)
Which part of the WHO checklist is this from?
- patient identity confirmation, site, procedure and consent too
- surgical site marked
- anaesthesia machine and medication check
- Any patient: known allergy, difficulta airway/aspiration risk, risk of >500ml blood loss (7ml/kg in children)
Sign in
to be read out before the induction of anaesthesia
What part of the WHO surgical safety checklist is this from?
- all team members introduced themselves by name and role
- surgeon, anaethatist and reg practitioner verbally confirm patients name, procedure and position
- anticipated critical eventsion: surgeon - blood loss, any specific equipments any cirtical or unexpected steps; anaeasthetist - any patient specific concerns, ASA grade, any monitoring equipment and other speicifc levels of support requirements e.g. blood; nurse/ODP - equipment sterility or any equipment issues or concerns.
- has surgical site infection bundle been undertaken -abx given within 60 mins [2h oral, IV 30min], patient warning, hair removal, glycaemic control
- VTE prophylaxis been undertaken
- essential imaging displayed
time out
(before start of surgical intervention)
What part of the WHO surgical safety checklist is this from?
registered practitioner verbally confirms with the team:
- name of procedure been recorded?
- confirmed completed counts of instruments, sharps, swabs are complete
- specimens labelled including patient name
- any equipment problems identified that need addressing
- surgeon, anaesthtist and reg practicioner: what are key concerns for recovery and management of this patient?
The sign out
(before any member of the team leaves the OR)
What score is used for anaesthetists to figure out a patients physical score of comorbidities?
ASA score!
e.g. american society of anaesthersiologists physical status classification system, comorbidities physical score status
ASA 1 = normal healthy patient - healthy, non smoker
ASA 6 = a declared brain dead patient (who is undergoing surgery) whose organs are being removed for donor purposes e.g. is deceased
A patient is ONE of these things:
- a current smoker
- or has well controlled DM/HTN
- or is BMI 30-40 e.g. obese
- social alcohol
- pregnancy
What ASA score would this patient have?
ASA 2
A patient with mild systemic disease
A patient has one of these features:
- implanted pacemaker
- copd
- >3 month hx thromboembolism
- alcohol dependence
- poorly controlled DM/HTN
- BMI >40
what ASA score would they get?
ASA 3
a patient with severe systemic disease
A patient has either of:
sepsis
< 3 month hx thromboembolism
What ASA score would you give them?
this is a patient with severe systemic disease that is a constant threat to life –> ASA 3
A patien has
- an ICH
- ruptured AAA
what is the ASA score of this patient?
= ASA 5
because they are a moribund patient who is not expected to survive without the operation
What is the investigation and management of the thyroid disease before a patient needs surgery (pre-op)?
Thyroid disease:
Rx hyperthyroid pre-op w/anti-thyroid drugs until pt is euthyroid
thyrotoxic storm is a rare but potentially fatal consequence of thyroid surgery
What is the investigations and managment of liver dysfunction & obstructive jaundice in the surgical patient (e.g. pre-op)?
Liver dysfunction & obstructive jaundice - operating is best avoided as
(1) ↑risk peri-op infection, (2) bleeding & (3) renal failure
Focus on preventing:
- COAGULOPAHTY: due to low vitamin K e.g. too much bleeding
- SEPSIS: due to reduced neutrophil function, bacterial colonisation of biliary tree & increased bacterial translocation
- RENAL FAILURE: pts with obstructive jaundice prone to developing renal failure post-surgery, possibly due to absorption of endotoxin from the intestines (normally limited by bile)
- → renal vasocon & acute tubular necorsis; give IV fluids to maintain UO
What are the investigations and managment of steroids in the surgical patient (e.g. pre-op)?
- STEROIDS: pts may not be able to mount an appropriate adrenal response to meet stress of surgery due to HPA axis suppression
- –> Extra corticosteroid cover may be required, depending on the type of surgery,
- for pts taking >5mg/d of pred or equivalent
- –> Extra corticosteroid cover may be required, depending on the type of surgery,
What are the investigations and managment of anti-coagulants in the surgical patient (e.g. pre-op)?
ANTICOAGULANTS: inform surgeon & anaesthetist
- Minor surgery don’t need to stop warfarin
-
Major surgery, stop drugs 2-5d pre-op (discuss risk-benefit);
- vit K +- Fresh Frozen Plasma may be needed for emergency reversal of INR;
- can switch to heparin (stop 6h pre-op)
- vit K +- Fresh Frozen Plasma may be needed for emergency reversal of INR;
What are the investigations and managment of INSULIN TREATED DIABETES in the surgical patient (e.g. pre-op)?
Diabetes = greater risk of post-op infection & cardiac complications;
–> tight glycaemic control improves outcome
INSULIN TREATED: no bolus morning of, normal the night before, try to place 1st on list & minimise fasting period, resume insulin with evening meal (if eating & drinking)
- VRIII - variable rate intravenous insulin infusion (“sliding scale”), omit all rapid-acting & mixed insulin (only give long acting with this), IV fluid required with this
- If not eating or drinking post-op, start VRIII 2hrs prior to surgery
- GKI infusions (glucose, K & insulin) can be used as an alternative to VRIII, although no longer used as standard in UK
What are the investigations and managment of TABLET TREATED DIABETES in the surgical patient (e.g. pre-op)?
Diabetes = greater risk of post-op infection & cardiac complications; tight glycaemic control improves outcome
- no meds morning of, usual meds night before UNLESS have long acting sulfonylureas then stop them 2-3 day pre op due to prolonged hypo when fasting
- sasme as insulin treated except you use VRIII during
- take missed drugs with lunch after surgery
- vs insulin dependent you resume insulin wiht your evening meal
