Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

um, so good evening, everyone, as George has, um, just said, we are starting today's session the first session of this year for stepped up. We have our lovely speaker here, Iran, who has an interest in anesthetics. And it's one of the most equipped ID people to give you this talk today. Um, I'm really excited for you to see this presentation and on to you. So perfect, Hannah. So I'm just going to share my screen, share my screen here very quickly. Um, so if somebody can just let me know, I'm just loading know PowerPoint here. Now, if that's showing okay for yourselves, it's good. Yeah. And is it moving on there? Yeah. Yep. Perfect. So I'll make start then. So hello, everyone. Um, as Hannah very nicely said there my name's or and I'm one of the fourth year medical students from Queens in Belfast and alongside a colleague of mine, a friend of mine. Rachel, we're going to discuss really this very of perioperative care over the next two days, tonight and tomorrow night. And unfortunately, you're stuck with me tonight for some preoperative care. Rachel will be looking at post operative care. Then tomorrow night. So here's just some of the things that we hope to cover We're going to really start off with. Looking at this concept of preoperative consent, we're going to try and, um, understand some of the the key areas of the preoperative assessment. Looking at things like the history, your examination, what this A s, a grading is and some of the preoperative investigations that we need to do. We're going to look at how we manage drugs around the peri operative period. Look at how we can administer nutrition to patient's pre operatively, then also talk about some of these concepts, such as the use of blood products in surgery and how things can differ slightly and how we go about doing all of this in some emergency scenarios as well. So I suppose it's probably not the best to look at pre operative care and isolations, but look at peri operative care as a whole. And as you can see here, really, the focus from this is that it's a patient centered, multidisciplinary area of medicine that really looks at the movement of patient's and the journey of patient's right the whole way. From the minute they first contemplate surgery with their doctor, their surgeon or being referred in from other healthcare professionals right up into the point where they fully recover from their from their operation. And really, what I want to discuss today is this. For these 1st 2 10, it's here already looking at their primary refer and their own things like the consent process. And then there's preoperative phase of how we optimize patients' and get them ready, really, for the operation. These are some of the things we're going to talk about, how we can really pre habilitating patient's and get them as medically optimized as possible. Look at some of the holistic psychological support that is necessary for somebody to go through really a major life event in that is surgery. You know, whilst I'm sure for a lot of doctors are involved in the theater and the theater environment, nurses and other healthcare practitioners that can see many cases day in, day out, it's important to supposed to recognize it for the patient. This is perhaps one of the biggest moments that they've had, and they made out of a lot of pent up anxiety over the last number of weeks, months, years on waiting lists to have this have this moment, and I suppose it's important to really explore that with them and make sure that they're prepared for that mentally as well. Obviously, consent is very important understanding of their operation and just checking how they are physically from a nutrition standpoint, how their medications are, how we need to maybe look into investigate their health. And then, as we've said, some of the things that we need to do if an emergency case comes in where everything, perhaps surgery, wasn't planned, and now all of a sudden is in the best interest to do that, how we get that done in a timely fashion. So first thing we're going to discuss here is the idea of preoperative consent. And again, as Hannah was saying there, you know, I maybe took a slightly different slant on this from anaesthetics perspective, but certainly from a surgical point of view as well, it's, um, the idea of consent from both parties and all parties involved in care is really important. And I suppose I used to have mentioned here the Royal College of Anaesthetics in particular, um with the Royal College of Anesthetics. I beg your pardon? Really? This transcends all the colleges and all the professional guidance revolving around surgery. So for people really over the age of 18 or 16 in Scotland does the law can be slightly different? Um, a person really has capacity to consent their own surgery if they can understand the information. Uh, really, that's being given to them if they can retain that information for long enough and use it to weigh up the information and weigh up the pros and cons of their decision and be able to communicate back to others Now, of course, on that, it's important to note that I suppose the use of interpreters, the use of things like that and other communication aids can be used to communicate that decision. However, of course, this idea of the GMCR referring to here the idea that patient's need to be able to doctors need to be able to tell patients about seriously or frequently occurring risks on the basis of all those other points. The information needs to be balanced and really given impartially in order for consent to be valid. Now these may differ, you know, this is As we've said, this is a national society People can be listening from all over. But in Northern Ireland, where we May and Rachel study, these are one of the main forms the consent forms, just we'll see in the in the surgical clinics and also when the patient's brought in the theatre, this will be brought in with them to go over with the surgeons, anesthetists and the nurses as part of the time out that I'll discuss later on. And really, as you can see here, you have your details, the risks and benefits that on the different points of the surgeon has to go through on this first page here, um, the idea that an interpreter can also give to ensure that they are speaking the truth and impartially as it cannot as it can as it comes, and also then some of the anesthetic risks. Now, obviously, this will be filled out with particular information pertaining to certain surgeries, but just the idea of some of the legal importance of this and the importance of good documentation and being able to, um, go over this consent. Of course, not all patient's can consent, and here's just some of the groups that we all may think of if we're looking at these patient's were consent in this process is slightly different. For example, young Children. That previous slide was referring to those under the age of 18 or 16 in Scotland. Adults lacking capacity, of course, in certain conditions, um, in certain conditions, particularly attend to things in mental health and other circumstances as well. It may be deemed that those four points that we discussed earlier on are not met, by which point it can become a complicated process through court's and other means in order to try and ascertain whether a patient is indeed, it has the capacity to make that decision. If somebody is unconscious, for example, a major trauma coming in and it's decided in the E D department that surgery is in this patient's best interests, well, then, really, the consent to a certain point, is implied. At that stage, for example, there are obviously more idea Wales of doing it, but that again is another demographic and of course, non English speakers in that form that I just showed you all was in English and and certainly