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PREOPERATIVE CARE AND ASSESSMENT Aashritha Buchipudi Year 4, MBChB, University of Birmingham Email: axb1546@student.bham.ac.ukTHANK YOU TO OUR PARTNERS! 1. Overview of preoperative care. 2. Understand the importance and be able to recall pre-op consent. 3. Understand pre-operative assessment; including key components of history, examination, ASA grading and investigations. 4. Recall perioperative drug management,including corticosteroid and diabetic medication, drugs to stop, drugs to alter and drugs to start (VTE prophylaxis). 5. Describe pre-operative nutrition; including nutritional support for L E A R N I N G malnourished patients as well as fasting pre surgery. 6. Understand group and save and cross matching guidelines and the O B J E C T I V E S surgeries these are indicated in.W H AT I S P R E - O P C A R E ? Patient-centred, multidisciplinary, integrated medical care that prepares a patient to undergo surgery safely. The preoperative period begins when the patient is booked for surgery and ends with their transfer to the theatre or surgical suite. ”Prehabilitation” Medical optimisation Holisitic/ Psychological support P R E - O P C A R E Consent Phyical Assessment Nutrition Medication management Investigations Emergency/ complication preparednessP R E - O P E R A T I V E C O N S E N T I N F O R M E D C O N S E N T What information is expected? – ‘Material’ or ‘significant’ risks or unavoidable risks of the proposed treatment; • Even if small – Alternatives to the proposed treatment; – Risks incurred by doing nothing. Find out about patients’ individual needs and priorities when providing information about treatment options.C A P A C I T Y Understand Retain Weigh Up Communicate V A L I D C O N S E N TW H A T I F T H E Y A R E N ’ T A N A D U L T W I T H C A P A C I T Y ? S P E C I F I C R I S K S O F A N E S T H E S I A ”What would this particular patient regard as relevant when coming to a decision?” Separate consent form specifically for anaesthetics is not standard practice. Risk can often be very difficult to quantify when counselling patients P R E - O P E R A T I V E A S S E S S M E N T History, Examination, ASA Grading & Pre-Op InvestigationsM E D I C A L H I S T O R Y 1. Presenting Complaint – Reason for surgery + Site of surgery 2. Past Medical History e.g. GORD, ankylosing spondylitis have anaesthetic implications. a. VTE Risk assessment – Mobility + Thrombosis risk vs Bleeding risk b. Waterlow Score for Pressure Ulcers 3. Cardiovascular 4. Respiratory 5. Diabetes – Type, How is it managed?, End organ damage? 6. Pregnancy 7. Sickle Cell Status – If relevant 8. MRSA status 9. CJD or vCJD statusR E S P I R ATO R Y Obstructive sleep apnoea: Functional status: • Exercise tolerance • Diagnosed or under investigation • Able to lie flat without becoming breathless? • BMI Asthma/COPD: • Observed apnoeic episodes • Regular medications, compliance and degree of • Daytime somnolence control • Recent oral steroid treatment • Do they use a CPAP mask at night? • Exacerbating factors • Smoking status Other: • Recent hospital or ITU admissions • Recent cough/cold or features suggesting current acute illnessC A R D I O VA S C U L A R Heart failure: Hypertension: • How is this managed and by who? • Exercise tolerance • Do they know what is normal for them at home? • Orthopnoea? PND? • Evidence of end-organ damage? – e.g. reduced renal function • Peripheral oedema Acute coronary syndrome (ACS): • Previous MI? When? Symptoms? What treatment? • Have they had angiogram/PCI/CABG • What vessels were implicated? • Recent ECHO? Atrial fibrillation: • Anticoagulation? A N A E S T H E T I C H I STO R Y 1. Past anaesthetic problems a. anaphylaxis, malignant hyperthermia, suxamethonium apnoea 2. Dentition – any loose teeth, caps or crowns 3. Any PONV? 4. Hiatus hernia/Pregnancy/High BMI 5. GORD 6. Review previous anaesthetic notesA I R W AY A S S E S S M E N T • Assess neck movements and jaw flexibility • Dentition – any loose teeth, caps or crowns? • Mallampati