Preoperative assessment

Question 1

Define emergency / urgent / elective surgery

Answer 1

Emergency - must be done within 1 hour
Urgent - must be done within 24 hours
Elective - No urgency - a pre-determined booked time

Question 2

Describe the triage system used at GSH to assign urgency to unplanned surgeries

Answer 2

Red: (Immediate)
Unstable bleeding gunshot
Imminently threatened airway
Ruptured AAA

Orange: (1 - 3 hours)
Acute abdomen d/t bowel perforation
Ectopic pregnancy ruptured/about to

Yellow: (< 6 hours)
Stable appendicitis
Open fractures

Green (<24 hours)
Stable, closed fractures
Changing of dressings
Cancer surgery

Blue (Elective surgery)

Question 3

What are the 6 components of informed consent

Answer 3

1. Advance
2. Writing,
3. Informed (Describe, Risk/ben, conseq, alternatives)
4. Voluntary (exclude duress),
5. Legally competent,
6. Witnessed: 3 signatures: 1 independent medical practitioner and 2 witnesses (not anaesthetist)

Question 4

What are the legal ages for consent for various types of procedures in RSA

Answer 4

Medical Rx - 12 yrs
Surgical Rx - 12 yrs
HIV Test - 12 years
TOP - no lower age 
Contraception - 12 years

Virginity - 16 yrs
Circumcision - 16 yrs
Sexual Intercourse - 16 yrs

Sterilization - 18 yrs

Interns cannot take consent - they are not independent medical practitioner

Question 5

What should be done about informed consent in the following circumstances:

1. Parent/Guardian not present or contactable
2. Unconscious/Incompetent patient

Answer 5

The surgeon accepts the responsibility of consent but must notify the Medical Superintendent of the problem prior to surgery.

Question 6

What is the heirarchy of an ‘authorized person’

Answer 6

1. Proxy nominated in patients writing
2. Person authorised by court/law
3. Spouse
4. Parent
5. Grandparent
6. Adult Child
7. Brother or sister

Question 7

Define the ASA classification

Answer 7

I - A normal healthy patient
II - Mild systemic disease without fxnal limitation
III - Severe systemic disease with fxnal limitation
IV - Systemic disease is a constant threat to life
V - Moribund: dead with or without surgery
VI - Brain-dead awaiting organ harvest

Question 8

When should oral hypoglycaemics be stopped and why

Answer 8

The day before theatre to avoid hypoglycaemia in fasting patients
Insulin sliding scale with glucose monitoring often required

Question 9

What should be done for patient’s on antifailure treatment including: diuretics/digoxin/K supplements

Answer 9

Check electrolytes

Question 10

Which medications should be discontinued before surgery and when should these be discontinued

Answer 10

1. Oral hypoglycaemics (Glibenclamide, gliclazide) - 1 day before (omit bolus and long acting insulin)
2. Warfarin - 4-5 days before INR < 1.5
3. ACEI (enalapril) - day before
4. Enoxaparin > 12 hours before surgery

Question 11

Should BB/CCB/Diuretics be continued before surgery

Answer 11

YES (check electrolytes)

Question 12

Describe management of patients with adrenal insufficiency or patients who have been on > 5mg of prednisone daily (or equivalent) for > 4 weeks

Answer 12

1. Hydrocortisone 200mg intraop
2. Hydrocortisone 50 mg IM over next 24 hours
3. Double regular dose of enteral steroid for 2 - 7 days depending on surgery and patient.

Question 13

What alterations in chronic asthma therapy should be made prior to surgery

Answer 13

Continue all preventers and relievers

Consider 5 day of prednisone 4mg daily to optimise prior to surgery

Question 14

Should NSAIDS be stopped prior to major surgery

Answer 14

This should be considered where any effect on coagulation may be critical

• Airway surgery
• Neurosurgery

Question 15

Should statins be discontinued before surgery

Answer 15

No. They also have anti-inflammatory action

Question 16

Why should antiviral agents not be stopped prior to surgery and what are the problems with this

Answer 16

Increased antiviral resistance
Interactions with anaesthetic agents
- Overall: Enhanced toxic effects of most anaesthetic agents

Question 17

Should aspirin be continued perioperatively

Answer 17

yes

Question 18

When should clopidogrel be stopped prior to surgery

Answer 18

Drug eluting stent placement
- Postpone elective surgery for 1 year

Other stents
- Postpone elective surgery for 1 month

Exceeding the above timeframes clopidogrel should be stopped 5 days before surgery (discuss and confirm with cardiologist)

Question 19

Psychiatric therapy

Answer 19

Continue therapy bt be aware that there are many enzymes induced and inhibited –> drug interactions with the risk the SSRIs and risk of serotonin syndrome

Question 20

Should the oral contraceptive be continued prior to surgery?

Answer 20

Ideally yes - stop for one month prior as it increases risk of VTE

Question 21

OTC drugs pre-op

Answer 21

Ascertain which ones and look it up

Question 22

What is the principle that should guide pre-operative investigations

Answer 22

Abnormal results –> there must be increased risk to patient

Normal results –> there must be reduced risk to patient

Question 23

Who gets ward Hb

Answer 23

Everyone

Question 24

Which age group automatically gets ECG, UE, URINE

Answer 24

> 45

Question 25

Who should have a pregnancy test

Answer 25

Females of child bearing age

Question 26

Which patients should undergo pulmonary function tests

Answer 26

Uncharacterised dyspnoea
Unexplained exercise intolerance
Admission for respiratory aetiology
Oral steroid use in the last year

Question 27

Which asthmatic patients require spirometry prior to surgery

Answer 27

Older asthmatics

Symptomatic asthmatics

Question 28

Which COPD patients require spirometry

Answer 28

Severe COPD (PMHx, PEFR, exertional tolerance)

Question 29

Which other patients may require PFT/spirometry

Answer 29

Previous lung surgery