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Oran McGilly 4 year medical student Queen’s University Belfast ● Overview of the features in preoperative care ● Understand the importance and be able to recall pre-op consent ● Understand the pre-operative assessment; including key components of the history, examination, ASA grading and investigations ● Recall perioperative drug management, including corticosteroid and diabetic medication, drugs to LEARNING stop, drugs to alter and drugs to start (VTE prophylaxis) OUTCOMES ● Describe pre-operative nutrition; including nutritional support for malnourished patients as well as fasting pre surgery ● Understand Group and save and cross matching guidelines and the surgeries these are indicated in ● Understand the perioperative procedures and protocols in emergency cases “Perioperative care, also referred to as perioperative medicine, is the practice of patient-centered, multidisciplinary, and integrated medical care of patients from the moment of contemplation of surgery until full recovery.” (Centre for Perioperative Care) Pre-operative care ”Prehabilitation” Medical optimisation Holisitic/ Psychological support Consent PRE- OPERATIVE Phyical Assessment CARE Nutrition Medication management Investigations Emergency/ complication preparednessPRE- OPERATIVE CONSENT▪ RCOA guidance for people age>18 (16 in Scotland),that a person has capacity if: 1.Understand the information relating to the decision they are about to make. 2.Retain that information. 3.Use or weigh that information as part of the process of making that decision 4.Communicate that decision to others. ▪ GMC expects doctors to be able to tell patients about‘serious or frequently occurring’risks. Adults lacking capacity (e.g. Unconscious Non-English Young Children Mental health/ patients speakers Dementia) ▪ Key recommendations (Yentis et al.) 1. For electives,anaesthetic room is USUALLY not the place for new info. 2. PROVIDE AN OPPORTUNITY FOR QUESTIONS. 3. ”What would this particular patient regard as relevant when coming to a decision about which of the available options to accept?” “Decision making is an ongoing process focused on 4. Separate consent form not needed for meaningful dialogue: the specifically anaesthetics. exchange of relevant information specific to the individual patient.”▪ Intubation – dental damage,sore throat ▪ Anaphylaxis ▪ PONV ▪ Nerve damage (temporary/ permanent) ▪ Epidural abscess ▪ Epidural haematoma ▪ Dural puncture headaches ▪ More exist…▪ Hard to quantify risk of ”common”/ very rare/ uncommon complications. ▪ Non- objective ▪ Meanings may differ according to healthcare workers experience/ choice of language.THE PRE-OPERATIVE ASSESSMENT▪Remember our definition of perioperative care? ▪MDT involvement Doctors (Surgeon) – Clinical dx,consent for surgery,interventions/ adjuvants to therapy Doctors (Anaesthetist) – Medical hx and optimisation,Anaesthetic Hx, and assessment Nurse – pre-op clinic,arranging/ conducting necessary investigations. Physiotherapy – pre-op exercise programs (Arthur et al.) Acknowledging this is an Statistically significant under researched area,but reduction in post-op length of also pointing toward positive stay. outcomes seen in small clinical Increased pre-op QoL during trials into this,as well as noting wait for operation. safety of pre-op exerciseCardiac ▪Any heart conditions – valvular disease ▪E.g Aortic Stenosis – high opening pressure,therefore hypotensive as they cannot adequately regulate SVR. Pre – op optimisation - consider valve replacement prior to elective surgery. Carefully monitor intra op fluid balance,use of alpha agonists to maintain BP – metaraminol/ phenylephrine.▪Major contraindication for anaesthetists → SPINAL ANAESTHESIA. ▪Stenosed AV = high opening pressure = increased BP needed to open the valve. ▪Spinal anesthesia = sympatholytic,decreasing preload to point AV will not open = profound hypotension/ hypoperfusion.▪Important to illicit HF symptoms in pre- op phase. ▪”How many pillows do you sleep on?” ▪“Ever awake gasping for air?” ▪”Out of breath going up stairs/ walking/ what is your exercise tolerance?” ▪“any ankle swelling?” ▪Patient’s more susceptible to haemodynamic instability if their sympathetic drive is knocked out by anaesthetic drugs▪ Assessment of cardiac RFx in pre-op can help ascertain necessary intra-operative/ post operative monitoring and recovery requirements. ▪ E.g.Art line insertion (awake?),ICU/HDU referral▪Respiratory Hx ▪What respiratory condition do they have? ▪Symptoms usually present? ▪Airway issues (e.g OSA) ▪Flare ups recently? Currently well/ well managed condition? ▪Any infections/ Abx last weeks – right time for elective op?