Pre Operative Assessment

Description

This is an interactive session on one of the core topics of anaesthesia: pre-operative assessment including history taking and examination, tests and investigations, ASA grading, risk and consenting.

We will be using Vevox during the talk which participants can join through a QR code. There will be MCQs throughout the talk and a short quiz at the end – all anonymous.

Presented by Dr Jesymin Choong, ACCS CT2 Trainee in the East of England

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Computer generated transcript

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ANAESTHESIA PERIOPERATIVEASSESSMENT Dr Jesymin ChoongACCS CT2AGENDA The purpose of pre-operative assessment History & examination Airway assessment ASA grading SAMPLE FOOTER TEXT 20XX 2PRE-OPERATIVEASSESSMENT &VISIT Pre-op assessment = preadmission assessment Pre-op visit = a meeting between a patient and their anaesthetist,usually on the day of surgery. Join at vevox.app Or searchVevox in the app store ID:175-255-290 Join:vevox.app ID:175-255-290 POLL OPEN WHAT BEST DESCRIBEDYOUR DA Y? 1. ^V^ 0% 2. o.O 0% 3. TT^TT 0% 4. Zzzz 0% 5. ? 0% 5 Join:vevox.app ID:175-255-290 POLL OPEN WHICH OFTHE FOLLOWING IS LIKEL YTHE MOST IMPORTANT PURPOSE FOR PRE-OPVISIT? 1. Arranging required investigations 0% 2. Obtaining consent for procedure/anaesthesia 0% 3. Identify any change in patient's condition since pre-op assessment 0% 4. Stopping medications that would cause negative impacts during surgery 0% SAMPLE FOOTER TEXT 20XX 6THE PURPOSE PRE-OPASSESSMENT PRE-OP VISIT  Reduce patient risk  Check that preadmission assessment has occurred  Prepare the staff and equipment required for  Check that identified problems have been planned surgery for and managed  Prepare staff and facilities for postoperative cae Whether the patient’s condition has changed 7 Join:vevox.app ID:175-255-290 POLL OPEN WHICH EFFECT DOES GENERALANAESTHESIA HAVE ONTHE BODY? Vote for up to 4 choices 1. Peripheral vasolidation 2. Loss of airway reflexes 3. Reduce nerve impulse conduction in the central nervous system 4. Loss of muscle tone 5. Decrease blood glucose 6. Increase core temperature SAMPLE FOOTER TEXT 20XX 8PERIOPERA TIVEASSESSMENT  One of the important reasons for pre-operative assessment is to assess the risk of not surviving surgery. 9MORTALITY RISK 1.5x 1.2x 2x • Myocardial infarction (MI)  Angina  Type 2 diabetes • Heart failure  TIA ** (Risk is 3x ifType I) • SBP>160mmHg • Stroke • Renal failure (creatinine >150 μmol/L) • Peripheral arterial disease 10RESPIRATORY DISEASES  Asthma  COPD  Smoker – cigarettes,roll-up,cannabis 11OPTIMISING RISK FACTORS  Treating hypertension  Glycaemic control  Cholesterol  Optimising cardiac & respiratory conditions  Weight loss in overweight/obese patient 12FASTING  General anaesthesia and sedation inhibit the protective reflexes that stop the stomach contents reaching the trachea and lungs.  If this occurs,it may lead to pulmonary damage,aspiration pneumonia and even death. SAMPLE FOOTER TEXT 20XX 13 Join:vevox.app ID:175-255-290 POLL OPEN HOW LONG SHOULD PATIENT BE FASTED PRIORTO SURGERY? 1. 4 hours for food,2 hours for liquid 0% 2. 4 hours for both food & liquid 0% 3. 6 hours for food,2 hours for liquid 0% 4. 6 hours for both food & liquid 0% SAMPLE FOOTER TEXT 20XX 14 Join:vevox.app ID:175-255-290 POLL OPEN IS MILK FOOD OR LIQUID? 1. Food 0% 2. Liquid 0% SAMPLE FOOTER TEXT 20XX 15 MEDICA TIONS SAMPLE FOOTER TEXT 20X6X Join:vevox.app ID:175-255-290 POLL OPEN A PATIENT IS DUE FOR SURGERYAT 8AM.HE HAS BEEN FASTED SINCE MIDNIGHTAND IS DUE HIS MORNING ORAL MEDICATIONS AT 6AM,CAN HE HAVE HIS MEDICATIONS? 