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Pre-operative Care Mark BurnsWhatwe’regoingtocover • Generaloverview • Pre-operativeconsentandcounselling • Pre-operativeassessment • Pre-operativeoptimisation • Nutrition • Drugsto review • Bloodtransfusion TheOverview Rapport What isthe pre-operativeperiodfor? History Examination Investigation Consent Assessing Risk Drug Review CONTROL THE CONTROLLABLE Preparation andPlanning Counselling Whatisthe generalgistofwhatyouneed to coverwhenexplaininga procedureto a patient? Openthe consultation Introduceyourself.Are youtalking to the right person?Are they here forwhat youthinkthey are? Perception and What do they knowalready? Theprocedure?Any worries?What do they want to know? Invitation Explain 1. Whathappensinnormalphysiology • Remember to stop regularly 2. Whythe surgery has become • Remember check understanding Explain fasting. Explain necessary • Don’tjargon medicationsthat they may 3. Whathappensinthe surgery • Discussbenefits haveto stop andhowto do • Discusscomplications so 4. Whatthey must dobeforeand after surgery • Discussalternatives Wrap-up Mop-uplast confusions.Givea leaflet.Summarise.Ask them to summariseback Consent Whatdoyouneedto beable to doto consent? 1. Understand information 2. Weigh-upthe information 3. Repeat it back to you Whatarethe types ofconsent? What are the types ofconsentform? • Informed • Expressed 1. Adults havinganaesthetic • Implied 2. Paediatrics 3. Procedureswithoutsedation 4. ”best interest”forthose withoutcapacity to giveconsent Whoshouldbe seekingconsentfor the procedure? Someonewho knows about the risksand benefitsAND candiscuss themConsent Male, 23, has beenbroughtintoED after beingstruck roundthe headwith a cricket bat, heis GCS7E2V2M3 He gets sent fora CT head Whatisthis? Rightextradural haemorrhage Can they provideconsent? No Can youstill perform surgery? Yes Why? Theycurrentlydo nothavecapacity. As this isan emergency, assumingnoother chicanery,a ”best interest”decisioncan bemade via Mental Capacity Act 2005 Image Source: https://radiopaedia.org/articles/extradural-haemorrhagePre-operativeAssessment These three components are essential for assessing then establishing the risk to the patient undergoing surgery • History • Examination • InvestigationHistory Presentcomplaint Whyispenicillinallergy a problem? Past Medical History Youhaveto givea differentantibiotic Systems Check What antibioticis giveninstead ofa We’ll have a look penicillinina surgicalsetting? Medications Teicoplanin at thesethreein more detail Allergies WhyisTeicoplanina problem? Reallycommonto have Previous an adverse reactionto it AnaestheticSystemsCheck RESPIRATORY Conditions?Are they controlled?Smoking?Can they lieflat? SleepApnoea? CARDIOVASCULAR Hypertension?ACS? When?AF? DIABETES Isitcontrolled?Whatisnormal?Howisit managed? RENAL Dialysis?Conditions?CKD? NEUROLOGICAL Previousstrokes? Any swallowissues?Epilepsy? Delirium? GASTROINTESTINAL GORD? Howis it managed? Alcoholandriskofwithdrawal? Image Source: https://geekymedics.com/anaesthetic-pre- operative-assessment-osce-guide/ MUSCULOSKELETAL Any spinalchangesthat may affect airways?Howare their teeth? GYNAECOLOGICAL Couldthey be pregnant?Investigations Differsbetween operations Differsbetween patients But considera few ofthese Over80 ECG Over60 andit’sa riskysurgery Someform ofcardiorenaldisease Bloods Watch outforanaemics Pregnancy Atrial Fibrillation Test