Preoperative Assesment - ASA classification, Preop Assessment, Bloods, Imaging, Medication Management, Fasting Flashcards
ASA classification - I
Normal healthy patient
Healthy
Non smoker
No/mininal alcohol use
ASA classification - II
Mild systemic disease without substansive functional limitations
Current smoker
Social alcohol drinker
Pregnany
Obese
Controlled DM, HTN, mild lung disease
ASA classification - III
Severe systemic disease with substantive functional limitations
1+ moderate/severe diseases
-poorly controlled DM, HTN, COPD
-Morbid obesity BMI 40+
-active hepatitis
-alcohol dependence/abuse
-implanted pacemaker, moderate reduction of ejection fraction
-ESRF with regular dialysis
-MI, CVAs 3months+ ago
ASA classification - IV
Severe systemic disease that is a constant threat to life
-MI, CVA within last 3months
-ongoing cardiac ischemia, valve dysfunction
-severe reduction of ejection fraction
-sepsis, DIC, ARD
-ESKF without regular dialysis
ASA classification - V
Moribund patient not expected to survive without the operation
Ruptured abdominal/thoracic aneurysm
Massive trauma
Intracranial bleed with mass effect
Ischemic bowel in the face of significant cardiac pathology or multiple organ dysfunction
ASA classification - VI
Brain dead whose organs are being removed for donor purposes
Preoperative assesment
-history - purpose and areas to cover
-examination
Assess fitness for surgery
Anticipate difficulties/requirements and plan for these
PC, HPC
SurgHx, AnaestheticHx
PMHx
DHx
-current medications, doses, timings
-allergies, reactions
-medications that need to be stopped - OCPs, AC, AP
SH
-smoking, drinking
-mobility, ADLs
General examination - overall wellness
-habitus
-anemia, jaundice, cyanosis
Auscultate lungs and heart - assess for undetected resp problems
-assess for undetected murmurs which may need intervention
Preop bloods and imaging
Establish a baseline to allow for post-op assessment and monitoring
FBC - identify low RBC,PLT to assess bleeding risk
-if anemic and likely to have significant blood loss, may have pre-op Fe or transfuions
G&S, X - especially in emergencies or procedures likely to cause significant blood loss
Coagulation - assess bleeding risk
U&E -baseline renal function, creatinine, electrolytes
LFTs if
-gallbladder or liver surgery
-RUQ pain, jaundice, known hepatic dysfunction
-Hx of alcohol abuse
Urinedip if
-emergency presentation of abdo/pelvic pain
-any surgery in diabetics
-women of childbearing age with abdominal symptoms or if they need radiography
Pregnancy test!
Lung function testing
-assess for any issues with ventilation
ECG, CXR if
-Cardiac or CVD Hx
-cardiovascular surgery
-Resp symptoms, signs, Hx
-risk factors for TB, thyroid enlargement, malignancy
Imaging based on procedure
Medications to stop/adjust before surgery
OCP
AP, AC
Diabetic drugs
Steroids
Management of OCP
Stop 4 weeks before major or limb surgery
Restart 2 weeks after surgery or full ambulation
Management of AP and AC
AP - stop 7-14 days before surgery
Restart 24hrs after surgery
Warfarin stopped 3-5 days before, replaced with heparin
Heparin stopped 6-12 hours before
Restart warfarin 12-24 hours after
Management of steroids
Continued or increased if concerns over Addisonian crisis
Importance of managing diabetes during surgery
Undetected hypoglycemia under GA
Increased risk of wound and respiratory infections
Increased risk of post-op AKI
Increased LOS
Insulin management
-Lantus, Levemir (once daily)
-Novomix, Humulin (twice daily biphasic or ultra long acting)
Lantus, Levemir (once daily
Day before - reduce dose by 20%
AM or PM surgery - reduce dose by 20%
Novomix, Humulin (twice daily biphasic, ultra long acting)
Day before - no change
AM or PM surgery - 1/2 morning dose, full PM dose
Metformin management
Day before - normal
AM or PM surgery
-OD or BD => normal
-TDS => omit lunchtime dose
