Pre-operative assessment Flashcards
who needs a pre-op assessment
o All need some form – differs how much
o Elective – GA, regional anaesthetics all pts
o LA – select pts – do need to be assessed because might need crash emergency GA
o Emergency – all
who does the pre-op assessment
o Initial assessment – nurse specialist led, surgical junior
o Secondary assessment if required if concerned about fitness or something flagged up – booked into anaesthetics pre-op assessment – anaesthetist
what is the purpose of the pre-op assessment
Identify risk – Airway – Anaesthetic – (Surgery - this should already have occurred) – Post-operative – May require further special tests • Modify risk – May require interventions pre-op • Make decisions on medication – Eg aspirin / metformin • Give advice on fasting individualised decisions on type of anaesthesia/analgesia taking into accounts risks benefits and wishes predict difficult airway • Make decisions on post-op care – Eg ICU / HDU o Explain to pt what to expect with stay and anaesthetics – can be done with surgeons assess need for thromboprophylaxis make sure right surgery optimise before surgery get consent, alleviate worry ie Pre-op assessment identifies problems, should be addressed, on the day they reassess and check airway and meds again and decide what med they will use
is info about surgery involved in pre-op assessment
no
o Pts should already have been seen in a surgical clinic, and talked about surgical team about complications – can be difficult to take in all info, so may need reiteration – but if too many qns – need to be redirected
when is the pre-op assessment done
After surgical clinic and decision to operate
• 2-4 weeks before surgery
– Long enough to arrange further investigations
– Soon enough to avoid interim medical problems
how is the pre-op assessment done
Pre-COVID19 – in person • Now – Initial assessment • Telephone / video – Attendance as required for • F2F review • Bloods • ECG • MRSA swab • Special tests eg echo • COVID swab
what is important in a pre-op history
Planned procedure – minor / intermediate / major
• Past Medical History
• Previous Surgery / Previous Anaesthetics
– Ask ‘any problems with previous anaesthetics’
systems review
med
allergies
social
Fx
BMI
can they lie down
what are possible problems with previous anaesthetics
airway/intubation problems, reaction to drugs, nausea/vomiting (‘PONV’), malignant hyperpyrexia (rare)
recent GA
what systems do you review in pre-op assessment
resp/cardio/renal/endocrine
Social Hx
Smoking / etoh / recreational drug use
– Support at home / work
Fx
– Ask ‘anyone in your family with a history of problems with anaesthetics’
• Malignant hyperpyrexia / Myasthenia gravis
dystrophia myotonica
porphyria
previous problems with muscle relaxants
cholinesterase problems
sickle cell - test if worried
PMHx
risks and comorbidities in full MI or IHD asthma/COPD hypertension rheumatic fever epilepsy liver/renal disease dental problems neck problems GI reflux or vomiting dm existing illness chronic lung disease arrhythmia murmur pregnant is neck/jaw/teeth stable - intubation risk
Dx
Know absolutely everything, inc over the counter – may have interactions or may cause bleeding etc
allergy
importance of Sx
Smoke = increased chance of chest infection, because of paralysis of cilia – 24hr cessation reduce risk
Alcohol stopped – see if would have withdrawal
Is someone at home if going home straight away, or not because no one home
what is malignant hyperpyrexia
dangerously hyperthermic in response to some volatile anaesthetic agents – dantrolene, ITU, cooling = treatment
what is the ASA score
American Society Anaesthesia
what are the different ASA grades
• I Healthy patient, uncompromised
• II Minor systemic disease
• III Severe systemic disease - limits activity but not incapacitating
• IV Severe systemic disease, constant threat to life
V moribund. not expected to survive 24hr even with op
VI brain dead - organ donor
eg for ASA 2
hypothyroidism, well controlled dm/htn
eg for ASA 3
– uncontrolled dm/htn, end stage renal failure needing dialysis
when would you find ASA 4
o – operate for their ASA to fall, in cardiac theatre – cardiac status is why have operation
ASA if eczema and not on steroids
1
what are the different magnitudes of surgery
minor
intermediate
major
major plus
egs of minor surgery
skin lesion w/o flap
breast abscess
intermediate surgery
inguinal hernia - primary
varicose veins
knee arthroscopy
major surgery
thyroidectomy
colonic resection
joint replacement
adrenalectomy
means need further investigations
major plus
cardiac surgery
what do you do if you can’t classify the surgery
o If don’t know what the surgery involves so you cant classify – ask, may be subtleties that increase the risk
what is involved in examinations
o Anaesthetic rather than surgical assessment
o Obs – HR BP temp sats – any trigger need for further investigations and treatment
o Airway
o CV – rate, rhythm, murmur, pain – full CV exam
o Resp – full resp exam – percussion, palpation and auscultation, can they walk up 2 flights of stairs, how far flat - exercise tolerance
o Abdo – good to know before surgery, but most anaesthetics wont – more aligned with surgical team duties. Even for hernia repair – should be examined on morning of surgery. Pick up issue – hepatosplenomegaly w/o cause – don’t want to do op
o Anything you pick up, have confidence in self that you’ve detected things – request the next tests
what are the 4 things involved in the airway assessment
Neck extension / flexion
Mouth opening
Mallampati
Jaw protrusion
why do you check neck flexion/extension
ask put chin on chest adn head all the way back
see if easily do it w/o stiffness/pain – to intubate needs to be partially extended. If oesteoA = painful extension RA AO instability = dislocation = dangerous – need technique in non-extended position – fibreoptic scope. look at notes, plain C spine XR, speak to rheumatologist
why do you see how wide people can open mouth
If small – difficult to get tube in safely – fibreoptic scope
want 3 of their fingers
why do you do airway assessment
o see how easy it is to insert endotracheal tube
o Some pts will have supraglottic airway (no cuffed tube below cords)
o Still need full assessment – if have problems with IGel – need ET tube – so need to assess
o Have clever ways of putting in tubes when know have difficult airway
ways of intubating a difficult airway
laryngoscope elevate the jaw and move tongue out of the way so ET tube can be inserted behind
o Video – have tv screen – so you and the other person can see down
o Fibreoptic intubation – fibreoptic scope through nose/mouth – identify scope between cords – thread ET tube over the top of that
o Assessment tell you if need to bring in the difficult airway trolly
why do you assess jaw protrusion
get bottom teeth in front of top teeth – laryngoscope into miouth – elevate tongue and jaw forward so soft tissue bought forward to make easier to get the tube in
how do you assess mallampati grading
o Ask open as widely as can – see what structures you can see
what can you see in class 1 mallampati
hard palate
soft
uvula
pillars
class 2
hard palate
soft
uvula
class 3
hard palate
soft
class 4
hard palate