▪ Rheumatoid arthritis/ ankylosing spondylitis =? Difficult airways ▪ Neck/TMJ involvement may make airway management intubation difficult. ▪ Dry eyes – corneal abrasion ▪ Immunosuppressed – infection ▪ Posture – difficult to position/ pressure sores ▪ Steroid use suppressing endogenous HPA.Diabetes Mellitus – whole body disease – if complicated,will precipitate perioperative complications. Diabetic nephropathy – risk of electrolyte imbalance/ fluid overload/ AKI Neuropathy – loss of sensation – pressure sores on tableHbA1c – measure of 2-3 month glycaemic control Above guidance= if HbA1c >69mmol/L – delay elective surgery, refer to diabetic expert and optimise Variable rate intravenous insulin infusions can be used where > 1 meal is missed for T1DM,HbA1c>69 mmol/L,emergency surgery Guidelines complicated and vary on trust by trust basis▪ Any previous reactions? - helps current anaesthetist anticipate/manage any issues (e.g anaphylaxis/ malignant hyperthermia/ suxamethonium apnoea). ▪ Any PONV? – may influence selection of airway management (LMA vs ETT) ▪ Allergies – influence pain management e.g. NSAIDS ▪ Any hernias/ GORD – aspiration risk ▪ Dental Hx- any crowns etc ▪ Fasted???▪ Genetic condition,precipitated by exposure to anaesthetic agents (gases e.g sevoflurane,and suxamethonium ▪ Precipitates en masse release of Ca2+ ions = muscle contraction. ▪ Increases metabolic activity massively,temperature spike and acidosis leading to arrythmia and cardiac arrest if not treated. ▪ Treatment – dantrolene,cooling,and correction of any metabolic acidosis, subsequent referral for genetic testing and muscle biopsy▪ Sux = 2 Ach molecules joined together ▪ MoA = muscle paralyzing agent by binding to Ach receptor sites and preventing action of endogenous ACh. ▪ Sux apnoea patients have a genetic deficiency in plasma cholinesterase,which breaks the drug down – prolonging its effect ▪ Usually paralyzes respiratory muscles therefore treatment = ventilate for extended period of time until sux wears off.▪Mallampati scale ▪Upper Lip Bite test Lee et al.Mallampati is Faramarzi et al.ULBT a good predicator of over 85% accurate in difficult intubation, predicting difficult poorer at predicting a airway difficult mask ventilation▪American Society of Anaesthesiologists ▪Metric of patients global health for surgery▪Doyle et al.say ASA approximately 75% sensitive in accurately predicting perioperative mortality. ▪Helps inform pre-operative Ix also… Dictated by 2 factors Operation severity ASASummary – in fitter patient – no routine Ix needed In less fit patients with comorbidities – may need some Ix. BUT… treat patients individually,use pre-op findings to ascertain need for certain IxPERIOPERATIVE DRUG MANAGEMENT▪Steroids need to be continued in the peri operative period ▪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.e.g Addison’s Disease (1ary) Steroid induced/ Sheehan’s syndrome (2ary)▪Common junior doctor job. ▪Surgery = risk factor forVTE ▪In particular,think hip/ knee ops as the classic examples/ exam questions where PE/ DVT may present.• This MUST be filled out on admission • Many surgical/ perioperative factors are risk factors for • thrombosis. • BUT – anaesthetic issues arise with spinals/ epidurals • Here,see AABGI guidance,as anti coagulants need held – times vary drug to drug.▪See local trust guidance… ▪In NI – Enoxaparin (Clexane/ Inhixa) 40mg SC OD ▪Inhixa = ”biosimilar”medication to Clexane. ▪If weight >100kg - Enoxaparin 60mg SC OD ▪If weight <40kg or eGFR<30 – Enoxaparin 20mg SC OD▪ Anti – coagulants in cases where spinals/ epidurals used (previous slides) ▪ ACEi and ARBs – other cardiac drugs may be given,but generally thought these pose a high risk of hypotension in synergy with general/ regional anesthesia. ▪ Diuretics – hypotension,AKI ▪ Food!▪ Cardiac drugs (except ARBs/ACEi/diuretics) ▪ Steroids – as discussed ▪ Bronchodilators ▪ Anti –convulsant On clerk in of these patients, need to consider routes of ▪ Anti – depressants/ psychotics administration/ any changes needed ▪ Antacids/ PPIs ▪ Parkinson’s disease medications – DAWS,rehab ▪ Thyroid medicationsNUTRITION ▪ Key pre-operative aim = identification of potentially malnourished patients. Duke Pre-Operative Score >/= 1 indicate potential Nutrtion Scre (PONS) malnutrition and need for support▪ Protein anabolism should be encouraged in the pre-operative phase ▪ Protein synthesis is key for wound healing,immunity ▪ Catabolism is needed to mitigate for increase in protein turnover in inflammatory states,such as the post surgical state. ▪ Recommendation for the pre surgical patient = 1.2-2 g/kg/day (Gillis et al.)