Preoperative consent

Question 1

What are the conditions for valid consent?

Answer 1

1. Patient must have capacity
2. Consent must be freely given and the patient must be suitably informed

Question 2

What are the 4 criteria’s for capacity?

Answer 2

1. Patient must understand information,
2. Patient must be able to retain information,
3. The patient must be able to weigh up the information.
4. Patient must be able to reach a conclusion and communicate the decision

Question 3

What is involved in a pre-operative assessment?

Answer 3

1. Pre-op history including; history of PC, PMH, past surgical history, past anaesthetic history, drug history, social history.
2. Pre-op exam including ASA grade
3. Pre-op investigations: Bloods, G&S, clotting screen
4. Other investigations depending on co-morbidities such as ECG/ECHO, Spirometry/CXR, cardiopulmonary exercise testing

Question 4

What are important pre-op history questions to specifically ask?

Answer 4

1. CV disease? - Hypertension, exercise tolerance
2. Respiratory disease?
3. Renal disease
4. Endocrine disease - Diabetes/thyroid
5. Gastro-oesophageal disease?
6. Pregnancy

Question 5

what are the fasting advice for surgical patients?

Answer 5

No food 6 hours before surgery
Sips of clear fluids till sent for surgery

Question 6

What drug are important to stop prior to surgery?

Answer 6

CHOW:
1. Clopidogrel - stopped 7 days prior to surgery. Aspirin can be continued.
2. Hypoglycaemics.
3. Oral contraceptive pill - stopped 4 weeks before surgery
4. Warfarin - stoped 5 days prior to surgery and started on LMWH
DOACs are stopped 24-72 hours before

Question 7

What drugs need altered prior to surgery?

Answer 7

1. Subcutaneous insulin - switch to variable rate IV insulin infusion.
2. Long-term steroids - must be continued but can be switched to IV. Steroids should be increased with additional IV hydrocortisone postop (first 24hr) and their normal dose should be doubled once eating/drinking for 24-72 hours

Question 8

What drugs should be started prior to surgery?

Answer 8

1. LMWH if there is VTE risk unless contraindications.
2. Anti-embolic stockings unless contraindications (PVD, neuropathy, skin grafts or serve eczema)
3. Prophylactic antibiotics (ortho, vascular or GI)

Question 9

What is the pre-op management of diabetes?

Answer 9

1. patients should be first on list.
2. Insulin should be switched to sliding scale if large operation or dose lowered.
3. Oral hypoglycaemics stopped 1 day prior.

Question 10

When is bowel prep required for surgery?

Answer 10

None is required for the following: Upper GI, HPB, small bowel surgery and right hemicolectomy.
Phosphate enema on morning of surgery for left hemi, sigmoid colectomy or abdo-perineal resection.
Laxatives are required the day before an anterior resection

Question 11

What are the alterations required pre-op for once daily insulins?

Answer 11

Reduce dose by 20% for day of surgery and morning of

Question 12

What are the changes required for type 2 diabetes drugs?

Answer 12

Metformin - take as normal
Sulphonylurea - omit on morning of surgery
DPP inhibitors - take a normal
GLP-1 analogues - take as normal
SGLT2 inhibitors - omit on day of surgery

Question 13

What are the changes required for twice daily insulin?

Answer 13

No changes except half the morning dose. Keep evening dose unchanges