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Hello, everyone. Thank you for joining us today. My name is Toshika and I'm one of the chairpersons at. So this year, we are very excited to begin our annual teaching series today. This week, we'll be focusing on peroperative care and we're very happy to have you all here today. Today, I am joined by Mark B who will guide you through preoperative care. Mark is 1/4 year student from the University of Southampton to make the session as engaging as possible. We'll be releasing balls throughout, these are completely anonymous. So we encourage you to participate actively. If you have any questions during this session, please pop them in the chart and we'll do our very best to address them as soon as possible. At the end of the session. We'll share a feedback form. If you complete this, you will receive a certificate of attendance and exclusive discount codes for teach me surgery and past the MRC S this session is being recorded. So the recording lens slides will be shared on a meal page a couple of hours after the session. So be sure to keep an eye out for that. Now, on to a very exciting announcement. So we're very happy to launch our very own learning portal which is hosted on our website through this learning portal. You'll get access to practice questions, session, recordings and revision material. As a bonus, all members will get a discount code to get 10% off the GKI Mes and national flashcards, surgery, flashcards and the knowledge Bal. The best part is you can access all of this for free. So be sure to head on to our website after the session to explore this. We also have another very exciting opportunity for all our attendees. Two lucky people will win free access to the GKI medics surgical flashcards and the GKI medics oy stations to send to enter simply complete the Google form that we provide at the end of the session and enter the unique code, the more sessions you attend, the higher your chances of winning. So be sure to stay until the end of two session and attend as many of our other sessions as well. Finally, before we begin, we'd like to thank our, our parts, the Royal College of Surgeons, England, GKI medics, the ND U more than skin deep metal, teaching surgery and past the MRC S without further ado I'll learn how to do to walk. Um Hi guys. Um I don't know whether you can hear me. Can I just check, we can hear your eyes more brilliant. Um So um hi guys, er as mentioned, I'm er fourth year at Southampton. Um I've just come back for my integration, so sort of in my fifth year, um I'll be talking you through pre op care. Um as mentioned um Here are some of the partners. Um Yeah. Um and this is the overview of what we're gonna have a look at today. Um Just a general overview of pre op medicine. Um A bit of the shenanigans around consenting counseling, a patient um and everything you do to that um completely um part of the preoperative assessment, preoperative optimization, a little bit on nutrition or a huge amount and um drugs to review of which there are quite a few and blood transfusion and the complications of it, which there are quite a few. Ignore the bo er the number in the bottom. I initially thought I had to make a vox of this but I didn't. Um anyway, so overview. Um so the preoperative period is uh although not exactly the immediately the most glamorous part of medicine is really quite important. Um very important for building your report. Very important too. Um very important for getting some investigations done consenting, which unless you want to get sued is obviously quite important to do as well. Um And then assessing risks that each patient may be um uh susceptible to in their surgery. And then, of course, in this period, we've got to do a drug review. Um and then just generally prep and plan uh, I was talking with a N test, um, just over here on the side if you can see my laser pointer. Um, and he sort of talked about it about, um, being the control of the controllable things can always go wrong in surgery. Uh, it can always throw a curveball at you, but the preoperative period is all about. Absolutely nailing down the stuff, er, that could be, you know, out of your control if you didn't address it beforehand and minimize and mitigate the risks that you could come across, er, in the surgical window. So, counseling, um, patients surprisingly aren't all doctors and they don't, I immediately know what's going on and even if they are, they may not know exactly what is going on cos you, they, they may be a doctor in the field that you're performing surgery on. So things need to cover when explaining procedures to a patient. Now, this is sort of based around what you might need of OSC, you might see some, something similar on the geeky me website. Um, open the consultation, uh, seems kind of dumb but make sure you introduce yourself. Um, make sure you're talking to the right person. Er, that could get quite awkward a bit further down the line and make sure they know, um, make sure they know what they're here for. Um, because if they don't know what they're here for, then that is a bit of a worry and a then makes it easier for you to then know how much you need to cover with them. If they're very knowledgeable on the topic and they know what they're looking at, then maybe a little less detail might be needed. Er, perception, invitation. Um, basically this all means what do they know, um, what about the procedure and always ask them what they're worried about. Er, patients have, er, worries about their treatment that you may not consider the main worry and if it can be easily addressed, do address it. Um, many times, you know, what do they want to know? They don't really want to know what bits you're chopping out half the time they want to know. Are they able to drive afterwards? Um, are they able to go for a swim? Are they able to go to the gym and you need to be able to address such concerns pretty concisely and then explain, explain what is normal in a person to be going on. Explain why the surgery has been, become necessary for a patient, what's gone wrong. Um, explain briefly what's gonna happen in the surgery. You don't have to go into obscene detail about each artery and vein. You might be, um, clipping or whatever. Um, and most importantly, of course, for their side, what they must do before they go into surgery and what they must do after surgery. So, remember to stop regularly, remember to check their understanding. They aren't necessarily medical, um, in all likelihood they're not medical. Uh, and so often times it's worth checking their understanding so that you don't get confused and it's a lot of information very quickly. Don't jargon, find the living daylights out of what you're saying. Discuss the benefits of receiving, er, proceeding with the surgery, discuss the complications of