Pre-operative assessment

Question 1

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

Answer 1

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

Question 2

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

Answer 2

• exercise tolerance,
• existing illness,
• drugs & allergies

Question 3

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

Answer 3

• MI
• diabetes
• asthma
• HTN
• rheumatic fever
• epilepsy
• jaundice

Question 4

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

Answer 4

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

Question 5

What questions should be asked regarding intubation and anaeathesia risk?

specific risks? DVT risk? surgery risk?

Answer 5

• 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

Question 6

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

Answer 6

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

Question 7

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

Answer 7

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

Question 8

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

Answer 8

Lithium and tricyclics - may cause arrhythmias

Tricyclics may also enhance adrenaline

while lithium may potentiate neuromuscular blocks

Question 9

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

Answer 9

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

Question 10

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

Answer 10

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

Question 11

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

Answer 11

beware hypokalaemia, dehydration

Question 12

What is a simple checklist of pre-op checks?

Answer 12

• 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?

Question 13

What questions should be asked regarding a patients drugs?

Answer 13

allergies?

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

INCLUDING OTC!

Question 14

What needs to be done in preparation for surgery?

Answer 14

• 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

Question 15

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

Answer 15

• 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

Question 16

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

Answer 16

no request

Question 17

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

Answer 17

G&S

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

Question 18

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

Answer 18

cross match

2 units

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

Question 19

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

Answer 19

cross match

4 units

Question 20

What blood request should be made for aneruysm repair?

Answer 20

cross match

6 units

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

Question 21

Legally, does consent need to be written?

Answer 21

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

Question 22

What 4 things does consent need to be valid?

Answer 22

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)

Question 23

Who can perform consent?

AKA whos responsibility is consent?

Answer 23

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

Question 24

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

Answer 24

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.?)

Question 25

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)

Answer 25

Sign in to be read out before the induction of anaesthesia

Question 26

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

Answer 26

time out | (before start of surgical intervention)

Question 27

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?

Answer 27

The sign out (before any member of the team leaves the OR)

Question 28

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

Answer 28

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

Question 29

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?

Answer 29

ASA 2 A patient with mild systemic disease

Question 30

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?

Answer 30

ASA 3 a patient with severe systemic disease

Question 31

A patient has either of: sepsis \< 3 month hx thromboembolism What ASA score would you give them?

Answer 31

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

Question 32

A patien has * an ICH * ruptured AAA what is the ASA score of this patient?

Answer 32

= ASA 5 because they are a moribund patient who is not expected to survive without the operation

Question 33

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

Answer 33

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*

Question 34

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

Answer 34

_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

Question 35

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

Answer 35

* 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

Question 36

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

Answer 36

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)

Question 37

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

Answer 37

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*

Question 38

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

Answer 38

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