that is a barrier to communication and really the process of understanding information. So, um, as I've said, different forms exist for this. And from a legal standpoint, obviously correct justification of these from the surgeons point of view is very important. As you can see here in Northern Ireland, we have formed four and form twos. The details like that are pretty, maybe different on obviously in different places. However, it's just to really emphasize that the different different forms with different legal provisions within them in different wording exist. And it's really important to select the right one to ensure your consent is valid. And I certainly have seen surgeries delayed on my placements recently because these haven't Perhaps there's been some ambiguity around whether these have been filled out properly or indeed, the wrong one has been filled out. So not how you given, you know, all the things we really want to speed up and improve care of getting people through the waiting rooms through the operating theaters and getting waiting lists down. You already will be want to dealing with today's like this, mentioning then things like people and we don't have English as their native language. This is from the one of the government websites that shows you all these forms in different languages that can help aid patient's interpretation and obviously alongside interpreters that many hospitals would have. Indeed, all hospitals will have access to this. Ian helps aid and ensure that the consent is valid and ensure that there's understanding there on the patient's behalf that they fully appreciate the risks, benefits and any other important information regarding their upcoming surgery. Looking from an anaesthetics point of view, you know, the Anesthetics Association of Great Britain and North and Ireland outlined some of their main recommendations for this, um, for elective cases, for example, you know, the anesthetic room just outside the theater isn't usually the best place for new information, however it is. Um, I just was better giving it than not giving it at all. However, really, the consent process should be structured in a way that all the pertinent information is delivered to the patient. In another environment. You really need to provide an opportunity for questions on the patient's behalf as well. I know the pre op assessment forms in the trust that I've been on placement in have a tick box at the bottom of them to ensure that this opportunity has been provided. Um, and one of the recommendations in this paper and these guidelines are that helping you decide what is relevant to consent. And I suppose this applies to an anesthetic antisurgical point of view as well would be if you thought to yourself, what would this particular patient regard is being relevant when coming to a decision on which treatment option to accept? If you think about that, really, the idea is that these authors suggest that that will help you cover all the main salient points that is needed for, um, given good consent and given a good, um, transparent review of the options. And indeed, all those different points that I have discussed, Um, another point as well, just a separate consent form isn't really needed specifically for anaesthetics. And indeed, on the ones that I just showed you. There was a section on the second page that dealt with some anesthetic issues, and they can also be covered in like a pre operative assessment booklet, which again, in the trust I open in has a preop it at the front, but then also looks at Inter operative and postoperative monitoring as well, and then just remind ourselves from quote from the G M. C. That decision making This is an ongoing process, really focusing on meaningful dialogues. We really want to explore patient's their ideas and expectations going into the surgery and also their concerns to help allay those were appropriate. But also explore them to really ensure that the patient is best consented as they can be for this operation and fully understanding, which really is important both from their perspective, but also from the doctor's perspective to really ensure that they're covered. And they're consented to do all the interventions that are necessary in the procedure. And the patient isn't surprised, perhaps by anything that may arise. Um, looking at some specific risks know of anesthesia. Um, that may be mentioned in a consent process, and certainly in a preoperative assessments are often discussed. Um, so obviously, with intubation, there's a risk that you're using the laryngoscope. I don't if anyone's you, certainly you're you're you're you're very much warned and reminded of the of the danger of knocking somebody's two front teeth out. And, um, indeed, if you have any dental work, or people may have expensive teeth, crowns and things like that. It's a risk from a monetary point of view as well. Um, however, that that risk is also always framed. Also discussed in the fact that it is important, obviously, to secure that airway and on a risk benefit ratio. It is explained that it can sometimes happen in in those emergency situations, and the sore throat is also common with having a supposed throat. A tube down the throat for a number of hours, perhaps can obviously irritate things and anaphylaxis again. I'm sure everyone's were extremely life threatening a real emergency. And with the number of drugs that really can be used in the preoperative and inter operative period, it's unsurprising that some patient's that perhaps haven't had these before can take these on towards reactions and again just explaining that risk and perhaps some of the measures that anesthetist and surgeons can use to manage it. Postoperative nausea and vomiting again. Certain surgeries carry more risk and certain demographics of people that can carry more risk. Going to be in that consent should be tailored to that patient and their circumstances in order to really explain that point, um, nerve damage that can be temporary and permanent. That really is in the context of things like regional blocks. Um, for example, um Spinals spinal anesthesia, regional blocks that are done in quite a lot of orthopedic surgeries and things like that that can be temporary or permanent. And again, these other things. For example, in obstetrics things that happen commonly can be epidural. Abscess is epidural hematoma and dural puncture headaches that can exist if, for example, pregnant at least had an epidural during their during their labor. And, of course, more exist. However, another good way to demonstrate this to a patient is really actually quantifying or illustrating what risk is. Um, risk in itself is a very non objective term, and it's for doctors as much as non medics. It is quite hard to quantify risk of common and very rare, for example, that really what I mean by that is trying to explain what does common mean or what does vary rare mean and the use of in the middle. Infographics like this here can help, really, to allay the concerns of a patient and really help to really using non medical language to help quantify this risk. For example, some of the some of the risks that I talked about their like your sickness, your nausea. They're very common and equivalent to one person in your family. So even using that one phrase can perhaps, um, I can perhaps help to a publication to understand their own risk benefit ratio, that if they can equate that to one person in their family, that can really it very easily to them, whereas perhaps saying more than one in 10 or more than 10%. So it may not really register with them as well. And it's just about really tailoring your choice of language. As I've said to your patient and the patient in front of you moving on to the actual pre operative assessment itself. Um, if anyone can remember the original definition