the surgery. Be honest, you know, if you know the odds give the odds. Um, I'm in, um, obstetrics at the moment and, you know, there's ev e endless, um, discussion of infection risks even though we don't give bridging antibiotics, you know. Um, and if need be, you can always discuss the alternatives. If the surgery doesn't go forward surgery isn't always the answer to everything and sometimes people aren't necessarily, you know, wanting the surgery or they're not necessarily, um, for a good surgery at that time. Ok. Yeah, it's all about just checking their understanding on repeat, unexplained fasting, um, and explain the medications they have to stop and how to do. So, which is what we're gonna, something we can cover more. Um, but this is, this is the part of, uh, the preoperative period that we have next to no control over. Uh, so make sure that they know what they're doing to make it all happy as you go along and then finally just wrap up, you would have given them a lot. Um, so if they have any more confusions, just ask for them, um, and tell them, there's no stupid questions cos there aren't. Uh And then just address those and, you know, if they haven't got it first time, maybe try a different explanation, different route to um, get them up to speed for your Aussies. Give them a leaflet um in real life, give them a leaflet, they'll want it. Um, they'll have a read of it. Many people are quite interested in what's going on uh and give them a little summary. Um That's also for you because if you give them a summary, you can then maybe suddenly remember. Oh, I forgot that bit, go back, add a little bit extra. OK? Um And, and if you're not too depressed on time, ask them to give you a little summary back of what they have to do. Ok? But in counseling, II roughly follow this sort of structure for any procedure that tends to get you over the mark uh consent wise. So what do you need to be able to do to consent? I'm sure you've been um bashed over the head with this for quite a, quite a number of years at this point. But they need to be able to understand the information, weigh up the pros and cons of it and repeat it back to you in time. They say, um which is a nonspecific thing, but it basically just means they have to be able to retain the er, information you give them for a period. Of time, sometimes it's blatantly obvious someone has consent. Sometimes it's a little bit, um, sorry capacity. Um, but sometimes it's really not very obvious that they have capacity and sometimes it's really obvious that they don't have capacity. Ok. Um, so that's sort of the three tenants, which I'm sure at this point you're aware of, uh, what other types of consent just generally, uh, you have an informed, an expressed and an implied consent. Ok? For surgery, it needs to be informed. They, you need to have quite literally told them exactly what's going on so that they know the decisions they're making. Ok. The patient comes in and says, I don't, I don't worry about any of this. I just want it done. That is an expressed consent. You still need to tell them the risks cos they may reevaluate in time. Ok. Um, importantly, there are different types of consent form hilariously for every single surgery in the NHS. There are four. and they all come under different sort of standards of capacity that you can have. It doesn't matter if you're having, you know, a tiny little exploratory lap collie or some enormous, you know, whipple procedure that will be signed on one consent. And these are ultimately a 12, a three and four. Um, one being for those who are adults with anesthetic, a nice simple 12 is a pediatric. 13 is a procedure without sedation and then four is best interests. So these are your, like, you know, your emergency surgery, somebody's out. Um, not, that's something to remember the next, er, slide. Um, and importantly, when seeking consent for a procedure, make sure the person do it doing it, knows what they're talking about. Don't get caught out doing something that you um, don't know about, um, or don't feel confident delivering to somebody. Ok, preferably really, you know, consent should be taken by somebody performing the procedure or you know, the consultant. But as you go, go on, just make sure that you're never consenting a patient for something you don't understand or you don't know the risks of, ok, cos that can wrap you up in all sorts of nonsense. Um, you know, Medicare legally, so little case study. Uh we've got a male, he's 23. He's been brought into the emergency department after being um whacked around the head with a cricket bat. Um He is a GSE seven E two MV. Um V two M three. He gets sent for act head. Um as somebody who comes to Ed with that low of a GC sra head injury would and you see that. Oh, as you can see, that's a nice big extradural hemorrhage. You've got that lemon shape. Ok. Cos it's been confined by the sutures. Um However, oh, there, there you go. Can they provide consent? Uh And the answer is no, they've got a reduced G CS, you know, they can't, their voices are too, so they're just gurgling and them making much noise. Um, they're obviously not going to be quite with it so they aren't able to, um, uh, make a capacitor decision. But the key point here is, can you still perform the surgery which, you know, this patient likely will need, you know, they've got the mass effect, all sorts of brain trauma, you know, damage going on there. And the answer is yes. Um and the reason that is, is because of what we're talking about with the um for er consent form for, ok, in the, in these medical emergencies, they need to be getting into theater quickly. And if they don't have the capacity, we don't have the time for them to get back to a state of uh a state of mind where they can provide capacity. They may not even reattain that state if you don't go on with the surgery. And that's why, um you know, a form for consents exist. Ok, so that you can get people into surgery when a decision is within their best interest. Ok. And there is a lot of um you know, decision making that comes with that as well. And it really oftentimes takes the um opinion of multiple er healthcare professionals to reach that decision. So covered consent, covered some counseling uh in the assessment uh as is with all things history, examination, investigation. Um History is your first port tool examination is your next and then your investigation is what you're gonna do about what you find during your history and examination. Uh, we're gonna talk about these quite broadly, er, because I'm not gonna go through a history for an M SK history for that you might have for, er, a knee pathology or, you know, some he Patil history. Ok. But the general tenants of all history taking ever, um, presenting complaint, your past medical history with a little asterisk in there also. Remember your surgical