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U tm ateO SC Eseries Pr-opertveassesm ent DeliveDr. Shahriar GhadiriDisclaimer BIDA SW teaching is led by students with supervision of junior doctors and consultants across the UK. These teachings are created to support students’ learning but should not replace your local Medical School teaching material.Learning Outcomes Understand the outline of Pre-op management Review Discuss the communication require pre-operatively Recognize Understand the different scoring systems used in surgery Understand the different drugs to stop/start Apply List the appropriate investigationsReason for evaluation • Anaesthesia and surgery are physiologically stressful and invasive interventions which may exacerbate or uncover underlying disease. • Some of the most feared complications include catastrophic events such as MI, difficulty oxygenating or ventilating, among others. • A proper pre-operative assessment allows the ability to stratify and reduce risk.Why is anaesthesia risky? • There can be difficulty obtaining an airway to adequately oxygenate and ventilate • Induction: iat a time of haemodynamic stress, patients may become hypotensive from the induction agents or hypertensive with laryngoscopy and intubation. • Maintenance: differing degrees of stimulation, fluid shifts, blood loss. • Emergence: physiologically stressful, secure airway may be lost, hypothermia. • Anaphylactic reactions to medications, injury during laryngoscopy, neuropathy from positioning. • Spinal/epidural carries risk: inadequate, need to convert to general.Outline • One outline that can be used • RAPRIOP • Reassurance • Advise (Communication) • Prescription • Referral • Investigations • Observations • Patient understandingCommunication • Reassurance • Patients will be anxious. Recognition of this and a kind word. • Advice – regarding fasting • Stop eating – 6 hours before • Stop dairy products (including tea and coffee) – 6 hours before • Stop clear fluids – 2 hours before • Chewing gum – 2 hours before • Why ?Communication • Pre-operative History • History of presenting complain • Past medical history • Past surgical history • Past anaesthetic history • Drug History • Family History • Social History • Allergy • Specific questionsPast Medical history • A full past medical history (PMH) is required, with the following specifically asked about: • Cardiovascular disease, including hypertension; exercise tolerance is a useful indicator of cardiovascular fitness and, particularly for patients undergoing major surgery, can help predict their risk of post- operative complications and level of care needed post-operatively • investigation, e.g. the presence of exertional chest pain, syncopal episodes, or orthopnoea• Respiratory disease, as adequate oxygenation and ventilation is essential in reducing the risk of acute ischaemic events in the peri-operative period •prolonged period or has a chronic cough are key as these may for a preclude spinal anaesthesia; also screen for symptoms and signs of obstructive sleep apnoea, if the patient has any risk factors• Renal disease, including their baseline renal function and any renal- specific medications • Endocrine disease, specifically diabetes mellitus and thyroid disease • Gastro-oeseophageal reflux (GORD), as the aspiration of gastric contents can potentially be fatal and the presence of GORD will likely alter anaesthetic technique • Whilst this may be overlooked as a diagnosis or in their past medical history, particularly if patient managed with over-the-counter medicines, it is important to ask about at the pre-operative assessment• Pregnancy – as part of the pre-operative checklist on the day of surgery, for females of reproductive age a urinary pregnancy test is mandatory in the majority of hospitals • Sickle Cell Disease – could they have undiagnosed sickle cell disease, especially if their country of birth does not have routine screening for sickle cellPast Surgical History • Has the patient had any previous operations? If so, what, when, and why? •change both the surgical time and ease of operation, and hencecantly influence the anaesthetic technique usedPast Anaesthetic History • Has the patient had anaesthesia before? If so, for what operation patient experience any post-operative nausea and vomiting? theFamily history • Whilst most hereditary conditions relating to anaesthesia are extremely rare, such as malignant hyperthermia, it is important to ask about any known family history of problems with anaesthesia • Malignant hyperthermia (MH) – a rare reaction to volatile anaesthetic agents and neuromuscular blocking drugs that can cause dangerously high body temperature and muscle contractions • Suxamethonium apnoea – a deficiency in enzymes required to break down suxamethonium, resulting in prolonged paralysis of skeletal muscle • Anaphylaxis.Social History • Ensure to ask the patient about smoking history, alcohol intake, and any recreational drug use • Other important social factors to make note of include: • Language spoken and the need for an interpreter • Living situation, as the absence of an adult at home may require an admission overnightAllergy • List all allergies and intolerances, regardless of the severity • Ask specifically about penicillin • Ask specifically about NSAIDsSpecific questions • Dentition – Caps/crowns/ loose teeth Why ? • Consent: Ensure the patient has consented appropriately for their operation AND anaesthetic. • Senior advice: Anything you’re unsure about should be discussed with a senior or with anaesthetist