ScoreA S A G R A D I N G ASA 2 Smoking Alcohol use Pregnancy BMI 30-40 kg/m 2 Controlled DM/HTN ASA 3 1. Alcohol Dependence or Abuse 2. History of MI, CAD, CVA, TIA (more than 3 months ago) 3. COPD 4. Uncontrolled DMI N V E S T I G AT I O N S : N I C E G U I D E L I N E [ N G 4 5 ] ASA Grade + Surgical SeverityI N V E S T I G AT I O N S : N I C E G U I D E L I N E [ N G 4 5 ] ASA Grade + Surgical SeverityI N V E S T I G AT I O N S : N I C E G U I D E L I N E [ N G 4 5 ] ASA Grade + Surgical Severity P E R I O P E R A T I V E D R U G M A N A G E M E N TW H AT I S N O N - E S S E N T I A L A N D W H E N T O S T O P ? A N T I C O A G U L AT I O N & A N T I P L AT E L E T T H E R A P Y Aspirin/Dipyridamole – Continue Warfarin - Stop 5 days prior to procedure (aim for pre-op INR < 1.3) & consider need for bridging DOACs - Time to stop before surgery (24-72h) depends on drug, bleeding risk, & renal function. Emergency surgery - Risk/Benefit discussion and consideration of reversal agentsA N T I D I A B E T I C M E D I C AT I O N S Drug Day prior to Day of surgery Day of surgery admission (morning operation) (afternoon operation) Metformin Take as normal If TDS , omit lunchtime dose DPP IV inhibitors (-gliptins) and Take as normal Take as normal GLP-1 analogues (-tides) SGLT-2 inhibitors (-flozins) Take as normal Omit Sulfonylureas (-ide) Take as normal Omit morning dose If OD Mane - Omit If BD – Omit both doses OD insulins (e.g. Lantus, Levemir) Reduce dose by 20% BDS Biphasic or Halve the usual morning dose. ultra-long-acting insulins No dose change (e.g. Novomix 30, Humulin M3) Leave evening dose unchangedS T E R O I D S Long term steroid use (doses equivalent to >5mg prednisolone daily), can precipitate suppression of hypothalamic pituitary axis. This reduces endogenous steroid production, meaning cortisol would not be produced in the intra/ post op period, when in reality, an above normal dose is required to facilitate increased stress to the body, on top of normal physiology. V T E R I S K A S S E S S M E N T A N D P R O P H Y L A X I S • Common junior doctor job • This MUST be filled out on admission and reassessed if clinical condition changes. • BUT – anaesthetic issues arise with spinals/epidurals. Enoxaparin Sodium SC *Unfractionated Heparin is preferred in patients with renal impairmentP R E - O P E R A T I V E N U T R I T I O NW H Y I S N U T R I T I O N I M P O R TA N T ? Nearly 50% of patients Malnutrition is a Therefore, identification admitted to hospital are modifiable risk factor - of potentially malnourished or at risk reducing infection rates malnourished patients = of malnutrition and LOS key pre-operative aim MALNUTRITION UNIVERSAL SCREENINGTOOL (MUST)FA S T I N G While pre-op nutrition is clearly important, there is a need to mitigate against risks, such as aspiration. ASA Fasting Guidelines A N T I C I P A T I N G I N T R A O P E R A T I V E B L O O D L O S S P R E -T R A N S F U S I O N T E S T S G R O U P A N D S A V E C R O S S M A T C H • Determines the blood group (ABO and RhD) and • A crossmatch is the final step of pretransfusion screens for any atypical antibodies. compatibility testing, to request blood from the • The process takes around 40 minutes. laboratory. • No blood is issued. • Involves physically mixing the patient’s blood with the donor’s blood, to see if any immune reaction occurs • After ensuring that donor blood is compatible, the donor blood is issued and can be transfused to the patient. Handwritten • Takes an additional 40 minutes. Label H O W M U C H B LO O D F O R A S U R G E R Y ? • Blood transfusion protocols dictated by Trusts own “Maximal Surgical Blood Ordering Schedule” policy – trusts will have their own. • The aim is to relate the ordering of blood to the likely hood that a transfusion will be required, mindful of blood bank resources • This is however a guideline and not a rule book – so this position is clarified upon patient check in/ WHO time out. Sample MSBOS from North Bristol Foundation TrustSee future sessions and watch recordings at: SUPTA.UK