histories. Do a systems check. I always do a systems check. Now, I think that's probably quite worthwhile. Um, medications allergies. Uh, II don't know who's taking the surgery placement here, but I'm sure, um, a reg at some point has told you to go back and ask for an allergy. Um, it's absolutely necessary that you ask about allergies. Um, and previous times they've had anesthetic just because that's really useful for anesthetists to know how they've handled it before. Uh, people who do well on anesthetic one time tend to do better. Well, do well on it again. Um, so, yeah, these are the three, we're gonna have a little bit more of a look into detail with and just a little bit thing with the allergies. Um, this is based off of my local guidelines. I don't know how it is in other people's hospitals but with penicillin allergy, um, you have to give them a different antibiotic that isn't, you know, something like Co Amoxiclav. Uh, and where we are in, where I, I've been in Portsmouth, the first thing we give after that is Tylan. Um, and anybody who knows about, er, Tylan know that it has something like a, something like a 70 II think it's a seven times higher incidence of, um, anaphylaxis to it than penicillin does. So you can get an o quite often get stuck between a rock and a hard place with, um, er, prophylactic antibiotics and surgery. Um, so it's often worth, um, asking patients about what happened to get them a penicillin allergy, um, on their notes or in their opinion, you know, was it a full blown angioedema anaphylaxis? They needed the adrenaline or was it, you know, sort of, they felt a bit itchy or they got a bit, a bit of a, you know, a bit of a dicky tummy because that's not true allergy and actually that'd be fine to go on penicillin, which is much, you know, more preferable to go on tich plan in, um, you know, when I was in, er, I was in ICU and I saw a lady came in who'd had some tiger plate in and she, er, and, well, she was on ICU, er, she was in quite a lot of trouble and if you've been able to have penicillin that probably been quite, quite the preference there. So, in the system check you gotta go through your systems funnily enough. Um So in your respiratory system full of questions, you might want to be asking what conditions do they have. So, if it's something like CO PD and asthma, how well controlled are they, have they had any recent exacerbations? Have they had any um hospitalizations recently? Somebody, you know, who is asthmatic but hasn't had an exacerbation since they were 12. Um, you're gonna be less worried about than somebody who's, you know, got brittle asthma and is in having wall to wall asthma attacks. Um, every week, smoking wise, you just wanna know about their smoking history is always useful. Um, can they lie flat really useful for your anesthetists? Um, they have sleep apnea, if they have sleep apnea, they're likely to have a less patent airway cardiovascularly hypertension. Are they going to have a heart attack on the table? When were these things? Ok. And do they have af, um, in surgery there's all sorts of, er, risks of stroke? You're in a, you know, you're in a pro thrombotic state. Um, so you've really gotta know about these conditions where a pro thrombotic state is really, really much more dangerous. Ok. In terms of diabetes. Oh, never mind. Look over there. That's just some stuff. Um, in terms of cardiovascular disease, this is a bit, you know, academic really. But this is the sort of stuff that classes patients as mild or severe cardiovascular disease in the eyes of the anesthetist diabetes is it controlled. Um, the main thing this is important for is insulin administration. I think it's, I think the cut off that's recommended now is, um, a, an HBA1C of 69 and above, um, when they're that high and the HP AC is that poorly controlled, um, then they'll almost immediately be put on a sliding scale. Um, insulin infusion for surgery. You also want to know how it's managed as we get on to later. That's really important in terms of drugs, what drugs you might stop. Um, and when, ok, um, in terms of your kidneys you wanna know, are they on something like dialysis, if they're on something like dialysis and you're shutting down a few more of their systems by putting in under anesthetic, you might wanna get involved, might want to call up your, um, ICU department and see whether this might be a patient that's fitting for them. Um, you want to know about other conditions, you want to know about their chronic kidney disease if they have it, um, neurologically, have they had any previous strokes? And can they swallow? Um, that's really important from an anesthetic, er, um, view if they cannot swallow, they're at higher risk of something like an aspiration pneumonia. They may, um, er, they may have more troubles, er, taking, er, down, er, an airway adjunct. Do they have epilepsy? Are they prone to having delirium? That's an absolute classic one for your EQ situations, surgery? Is a massive insult much. They're much more likely to go into a delirious state. Gi wise they have gourd. Um, this is again, as you, as you'll hear me repeat over and over again, the problem with reflux is, is you're refluxing, you're more likely to aspirate and get an aspiration pneumonia, which is all sorts of trouble. Again, ask them how they manage it. Um, alcohol wise, always worth doing an alcohol screen no matter what you do. But equally with surgery, that's a long time where they can't drink. Are they at a risk of withdrawal in that period of time? Because you don't want somebody to have a seizure, uh, while under the knife, you know, uh, Musculoskeletally, you know what their spine's like. Um, you need to get an airway past them if they've got great big changes in their spinal cord and they may struggle to tolerate an, uh, a tube. And also I've just chucked it in here cos I, we don't really know about teeth particularly, but how are their teeth? Um, you're gonna be putting a big, if they're going on general anesthetic, you're gonna be putting a great big tube through there and you might knock their teeth and then gynecologically, um, I think this is a very important point to make. Uh, could they be pregnant? Ok. This is absolutely 100% important in all things. Could they be pregnant? Anything you do? You don't want to, um, potentially be putting, uh, a fetus at harm. Ok. Investigations wise again, differs between operations. This is a very broad look at these things. And once again, disc between patients, there's not one set list of things you should be doing every single time for every single patient. You'll drive your hospital crazy with the amount of investigations you're ordering. Ok. It's all about picking, picking appropriate investigations for appropriate operations and appropriate for that patient every single time. These are the ones I'd consider