that we give, it's really it's a multidisciplinary operation, this in itself. So you have this the the doctors be at your surgeon who will, in most cases give your original clinical diagnosis and go through the main consent for surgery, the interventions they're going to perform, and any adjuvants that you may need to your surgery for example, in the context of cancer, looking at things like chemotherapy and other things that may go hand in hand with your actual operation itself. You're anesthetist is, of course, going to look at medical history and how we optimize that you're on aesthetics history in terms of your previous operations and also your physical assessment. But however, nurses, for example, in many cases run these preoperative clinics. They arranged conduct necessary investigations and in many instances are real source of support to families and patient's going through these operations tell other concerns and also, um, divert them to the right people to perhaps deal with any issues and any questions they may have, um, in terms of physio then this was an interesting point that really had picked up when I was researching this and looking at these pre op exercise programs, which, as somebody that myself, that is a bit involved in sports, and you can definitely understand that there would be a benefit from it. And some of these studies do, um, corroborate that. So this first study at the top here looks really at saying that there is a significant difference in reduction of postoperative length of stay and increased preoperative quality of life on the waiting list. If they can get these patient's on to exercise programs and just improve their well being. In general, there's both beneficial, really, in what can, unfortunately, the minute as I'm sure you're all there will be quite a long period between consenting for surgery and ending up, ending up actually getting your operation. But then, of course, it's important as well, both from a patient point of view and also from a healthcare point of view. In order to get these patient's back on their feet and get them out of the hospital and get them rid of all the risks associated with prolonged hospital stays as quickly as possible. However, we are working under research area, and despite the fact that it seems to be acknowledged as a safe intervention, it is something that probably needs more research before it will become really any sort of a mainstream activity. Looking at your pre op history, take and you really want to look quite in depth at your cardiac history, any heart conditions at all, but in particular one that you want to look at his value, their disease and one that was taught and discussed quite commonly when I was in the department was aortic stenosis, obviously, to briefly explain the physiology of that. The path of physiology. If you have this high opening pressure, if you need a high pressure and the afterload to get that aortic valve open, um, it's going to become more difficult to get that blood out and perfuse to ensure profusion. So and this is obviously difficult. If the patient is hypotensive and if they can't adequately regulate the systemic vascular resistance, it really get that squeeze of blood to get that valve open. If it's more difficult than normal. In ideal scenario, you really would be looking at wanting to get the valve replaced prior to elective surgery. However, that's why it's official guidance. It may be challenging to coordinate that, and indeed, you know, cardio, thoracic and other do operate other departments that would conduct this operation. It may not be practical to get that operation done in time, so really, with regards to that is, if you do have aortic stenosis and it is deemed safe to operate, you really want to need to look carefully at your inter operative fluid balance. Make sure the patient isn't drying or overloaded all either, but also then using the use of these alpha agonists to really get that BP up, Um, things like metaraminol and phenylephrine a good because they're alpha agonist, they are less cardioselective. And in these patient's is where you want to avoid your tax security and things like that. You really want to focus on getting that vascular resistance up. And these drugs are the better ones are doing that. And the ones that would be used in these instances, of course, the whole idea of being hypertensive. The issue with that is anesthetics. It's a well known, um, effect of anesthetics, and as a result, that's where we run into these problems of dropping pressures and not getting enough pressure to get your valves open. And, of course, if one of the main issues with this as well is, you know, the coronary arteries branch off just distantly aortic valve so you could run into problems potentially with myocardial ischemia and dangerous issues like that with within surgeries. If you don't get this BP up and sure profusion throughout the surgery, as I've said. Previously, a major Contra indication for spine and anaesthetics is aortic stenosis. As knows, the V. As I've said, it is a high opening pressure, and you really need an increased BP, a good BP to get that valve open. However, in Spain and Honesty's yeah, it's what's known as a simp athletic. So it basically breaks up your sympathetic drive or you drop your sympathetic drive and this decreases probably approved and your afterwards sorry to the point where you're a V will not open, and you get this profound hypertension and hypo profusion as a result. So hopefully that's some rationale as to why this is a very important condition to look for in the pre operative period. Heart failure itself really also illustrates the point in getting a good pre op history in and history of thinks one of the main ways that you can ascertain this. Of course, you can look at E. C. R and things like that to document if there's documented heart failure, but even just asking simple questions such as How many pillows do you sleep on if you're looking for orthopnea? If you ever awakened gasping for air for PND and then looking at exercise tolerance and ankle edema. All these questions can point towards a diagnosis of heart failure, which may make patient's more susceptible to being quite hemodynamically unstable in their operation. If this if they're sympathetic, drive is knocked out by anaesthetics, they're less able to compensate naturally. For this is the gist of that. You can classify here very briefly the different types of heart failure. And of course, this would feed into things like your A s agreed and your suitability for surgery. So if you were just very briefly go over this if you're a class for for example, you would be having a severely limit ated quality of life and severe limitations to your ability to perform activities of daily living. Whereas if you were class one, you perhaps wouldn't be really symptomatic at all. And class two you would be mildly symptomatic. So really, if you had somebody with heart failure, you would want them in those earlier classes in terms of getting your better peri operative outcomes and being more durable, really, to the regular of surgery, just cardiac history to finish off now in general, would be really assessing these cardiac risk factors are really key. And try and ascertain what inter operative and postoperative monitoring you want in these patient's. So, for example, what I was saying was, if somebody was coming in for an aortic stenosis with aortic stenosis for a procedure, you would want an art line insertion really awake as well, getting that into the patient early so as you can keep a really good close control of their BP and a close eye on that, um, somebody that was, perhaps, in the context of emergency surgery particularly ill, you'll be wanting to get ICU or high dependency involved. And you can also look at other interventions, which