responsible for the surgical list.Scores • Surgical Severity score • Grade 1 – diagnostic endoscopy, laparoscopy, breast biopsy • Grade 2 – inguinal hernia, varicose veins, adenotonsillectomy, knee arthroscopy • Grade 3 – total abdominal hysterectomy, TURP, thyroidectomy • Grade 4 – total joint replacement, artery reconstruction, colonic resection, neck dissection • ASA – American Society of Anaesthetist Score 1. Normal healthy patient 2. Mild systemic disease (e.g. asthma) 3. Severe systemic disease 4. Severe systemic disease that is a constant threat to life 5. Moribund patient, not expected to survive without the operation 6. Declared brain-dead patient – organ removal for donor purposesOther Risk Assessment scoring tools • NELA – National Emergency Laparotomy Audit • SORT – Surgical Outcome Risk Tool • POSSUM – Physiological and Operative Severity Score for the enumeration of Mortality and MorbidityScores • Scores for assessing airway • MallampatiWilson's Score • Score <5 suggests easy laryngoscopy • Score 5-8 suggests potentially difficult laryngoscopy • Score 8-10 indicates a risk of severe difficulty in laryngoscopy • Scoring system is not frequently usedWilson's ScorePrescription changes • Drugs to stop • Clopidogrel – stopped 7 days prior to surgery • (Aspirin, dipyridamole and NSAIDs can be continued) • ACEi – withheld on morning of surgery • Oral contraceptive pill (OCP) or Hormone Replacement Therapy (HRT) – stopped 4 weeks before surgery • Warfarin – usually stopped 6 days prior to surgery – if emergency consider INR and vit k • NOACs – Apixaban, Dabigatran wait 48hrs before neuroaxial block • LMWH – Prophylactic dose enoxaparin: wait 12 hours before neuroaxial block • LMWH – Treatment dose enoxaparin: wait 24 hours before neuroaxial blockPrescription changes • Drugs to alter • Subcutaneous insulin – may be switched to IV variable rate insulin infusion (continue long acting insulin) • Long-term steroids – must be continued, due to the risk of Addisonion crisis if stopped • If the patient cannot take these orally, switch to IV (a simple conversion rate is 5mg PO prednisolone = 20mg IV hydrocortisone)Prescription changes • Drugs/treatment to start • Low Molecular Weight Heparin • TED stockings – all patients (with the important exception of vascular surgery patients) • Antibiotic prophylaxis – patients having orthopaedic, vascular, or gastrointestinal surgery will require prophylactic antibiotics.Prescription changes • Medications Anaesthetists may start • Analgesics – Paracetamol + codeine • Antacids – Omeprazole or ranitidine – minimise stomach acid • Anxiolytics – Midazolam – for anxious patients • Anti-sialogogue – glycopyrrolate – to reduce oral secretionsPrescription changes • Diabetes Mellitus • Type 1 • Night before surgery reduce basal insulin dose and 1/3 , omit morning insulin and start on IV VRII • Type 2 • If on oral hypoglycaemics Metformin stopped in morning of surgery, others stopped 24hrs hour before and started on IV VRIIPrescription changes • Specific Preparations • If having colorectal surgery may need a bowel preparation • General guide: • Upper GI, HPB, or small bowel surgery: none required • Right hemi-colectomy or extended right hemi-colectomy: none required • Left hemi-colectomy, sigmoid colectomy, or abdominal-perineal resection: Phosphate enema on the morning of surgery • Anterior resection: 2 sachets of picolax the day before or phosphate enema on the morning of surgeryReferral • Will the patient require higher level of care post-operatively, • In which case and HDU or ITU bed must be bookedInvestigations • Bloods – FBC, Clotting, U+E, G+S, LFTs, G+S, cross match requesting units • Condition Specific – HbA1C or Thyroid Function Tests • ECG • CXR • Pregnancy test in females of certain agePatient understanding • Ensure patient is informed and understands the plan • Ensure you have answered all the patients questionsCase Scenario 1: • Mrs S attended a preoperative assessment before her right hemicolectomy. Unfortunately, her social history missed that she was the main carer for her disabled husband. Postoperatively, her discharge was delayed until she was fully recovered and able to return to caring for him.Case Scenario 2: • Mr A attended a preoperative assessment before radical cystoprostatectomy, and a thorough smoking and alcohol history was taken. Postoperatively, he was admitted to the surgical high dependency unit, where he developed agitation and shakiness. He underwent an extensive septic screen, and the surgeons were called in to rule out complications. When the anaesthetic house officer looked back at his preoperative clerking, he realised Mr A consumed up to 56 units of red wine a week and had alcohol withdrawal. • This situation could have been avoided if his alcohol history had been highlighted and appropriate medication prescribed.Case Scenario 3: • Mr N attended a preoperative assessment before his anterior resection. After a thorough history and examination, specific note was made of known comorbidities (type 2 diabetes, hypertension, and hypercholesterolaemia), a 75 pack year history, and three pillow orthopnoea. No further action was taken, however. Postoperatively, Mr N developed type 2 respiratory failure and congestive cardiac failure. • Preoperative pulmonary function tests, an echocardiogram, and respiratory and cardiology specialist opinions might have optimised his condition before surgery and avoided this outcome.References • NICE guidelines • Teach me Surgery • Geeky MedicsFeedbackFOR FEEDBACK AND QUERIES: Email @ info@bidasw.com