Ec GS. Ok. Just threw it out for a little bit of fun. Um, those of you there, keep yourself interested, try and figure out what that is. It's not too difficult. Um, the key thing is you'll give it to all people who are over 80 pretty much everybody over 60 half the time. Um, and anybody with something going on with their heart and their kidneys, ok. Bloods rather important when you're going to be cutting somebody. Um, you want to check what their baseline is and especially, you know, you wanna know about their anemia, ok? If somebody's bleeding and they haven't got much reserved blood to give, uh, that might be something worth correcting before you take them to surgery. Uh, pregnancy test again. I'm gonna harp on about this. This is very important. All women of, uh, of reproductive age is a bit of a broad term. Uh, I think some, yeah. II, I've, I've seen some cut offs between 12 and you know, 65 or something. But use your, use your um, intuition there. Um, and don't be afraid of doing a urine dip and, and check for a pregnancy test. Ok. Uh It's not a mistake. You'd like to make BP wise. Essentially, you know, in a hospital we w when in the community setting, a high BP is a great big problem in the hospital setting. A high BP is slightly less of a problem. If it's going as high as something like 100 and 80/100 just wait. Ok, you, you need to get that under control before you take them to surgery. And chest X ray, there are some really important situations, uh, to order these for, are they going to ICU? Um, those of you who have been in ICU, uh, patients receive regular, a lot of the time, receive regular chest x rays um, to check their progress and check that their lungs are ok and they're not, they're not getting any new problems, especially with, um, with, um, uh, being intubated, there's all sorts of lung pathologies that are linked with those as a side effect. Um, and it's really important to understand what somebody's lungs look like before they go into surgery, to see if you've developed a problem, created a problem and then to see how that problem improves with time. Ok. Er, worthwhile doing when they're older and for things like, um, a neck of femur fracture. They can be routine. Er, and that's because, uh, I don't know how many people know about this sort of stuff, but when you break a bone, there's a high chance of you having a fat embolus and throwing off an embolism that can go to your lungs and cause all sorts of damage. So, it's worth having a check, check, uh, chest X ray to see what's going on. Ok. And yeah, that's just afib for those of you who are paying attention up there, soap, preparation for surgery. Uh, the main thing that people want to do are the fasting periods as you see on the bottom. Unfortunately, you've sort of got your answer already. We do the fasting periods to mitigate the risk of an aspiration pneumonia. Now you'll see on your X ray. I mean, you can do your full rundown of how it goes. But the key thing I look, want you to look for is right here. Ok. You've got this nice little area of consolidation, which is an aspiration pneumonia. And the reason we do a fa uh fasting period is, is because when we, um, when we aspirate it goes down, our lungs causes all sorts of trouble there. And so you fast so that you've got nothing in your stomach for you to put into your lungs. Ok. So it's important that the stomach is as clear as it can be before you go into a theater where you're at a higher risk of doing that. So, nonclear fluids and food, stop six hours before surgery. At which point you start your sip until send. Now by the book that's you stop all clear fluids two hours before. But that's sort of a bit of a bit of a lie. Um, the sip and send is sort of a more normal thing to do where they're just allowed to have small sips of water, uh, until they go, um, with diabetics, this is sort of another point. Um, uh, they are particularly complex patients and we really need to be careful of them, um, going hypoglycemic. Um, so whenever you have a diabetic on your list in the future, as I'm sure you'll all be surgeons, um, you've got to make sure that you're aiming to get them done first thing on the, in the morning. Ok. That just makes it a bit easier. And then it lets the ward know that they've got a diabetic patient coming back from surgery and they can get on top of that patient. Nice and early. Ok. Um, other po points of preparation for your surgery, you gotta have an airway exam reason we do. This is, you know, we gotta find out whether there's gonna be any problems securing their airway. Once they're asleep. Once they're asleep, they stop supporting their airways. Ok? And you don't want any nasty shocks before you go in. There's a few ways they do it um assess this. You've got things like the Mallampati score which all just to do with the amount of hard and soft palates that's visible. Ok. One that's the easiest, a nice clear route down four. That's the hardest, not such clear route down. Ok. And that would be, that would be a harder airway to intubate. Um You've also got other things like this which um are used to determine how difficult a patient might be to intubate as well. Ok. So it's through different levels of um comp complexity. When assessing airways, you've got sort of the eyeball test as it were and a more academic view of doing these things, ok. Airway adjuncts. So this is sort of shifting away from preparation and sort of thinking about how you might secure the airway. So you've got all sorts of fun little bits. This is my personal favorite. Um So you've got things like your maneuvers. That's the first thing, first port of call. So you do your jaw thrust and you can do your chin lift. The jaw thrust is the one you most commonly do. And that's where you're just pulling the jaw upwards and outwards and that just opens the airway in terms of kit. So all the kit is about finding different distances and routes so that air can get from there all there. But from these two slots through down here. Ok. So you've got your Cadel which should pop in your mouth. Ok. Um These are really good bits of kit. Um, but patients do not like them so much when they're waking up, they're quite bulky, they're in their mouth and they don't tolerate them so well at that point, but they're very useful, obviously, lots of patients with them in and they just sort of, they just pop round here and just keep that tongue off the back. Ok? And that lets the edge pass through nicely. Other things you got. Ok. So you got your nasal ph pharyngeal airway. So these come in here, pop down there, down the back of your nose and find your airway down this way. Ok. These are much better tolerated in patients when they're awake. Ok? They're a bit of a, they're pretty uncomfortable as they go in, but once they're in, they're, they're fairly comfortable. So if your patient