Pre-Operative Care

Question 1

what is the importance of the pre-op period?

Answer 1

assess surgery risks (e.g. fitness for surgery, risk factors, comorbidities)
optimise pt

Question 2

what does pre-op optimisation depend on?

Answer 2

urgency and severity of operation

Question 3

types of surgeries?

Answer 3

minor - not much physio derangement, short duration, superficial
intermediate - physio derangement, open cavity
major
major +

Question 4

examples of minor surgeries?

Answer 4

incision and drainage of abscess
lump excision

Question 5

examples of intermediate surgeries?

Answer 5

knee arthroscopy
appendicectomy
hernia repair
cholecystectomy

Question 6

examples of major surgeries?

Answer 6

laparotomy
hip replacement
knee replacement
bowel resections
hysterectomy

Question 7

examples of major plus surgery?

Answer 7

open heart surgery

Question 8

what is a myomectomy?

Answer 8

remoal of uterine muscle tissue?

Question 9

what is a myomectomy?

Answer 9

remoal of uterine muscle tissue

Question 10

urgency levels for surgeries?

Answer 10

• elective (few months)
• emergency (few weeks)
• urgency (few days)
• immediate (few hours): neurovascular compromise from NOF fracture, testicular torsion (<6h), CLI

Question 11

preassessment for elective surgeries?

Answer 11

what is the operation, name, dob

physical fitness
cardiovascular reserve
hx of anaesthetic use/any comps

pmh, dh, allergies (and deegree of allergy), sh

Question 12

how to assess cardiovascular reserve in a mobile pt?

Answer 12

ability to climb 2 flights of stairs

Question 13

what is the typical basal metabolic requirement?

Answer 13

250ml/min O2

Question 14

how much does the BMR increase by in the intraop/immediate postop period?

Answer 14

by ~4x due to physiological stress

Question 15

who has poorer cardiovascular reserves generally?

Answer 15

elderly

Question 16

how can cardiovascular reserve be assessed in non-mobile pt?

Answer 16

stress echocardiograms - inject dobutamine to increase cardiac activity, then do echo to see heart function under this stress

generally done in more severe ops

Question 17

most common drugs causing anaphylactic rxn?

Answer 17

1. penicillins
2. muscle relaxants

Question 18

how can smoking influence fitness for surgery?

Answer 18

long-standing -> reduces resp capacity/lung function

occasional -> hyperactive resp epithelium, induces liver enzymes so need higher drug dose as fast metabolism

Question 19

how can a hyperactive epithelium infelunce airway management?

Answer 19

airway instrumentation is a resp stimulant

so more prone to airway comps during induction of recovery (laryngospasms, bronchospasms)

Question 20

how can alcohol influence periop management?

Answer 20

cns depressant
acute consumption - electrolyte disturbance
chronic consumption - liver derangement -> higher dose; deficiency of clotting factors

Question 21

how can you recognise if airway mx is going to be difficult?

Answer 21

hx - prev problems, difficult airway alert, congenital anatomical disorder, comorbid condition (e.g. obesity)

exam - general appearance, specific tests (mallampati, cormacke-lehane)

special investigations (rarely used) - ct, nasal endoscopy

Question 22

what does the mallampati score assess?

Answer 22

visual assessment of tongue base to mouth roof, thus amt of space in which there is to work

indirect way of assessing how difficult an intubation will be

Question 23

describe the mallampati scoring system?

Answer 23

Class I: Soft palate, uvula, fauces, pillars visible.

Class II: Soft palate, major part of uvula, fauces visible.

Class III: Soft palate, base of uvula visible.

Class IV: Only hard palate visible.

note - can intubate all grades

Question 24

what is looked for in examination of the airway?

Answer 24

general assessment of mouth, chin
- scarring
- burn marks
- contractures

can they open mouth as wide as 3 finger breadths?
assess jaw mobility
assess neck mobility
mallampati

Question 25

what may affect mouth opening?

Answer 25

TMJ issues
multiple sclerosis
etc

Question 26

how can neck mobility be assessed?

Answer 26

thyromental or sternomental distance at full neck extension

look up - check if chin higher than occipitus

Question 27

why is neck mobility important?

Answer 27

if the neck is immobile, interferes with ability to align pharyngeal axis, oral axis, laryngeal axis

Question 28

how to assess jaw mobility?

Answer 28

protrude lower jaw beyond upper jaw

Question 29

what are standard ix for elective procedures?

Answer 29

bloods - fbc, u&e, lft, bm
g&s + x-match
ecg

if needed:
echo, exercise ecg

Question 30

what is done in optimisation before surgery?

Answer 30

if new dx detected, refer appropriately and treat this, postponing surgery

if uncontrolled disease, then modify/stop treatment

lifestyle - diet and exercise, smoking

correct any anaemia

Question 31

what drugs would not be started in optimisation?

Answer 31

abx - given as prophylaxis during induciton instead of premedication

Question 32

when are acei/arb stopped before surgery?

Answer 32

stopped if BP is well-controlled as they may otherwise exaggerate the hypotensive effects of anaesthesia

Question 33

when are hypoglycaemics stopped before surgery?

Answer 33

on day of surgery

Question 34

when are anticoagulants stopped before surgery? CHECK

Answer 34

stop clopidogrel 5 days prior
stop rivaroxaban 3-4 days prior
stop warfarin, but give bridging LMWH to avoid comps (e.g. PE)