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Hi. Good evening, everyone. Can everyone here me? Can everyone see me? Is that a yes? That's a yes. Okay, okay. Just wait for a few more people. Think will be good to go. Okay. Okay. Great. So good evening, everyone. I'm Sarah Moti. I'm one of the education officers here at M s. TS also got a few more other members also listening in, Um, so welcome to today's lecture. So this is the first of three lectures that we will be doing. So it's our theater experience series, and so today will be covering pre op. And then on Friday, they'll be one covering Interop. And then on Monday, we'll have our third lecture covering POSTOP. So, um, to begin with. So I'll be talking about how you as an F one, can sort of optimize your patients in the preop stage. So before we sort of begin, I just want to mention surge easy, which is part of our ski easy. And so we'll be collaborating with them on this lecture series, so feel free to check them out on Spotify, YouTube and the other social media. Okay, great. So let's start. So I've got a scenario here. So you're the one on call for gyn surgeon Your registrar has asked you to review patient in E D. Who might be needing emergency surgery. So you go down to E. D. And you can see that it's a 60 year old man with Abdul pain and vomiting. You have a look at the obs, and you can see them here so we can see that the BP is low. Heart rate is high. Temperatures sort of, um, bordering on being, um, like a low grade fever. Respirator. Okay, um, oxygen, sats are okay. And then you have a look, and you see that already have done a CT scan. And this shows that there's free air within the peritoneal cavity. So do you have any thoughts on you know what we think could be going on? Yeah, yeah, yeah. So we basically be worried about bowel perforation. So you go down to see your patient. What would you say is the first thing that you would do in terms of assessing them? Or what is our structure that we would use to assess the patient? Yeah, Yeah, 80 e. That's correct. So, yeah, we want to do are 80. So we want to start off with the airway, move onto breathing, then circulation, disability and then exposure. And so, with each of these sort of sections of our assessment, we want to use a look feel. Listen, measure, treat, approach. And it's important to remember not to move on to the next one until the one before is all fine. Um, and that's because the order that we do this in is the order that would kill you so as an F one when you come to see our patient. So once you assess the airway, if you have any concerns here at this point, this is where you're an F one should probably put out a period or oscal or a crash call, because it's not something that you'd want to deal with on your own. Um, so with our patient, the airways painting, So we move on to breathing. Um, so here we can see that our patients respirators. Fine. That 02 SATs are good. So we have no concerns here. But if you did, then you'd want to think about your supplemental oxygen, possibly doing a blood gas. Um, seeing if there's a chest X ray that's been done, or maybe ordering another one. Then we move on to circulation. So this is our main concern in a surgical patient. So with our patient here, we can see that their BP is low and their heart rate is high, so they're going to need circulatory support. So, um, we would sort of do that and then move on to the other things. Um, but I'll just briefly cover So with disability, you want to make sure that you're checking. Um, so they're GCS, um, their blood sugars. And also they're pupils if they're responsive and then moving on to exposure where you'd examine their abdomen, have a look at all of their limbs and things like that. So, with circulatory support, essentially, what we'll be doing is giving crystalloid fluid. Bolus is So does anyone know what our crystalloid fluids are? Yeah. So we've got sodium chloride. Yeah. And there's another one. Yeah. Oh, well, is that ring is lactate? Yeah. So essentially are two crystalloid. Um, fluids are Hartmann's and sodium chloride, and so we'd want to give give it as a 500 mil bolus, but if you're concerned about them being overloaded. If there's any heart failure concerns, then you would give to 50. But the most ideal bolus amount is 500 and, um, normally Hartmann's is preferred over sodium chloride because it's the closest physiological solution. And with the sodium chloride, there is the chance that you sort of risk the patient developing hyperkalemic metabolic acidosis. So that's why um, Hartmann's is preferred. And then, after you've given the bolus, you want to monitor for your markers of the limericks status, so you want to go back to your OBS. You want to check the BP, see if that's improving. Check the heart rate. You could also check the urine output so you could consider putting in a catheter if they don't have one. And then there's other clinical markers, so checking the cap refill time, making sure it's less than two seconds checking. Um, sort of the volume character of their pulse is also examining the JVP, and then there's also biochemical markers such as lactate and keeping an eye on these other things. Besides, BP is actually very important because, um, often, um, your BP is the last thing to drop when a patient is in circulatory shock. And the reason why circulatory support