doesn't like these while they're waking up or while they're awake, pop over to one of these. Ok. Uh, next up is the I gel, the world's easiest thing to put in. If you get the chance to put these in, in theater, they take about four seconds, they're almost foolproof. The idea is you just pop them in, they curve round and then this section here just sits over this and forms a seal there. Ok. Uh, and you know, you can have an, er, you can have general anesthetic and ventilation done just purely through these. Finally, it's the main thing, the endotracheal achieve. Ok. Um, that comes back down through here. Ok. And it forms a cuff here which keeps the airway patent and allows for the delivery of, um, er, through to the lungs. Ok. But, yeah, these are your key adjuncts maneuvers first. If you're in a rush, you can pop one of those in. If they don't like that, go to that and then from that, you can go up to there and eventually you'll need, you need to call anesthetist to pop one of these in. But that's essentially all you need to know about airway, a adjuncts. Now, assuming you've done everything before, you've done your history, you've done your examinations, you've done your investigations, you checked their airways, ultimately, you'll be, um, left with your assay. OK? Figure out an cyst, OK? This is the ranking and it basically tells you how, how tricky a patient might be during the surgery from an aesthetic point of view. Uh It's a key part of your surgical safety checklist. For those of you have been in the theater. Um, you've got your sign in which is when the, you know, is before the patient goes, um, under anesthetic, you've got your time out, which is before skin incision and then you've got your sign out, which is when the patient leaves the, leaves the operating room. Ok? And you'll hear them throughout the surgery. Go SA two or a SA one, a SA three. And that's just to talk about how tricky a patient this is surgically from a medical point of view. Ok. And that's your final po um point. So, um Rohita, this is the first pole. Um I don't know whether it's open yet. Um, but it's so this will be our first hour check. How long should a patient abstain from clear fluids before elective surgery and fingers crossed? There should be a poll open for you to answer the, I will read out the EMS form in just a second. Ok. So it took a sense, say two hours before? Wonderful. Yeah, you've mailed it. Gosh. Um, six hours is the other cut off point. Remember two hours is, is the, if you're given the option in M CQ at, at UNI, that's the option you'll go for. But often with patients you just let them sit clear fluids until they're called cos it's awful nasty having a dry throat. But yeah, and six hours is your cut up point for food and non clear fluids. Another little point. This is what clear, clear, clear fluids are, you got your water, your juice without bits, coffee and tea, but without, without the milk. Ok. So drug review, we'll fly through this cos it's really quite dry. Um, but the key ones exams, uh especially are, are your combined pill, your anticoagulants, your anti hypertensives and your Metformin. Ok. So you combine pill. So the reason we worry about this is because of the VT risk. Um I'm sure those of you who've painstaking learned your UK met, met criteria know that um absolute contraindications when they, people had recent strokes. OK? Um And in a surgical setting, somebody's immobilized for a long period of time, they're in this um very insulted state physiologically, they are a much higher risk of clot following. OK? So here you go, you've got the stasis, you're gonna have damage and you're gonna have some changes going on that promote coagulation. So you gotta make sure you're off the cock, cos you've got that estrogen working on your liver which increase the synthesis of certain clotting factors. OK? These are the ones you wanna look out for. You've got inhibition of antithrombin three which you know does what it says on the tin, it's antithrombin. So that's a clot buster. Er but it increases um the prevalence of fibrinogen and factors seven and 10. So you're in this higher coagulable state. Um I'll just put a little note at the bottom here. They're of contraception. Be ready to prepare to counsel on that front. OK. When you're taking someone off um any form of contraception, they may not know how to then handle that. Ok. So advise about condom use. OK? Until that moment to let them know that if they have sex from this period of time, they may become pregnant. So how do we manage to cop around the surgical period we stop it four weeks before. Ok. Um I've just also put in here about estrogen. Ok. Basically the problem is estrogen. Um, and the effect that has on the liver. Ok. So we stop it four weeks beforehand to try and get the body back to, back to normal anticoagulants. Um, I've been a little bit naughty here. Um, but the key, different types of anticoagulants, we've got, we've got Warfarin, we've got a Donax, we've got, er, Fondaparinux, er, and Oxin and we've got antiplatelets, which aren't technically anticoagulants, but I've just chucked them in here, um, because they're also something that you need to be aware of. So why are anticoagulants a problem with the surgery? You bleed? Um, and we'd rather, you didn't, um, at least not too much. Um, so if they're on a anticoagulant, they're also likely at a higher clotting risk too. So if you take them off the anticoagulants, you then tip back over into that situation where they might clot more. And so you need to properly assess the severity of, um, their clotting or their risk of bleeding. So, just a quick little terminology, you'll see this all the time bridging. Um, it's the term we use where you're sort of working them up to that surgical period. You usually use a low molecular weight heparin. Um, and basically it has a much shorter half life. So it allows a really, really easy control of someone's bleed, bleed ability as it were. So, yeah, you've got your Warfarin, you've got your dua, which are your Zaban and you've got these fellas. Ok. So Warfarin um I've linked these from some guidelines. You've got your low risk people and I'm looking what I'm saying here is have a look for the, the common threads in all of these. All right. So you go through your different risks here at your v very high risk as you see, like you're really thinking you don't even want to give them surgery. But the key thing you'll be seeing throughout this is stop the warfarin five days before surgery. Ok? You'll try and get ir to normalize equally in here. You see, you've got the um Darin, which is the low, er, low electro weight heparin. Ok? And that's used to bridge. Um, and it's all about keeping, er, them in appropriate R and R age. Ok. Uh If they're floating around these levels, you want to be in touch with the hematologist. A