Preoperative Assessment/Acutely Ill Surgical Patient Lecture Flashcards
Define pre-operative care.
Pre-operative care is the preparation and assessment, physical and psychological of a patient before surgery (Mallett & Dougherty 2000).
What are the aims of pre-operative assessment?
- EXPLAINING procedures, associated risks and aftercare
- INFORMED DECISIONS
- IDENTIFYING co-existing medical conditions and how to optimise the patient’s health, while appreciating the urgency of their operation
- SUPPORT patients to be as fit as possible before surgery e.g. smoking cessation, better nutrition, reduced alcohol and moderate physical exercise
- IDENTIFY hig hrisk patients
- IDENTIFY appropriate level of postop care
- DESCRIBE discharge planning
- IDENTIFY variables for prognostic information
- EXPLAIN details of pre-op anaesthetic history and assessement
- AIRWAY assessment, previous anaesthesia exposure + adverse reactions
Describe the peri-operative physical assessment.
ASA 1: Healthy patient
ASA 2: Mild systemic disease. No functional limitation
ASA 3: Moderate systemic disease. Definite functional limitation
ASA 4: Severe systemic disease that is a constant threat to life
ASA 5: Moribund patient. Unlikely to survive 24 hours, with or without treatment
Postscript E indicates emergency surgery
What are the grades of surgeries? Give 2 examples of each.
- Grade 1: Minor procedures e.g diagnostic endoscopy, breast biopsy
- Grade 2: Inguinal hernia repair, varicose veins adenotonsillectomy, knee arthroscopy
- Grade 3: Total abdominal hysterectomy, TURP, lumbar discectomy, thyroidectomy
- Grade 4: Major procedures, e.g. total joint, artery reconstruction, colonic resection, radical neck dissection
What investigations would you do pre-operatively?
List some conditions that affect perioperative care.
- Ischaemic heart
- Congestive cardiac
- Chronic respiratory
- Diabetes
- Liver or kidney
What 3 domains help assess the cardiac risk index?
- 1 procedure -related risk factor
- 5 patient-related risk factors
- Poor functional capacity
What factors affec the cardiac risk index? Give examples.
1 procedure-related risk factor: intrathoracic surgery, intra-abdominal surgery, or suprainguinal vascular surgery
5 patient-related risk factors:
- Ischaemic heart disease
- Congestive heart failure
- History of stroke or TIA
- Creatinine > 2.0 mg/dL
- Insulin-dependent diabetes mellitus
Poor functional capacity: patients who become breathless and/or have chest pain while climbing a flight of stairs, walking on level ground at 4 km/hr, or performing heavy work around the house
What would suggest a poor functional capacity?
Poor functional capacity: patients who become breathless and/or have chest pain while climbing a flight of stairs, walking on level ground at 4 km/hr, or performing heavy work around the house
What investigations would you do to assess cardiac risk index?
- Blood tests
- FBC, U&E, LFT, Coagulation Screen, G&S (anything else?)
- Electrocardiogram
- Hospital protocol may require a baseline electrocardiogram.
- It could be a key comparison in the event of any adverse cardiac events postoperatively.
- Chest radiograph
- Sometimes (when)?
When shdoul you do an ECG?
Patients with > 1 RCRI risk factor and one of the following:
- Age > 65 years
- COPD
- Peripheral vascular disease
- Arrhythmias
When should you do an echo?
- Exacerbation or new onset of cardiac symptoms (e.g., dyspnea, chest pain, syncope)
- Patients with moderate or severe valvular regurgitation or stenosis who have not had an echocardiogram in the past year
When should you do a CXR pre-op?
- Surgeries of the head and neck, thorax, upper abdomen
- Clinical features and/or a history of cardiac or pulmonary disease (e.g., COPD, congestive heart failure)
- > 60 years
- ASA score > 2Hypoalbuminemia
- Emergency procedures
- Prolonged surgeries (> 3 hours)
When should you do pulmonary function tests pre-op?
- Unexplained dyspnoea or exercise intolerance in patients who are about to undergo thoracic or upper abdominal surgery
- Patients with COPD or bronchial asthma who have not had a baseline pulmonary function test
Give 2 examples conditions in each region of acute abdomen.
What shoudl you do first if urine output is <0.5mL/kg/hour for >6 hours post operatively?
Check catheter patency
What is used for stree ulcer prophylaxis?
Proton pump inhibitor
What do you use for thromboprophylaxis pre and post operatively?
low-dose LMWH or unfractionated heparin (FH)
What can you do to prevent lung atelectasis post operatively?
Incentive spiromentry and breathing exercises
Why should enteral nutrition be started ASAP after surgery?
To prevent villous atrophy
How should you assess and management fluid status?
- Look at observations, urine output and fluid balance chart
- Look at lying and standing BP/HR/JVP/mucous membranes
- Auscultate chest and look at peripheries/sacral oedema
- Check electrolytes
- Oral instead of IV?
Which patients are in need of fluid optimisation?
- diarrhoea and vomiting
- where the patient has been immobile / debilitated for a prolonged period prior to admission (which has decreased fluid intake)
- elderly patients with reduced renal function that makes fluid balance maintenance more challenging
- drugs that lower renal fluid exchange functions
- low BMI patients in whom ‘normal’ fluid loss volumes will be more significant.
Give 2 examples of fluid used for optimisation.
- Hartmann’s
- Normal 0.9& saline and dextrose
What is the immediate management of post operative patients?
