Preoperative Preparation Flashcards
Complications during past surgery and anesthesia to be asked during history
1- intraabdominal adhesions
2- suxamethonium apnea
3- family history of problems with apnea
Laparoscopic procedures are inappropriate in which patients
Those who cannot tolerate
1- pneumoperitoneum
2- head down positioning
Infections to be checked and treated in the preoperative period
1- infected toes
2- pressure sores
3- teeth
4- urine (if surgery is not elective but emergent give antibiotics and maintain urine output throughout)
5- chest infections (delay elective surgery for 4-6 weeks)
Prep investigations to be done in all patients
1- FBC
2- sickle cell trait in patients of afrocarribean origin
3- urea and electrolytes
4- urinalysis (dipstick test)
In which patients preop ECG is done
Patients over the age of 60 Cardiovascular Renal Cerebrovascular involvement Diabetes Patients with severe respiratory problems
Preop management of patients with systemic disease
1- check baseline organ function capacity
2- optimisation
3- alternative
4- theatre preparations
Echo is done in which patients
Symptomatic valvular disease or poor left ventricular output
Critical ejection fraction
Less than 30 percent
Refer patient to cardiologist if
1- murmur and patient is symptomatic
2- poor left ventricular output or known cardiomegaly
3- silent MI on ecg
4- abnormal rhythm on ecg
Blood pressure ideal for surgery
160/90
New antihypertensive should be given how much time
Atleast 2 weeks
How long to delay surgery after MI
3-6 months
How long to delay surgery after stent placement
After the stoppage of dual antiplatelet therapy
1- 6 weeks in metal stent
2- 12 months in drug eluting stent
If surgery cannot be postponed can antiplatelets be continued during it
Yes.
Better to discontinue clopidogrel
And continue aspirin.
But if possible stop aspirin 7 days before and clopidogrel 10 days before
How long before surgery should warfarin be stopped (patients of A fib, mechanical heart valves)
Atleast 5 days.
Unfractionated heparin is given in this time period and it is also discontinued 2 hours before surgery
Consequences of the use of bipolar diathermy in pacemaker patients
Pacemaker detects it as ventricular fibrillation. So turn pacemaker off preoperatively or set it to VOO mode(ventricle pacing. Not sensed with no response to sensing)
If patient found to have heart block preoperatively
Temporary pacemaker insertion is required
Jehovah’s Witness and blood transfusion alternatives
1- cell salvage
2- reinfusion from drains
Asthmatic Patients prior to surgery require
Additional dose of bronchodilators and additional steroid coverage (esp if already taking 10 mg or more of prednisolone) and are ‘Brittle asthmatics’
Critical FEV1
Less than 30 percent
Can patients still take medications in the NPO period
Yes with sips of water
Which patients are at extra risk of pulmonary aspiration despite NPO
Hiatus hernia patients Obese Pregnant Diabetes (Give them antacids, h2 blockers and omeprazole)
Preop prep of renal disease patients
Acidosis
Hypocalcemia
Hyperkalemia of greater than 6mmol/l need to be corrected
Patients on dialysis before surgery
Dialysis should be discontinued a few hours before surgery and after last dialysis send patient for FBC and urea and electrolytes
Acute renal failure patients undergoing surgery
Concomitant medical and surgical management
Management of malnutrition before surgery
BMi less than 15. Give nutritive support for 2 weeks.
BMi greater than 35. ask patients to reduce weight. Check for sleep apnea via perioperative sleep apnea prediction scoring. Give CPAP device
Diabetic patients going for surgery
Check blood sugar every 2 hours.
Put them first on list.
If morning surgery. Skip breakfast and morning dose.
If evening surgery. Breakfast with half dose of insulin or full dose of oral antidiabetic drugs can be given
Can you give contraceptive pills in the perioperative period
Progerestone only. Yes
Combined. Do risk benefit analysis.
HRT stop 6 weeks before surgery.
Risk factors for thrombosis during surgery
1 - age greater than 60 2- BMi greater than 30 3- anesthesia for greater than 90 minutes 4- reduced mobility for 3 days 5- pregnancy 6- varicose veins 7- contraceptive pills 8- known active cancer 9- deficiency in antithrombin 3. Protein C or S
Which neurological medications can be given perioperatively
Anticonvulsants
Antiparkinson drugs
Which psychiatric medication has to be discontinued
Lithium atleast 24 hours before and check blood levels to exclude toxicity.
If patient is on tricyclics or monoamine oxidase inhibitors inform anesthesia as these may interact
Preoperative preparation in rheumatoid arthritis patients
There is possibility of spinal cord injury during intubation so get flexion and extension lateral cervical spine x rays
Problems likely to be encountered in anklyosing spondylitis patients preoperatively
Spinal or epidural anesthesia can be challenging
SLE patients in surgery
Increased risk of thrombosis and airway obstruction
Risk of death
Doubles with every 7 years of life lived.
MI. Heart failure. Stroke. Peripheral vascular disease. Renal failure. Each independently increases risk of death by 1.5 times.
Gillicks competence
Patients under 16 who seem to understand the risks of surgery and are deemed competent for consent
Which patients should be prioritised on the list
Children
Diabetics
Life and limb threatening surgery
Cancer patients
Consent - LED TO REASON
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