gets very complicated with all this and when you start talking about using um antidotes, er, or reversal agents, it starts to get very confusing. So keep everybody informed the whole time and stop your warfarin five days before surgery. That's the key thing five days before with your do ax way easier. Um So if they're low risk, you probably don't even need to discontinue them. Ok. These are less problematic and which is why we're shifting over to them. Warfarin is becoming increasingly less sexy drugs now that we have the do a. Ok. So each one has slightly different um, er, ways that handles and where they might be, might be withheld. Ok. Um So, you know, day before, day before, but if they're at a higher risk, ok, then it can become more problematic. All right. Another point here again about reversal agents, they get very tricky. So for dabigatran, you got um is a cuz as your reversal agent if you need it, that's what I always see in the MC Qs and for your um er for your Zaban, OK. Fact factor Xa is your reversal agent on the paramax and fragment. So these are essentially low molecular weight heparin. Um So slightly less of a worry. OK. But still, still worthwhile knowing. Um As you can see here, you're just trying to wean them down until on the day of the dose, you admit it because it's short acting and if it's short acting, hopefully it's cleared, there are slightly lower bleed risk and then you can restart that dose to take them back up to that appropriately, thinned level antiplatelets wise. So remember these aren't anticoagulants a bit a bit naughty. Um and er these are handled a bit case to case, OK. Just to remind you, OK, anticoagulants is sort of on your veiny side of the body that these work. Whereas the antiplatelets are more on your arterial side of the body where they work. Um, but when do you stop them? So, aspirin and prazole, you want to stop those seven days before surgery and clopidogrel and erl is 5 to 7 days before surgery. Ok. Um, but, yeah, uh, just for completeness. But remember these aren't the same. Yeah, I know. It always gets really confusing. Remembering what's, what the difference between them are. Just remember, anticoagulants for the blue side, antiplatelets for the red side in terms of antihypertensives. Um It's the usual culprits. You know your ace inhibitors every single time if you're ever in trouble, if anything's a side effect and you've got nothing else to put in your multiple choice questions. Just put Ramipril. OK? Remember what's going on in your system. OK. The problem is with these is that they vasoconstrict. Uh they, they, they inhibit your ability to vasoconstrict. OK? You're inhibiting ace, you can't get your angio angiotensin two. You can't get your vessels to constrict. OK? And therefore your body's less reactive and it can um uh it can respond with less skill to the insult of surgery equally if you go hypertensive, those of you who know your causes of AK I hypertensive lead can lead to essential hypovolemia. So effectively works like that leading to the hypoperfusion of your kidneys, kidneys don't like that. They go into an AK I and then in AK I ace inhibitors and um Arbs are even worse. Ok. So these buggers, you wanna get rid of them? Ok. So when do we stop them 24 hours bef before surgery? All right. But, yeah, my piece of advice here would really be if you're ever in trouble in an exam and you don't know the answer. And Ramipril or another a ace inhibitor is there. That's not a bad option to go for, uh, Metformin. So, for diabetes, um, mostly type two diabetes, um, and also gestational. but uh this is a usual a culprit. Um and the key side effects of Metformin, you've got your gi upset and your lactic acidosis. Um I'm sure many of, you know, that's your acidosis is a theoretical side effect more than it is a real side effect. It's pretty, pretty damn rare, but it's something we still worry about. And the worry, the worry is is that in surgery you're a higher um high risk of lactic acidosis. Um The reason I sort of say it's a bit of a nothing side effect is you'll deal with how we handle it. Um If it's taken once daily or by daily, we don't change anything about the prescription of it. You know, that's how minimal a risk this lactic acidosis is. Ok. However, if it's taken three times daily, we do omit the lunchtime dose. Ok? But that's the only change. It's a pretty minimal risk, but it's still one that is accounted for. So, next poll, uh which is the following drug, um which of the following drugs is most likely to be stopped before surgery. Um, Bisoprolol, bendroflumethiazide, um, amLODIPine or Ramipril. Hopefully, you've been listening to me for about the past two minutes. 96% have saccharic. Brilliant. You've listened to me every time. If you're stuck for an answer, go for Ramipril. Ok. It's almost always your an, I mean, it's not literally, almost always the answer, but if you're out, if you're out of options, go for Ramipril. OK? Blood transfusions. Um this is probably a bit of a flying visit. Um but we'll just go over a little bit of the basics. Um And then we'll cover some of the complications you can get uh through having a blood transfusion. So why do we give blood products? Um So they're colloid fluids, which means they have a protein content. Those of you who are really into your physiology, that means you've got a um it contributes to your oncotic pressure which helps you retain water within your vasculature. Uh You also give them for really specific reasons. So we'll talk about it in a second, but replenishing your clotting factors, improving your oxygen carrying capacity. The problem with fluids is non blood fluids are that they don't contain any red blood cells and therefore you can pour on as much fluid and as much fluid as you want. But all you're doing is ultimately diluting out your plasma and your red blood cells. Um So before you give blood, you wanna cross match and we wanna group save. Ok. Um, and there's different, um, instances in which we do each so cross match is simply, you know, um, for higher bleed risks and group and savers, for those who are less likely to need a transfusion. But it's, as we say, with surgery, it's, it can be pretty unpredictable. So even if it's unlikely there is a potential risk and it's rather nice being able to go to the fridge and get the correct bag of blood if you need it, but you don't necessarily have, need to have it on hand like you would in a um high bleeding risk surgery. Ok. Uh In terms of different blood products, uh there's a list as long as your arm frankly, um, you've got whole blood, you've got packed red blood cells, you've got your platelet rich plasma, got your platelet concentrate f FP cryoprecipitate. They all do different, slightly different things. Um uh and they all address slightly different prob er problems, things like, you know, platelet