is a central line and other quite, um, serious monitoring to in order to ensure that you can administer drugs and perform any interventions necessary. If this patient was to become unstable at any point, looking in more some of the other systems with regards to your respiratory history, you want to look really at what condition they have. Are there symptoms usually present really the degree of how symptomatic they are? It's not too bad, or if they're symptomatic to the point where they're becoming extremely um their quality of life is becoming reduced. You want to look within the context of respiratory history. If you're having any airway issues such as obstructive sleep apnea that may impair your airway, management may impair ventilation may empower intubation in the in the preoperative in the inter operative period as well, and it's really important to get a sense of the patient's current condition as well. You want to look at it at any flare ups recently if they're well at the minute, if they've been managing their condition well or if it's been really coming in fits and starts and becoming their conditions really fluctuating, Um, and particularly if there's any infections or antibiotics recently, really, all of these things together would really you need to question whether if you have somebody that's having flares, that you have an antibiotics and infections things like that. You really question whether this is the right time for an elective operation or if you want to send these patient's away and get them, help them or send them back to primary care that they can get rehabilitated to the best of their ability and get them back in as fit a state as possible for their surgery. Looking at now in musculoskeletal history, things like rheumatoid arthritis and ankylosing spondylitis. You know, some of the the anesthetist that I worked with on my placement work, particularly, um, concerned when they seen a patient with ankylosing spondylitis due to the propensity of having a difficult airway. It's challenging from the perspective of actually positioning the patient on the bed and getting them comfortable in negating, uh, the risk of pressure sores and things like that, but also from a perhaps more lifesaving point of view is the difficulty in managing there are away. For example, if you had somebody with a particularly severe ankylosing spondylitis or indeed rheumatoid arthritis in the C Spain, you can imagine it would be difficult in order to get a head tilt, chin left or any, or even to maneuver the head in order to get a view during intubation and things like that. Um, really, that just covers what I've said, and indeed, the TMJ temporomandibular joint as well. If you were doing a jaw thrust, for example, during your pre oxygenation and other things like that, that would if that was involved with things like rheumatoid arthritis would present difficulties as well. Um, dry eyes with things like psoriatic arthritis and other conditions can increase the risk of corneal abrasion during surgery. And hence the reason why those little eye covers are put on patient's once there once they're awake. Obviously, once you're asleep. Sorry. Um, obviously as a side effect of rheumatoid arthritis or sorry. Indeed, a management point of rheumatoid arthritis is methotrexate and then, you know, suppressant. So that can increase your risk of infection in the post operative period and certainly preoperative as well, increasing that risk of habit and picking up an infection in the pre op period that would indeed impair your ability to have surgery or indeed recover from it. We've already touched on the positioning and a point I will discuss later is the issue around steroids in many of these conditions in press suppressing the endogenous hypo for the hypothalamic maturity access. And as I said, we'll discuss that later on. Um, in terms of endocrine, there's obviously a lot of things to discuss. One thing in this talk that I just wanted to discuss was obviously diabetes, very, very common condition that affects many different parts of the body, and indeed many more than I have talked to talked about here. If it is complicated, patient is is particularly if it isn't well controlled, it will precipitate peri operative complications. So things like diabetic nephropathy really puts the patient at risk of things like electrolyte imbalances, fluid overload and or indeed, on the flip side of that, things like an AK. If that isn't managed properly, um, diabetic neuropathy is another issue loss of sensation. It can precipitate pressure short on the table, but also in the perioperative period when a patient may be bedbound for some time for a number of, uh, period of time, they may not be able to convey their pain and convey things like that, and it certainly would increase the risk of not being able to get that patient up and getting them rehabilitated as quickly as possible if they had complications such as this, which required treatment looking to get out of this other gay veins. Looking at the sort of perioperative and, more specifically, pre operative management of diabetes, Um, you really want to look your main monitoring and this will be your HBA one c It's a measure of glycemia control over a period of 2 to 3 months prior to you're taking the blood test and the guidance from the Anesthetics Society here would be that if anyone had an HBA one c of above 69 million moves per liter, you would want to delay the elective surgery, refer them to the endocrine team of the diabetic team and get that optimist and get before you would consider taking them back for surgery. Um, short of that, um, if the surgery was necessary or in other circumstances such as if, UH, one more than one way meal was missed for Type one diabetics, you can use things like a variable rate infusion in these patient's. However, I'm declined really to talk too much about that, because the guidelines do very and on a trust by trust basis. And it would be best that if you did want to be on a certain area and placement, it would be better to have a look at your individual trusts. Gay lines on this, which do set them out quite clearly. Um, moving on into the anesthetic history side. If anyone has any questions by the way at any stage. Just shout out, or if tape into the chat and somebody will alert me to them. But, um, otherwise, I'll just crack on and discuss the anesthetics history. So, really, with this, you want to precipitate and Tran look at any other issues that may arrays. What if the patient is under anesthesia and particularly want to look at any of these quite serious reactions that they might have had previously, such as anaphylaxis, malignant hyperthermia or socks? A meconium apnea, which we'll discuss later on if they've had any postoperative nausea or vomiting previously? This may influence your choice of our way that you're going to use to manage that airway. For example, some patient's and certain operations may be amenable to an LMA or a good, uh, Nigel. However, if they have this history of postoperative nausea and vomiting, you do really want to secure that doorway and would probably want to move to any T tube. Um, if there's any allergies, for example, this would influence their pain management and, for example, the use of NSAID use of codeine. Things like that, which people often report if not allergies, certainly intolerances to them on a frequent enough basis. If there been any histories of hernia or other gastro issues such as gourd, that would increase the risk of aspiration. And as I mentioned earlier on with intubation, if there's a dental history through any expensive crowns that they would rather not damaged or indeed any teeth, any loose teeth within the mouth, you really want to be aware of that just when you're interviewing them to maybe take care. However, in many cases you