Preoperative Assessment

Question 1

Which patients require an FBC at the pre-operative assessment?

Answer 1

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

Question 2

Which patients require U&Es pre-op?

Answer 2

Age 60 or over
Diabetes
Renal disease
ASA 3 or more
Major surgery
Dehydration
On anti-hypertensives
History of fluid loss

Question 3

Which patients require a blood glucose pre-op?

Answer 3

Diabetic (past or current)

Positive glucose in urine dipstick

Question 4

Which additional test should be ordered for all diabetics pre-op?

Answer 4

HbA1c

Question 5

Which patients require LFTs pre-op?

Answer 5

Cholecystectomy
Liver disease/mets
Jaundice

Question 6

Which patients require an ECG pre-op?

Answer 6

Age 60 or more
Any cardiovascular history
Hypertension
COPD
Diabetes
Morbid obesity
Cardiac symptoms
2 or more CV risk factors + age 40 or more

Question 7

When should INR be checked pre-op?

Answer 7

Patients on warfarin

At pre-op assessment + repeat 12-24 hours before surgery

Question 8

Which patients require a clotting screen pre-op?

Answer 8

Severe liver disease
Clotting disorder
On anticoagulants

Question 9

Which patients require urinalysis + MSSU pre-op?

Answer 9

Urology surgery

Joint replacement

Question 10

Which patients require a CXR pre-op?

Answer 10

Signs of cardio-respiratory disease

- not required if no change or CXR in the last 12 months

Question 11

Which patients require an echocardiogram pre-op?

Answer 11

Symptoms of LVF

Undiagnosed murmur

Question 12

Which patients require pulmonary function tests pre-op?

Answer 12

Moderate/severe lung disease

Poor exercise tolerance

Question 13

Which additional test should be done pre-op in patients of African, Caribbean, Eastern Mediterranean, Middle Eastern or Asian ethnicity?

Answer 13

Sickle cell test

Question 14

What shoulda patient do with their aspirin pre-op?

Answer 14

Stop 7 days before surgery

Question 15

What should a patient do with their clopidogrel pre-op?

Answer 15

Stop 7 days before surgery

Question 16

Do cardiovascular drugs need to be stopped pre-op?

Answer 16

Majority can be continued –> cardioprotective

EXCEPT –> ACE inhibitors, ARBs + diuretics (don’t take on day of surgery)

Question 17

What should a patient do with their COCP or HRT pre-op?

Answer 17

Stop 4 weeks before major surgery or lower limb surgery

Alternative contraception if required

Question 18

What is the general rule for warfarin pre-op?

Answer 18

Stop 5 days before surgery to normalise INR

Question 19

Can any procedures be carried out without stopping warfarin?

Answer 19

Yes, low bleeding risk procedures providing INR is in target range
e.g. dental work, OGD, ERCP

Question 20

What is the target INR for patients on warfarin about to have an invasive surgery/procedure?

Answer 20

= 1.5

Question 21

What is the procedure for stopping warfarin in low risk patients (the majority)?

Answer 21

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

Question 22

When should warfarin be re-started after surgery?

Answer 22

Restart warfarin on day of surgery (its taken in the evening)
Re-check INR 48 hours after re-starting warfarin

Question 23

What is the procedure for stopping warfarin in high risk patients?

Answer 23

The same as in low risk patients + bridging therapy

Question 24

What is bridging therapy and when is it taken?

Answer 24

Commence on 3rd morning after last evening dose of warfarin

- unfractionated heparin or LMWH

Question 25

How should diabetes be managed in the days prior to surgery?

Answer 25

Optimise blood glucose in the weeks/months prior to surgery

Normal medications until the day of surgery

Question 26

What should be done on the day of surgery for a patient with diabetes?

Answer 26

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

Question 27

When can a diabetic patient return to SC insulin post-op and how is the changeover managed?

Answer 27

Change back to SC insulin when eating normally

Continue IV infusion for 60 minutes after first SC injection given

Question 28

Which types of patient should the anaesthetist be informed about prior to the day of surgery?

Answer 28

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

Question 29

What is the fasting time for solid food pre-op?

Answer 29

No solid food for 6 hours

- includes cow’s milk as forms a solid with stomach acid

Question 30

What is the fasting time for clear fluids pre-op?

Answer 30

2 hours

Question 31

What is the fasting time for breast milk pre-op?

Answer 31

4 hours