rich. If it's platelet rich, you're probably giving it for someone who doesn't have many thrombocytes. Ok. So if someone who's thrombocytopenic, you're looking more at these, these fellows to give. Ok. Um But yeah, group and save is ultimately for finding AD O and rhesus compatibility, ok. Um Which I won't bat you o I actually, I will bat you over the head in a minute with. Um, yeah, also just quickly, how do we group and save? Um, there's just a few little bits of, er, slightly boring, er, housekeeping, but you need to have valid samples. Ok. So if someone's recently had a transfusion, their sample for a group and save, um, test is less, is, is valid for a much shorter period of time. And you always need two samples to verify your results. Um, that can be, you know, I, if you, if they've had one sample taken and never had a transfusion and it was about, you know, 30 days ago, that can be fine, that's fine. That can be used as a sample. You just take, need to take another um uh blood sample for another check. OK? Make sure you do it pre op seems a bit obvious but get these things done early. Um because you don't want to be rushing around trying to figure out what blood you can put in someone while they're, while they're in the surgery. So, um you definitely can't tell that I did a biochemistry degree last year. Um This is what A bo is, OK? A bo is simply all about what antigens are on the sur surface of a red blood cell. OK? So I put selfish and selfless here with your A BS, OK. You've got um both antigens on your cell surface. So therefore your body doesn't produce antibodies to either A or B. So therefore these guys can take everything, OK? Group O, they're brilliant for donating cos they've got nothing on the outside but they're brilliant for, er, they're rubbish at receiving blood. Ok. Cos they've got no antigens, they produce antibodies to both B and A. Ok. That's all a bo means. So, if someone has an acute hemolytic reaction, which is when, ok, I imagine in an O you've just given them a bag of b, uh, you get fever, you'll get abdominal pain and it'll go hypotensive. Ok. That's all because you're getting a, um, you're getting an immune reaction to the blood that's come in. Ok. The antibodies have recognized it and they're trying to clear that blood cos they don't recognize it as themselves and what you need to be doing here is stopping the transfusion immediately. Ok. Um, and then what you want to be doing next is supporting them. Ok. Hypertension, I'm sure, you know, it causes all sorts of problems in all sorts of people. And so you want to get that BP back up so they can keep perfusing their kidneys, keep perfusing their tissues and not cause any ischemia elsewhere following that. Your patients survive because you cos you've attended this talk, do the paperwork and have a look through what's happened. Ok? Um, mistakes happen. I'm sure you've heard this before, but mistakes do happen. You need to find where in the chain, the mistake was made that a, er, the wrong bag of blood has been administered to somebody because somebody basically needs to be educated on what went wrong. Um and the severity of the problem. Ok. But yeah, principally stop the transfusion and spot them for us as much as you can. Anaphylaxis. So, um it's a bit of unknown etiology but it does happen. Um I've heard there's multiple theories running around. Um So yeah, there's theories about, you know, when someone donates the blood, they might have had a Snickers in the morning. And so therefore there's peanut floating around in their blood and then you give it to someone, the peanut allergy and that causes the anaphylaxis. All right. Uh, but there's all sorts of, er, etiologies for these sorts of things that are thrown about. Um, so somebody, um, is anaphylactic, it's the usual things. Again, they're hypotensive, they're short of breath because their airways are swelling. Ok? They've got wheeze because their airways are swelling and they've got angioedema because in the context of anaphylaxis, your vessels go all leaky and at least a fluid just flooding out of them and exploding those tissues open. Ok. How do we manage? Anaphylaxis? Um, no gold stars for knowing this one. Stop the transfusion, give them adrenaline quickly. You also want to do an A to e check and you want to do that quickly because as you see here you're getting short of breath, you're wheezing, you really wanna make sure that airway is working. Ok? If, um, if that airway starts to fail and they're you know they're deat you need to be considering um uh intubation pretty quickly. Alright? You wanna get that jaw thrust on, you wanna use those airway adjuncts we talked about and you wanna help them, help them through that while you're supporting them and getting the adrenaline on board. Um a trolley. So what is trolley transfusion related acute lung injury? Um this is another one with a slightly wonky etiology. Uh but the idea is is that you put blood into somebody and due to some reaction going on with neutrophils or whatever, it causes loads of fluid to just seep out of your uh vessels and onto your lungs. So, and you can see that here, all this fluid on my lung and how does the trolley present? They're short of breath. They've got a fever and they're hypotensive. We've got another hypertension situation here. Um The key finding here, you've got all these infiltrates, ok? Now, the problem with Charlie is OK, you stop at the transfusion, you spot with oxygen, but the problem with the trolley is it looks very similar to something else called a taco, uh which we'll talk about in a second. And the key thing you want to be looking for when trying to differentiate these. Ok? Is that state of the hypertension? Ok. Um In a trolley that'll be hypotensive in Attackers will talk about they'll be hypertensive, but once again, stop the transfusion, they've got loads of liquid on the lung. Ok. So you want to be given lots of oxygen to make sure what blood is in contact with the alveoli is picking up oxygen and then supporting through it. A taco. So this is a circulatory overload. Um Essentially we're just pumping way too much blood into somebody whose heart either can't manage it or is just doing it really quickly. Um, this becomes a particularly problem in a heart failure situation. So you get blood backing up, anybody knows left, right, uh left heart failure up into the lungs, you're gonna c so cause all sorts of problems. So as you back up your hydrostatic pressure, intravascular is gonna increase and increase and increase. And then as a result, fluid is gonna leak out into your interstation, ok? And you're gonna get fluid on the lungs again. Uh I'm sure this feels a bit deja vu it's, it seems quite similar to a Charley. Um But as I mentioned, you get hypertension instead of hypotension, ok? Because of Charley. And however, it works, you