needed us to explain the risk that you know if they have to choose your life for your teeth to choose their teeth, choose, choose their life. Sorry if which is how it's been, I've seen part to patient's, and it's quite a useful way to frame that risk versus benefit anyway, Um, and also an anesthetic history, especially an emergency surgery. If the patient is faster or not malignant hyperthermia just to discuss this briefly, it's genetic condition, and really, it's the causative agent can be one of the anesthetic gases, usually such as civil Fleurian or socks meconium. Um, basically, what happens is you get this on mass release of calcium ions into the muscle and that causes all the muscles to contract it once and basically turn your metabolism up to 11. You get the this massive temperature spike and a profound acidosis which can lead to arrhythmia and cardiac arrest for, um, the treatment for this you for exams and for life and medical knowledge as well. Um, Dantrolene is a is the treatment for this. It's usually in a box somewhere in the theater and there would be signs and things pointing you to that. Um, you want to correct any metabolic acidosis? There is, or any acidosis, any abnormalities on the gas. And you would also then be referring this patient for genetic testing and muscle biopsy once they were resuscitated in order to confirm the diagnosis and establish a family risk. Also suxamethonium apnea. So sorry to bring anyone back to a level chemistry here, but basically what suxamethonium is our succinylcholine, as it's called in this diagram is two molecules of acetylcholine joined together, and it works as a paralyzing agent by binding to the S C H the acetylcholine receptors and preventing the Axion of your body's naturally occurring acetylcholine. These patient's with socks apnea have a genetic deficiency in the enzyme that breaks this acetylcholine down and what happens is then. So this suxamethonium stays on its receptor and stays activated. So it prolongs the paralytic effect of the drug and, in essence, that the treatment in theory, is relatively simple. Durst Durst Not so simple in real life. But the idea basically is you event to keep this patient on a ventilator transfer, and I see you for an extended period of time until the drug wears off. Basically, um, looking now back to perhaps more mainstream pre operative assessment would be the anesthetic exam, and two of the things you'll be looking at here are the patient's Mallampati scale. They're great and also their upper lip by test. So the talks on this image, um, the Mallampati score, as we can see here at great one, you can have a really good view of the back of the mouth, the uvula and also to the back of the soft palate. Um, a class two you're starting to obscure, but you can still see most of the uvula with class three. The uvula really can only be seen. They're the top part of it. And in a class four, you're going to have complete or almost complete nonvisualization of the back of the mouth and the upper lip by tests, as you can see here, the vermilion border of the top lip. If you can bite over that, you're a class one. If you can bite your lip but not cross the vermilion, border your class, too. And if you can't do that to your class three and basically what these pre empt are in the case of the upper lip by test your predicting your airway difficulty on the Mallampati score, you're predicting how difficult it might be. Two. Tube that patient and whether you may use the likes of a McGrath or things like stay, they stay, let's or boogie catheters in order to try and increase your chances of a quick success in your plan. A Moving on now to look at s grating. So really, with your essay essay stands for the American Society of Anesthesiologists, as they're known over there, and basically it's a metric of how well a patient is in general prior to the surgery. So if you have a s a one, you're amongst the fittest people, your normal, healthy person with no real co morbidities, you're not not a smoker. Very minimal alcohol, right up to the point where if you're a great five, you're morbidly morbidly sick, and you basically will not be expected to survive without this operation. Um, in reality, I suppose, probably. You know, some of the smaller grades are more common, so you would have fit Patient's, perhaps undergoing things like athletes undergoing joint replacements or orthopedic surgery. And then a lot of people, of course, will be classes two and three that have multi morbidities or that have that can be limiting and also the patient's with your grade twos that would have mild systemic disease, but by but I would really be quite comfortable with most most of their lifestyles. You know they'll be able to do most activities of daily living and things like that, and also they're great. Great. Six would be a patient who's been declared brain dead, and they're being there in theater for the purposes of organ recovery for donor purposes and then some of the pre op assessment. You also see an E beside this. That's just if it's an emergency case, for example, a to a or a one C that has been involved in a car accident and being brought to theater. Um, so these studies really estimate that it's about 75% sensitive and accurate accurately predicting how likely somebody is to experience mortality or death in the perioperative period. And it's really important in helping to inform preoperative investigations and which ones you would like to do also, um, looking at preoperative investigations. Ultimately, these are dictated by two factors. Really? How severe the operation is. And your essay. And on the left here, I've already discussed s a bit on the left. You can see here. Nice K. This is the nice guidelines on really some of the things that that constitute minor, intermediate or major surgery. So, for example, minor surgery would be things like your, um, some of your dermatology surgeries, some of your day cases that may be done in day surgery. Um, intermediate surgeries. You're moving up now, So you're looking at tonsillectomies arthroscopies things like that. And then your major complex surgery. Of course, you're looking at things like necklace actions, hysterectomies and thyroidectomy, which can incur quite significant rehabilitation periods. And also other inter operative. Excuse me. Risks such as blood loss and things like that, which we will discuss later on. Um, really do not deliver this point too much, really? So as you can see here, the ESA dictates which of these diagrams you follow. But again, these are all taken from nice there certainly better tables than I could produce. So really, the gist of this here for minnery certain minor surgery and Fetter Patient's routine investigations usually aren't carried out, however, in some more morbid patient's with comorbidities, you may need some investigations, and indeed, the point of this is to really treat patient's individually. You want to use your pre operative findings and really your own history with that patient, your history and your examination, finding that you've obtained in the pre op to ascertain what each individual patient would need and what would maximize the safety for them in the peri operative period. Moving on to intermediate surgery. As you can see here, there's a bit less of a threshold for getting some investigations again. The fittest people uses your A s a ones on the left hand side not routinely needed many investigations, but at this point you're starting to think that essay to as many some investigations done routinely, and certainly you're less fit patient. You'll be wanting to get quite a few of these investigations as can be seen here and on that last point. It's always important to involve your senior colleagues. If you're unsure as to decision around things like this, it's better to be safe and