1. Yes 0% 2. No 0% SAMPLE FOOTER TEXT 20XX 17 Join:vevox.app ID:175-255-290 POLL OPEN WHICH OFTHE FOLLOWING MEDICATION(S) SHOULD BE STOPPED PRIORTO SURGERY? Vote for up to 4 choices 1. aspirin 0% 2. clopidogrel 0% 3. warfarin 0% 4. beta-blocker eg,bisoprolol 0% 5. calcium channel blocker eg,amlodipine 0% 6. ACE inhibitor eg,ramipril 0% 7. Angiotensin II blocker eg,losartan 0% (% = Percentage ofVoters) 18MEDICATIONS  Aspirin – at low dose 75mg risk of bleeding < risk of thrombosis  ACE inhibitors - more likely to have profound hypotensive episodes with regional and general anaesthesia  Warfarin - the last dose should be taken 5 days before surgeries for which the risk of bleeding exceeds the risk of thromboses.If high risk of thrombosis,warfarin can be replaced by subcutaneous high dose low-molecular weight heparin,given at home before admission.  Clopidogrel – stop 5 days before surgery  Beta blockers & calcium channel blockers – CVS protective effect. 19 Join:vevox.app ID:175-255-290 POLL OPEN WHICH OFTHE FOLLOWING SHOULD BE STOPPED BEFORE SURGERY? Vote for up to 2 choices 1. proton pump inhibitors eg,lansoprazole 0% 2. oral steroids eg,prednisolone 0% 3. sulphonylurea eg,glicazide 0% 4. metformin 0% 5. long acting insulin eg,lantus 0% (% = Percentage ofVoters) SAMPLE FOOTER TEXT 20XX 20 Join:vevox.app ID:175-255-290 POLL OPEN WHICH OFTHE FOLLOWING SHOULD BE STOPPED BEFORE SURGERY? 1. oral morphine solution 0% 2. morphine sulfate modified released 0% 3. gabapentin 0% 4. amitriptylline 0% 5. paracetamol 0% 6. none 0% SAMPLE FOOTER TEXT 20XX 21MEDICATIONS  Diabetes drugs – continue long acting insulin +/- insulin infusion,stop oral hypoglycaemic agent  Never stop inhalers and steroids!  Do not stop usual pain relief,other than NSAIDs if concerns regarding platelets function or risk of bleeding 22AIRWA YASSESSMENT LEMON  Look externally  Evaluate 3-3-2 rules  Mallampati score  Obstruction  Neck movement Dentition BMI 23 Join:vevox.app ID:175-255-290POLL OPEN WHOWOULDYOU CHOOSETO INTUBATE? B A 1. A 0% 2. B 0% 3. C 0% 4. D 0% C D 24 ASA Physical status Grade ASA GRADING 1 Normal health patient  American Society of 2 A patient with mild systemic disease without functional limitation Anesthesiologists (ASA) system of grading physical status. 3 A patient with severe systemic disease which limit function 4 A patient with severe systemic disease that is a constant threat to life 5 A moribund patient who is not expected to survive with or without the operation 6 A declared brain-dead patient whose organs are being removed for donor purposes E Suffix added for any emergency 25 Join:vevox.app ID:175-255-290 POLL OPEN 78 years old female,known COPD,poorly controlled type 2 diabetes,previous myocardial infarction and has a pacemaker in situ for complete heart block. What is herASA? 1. 1 0% 2. 2 0% 3. 3 0% 4. 4 0% 5. 5 0% SAMPLE FOOTER TEXT 20XX 26 Join:vevox.app ID:175-255-290 POLL OPEN 28 years old male,fit and well,smokes 25 cigarettes per day since age 18. What is hisASA? 1. 1 0% 2. 2 0% 3. 3 0% 4. 4 0% 5. 5 0% 2728 Join:vevox.app ID:175-255-290 POLL OPEN WHICH OFTHE FOLLOWING CONDITION CARRIESTHE HIGHEST RISK OF SURGICAL MORTALITY? 1. Previous myocardial infraction 0% 2. High blood pressure 0% 3. Type 1 diabetes 0% 4. Stroke 0% 5. Angina 0% 29 Join:vevox.app ID:175-255-290 POLL OPEN MRS B HADATOAST &A CUP OF BLACK COFFEEAT 6AMTODAY .WHEN IS THE EARLIEST POSSIBLETIME SHE CAN HAVE HER SURGERY SAFELY? 1. 8am 0% 2. 10am 0% 3. 12pm 0% 4. 2pm 0% 30 Join:vevox.app ID:175-255-290 POLL OPEN WHICH OFTHE FOLLOWING IS NOTA RISK FACTOR FOR DIFFICULTAIRWA Y? 1. Protruding anterior teeth 0% 2. Restricted neck extension 0% 3. Facial burns 0% 4. Wide mouth opening 0% 5. Morbid obesity 0% 31 Join:vevox.app ID:175-255-290 POLL OPEN HOW MANY DA YS BEFORE SURGERYWARFARIN SHOULD BE STOPPED? 1. 3 0% 2. 5 0% 3. 7 0% 4. 10 0% 32SUMMARY The purpose of pre-operative assessment is to optimise patient’s condition and ensure preparation is in place for surgery to be conducted as safe as possible. Airway assessment – remember the LEMON rule. Fasting;at least 2 hours for fluid and 6 hours for food. ASA grading 33THANKYOU Any questions?