▪ While pre-op nutrition is clearly important,need to mitigate against risks,such as aspiration,need considered. ▪ Recent studies suggest 1.5ml/kg of aspirate can cause clinically significant lung damage (Van de Putte et al.) ▪ However,fasting concept of“nothing from midnight”,may be over cautious and deleterious to pre-op nutritional optimisation.▪ May have heard of this in the context of sport/ elite athletes. ▪ Surgery is also a highly metabolically taxing endeavour,which can cause increased insulin resistance and consequently be associated with poorer post surgical outcomes (Sato et al.) ▪ Carb loading defined as having consumed 45g carbohydrates <4h pre-op. Facilitated by adding sachets to water – clear fluid within fasting time frame. ▪ Helps reduce PONV ,wound dehiscence,pain and diarrhoeaPRE-OP ANTICIPATION OF BLOOD LOSS ▪ 2 separate requests,despite similar names. ▪ 2 steps leading up to transfusion G & H Group and Crossmatch • Where blood loss not • ”Final check”,prior to transfusion expected,but may be needed if surgery has • Mixing actual sample with the blood excess bleeding that will be given and observing for • Will determine blood group, any agglutination ABO,Rhesus status,and any atypical antibodies in the blood▪ Trusts will have their own policies ▪ Blood transfusion = its own form! ▪ Must be filled out by the person taking blood. ▪ Identity check with wristband/ all sampling and filling in done @ bedside ▪ 2 samples taken separately – unless very emergency situation. ▪ NO LABELS on bottles – handwritten only.▪ Blood transfusion protocols dictated by Trusts own“Maximal Blood Ordering Schedule”policy – trusts will have their own. ▪ Stands to reason that minimally invasive/ minor surgeries will USUALLY,have lesser requirement for blood than larger,open surgery in highly vascular areas of the body. ▪ This position is clarified upon patient check in/WHO time out.https://www.nbt.nhs.uk/sites/default/files/%E2%80%8BMaximum%20Surgical%20Blood%20Ordering%20Schedule.pdfEMERGENCY PROCEDURES▪NICE guidelines CG45 from earlier – ELECTIVE patients – may not have TIME for them all/ facilities to do them OOH. ▪Still can do anaesthetic hx if possible,assess airway. ▪Collateral hx if consciousness impaired? ▪ECR – review medical history,if documented,take appropriate anaesthetic decisions regarding treatment/ monitoring▪Bloods usually taken off in ED - ▪G&H/ G& Crossmatch needs done quickly if surgery that need them being considered – Major Haemorrhage Protocol – ( O negative blood STAT,may take 1h for full group and cross match,G&H quicker) ▪Patient assessment and Ix interpretation will help inform need for further MDT support in emergency surgeries – i.e ICU/HDU▪ Scoring system to help ascertain perioperative SURGERY (not admission)F ▪ Mostly concerning general surgical patients. ▪ High score can confer very high levels of mortality in perioperative period. ▪ P-Possum very closely matches with observed in- hospital mortalityi.e Consent still an important aspect of emergency care▪ Association of Anaesthetists of Great Britain and Ireland.AAGBI:Consent for anaesthesia 2017. Anaesthesia 2017;72:93-105. ▪ https://www.rcoa.ac.uk/patients/patient-information-resources/anaesthesia-risk ▪ Association of Anaesthetists of Great Britain and Ireland.AAGBI Pre-operative Assessment and Patient Preparation The Role of the Anaesthetist.2010. ▪ Arthur HM,Daniels C,McKelvie R,Hirsh J,Rush B.Effect of a preoperative intervention on preoperative and postoperative outcomes in low-risk patients awaiting elective coronary artery bypass graft surgery:a randomized,controlled trial.Annals of internal medicine.2000 Aug 15;133(4):253-62. ▪ O'Doherty AF,West M,Jack S,Grocott MP.Preoperative aerobic exercise training in elective intra- cavity surgery:a systematic review.British journal of anaesthesia.2013 May 1;110(5):679-89. ▪ Faramarzi E,Soleimanpour H,Khan ZH,Mahmoodpoor A,Sanaie S.Upper lip bite test for prediction of difficult airway:a systematic review.Pakistan journal of medical sciences.2018 Jul;34(4):1019.▪ Lee A,Fan LT,Gin T,Karmakar MK,KeeWD.A systematic review (meta-analysis) of the accuracy of the Mallampati tests to predict the difficult airway.Anesthesia & Analgesia.2006 Jun 1;102(6):1867-78. ▪ Routine preoperative tests for elective surgery’,NICE guideline NG45 (April 2016) © National Institute for Health and Care Excellence 2016.All rights reserved. ▪ Woodcock T,Barker P,Daniel S,Fletcher S,Wass JA,Tomlinson JW,Misra U,Dattani M,ArltW, Vercueil A.Guidelines for the management of glucocorticoids during the peri‐operative period for patients with adrenal insufficiency:Guidelines from the Association of Anaesthetists,the Royal College of Physicians and the Society for Endocrinology UK. 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