have it run by an expert or somebody more senior in order to ensure the patient has the best outcomes and the best care that can be given to them. Looking now at major surgery. Of course, there's a much, much less, er threshold for this, Um, and indeed everybody, given the nature of the blood loss that I've talked about, we'll be getting a full blood count. And indeed, most investigations would be done there in people of all the essay grades in order to try and preempt some of the risks of surgery and get a better idea of their physiological baseline for the post operative period. Okay, everyone, so anyone, if anyone has any questions at this point, feel free to tape into the chat and Hannah or somebody could let me know if there is any, Um, looking at the this peri operative drug management now. Okay, so as I talked about earlier on steroids are they do need to be continued in the peri operative period and as they talked about earlier long term steroid use the guidelines, Which would say so if doses your dose equivalent of 5 mg of prednisolone or more daily for a period of I believe, four weeks can precipitate suppression of the hypothalamic pituitary axis, which is obviously the nature of the pituitary gland that releases your releases on dictates hormone on steroid release. Um, As so as I've said, this reduces endogenous or story production within the body, meaning cortisol, which is known as the stress hormone, would not be produced in the intra or post operative period. If this medication was withdrawn when in reality and above normal dose would be needed, a super physiological dose would be needed to facilitate the increased stress on the body in this post surgical recovery period. As with all these things, thankfully there is guidance has been issued here, and I suppose the details of this are probably a wee bit above what any of us need to know at our stage. But as you can see here, it's just an appreciation of the needs of administering steroids in the Inter operative period, getting a good medical history to ascertain if this is a problem in the pre operative assessment and how you then we administer the steroids in the postoperative period as well. So this is for patients with primary and secondary renal adrenal insufficiencies for things such as Addison's disease, for example, as a as an example of a primary deficiency insufficiency. And again, just looking at this guideline for people. As I've said that we're receiving these adrenal, suppressive doses of steroids, and there it is, so favor more milligrams of prayed for more than four weeks would constitute this or indeed an equivalent dose of another steroid. Moving on now to another thing that probably is very relevant to ourselves. In the near future would be this idea of viti or venous thromboembolism prophylaxis, and you're on the drug yard axis you're getting these filled in as a patient is admitted, is a very common job for a junior doctor. Surgery itself is certainly a risk factor for VT and in particular So if we think of even our exam questions, you know the likes of hip and knee operations, which are often times a classic example of where pas and DVTs may develop in the post operative period. So again, sorry if anyone's were Me and Rachel are in Northern Ireland. So if we opened up in any of our hospitals here, if we opened up our drug card X, this would be what we would be greeted within the first page, and this really should be filled out on on admission. So in our context here for surgical patient's Step one, they're automatically risk because they're a surgical patient. And so you want to review this risk. And as I've said here, these with the Red Arrows are some of the main issues pertaining to surgery. That would be an issue and indeed some other ones, for example, such as cancer or an advanced age. However, particularly there we go. So obviously, the hip and knee replacement hip fractures, prolonged surgeries over 90 minutes, um, surgeries involving the pelvis to lower limbs and indeed, surgical admission's and an emergency and critical care scenario, or where a patient will be a mobile POSTOP. So, as we say, many of these factors are risks for thrombosis. However, anesthetic in themselves is also bleeding risk for things such as neurosurgery, spinal surgery or a surgery, but also things like epidural spinal spinal analysts. Anesthetics. Um, you really need to work. You really need to consider whether BT is the right thing for these patient's. And indeed, the Anesthetics Association Gay lines would be that anticoagulant drugs need to be held in patient's, where there is a plan to do a spinal lumber punctures or anything like that. And really, this again is I'm not going to go into this any detail. But as you can see here, this is just to demonstrate there is guidelines for how long you should hold your anesthetic. Hold your anticoagulant for prior to a surgical procedure. So if there's any doubt as a doctor in the ward that you could consult literature like this, um, in terms of a standard vte prophylaxis, so this would always be set out in your trust guidelines. However, in Northern Ireland we would use this prescription quite quite regularly. It would be it would be your standard one anyway, Enoxaparin UM, which is brand names Clexane or Nixa, and that will be 40 mg sub cut once daily. If the way it was over 100 kg, that would be moved up to 60 mg and if they were had renal impairment or wait a little bit less, that would be halved to 20. But as I've said, that's very much dependent on which one of these the the trust that you're in or the trust that you're going to work in will use looking at the drugs that you want to stop in the stop preoperatively. As I've said, anticoagulants are one of the big ones, and the the guidance around it obviously is quite complicated and also s inhibitors and ARB s, which can be given. And certainly cardiac drugs aren't a blanket ban prior to surgery. But it is generally thought that these post composer risk of hypertension in synergy with somebody that's getting a general or regional anesthetic as we've talked about the risk of that with aortic stenosis, for example, um, well, if it is controversial, and certainly certain teams would have different opinions, even within the hospitals that I've done my anesthetics and it um, same money as we've been controversial as to whether some of them like to hold them or some of them don't or some of them aren't too bothered. Really. It depends again on the supposed patient circumstances. Um, diuretics as well can predispose to hypertension and acute kidney injury. And when it's not necessarily a drug, you obviously do want to think about stopping food and having patient's fasted prior to their surgery. Um, looking then at continuing or indeed, altering certain drugs these drugs can be can be, um, continue to be administered your cardiac drugs as we've discussed steroids. Broncho Dilators for, for example, for asthmatics, you may have anticonvulsant medication, antidepressants, antipsychotics as well as antacids and PPS. Parkinson's disease medications are quite interesting, actually. So, for example, leave it open. If you withdraw that, you can get this, um, sort of this sort of syndrome, really of confusion, muscular pain and, quite importantly, rigidity, which is actually quite important that if they don't get that medication, it could interfere with their postoperative rehabilitation. If, for example, in many orthopedic surgeries, you do want to get the patient up and mobilized quite quickly, having the patient have an exacerbation of their Parkinson symptoms would certainly impair that. And indeed, for drugs like repair and all, you can get this thing called a dopamine agonist withdrawal syndrome, which can present really with quite a number of physical psychiatric symptoms that again are