Allwomenofreproductive age Image Source: https://www.aclsmedicaltraining.com/atrial-fibrillation/ Blood Ifit’s>180/100mmHg onthe day, holdyourhorses Pressure CXR Reallyusefulfor those whoare goingto be headingto ICU, older (>75), andneck offemur fractures?Preparation Whydowe do fasting periods? Mitigatingriskof aspiration Howdowe do fasting periods? Non-clearfluidsandfood–Stop 6 hours beforesurgery (sipuntilsend) Clearfluid–Stop 2 hoursbefore Whataboutthe diabetics? Aim to get them donefirstthingonthe list Image source: https://emedicine.medscape.com/article/353329-overview#a2AirwayExamination Whydowe do this? Willthere be anyproblems securingthe airway oncethey’re asleep Whatdo weuseto assess the airway?AirwayAdjuncts Kit i-Gel Guedel/ OPA NPA Manoeuvres Endotracheal Tube ASAGrading WHOSurgical SafetyChecklist. Sign-in,Timeout, The endpoint.You’ll heretheASAgrade beingreadout sign out beforea surgery starts in the operatingtheatre KnowledgeCheck How long should a patient abstain from clear fluids before elective surgery? A)1 hour B)2 hours C)4 hours Clear fluids include: Water, D)6 hours juice without bits, coffee and tea (without milk)DrugReview • Combined-oral contraceptive pill • Anticoagulants • Antihypertensives • MetforminCOCP Whydowe worryaboutthe COCP insurgery? Howdowe managethe COCP aroundthe surgical period? Increased VTErisk Thoseonthe COCP (oroestrogenvia HRT) to stop it 4 weeks before Whyareyoumore coagulableonthe COCP? Oestrogenalters liversynthesis AntithrombinIIIis inhibited Increased fibrinogen and Factors VIIand X Whatmustnowbe considered? Theyare offcontraception!Be prepared to counselonthat front Anticoagulants What arethe differenttypes of anticoagulants? Warfarin Whyare anticoagulantsa problem insurgery? DOAC Apixaban • Youbleedinsurgery. We rather youdidn’t too much Rivaroxaban • Ifthey’reonan anticoagulantthey’re likelyat a higherclottingrisk • Thisallneeds assessing Fondaparinux Enoxaparin Whatis“bridging”? The useofa shortacting bloodthinner(normallya LMWH) Aspirin aroundthe surgical periodinplace ofordinaryanticoagulation. Antiplatelet Prasugrel EssentiallyallowsforeasiercontrolofINR aroundsurgerytime ClopidogrelWarfarinDOACs Reversalagents are tricky • Dabigatran ->idarucizumab • -xaban -> factor XaFondaparinuxandFragmin Bear in mind these guys are essentially LMWHFondaparinuxandFragmin Bear in mind these guys are essentially LMWH Antiplatelets These onesare a bit quirkier(they’re not anticoagulantsat all,Ihaveadded themforcompleteness).Theseare handled case to case andare based onbleed riskvs thrombotic risk Whendo youstop? ASPIRINandPRASUGREL 7days beforesurgery CLOPIDOGRELandTICAGRELOR 5-7 days before surgeryAntihypertensives Predictably the antihypertensivesto stop are the usualculprits… ACEi or ARBs Whydowe stop ACEior ARBs? Theyare associatedwith a risk ofintraoperativehypotension AKI (whichACEi and ARBs worsen) Whendo westop ACEior ARBs 24 hoursbeforesurgeryMetformin Whatismetformin for? Diabetes Mellitus(mostlytype II) Whatarethe side effects ofmetformin? • GIupset (D andV) • Lacticacidosis Whywouldwestop metformininsurgery? Increased riskof lactic acidosis(so they say) Howdowe stop metformininsurgery? Iftaken OD orBD…? We don’t,take as normal Iftaken TDS…? Don’ttake the lunchtimedoseKnowledgeCheck Which of the following drugs is most likely to be stopped before surgery? A) Bisoprolol B) Bendroflumethiazide C) Amlodipine D) RamiprilBloodTransfusion • Basics • Acute Haemolytic Reaction • Anaphylaxis • TRALI • TACOBasics Whydowe givebloodproducts? • Colloidfluid • Givenforspecific reasons i.ereplenishclotting factors, improvingoxygen carryingcapacity Whendo wecross-match andwhendo we groupandsave? Bleedingriskofthe surgery • Unlikelyto need to transfuse-> groupandsave • Likelyorhigher-> crossmatch (volumesdepend onlikelihood) Whatarethe differentbloodproducts? What isgroupandsavingfor? • IdentifyingABO,RhDetc. • Wholeblood • Packed RBCs Howdowe groupandsave? • Platelet richplasma • Platelet Concentrate • Samples havelimitedvalidity(esp. if • FFP transfusionrecent) • Cryoprecipitate • 2samples needed to verifyresults • Do itpre-op AcuteHaemolyticReaction Whatcauses anacute haemolyticreaction? Antigens onthe surface ofRBCs ABO incompatibility What do A, B and Odenote? How may someonewith an AHR present? • Fever • Abdo pain • Hypotensive Howwouldyoumanagean acute haemolyticreaction? • STOPTRANSFUSION • Supportivecare (fluidresus) • Paperwork,this has happened due to humanerrorAnaphylaxis Whatcauses anaphylaxisinbloodtransfusion? Not totally clearaetiology–Theoriesaround whetherdonorshaveallergens present in bloodat donationtime Howmightsomeoneinanaphylaxispresent? • Hypotensive • Shortofbreath • Wheezing • Angioedema Howare they managed? • STOPTRANSFUSION • IMAdrenaline • A-E and supportTRALI Whatisa TRALI? Transfusion-relatedAcute LungInjury • Not reallysurethe cause • Ultimately vasculaturebecomes leaky • Thiscauses fluidonthe lung Howdoes aTRALIpresent? • Shortofbreath • Fever • Hypotensive What’sthe key findingonthis CXR? Bilateralinfiltrates Howisa TRALImanaged? • STOPTHE TRANSFUSION • OxygenandSupport Image source: https://www.obermair.info/latest-news/blog/aspiration-at-anaesthetic/TACO Whatisa TACO? Transfusion-associatedCirculatoryOverload • Morebloodthan the body can handle Bloodbacks up Hydrostatic Pressureincreases • Either dueto excessive rate oftransfusion • Or thereis pre-existing heart failure Fluidoutofthe vasculatureontothe lungs Inwhichkeyway does a TACO differto a TRALI? Thereishypertensioninstead ofhypotension Howisa TACO managed? • STOPTHE TRANSFUSION(orslowit) • Youwantthe fluidsoff.IVLoop diureticKnowledgeCheck A patient develops hypotension and abdominal pain shortly after starting a blood transfusion. What is the next step? A) Continue the transfusion at a slower rate B) Administer intravenous diuretics C) Stop the transfusion immediately D) Order a repeat crossmatchWrap-Up There’s a lot toremember Chunk the pre-operative period intokeysections INFORMED Consent Good History Good Examination Appropriate Investigations Drug Review When giving blood, keep certain differentials top ofyour list Any Questions?References 1.Radiopaedia.Extradural haemorrhage[Internet].Availablefrom: https://radiopaedia.org/articles/extradural-haemorrhage 2.ACLS MedicalTraining.Atrial fibrillation[Internet].Availablefrom: https://www.aclsmedicaltraining.com/atrial-fibrillation/ 3.GeekyMedics. Anaesthetic pre-operative assessment-OSCEguide[Internet].Availablefrom: https://geekymedics.com/anaesthetic-pre-operative-assessment-osce-guide/ 4.Medscape. Perioperativemanagement and fasting guidelines[Internet].Availablefrom: https://emedicine.medscape.com/article/353329-overview 5.Obermair A. Aspirationat anaesthetic -latest news[Internet].Availablefrom: https://www.obermair.info/latest-news/blog/aspiration-at-anaesthetic/