just have fluid leaking straight out. It's more of a compromise of the structure of the vasculature, ok? Whereas with a TCO it's a compromise of the amount of blood you're putting in. So you need to have a high pressure within your um within your vasculature to push that fluid out how we manage a tackle again. Stop the transfusion. I'm sure if you become more competent and the symptoms are pretty, um, mild. You can just slow it, but you wanna get those fluids off as well. Ok. So consider something like a loop diuretic to get them off, uh, because you wanna minimize the damage you're doing to that lung. Ok. And you wanna get them oxygenated again. So, the final poll patient develops hypertension, abdominal pain, uh, uh, shortly starting a blood transfusion. What is the next step? Do you continue the transfusion at a slower rate? Do you administer uh the diuretics? Do you stop, stop the transfusion immediately or do you order a repeat cross match then says, stop the to's fusion immediately. Yep, that's the one. So what we've got here is we've got a acute hemo hemolytic reaction. All right, you've got that pain because you've got all the exploding red blood cells in your vasculature. Ok. And that's quite painful for a person. You've got hypertensive cos you've got that. Uh You're hypotensive cos you've got an acute reaction going on. So your vasculature has gone all leaky and, and letting, letting fluid out. And so what you want to be doing is stopping that transfusion. You want to stop the problem. Well, you want to stop the thing that's causing the problem. Ok. Um Well, that is my main takeaway fact. All right. Um I think Mark has had some technical difficulties here, but I think we'll continue. He did finish his session and that was really amazing. I hope all he found that helpful. Um Before I carry on, I'd like to invite our director Connor who will also talk to you about the another hotel patient doing a drug with you. And then when you are giving blood, keep certain differentials top of your list. Alright. Your charlie your taco your acute hemolytic reaction and then hopefully you should be cushty. Ultimately, any questions from that and there's some references. Thank you so much, Mark. Um II think we lost you for a little bit towards the end then. Oh, where did you leave? Where do I, where did you lose me at? It's OK. We, we caught up midway through your wrap up but we just lost like 30 seconds. But uh I think, I think we got the gist. I'm sure you got the idea. Yeah, really? Um ex excellent session, Mark. Thank you so much um for everyone else. I just uh my name's Connor. Um um Before we go on to the questions and answers a bit, I just want, I'm the director for su I just wanna show you guys the learning portal so you guys know where to go um after the session and I should help share my screen and yeah, you guys can see that. Um So um this year we've got a learning portal set up which includes um lots of catch up materials, including recordings of the sessions, multiple choice questions and stuff like that. Um There's one already set up for MARK session, so you can go straight after this and start recapping or if you want to um come back at a later date. Um The way you access it is by going to suta.uk, which is our website. Um And you click join now on the home page, it's going to ask you to prop, to create a two accounts and you can use the same details for both. It's just a, an annoying quirk of, of the website host that we're using at the moment. Um But when you, when you do log in, you'll, you'll be presented with your learning portal page, um which is this, which keeps track of your progress as you learn. Um, you can click learning portal and these are all the sessions which um which s to are running throughout the year. Um We can see here, preoperative care is mark session, you can click that we'll have a recording session come up at the top of it and, er, there will be all these helpful revision materials um to go along with. It's a nice bullet point, summaries of everything that he's talked about. Um, and then at the very end, we've got, er, some, er, multiple drug questions um specifically related to the session, um which include your little descriptions and things like that. To go along with it. All the content which is on here has been reviewed by Anesthetic Surgical patrons and it's all accurate and good to go learn from, uh, as you go through the portal, it'll track your progress so you can keep track of how you go as, as you go along. Um, and, er, and we've also got a dedicated multiple choice question thing a bit like passed. Um, at the moment, we've only got a small number of questions in, but as every session happens throughout the year, we'll be adding more and more questions to the bank. So it'll be getting bigger and bigger. Um, and er, there you go, it should be fairly intuitive, it's free to use. Um We just want you guys to go and play around with it and give us some feedback and we'll, we'll build on it and adapt it as the year goes on based on what you guys tell us. Uh That's everything I wanted. Uh Thank you again, Mark, I think we're gonna do a little quick question and answer and then, then we'll leave you to it. Exactly. Thank you. Hopefully all of you to get a membership. Um If anyone has any questions, please put them in the chart and I think come off, you can see the chart as well. Yeah, I'll just stop sharing. Mhm. From now. Fingers crossed. Ok. Um I don't see any questions at the moment in the chart, so just a couple of bits. Um, so we will be, uh the feedback form is available in the chart. Don't forget to fill it out to receive a certificate as well as the discount codes to teach me surgery and pass the MRC S. Um I've also released the global form for a chance to win free access to the gi me surgical flash cards as well as the A stations. The link for this is available in the chart. Our next session is tomorrow and that will be covered. Uh That will be on postoperative care. So we'd love to have you guys join us again. This is at 630 pm tomorrow. Once again, make sure you follow us on our social media platforms. The links for which are all available in the chart through this. You will be able to receive updates on the upcoming sessions. We have also posted the additional S PA S on a learning platform. So definitely check this out. We hope you found to found today's session, helpful and engaging. Thank you once again for joining us today and we'll see you all tomorrow. Thank you, everyone. Um Can you share the feedback form again? Um Just because some people are asking for it. Yes, I would. Thank you. I don't think I put the unique code in the message earlier, but I will send it now in the chart. Um Hopefully all of you can access that and I have sent the feedback home in the chart once again. All right. Thank you, everyone. Five