probably really in in excess of what we need to know. But I just thought it might be. It might be interesting to some of use to know about that. Um, thyroid medication can also be continued. However, when you're clerking, these patient's in. It may be worthwhile trying to think ahead and work out if a change of administrative administration is needed in the periople pre op period in any of these medications and facilitating getting that written up moving now to talk briefly about preoperative nutrition. So really the key, um of this is to identify people who are potentially malnourished and they're probably There is quite a number of different scales and scores that can be used. But one example is things like the Duke preoperative nutrition score, and that looks at for so as you can see, step one. If somebody's low B M A. If they have a lot of recent weight loss or if they have been down on their eating really in the proceeding while before the surgery. And indeed, looking at the biochemistry as well. If they're low albumin albumin or a low vitamin D there, perhaps likely to be at risk of malnutrition in the perioperative period, and you would want to be earmarking these patient's for good peri operative support with their nutrition. So what protein An embolism should always building up Protein should also be encouraged in the preoperative phase, as this is key and having a good protein reserve in the body, which is also, um, contingent on essential amino acids concerned by the diet um, for things like wound healing and also for immunity and just general health obviously don't want to pick up things like wound infections in the pre perioperative period postoperative period. And getting this good nutrition in preop is essential in ensuring that is the case. Um, it also is important to mitigate for increased protein turn over in the proinflammatory state that is surgery. So that's again another reason why you want to have patient's as nutritious as well nourished as possible, with a good balance of the macros particular protein in the pre surgical phase. Um, the recommendation for these patient's is that they would have 1.222 g per body. We had kilogram of protein per day. Fasting It is, obviously, while the preop nutrition is important, as with so much in this talk, we've wanted to ray up the risks and benefits and risks such as aspiration on a full stomach do need to be considered. And indeed, recent studies suggest that around 1.5 mils per kilogram of liquid aspirin can cause a clinically significant lung injury. So even in somebody that perhaps is slightly heavier at 100 kg, huh? You know it doesn't take. As you can see, there are a large volume of fluid to cause much of an to cause an issue. Um, however, this this concept of nothing from midnight is sometimes misinterpreted can be over cautious and indeed deleterious to pre op nutritional optimization. If people don't eat from the night from bedtime perhaps the night before, especially if they have a late morning, a delayed AM case which can run into the PM and you could be looking at really quite a prolonged period of fasting. They're much in excess of the official guidance, which is seen here. And in theory, if somebody was quite ardent on this, you could have somebody fasting for up to 24 hours, even by liquid having nil by mouth. And really, in reality, they don't need to be doing that. And I suppose as you can see here, these processed heavier foods like fried food, fatty foods, meats, things that are harder to say Yes, and we'll stay in the stomach for longer are really, really the only things that would require these big, long yet our period of fasting before morning case, um, so carbohydrate loading. Now, you may have heard of this in the context of sports and elite athletes. And, you know, when I nailed my colors to the mast and put this picture on, we've They obviously haven't been carb loading cause we haven't won any matches since I actually put this on. So, um, basically, it's, uh, it's basically when you want to get the carb carbohydrates on board and there is evidence that this can improve postoperative, um, postoperative outcomes, really, in terms of decreasing insulin resistance and helping the patient get back to their baseline as quickly as possible and post up. So, really, what carb loading in the context of preoperative optimization is, is when you're having consumed around 45 g of carbohydrates less than four hours preop. And this is facilitated by adding carbs. Sashes to water, which is a clear fluid, and within the fasting time frame, which from the previous slide, as you can see, was two hours. This carb loading has been shown to help reduce, um, nausea and vomiting in the perioperative period. Improve your wound healing. Reduce the chances of the wound splitting apart. Also also also things like pain and diarrhea in the POSTOP period can be mitigated by performing this intervention prior to surgery. Um, we're nearly there, so I'm just going to finish off now quickly by discussing your pre op anticipation of blood loss and discussing the group and hold on your cross match. So they're two separate requests. Despite a similar name. They're collected in a bottle like this, shown in the top right hand corner, and they're basically the two steps leading up to what you must do to get a transfusion. So we'll start off with quite often. The first one done is a group in hold. This is where blood loss is not necessarily expected, but you may need it if there's a surgery has access to what is expected in terms of blood loss. This is going to determine the blood group in terms of it's A B o status. It's racist status and any atypical antibodies in the blood. So you get that result, however, you still need to do your cross match, and this is the final check prior to your transfusion. So what you want to do is this is where they physically take a sample of the blood, put it into the type of blood that's going to be given and observed for any igloo tenation. So this would be the more this group and cross match would be, the more sensitive, really to pick up any issues that would raise. And the more accurate as it is actually mixing the bread, the real blood per se him a vigilance is really important. And I suppose in a Kaskey scenario or something like that, you know, this could certainly arise. Apologize. The quality of this image But again, all the all that really serves to do is illustrate the forms and the extra paperwork that needed to be filled out In order to make this a safe process and get the right patient the right blood, Um, its its own form. It must be filled out. The person taking the blood. Um, you want to check the identity on the wrist band all the sampling and have this all filled out and done at the bedside? Um, they needed the labels. Need to be on the bottles. Need to be hand written. They can't stick in a dress, a graph relatable on them. And you really want to samples taken the two separate times for a group and hold and a group and cross match. And on this is a very emergency cell. And this is a very, very emergent situation where you can't wait to space. These samples out, Um what blood? For what surgery? With that again is a question really dictated by trusts and their maximum blood ordering schedule. This is a policy that dictates. Really? What of these checks should be done leading up to whatever surgery you're going for. Um, and It stands to reason that these minimally invasive surgeries will have less blood requirements and less need for the labs to process these tests. Whereas obviously your major surgeries with lots of anticipated blood loss, you do want to check, um, that you have this blood sitting ready to go in case you need it. Um, and this would always be clarified in the patient check in the theater and also in the w h o time out, which can