Pre-Operative Care

Question 1

Examples of things that need addressed

Answer 1

• Pre-operative assessment (pre-op)
• Consent
• Bloods (including groups and save / crossmatch)
• Fasting
• Medication changes
• Venous thromboembolism assessment

Question 2

What does pre-op assessment involve

Answer 2

• Assessed if fit to undergo specific operation, exploring co-morbidities, risk from anaesthesia, frailty status, cardiorespiratory fitness and full history

Question 3

What is used to grade physical status of patient

Answer 3

ASA grade

Question 4

Describe ASA grades

Answer 4

• ASA I – normal healthy patient
• ASA II – mild systemic disease
• ASA III – severe systemic disease
• ASA IV – severe systemic disease that constantly threatens life
• ASA V – “moribund” and expected to die without the operation
• ASA VI – declared brain-dead and undergoing an organ donation operation
• E – this is used for emergency operations

Question 5

Examples of pre-operative investigations

Answer 5

• May be required, follow local guidelines
  
  • ECG if there is known or possible cardiovascular disease
  • Echocardiogram if there are heart murmurs, cardiac symptoms or heart failure
  • Lung function tests may be required if there is known or possible respiratory disease
  • Arterial blood gas testing may be required if there is known or possible respiratory disease
  • HbA1C (within the last 3 months) for people with known diabetes
  • U&Es for patients at risk of developing an acute kidney injury or electrolyte abnormalities (e.g., taking diuretics)
  • FBC may be required if there is possible anaemia, cardiovascular or kidney disease
  • Clotting testing may be required if there is known or possible liver disease
  • Group and save
  • Crossmatching
  • MRSA screening

Question 6

What is group and save

Answer 6

• Refers to sending of sample of patients blood to establish their blood group
• Sample saved incase they require blood to be matched for them
• Done when low probability they will require blood products, lasts certain time period

Question 7

What is crossmatching

Answer 7

• Taking a unit or more blood off the shelf and assigning it to the patient in case they need it quickly
• Done when higher probablity will reqquire blood products

Question 8

What fasting is done before surgery

Answer 8

• 6 hours of no food or feeds before operation
• 2 hours no clear fluids (fully nil by mouth)

Question 9

What are some specific medications often required to be changed before and after operation

Answer 9

• Anticoagulants
  
  • Warfarin needs stopped before surgery, LMWH or unfractionated heparin infusion can be used to bridge gap between stopping warfarin and surgery in higher risk patients (eg mechanical valve or recent VTE)
  • COADs stopped 24-72 hours before surgery depending on half life and kidney function
• Oestrogen-containing contraception or hormonal replacement therapy
  
  • Stopped 4 weeks before to reduce risk VTE
• Long-term corticosteroids
  
  • Needs more due to adrenal suppresion being unable to produce own additional steroids to deal with surgery
  • Can be additional IV hydrocortison at induction or double of their normal dose once eating or drinking for 24-72 hours before operation

Question 10

Options for long term corticosteroids

Answer 10

Can be additional IV hydrocortison at induction or double of their normal dose once eating or drinking for 24-72 hours before operation

Question 11

Diabetic considerations for surgery

Answer 11

• Sulfonylureas (eg gliclazide) can cause hypoglycaemia so are omitted until patient is eating and drinking
• Metformin associated with lactic acidosis
• SGLT2 inhibitors (eg dapagliflozin) can cause diabetic ketoacidosis in dehydrated or acutely unwell patients
• Follow local policy for insulin

Question 12

What is usually done for patients on insulin

Answer 12

• Continue lower dose (BNF says 80%)
• Stop short-acting insulin whilst fasting or not eating, until eating and drinking again
• Have a variable rate insulin infusion alongside a glucose, sodium chloride and potassium infusion (sliding scale) to carefully control balance

Question 13

VTE prophylaxis

Answer 13

• Follow local and national guidelines
  
  • LMWH such as enoxaparin
  • DOACs can be used as alternative
  • Intermittent pneumatic compression (inflating cuffs around legs)
  • Anti-embolic compression stockings