is, um important, especially for us from a surgical point of view, is because when our patient is in theater, we want to make sure that their organs are, well, perfused. And so, if your cardiac output is low, this will affect your perfusion pressure. So by us, giving fluids were able to increase, um, stroke volume. And then this will in turn increase our cardiac output. And so once our patient is there, new bulimic, um, it's also important to make sure that you give maintenance fluids and replace for any ongoing losses. Now you've finished your surgical on call and you're back on your awards. Um, and so I've got another question. So it's Monday morning you have a patient in Bay won bed one that's due to have her gall bladder removed on at two PM on Tuesday. So which of the following options is most correct Regarding what meals and drinks she can have on Tuesday. So I've got a hole here. We'll stop. Hopefully, everyone can see this. Okay, I'm just going to wait for a few more answers to come in. We've got quite a lot of variety in responses at the moment. Okay? I'll give it a few more seconds. Get any last minute responses in. Okay, I will send it there. Got a couple more anymore. Okay, I agree. So the correct answer is number five. So breakfast at seven. Water until 12. And then a black coffee at 11. She chooses. So? So the majority did go for that. So 30%. But then I got 25% also going for number one and number four. So this brings me on to talk about our starvation rules before, um, theater. So when a patient is under general anesthetic, um, the G A will suppress your cough, and your gag reflex is and it also reduces the competency of your lower esophageal sphincter. So it's really important that your patient is starved. Um, just to reduce your risk of aspiration. So patients are allowed food up until six hours before the operation and then also clear fluids up to two hours before and so clear fluids, Um, include water, black tea and black coffee. So with our patients, the operation was at two. PM So the last time she can eat is eight AM So that's why she can still have your breakfast at seven. And, um, she can drink clear fluids up until 12. And so also milky drinks do count as food. So that's why it can only be a black coffee and not a lot or anything else. And also it's important just to know that you can still take a few small sips of water for medication purposes. And so another thing to be aware of as an F one on on your ward is V T prophylaxis. So this very much depends on the e g f r your bleeding risk and clotting risk. So DVT prophylaxis is considered in prolonged surgery, abdominal and pelvic surgery, prolonged bed rest in patients who are obese and, um, in surgery. Um, sorry, oncological, um, surgical procedures. And this is something that will usually be decided on by the consultant, um, and the sinusitis. And so your prophylaxis is usually Ted stockings or low molecular weight heparin. And so these are things like, um dalteparin or not separate. Um, but if you are a patient who has CKD, so your e g f R is less than 15, you would be placed on, uh, unfractionated heparin. Um, and then as the F one, it's important that you, um it 1 to 2 doses before any surgical intervention. And the dose itself depends on the surgical specialties. So, in general surgery, usually less is given, um, than, say, in orthopedic surgeries. Um, And when you restart your DVT prophylaxis, this depends on what type of operation you've had. So usually in prostate or bladder receptions, Um, the patients will just continue to have Ted stockings for the rest of their time. And with some patients, they might need to continue the DVT prophylaxis after discharge. So stay with patients who've had a hip replacement. They will be given rivaroxaban to continue at discharge. And then another thing, um, with your patients is they might also need antibiotic prophylaxis. So, um, you usually would consider this, um, if your patient has a heart valve problem and, um, this is usually prophylaxis against bacterial endocarditis. And again, this is something that is decided on by the surgeons or by the anesthetist, but it's just something to be aware of. So as the F one, um, should be able to, you know, talk to your seniors, have a look at the plan, and see if this is something that your patient need. Okay, so now we've got another case. So we've got bay to bed one, They're having their gallbladder removed on Friday, and so she's on these following medications, so we can see here on the left. Um, those are medications. Um, for type two diabetes and then on the right, we can see some other medications. Um, you can sort of tell that they're on bisoprolol, candesartan and Spiro. So our patient might be having heart failure. Um, and the nifedipine is for angina, and then you can also see that they're on warfarin. So this might be for a f or, um, something else. So now you as the effort and you have to decide what changes should be made on the day of surgery for her diabetes medication. So again, I'm just going to put out another pole. Okay, So last time we managed to get around 40 responses also, so we'll see if we can get the same number this time. Okay, Let's see if we can get a few more. Okay. We'll send it there. So the most popular answer was number three stop sitting lifting and a gap of the flows in, um, but the right answer is actually