Preoperative Assessment Flashcards
Which patients require an FBC at the pre-operative assessment?
Age 60 or over Significant comorbidities (ASA 3 or more) Renal disease Malignancy Haematological disorder Anaemia Infection Diabetes C-section, blood loss expected, history of blood loss, cancer surgery Eclampsia or HELLP Menorrhagia or post-menopausal bleeding
Which patients require U&Es pre-op?
Age 60 or over Diabetes Renal disease ASA 3 or more Major surgery Dehydration On anti-hypertensives History of fluid loss
Which patients require a blood glucose pre-op?
Diabetic (past or current)
Positive glucose in urine dipstick
Which additional test should be ordered for all diabetics pre-op?
HbA1c
Which patients require LFTs pre-op?
Cholecystectomy
Liver disease/mets
Jaundice
Which patients require an ECG pre-op?
Age 60 or more Any cardiovascular history Hypertension COPD Diabetes Morbid obesity Cardiac symptoms 2 or more CV risk factors + age 40 or more
When should INR be checked pre-op?
Patients on warfarin
At pre-op assessment + repeat 12-24 hours before surgery
Which patients require a clotting screen pre-op?
Severe liver disease
Clotting disorder
On anticoagulants
Which patients require urinalysis + MSSU pre-op?
Urology surgery
Joint replacement
Which patients require a CXR pre-op?
Signs of cardio-respiratory disease
- not required if no change or CXR in the last 12 months
Which patients require an echocardiogram pre-op?
Symptoms of LVF
Undiagnosed murmur
Which patients require pulmonary function tests pre-op?
Moderate/severe lung disease
Poor exercise tolerance
Which additional test should be done pre-op in patients of African, Caribbean, Eastern Mediterranean, Middle Eastern or Asian ethnicity?
Sickle cell test
What shoulda patient do with their aspirin pre-op?
Stop 7 days before surgery
What should a patient do with their clopidogrel pre-op?
Stop 7 days before surgery
Do cardiovascular drugs need to be stopped pre-op?
Majority can be continued –> cardioprotective
EXCEPT –> ACE inhibitors, ARBs + diuretics (don’t take on day of surgery)
What should a patient do with their COCP or HRT pre-op?
Stop 4 weeks before major surgery or lower limb surgery
Alternative contraception if required
What is the general rule for warfarin pre-op?
Stop 5 days before surgery to normalise INR
Can any procedures be carried out without stopping warfarin?
Yes, low bleeding risk procedures providing INR is in target range
e.g. dental work, OGD, ERCP
What is the target INR for patients on warfarin about to have an invasive surgery/procedure?
= 1.5
What is the procedure for stopping warfarin in low risk patients (the majority)?
Stop 5 days before surgery Check INR the day before surgery - if = 1.5 --> proceed - if 1.6/1.7 --> 1g oral vitamin K - if >/= 1.8 --> 2g oral vitamin K
When should warfarin be re-started after surgery?
Restart warfarin on day of surgery (its taken in the evening)
Re-check INR 48 hours after re-starting warfarin
What is the procedure for stopping warfarin in high risk patients?
The same as in low risk patients + bridging therapy
What is bridging therapy and when is it taken?
Commence on 3rd morning after last evening dose of warfarin
- unfractionated heparin or LMWH
How should diabetes be managed in the days prior to surgery?
Optimise blood glucose in the weeks/months prior to surgery
Normal medications until the day of surgery
What should be done on the day of surgery for a patient with diabetes?
Aim to put patient first on list (minimise fasting)
Check glucose + commence IV infusion of glucose + insulin
Patient can continue long acting insulin
Make sure they do not receive any short acting insulin
Check glucose hourly pre-, intra- and post- op
When can a diabetic patient return to SC insulin post-op and how is the changeover managed?
Change back to SC insulin when eating normally
Continue IV infusion for 60 minutes after first SC injection given
Which types of patient should the anaesthetist be informed about prior to the day of surgery?
Clearly difficult airways e.g. facial abnormalities, restricted mouth opening/neck movement
Grossly obese patients (BMI > 35)
Personal or family history of adverse reactions to anaesthesia
What is the fasting time for solid food pre-op?
No solid food for 6 hours
- includes cow’s milk as forms a solid with stomach acid
What is the fasting time for clear fluids pre-op?
2 hours
What is the fasting time for breast milk pre-op?
4 hours
