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Critical care/Anaesthetics > Pre-operative assessment > Flashcards

Pre-operative assessment Flashcards

1
Q

Why do we do a pre-operative care/assessment?

A

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
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2
Q

In pre-op checks what should be considered regarding the CVS?

A
  • exercise tolerance,
  • existing illness,
  • drugs & allergies
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3
Q

What is something to consider regarding PMHx in a pre-op check?

A
  • MI
  • diabetes
  • asthma
  • HTN
  • rheumatic fever
  • epilepsy
  • jaundice
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4
Q

What things should you consider with FH in a pre-op check?

A

may be relevant e.g. in malignancy, hyperpyrexia, dystrophia myotonica, porphyria, cholinesterase problems, sickle-cell

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5
Q

What questions should be asked regarding intubation and anaeathesia risk?

specific risks? DVT risk? surgery risk?

A
  • 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
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6
Q

When should contraceptive pill & HRT be stopped before/after major or leg surgery?

A
  • Contraceptive pill & HRT: stop 4wks before major/leg surgery, restart 2wks after
  • May be increased risk of DVT/PE
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7
Q

what may antibiotics such as tetracycline & neomycin, as well as lithium do to the body which is relevant for pre-op checks?

A
  • Antibiotics: tetracycline & neomycin may ↑neuromuscular blockade.
  • Lithium: get expert help - may potentiate neuromuscular blockage & cause arrhythmias
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8
Q

Which drugs are necessary to check for in pre-op assessment and may cause arrhythmias?

A

Lithium and tricyclics - may cause arrhythmias

Tricyclics may also enhance adrenaline

while lithium may potentiate neuromuscular blocks

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9
Q

What should be done if on pre-op assessment the pt is on anticoagulants?

A
  • tell surgeon, avoid epidural, spinal & regional blocks
    • discuss stopping clopidogrel with cardiologists/neurologists
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10
Q

What should a pre-op patient on beta blockers, anticonvulsants and digoxin do regarding their medications for surgery?

A

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
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11
Q

What should you be aware of for a patient on diuretics (pre-op assessment)?

A

beware hypokalaemia, dehydration

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12
Q

What is a simple checklist of pre-op checks?

A
  • 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?
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13
Q

What questions should be asked regarding a patients drugs?

A

allergies?

informa anaesthatist about all drugs (e.g. as interactions with the drugs anathetist uses to sedate, muscle relax and painkillers etc)

INCLUDING OTC!

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14
Q

What needs to be done in preparation for surgery?

A
  • 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
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15
Q

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

A
  • 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
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16
Q

What blood requests should be made for minor day case sugery operations such as carpal tunnel release, lipoma removal?

A

no request

17
Q

What blood requests should be made for laparoscopy, appendicectomy, cholecystectomy, hernia repair, simple hysterectomy, liver biopsy, mastectomy, varicose veins, thyroidectomy?

A

G&S

(blood transfusion e.g. cross match made if over 1 unit of blood loss)

18
Q

What bloods should be requested for colectomy, hemiarthroplasty, laparotomy, TURP, THR?

A

cross match

2 units

(blood transfusion e.g. cross match made if over 1 unit of blood loss)

19
Q

What bloods should be requested for abdominoperineal resection, hepatic/pancreatic surgery?

A

cross match

4 units

20
Q

What blood request should be made for aneruysm repair?

A

cross match

6 units

(blood transfusion e.g. cross match made if over 1 unit of blood loss)

21
Q

Legally, does consent need to be written?

A

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
  • 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
22
Q

What 4 things does consent need to be valid?

A
  1. 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
  2. Proposed Rx must be clearly understood by pt
    • Benefits, risks (complications), additional procedures, alternative courses of action & their consequences
  3. Given by a patient who has capacity (can understand, retain & weigh up the necessary information)
    • Assessment of capacity must be time & decision-specific
  4. Given voluntarily

(understand, weigh up, communicate, voluntary and w/capacity)

23
Q

Who can perform consent?

AKA whos responsibility is consent?

A

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
24
Q

What 3 parts does the WHO surgical safety checklist consist of?

A
  1. Sign in (before induction of anaesthesia)
  2. Time out (before start of surgical intervention)
  3. 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.?)

25
Q

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)
A

Sign in

to be read out before the induction of anaesthesia

26
Q

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
A

time out

(before start of surgical intervention)

27
Q

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?
A

The sign out

(before any member of the team leaves the OR)

28
Q

What score is used for anaesthetists to figure out a patients physical score of comorbidities?

A

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

29
Q

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?

A

ASA 2

A patient with mild systemic disease

30
Q

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?

A

ASA 3

a patient with severe systemic disease

31
Q

A patient has either of:

sepsis

< 3 month hx thromboembolism

What ASA score would you give them?

A

this is a patient with severe systemic disease that is a constant threat to life –> ASA 3

32
Q

A patien has

  • an ICH
  • ruptured AAA

what is the ASA score of this patient?

A

= ASA 5

because they are a moribund patient who is not expected to survive without the operation

33
Q

What is the investigation and management of the thyroid disease before a patient needs surgery (pre-op)?

A

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

34
Q

What is the investigations and managment of liver dysfunction & obstructive jaundice in the surgical patient (e.g. pre-op)?

A

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
35
Q

What are the investigations and managment of steroids in the surgical patient (e.g. pre-op)?

A
  • 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
36
Q

What are the investigations and managment of anti-coagulants in the surgical patient (e.g. pre-op)?

A

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)
37
Q

What are the investigations and managment of INSULIN TREATED DIABETES in the surgical patient (e.g. pre-op)?

A

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
38
Q

What are the investigations and managment of TABLET TREATED DIABETES in the surgical patient (e.g. pre-op)?

A

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

Critical care/Anaesthetics (4 decks)

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