number four. So well done to the 25% of you guys that got the answer, right? And so just to go through this, So, um, act Rapid is a short acting insulin, and then tresiba is a long acting insulin. Um, so we can see that our patient is on what's known as a basal bolus regime. So they'll have their long acting tresiba, um, in the background. And then every time they have a meal, so three times a day, they will then get their short acting insulin. And then we've also got some other medications. So we've got metformin, and then we've got sitagliptin, which is a DPP four inhibitor, and then we've got dapagliflozin, which is a S t l t two inhibitor. So, with our diabetes medications, um, it is important to know which ones you should stop. Which ones you should, you know, sort of keep the same if there's anything new that you need to do, so you should stop on the day of surgery sulfonylurea ears. So these are like your glipizide bank limited. So that's because they can cause hypos, um, and SGLT two inhibitors. You should stop them as well. Well, so those are your medications that end in the world, um, flaws in. And, um, this is because again, there's a risk of hypos as well as you glycemic, um DK and hypertension. And once that you should continue as normal, so you don't need to do anything with them. So those are your GLP one agonists. So those are medications like exenatide and lyrically tied, um, as well as pioglitazone and your DPP four inhibitors. So these are things that end in the word gliptin. Um and then with metformin, Um, it sort of depends. It very much depends on your hospital and your policy, but you can continue metformin. So this is if your e g f r is good. So if you have an e g f r over 60 and your patient is low risk of having a AKI and only one meal will be missed, then you can continue metformin. So say, if you're on metformin three times a day, you can admit your lunchtime dose But if you're patient will end up being billed by mouth for more than 48 hours, then you should stop metformin. Um, and the reason why metformin is stopped is because it is renally excreted, so your patient is at risk of developing lactic acidosis during surgery. If there's a renal impairment and then with insulin, when it comes to sort of pre op, you want to stop your short acting insulin. So in our case, it was stopping. Act rapid, and then you want to continue your long acting insulins So your long acting insulins are ones like tresiba in this case, but there's also Lantus and Levemir um, and then for short acting insulin. So there's Act Rapid. There's also Nova Rapid and Humalog S and, um, because your patient will be nil by mouth. But you're still giving them some insulin through the continuing your long acting their blood sugars will drop, so you should also want to consider whether or not they need to be started on a variable rate insulin infusion or IV dextrose. And, um, there's other things to think about when deciding on which one so often it's you have to think about whether they're a type two diabetic and how long the surgery will be. So again, this is something that you know your seniors will have decided on and put in the plan. Um, so your consultants, surgeons and anesthetist and but for you as the f one, Um, there are a few other things that you should think about with diabetic patients. Preop. So, um, so you would want to, uh, make sure that the nurses know to do to hourly, um, blood glucose monitoring for them and then also just be aware that diabetic patients are usually, um, at the start of the operating list. So that's something just to, you know, keep in the back of your mind. And then you should also want to prescribe PR medications for them, just in case they have a hypo or hyper. And then, um, diabetes patients will also need an e c G and use the knees. But this is something that your necessities will have, um, sort of done hopefully all sorted out in their pre op assessment. So, um, someone asked what was the 48 hour rule for metformin again? So, um, it's that if your patient will be nailed by mouth for, um, more than 48 hours. Then you should definitely stop the metformin. But again, um, it's very much depends on what your hospital does and what the consultant, surgeon or any statistic think should be done. Okay, So, back to your medications. What changes, Um, should you make to her warfarin? Her operation is on Friday. I'm going to start another pole. Okay. Again, Let's see if we can get a few more answers. Okay? Any more? It seems like more people are unsure about this one than my previous couple of questions. Mhm. Okay, we'll stop it there. Okay, So the majority of people went for one. So with hold her warfarin from Wednesday, So I'm just gonna go through these answers. So just to mention so rivaroxaban is a dose pack and the nox aspirin is a low molecular weight heparin. And so with option one you would be with holding her warfarin for two days before her operation, and then this one switching it, and then this one here, you'd be with holding it for five days and again, Another switch. So the correct answer is, um number three so well done to you if you got this one, right. So you want to withhold her warfarin from Sunday? And this is because with warfarin you want to stop it five days before and then you want to restart the evening of. So after they've had the operation, usually within 