be seen here. And it's done. I'm sure if you've all been in theater, you have heard this. And you, you. This is where you assess your risk of blood loss. And again, I don't know if anyone anywhere else. It's called the Who, but there's a little bit of trivia. So if you ever come to Northern Ireland, you might hear Call that and wonder what it is. But that's a little just a little point for you. And this is an example of one of these one of these blood order schedules from a trust in England. But as you can see, it stands to reason that if somebody is having a Triple A Triple A repaired or some of these vascular surgeries, you're going to want to get your bloods crossed match. Um, cross matched preoperatively. Whereas somebody having these, um, somebody having things like laproscopic procedures and things there. There's less of a need for your cross matches and having four units sitting ready. Um, not very correctly. Just to finish, we're talking about your emergency procedures. Um, so your clinical guidelines from earlier on your elective patient's you may not have time to do all of these investigations and all of these procedures that we talked about for elective patient's out of ours. You still want to do your anaesthetics history, of course, And get assess your airway. And you could also look at things that getting a collateral history if their consciousness was impaired and taking the time to review EC are so that's the name of our online system to look at the patient's medical records. Basically, um, just in case it's called something different elsewhere and review their history if it's documented, and try and make some decisions based on what you see there, and that can be done. For example, if there's a trauma call and, uh, it needs to test of the surgeons waiting on the trauma call on standby. And this could be if, if you're lucky enough to have patient details, you could definitely go ahead and do this somebody in the team to get this information and get thinking as quickly as possible. Um, so if these emergency patient's rolled in D. D. You would like to think you will access, of course would be gained, and you would get any necessary bloods drawn off. If you activate the major hemorrhage protocol, you would get these group and holds and group and cross match is done quite quickly. However they're not. They're not immediate. So you would have things that go negative blood in certain departments on standby, actually in the department, as it may take up to one hour for a full group and cross match in these situations, but a group in hold may be available quicker. Indeed, this patient assessment and the interpretation of any investigations done any D such as gas is blood gasses will help indeed inform the need for further multidisciplinary support in these surgeries. For example, Really, what I'm getting out there is whether if a patient is particularly sick, landing, Indeedy, you may have a lower threshold for getting your I see you in HD. You teams involved in their care as early as possible, or at least making them alert to the situation. Um, one thing that can be done when you're handing over to the legs of I see your peach I see you in particular, would be the things like P possum. And this is a scoring system validated for general surgical patient's that really just the gist of it. As you can see all those different scoring points there and the higher the score, it really confers higher levels of mortality. In the peri operative period, there was originally possum and P. Possum, however, has been modified slightly, and it has been shown in studies to observe very trend very closely with the actually observed in hospital mortality in the perioperative period. In these emergency very sick patient's, um, and finally um, looking at consent in these emergencies, you may think, you know, if it's an emergency, that becomes less of an important. But as you can see, this, gay lines from the R. C. O. A does dictate that consent is still an important aspect of emergency cure all your discussion's and all decisions should be documented. And you still want to, um, get an explanation of the risks and benefits to this patient, if at all possible, and communicate that your decisions as best you can. Just some references that I've made presenting this and thank you all very much. And if you have any questions, I'd be happy to answer them now. Thank you very much. Um, I have been answering a few questions in the chat. So, um, have a quick flick through, see if there's anything that you would say differently. Um, if you do have any questions, please put it in the chat for us. Otherwise, please lend feedback form. Um, really helps us to make these sessions for you guys. Um, and you'll get a certificate at the end. Yeah, so just that question on a on an art line. Sorry, I should have probably been better in the terminology, So that's an arterial line. George's explained that really, George has explained that perfectly. They're really and it was in the context of aortic stenosis. What I was saying was, it's for real. You can you know if you just put a cough on a patient during surgery, you would set that to cycle every few minutes. But really, an art line would give you that in real time throughout the operation. And it does also have the added benefits there of drawing things off and of drawing samples off and getting an a B G without having to, of course, like you might have seen it done needy. Stab somebody again with the needle. You can just draw that straight off. So that's one of your advantages group and hold is also called a group. And see it again. Sorry if my, um, Irish terminology slightly different to what everyone else can say. Um, yeah. So and again, all of those questions that George's happily answered. Apologies. Which one? Either way, whatever way. I was wearing my slides, you couldn't actually see the chat. So, um yeah, so unless anyone who don't want any more clarification, I'm happy enough to leave it there. So thanks very much for your attention, folks. And, um so there's another question. So, really, just what I was saying about the aortic stenosis is So, uh, so the question sorry is could you explain what you were saying about ischemia and the Orix stenosis in a hypertensive crisis. So the hypertension of the low, low BP could arise from the actual anesthetic itself. And with aortic stenosis, you obviously have quite a stiff aortic valve, so the actual ability they would need you need more pressure. You would need more of a squeeze from the left ventricle to get the blood through a door. That's if you think of a door that is a bit jammed with. The hinges are a bit rusty. You might need to put a bit more shove into it with your shoulder to get it open. Where the door that's fresh and fitted well should just slide open and close with one finger. So it's a bit like that, really. So if you just you just need more of a squeeze to get the blood ax. The oxygen boxes need the blood, of course, out of the left ventricle, into the aorta and into the circulation to actually perfuse your tissues. So and the point Then I was saying about ischemia. So obviously, if you can't, this is an extreme example. But if you can't get blood. Enough blood out. You're not going to squeeze blood Klay or down every other part of the body. But the profusion of the actual coronary arteries as well will be impaired because they set the opening of those sets just in the aortic root. So if you can't get enough blood out, you're not going to refuse them with enough pressure to the point. Well, cause my security ischemia and, indeed tissues of any other part of the body, which you can't refuse because you can't get that blood out of the left ventricle. If it's two under two, lower pressure. If that makes sense, no bother. Qwerty. All right, thanks for your questions.