48 hours. And if your patients on a dose pack So these are medications like rivaroxaban apixaban. Um, dabigatran. Then you want to stop 1 to 2 days before and then you want to restart 12 days after. Okay. And now what changes should be made to her other medications. I'm going to put out another pool. Yeah, yeah, yeah, yeah. I know. With this one, there's a lot of things to think about, so I'll give you guys a little bit longer. Can we get any more people to respond? Okay, let's see if we can get a few more. Okay, We'll stop it there. Okay, So the majority have gone for number four, so stop candesartan and spironolactone, okay? And the majority are correct. So just to run through these medications, So we've got the metoprolol, which is a beta blocker. We've got candesartan, which is a ob. So an angiotensin two receptor blocker. We've got nifedipine, which is a calcium channel blocker. We've got spironolactone, which is a potassium sparing diuretic, and then we've already dealt with the warfarin. So before I go on to talk about more about medication changes, I'd be really grateful if we could just do some feedback now, because we're nearing the end of the talk. So, um, also put the feedback link in the chat. And if you complete the feedback from you will also get a certificate for attending. Yeah, so we'll sort of take a small break here just so that you can fill in the feedback and then we'll continue. Okay, I'll give just one more minute, and then I'll move on. Yeah, sure. So, um, go back to the slide with the answer for the water. So is it this slide? And then we've also got that slide. Is that okay? Okay. I will continue. Um, if you need to see the slide again at the end, just let me know. Okay. So, with our preop medication changes, this is something that is really important to know as an F one on the ward um, for your for your patients before they go to surgery. So with your cardiovascular medications, you want to stop your ace inhibitors and your arms, so you want to stop these 24 hours before surgery. And this is because they can cause severe hypertension. Um, after the induction of anesthesia and then with your potassium sparing diuretic. So this is, um, spironolactone also amiloride, um, they can cause hypercholesteremia. Um, if the renal function is impaired or if there's tissue damage, then if your patient is asthmatic and they're on inhaler, you want to continue this, um, and then if your patient is on, um, steroids, you want to switch from oral to IV and then with your female patients who might be on the combined oral contraceptive pill or if they're on hormone replacement therapy, you want to make sure that they've been stopped four weeks before and then resume them two weeks later. So back to the cardiovascular medication. So with your beta blockers and your calcium channel blockers, So in our example, so bisoprolol and nifedipine, they're completely fine to continue. And then another medication, um, types of your neuro medications. Um, this again is really important to know a bit about. So if your patient has Parkinson's, um, you only want to stop the monoamine oxidase inhibitors. So, um, these are the medications such as selegiline, and this is because they can cause important interactions with some drugs used during surgery. But besides selegiline, you want to continue all other Parkinson's medications at the exact time, so Parkinson's patients can have medications at various times throughout the day. That might be different what you normally see. So if your patient takes their medication six times a day, you make sure that they still get their medications six times a day at the correct time. Then with lithium, it's really important that you stop this 24 hours before major surgery. Um, although sometimes with minor surgery, you can continue it. For the most part, you want to stop lithium. And besides that, you can continue your anti epileptics, your antipsychotics, your anxiolytics, then with your tch so your tricyclic antidepressants you don't need to stop them, but it is important to be aware that they do increase your risk of arrhythmias and hypertension. And so that is the end of today's talk. Um, thank you very much for joining. Hopefully you've learned a bit more about the importance of resuscitation, more about starvation rules and prophylaxis and medication changes. Do you have any questions? And the feedback link is also still in the chat. So if you haven't filled it out, please do, um, fill them in. Great. Thank you. So, like I said, we will also be doing our next lecture on Friday, and that will be covering the do's and don'ts of theater. Someone mentioned what would be the best way, in your opinion to gain or enhance your clinical knowledge. I think the best way to do that really is to go in and to get as involved as you can. Um, try and be proactive on your ward rounds. Um, you know, have a go at writing in the notes, um, in theater, asking if you can scrub in asking questions, not being shy, really sort of talking. I think sometimes, um, you know, as a medical student, um, you might feel like you might feel a bit shy to talk up, but really, um, I think all doctors are more than happy to answer your questions, so just try and get as involved as possible. Yep. And attend STS lectures. Great. Thank you, everyone. Hopefully you'll enjoy the rest of your evening. Yeah, I see.