Pre-admission Clinic and Pre-operative assessement Flashcards
(40 cards)
1
Q
Who comes to the pre-assessment clinic
A
- people who are going to have elective surgery
- patient who comes in from a ward
- patient who comes in from an emergency
- patient who was an outpatient
2
Q
Categorise the 4 levels of operation
A
- immediate
- urgent
- expedited
- elective
3
Q
What is an immediate operation
A
- immediate lifesaving or limb or organ saving intervention
- resuscitation simultaenous with surgical treatment
- target time ot theatre is within minutes of decision to operate
4
Q
What is an urgent operation
A
- Acute onset or deterioration of conditions that threaten life, limb or organ survival
- fixation of fractures
- relief of distressing symptoms
5
Q
What is an expedited operation
A
- Stable patient requiring early intervention for a condition that is not an immediate threat to life limb or organ survival
6
Q
What is an elective operation
A
- Surgical procedure planned or booked in advance of routine admission to hospital
7
Q
What is the definition of a pre-operative assessment
A
- pre-operative assessment establishes that the patient is fully informed and wishes to undergo the procedure
- it ensures that the patient is as fit as possible for the surgery and anaesthetic
- it minimises the risk of late cancellations by ensuring that all essential resources and discharge requirements are identified and coordinated in advance
8
Q
Why do we do a pre-operative assessement
A
- Reduces morbidity & mortality
- Reduces cancellation on the day
- Reduces total bed days
- Helps identify patients at risk and gives an opportunity to address those risks (e.g. plan post-op ITU care)
- Gives a chance to optimise patients if possible
- Helps to avoids predictable complications
- Facilitates same day admissions for surgery
- Allows timely MRSA screening
9
Q
What is the rule of 6 Ps
A
Prior preparation prevents pathetically poor performance
10
Q
How does the pre-assessement clinic work
A
- Specially trained nursing staff
- Assisted by HCA’s and administration staff
- May have input from senior or junior surgical/anaesthesia doctors
- Overseen by consultant anaesthetists
- Access to phlebotomy, ECG and radiology services (empowered to order Inx) • Some units may have specialist equipment (e.g CPET)
- Gold standard: ‘One Stop Service’
11
Q
What is done in pre assessment
A
- History
- Examination
- Order appropriate tests
- Optimise patients
- Identify risk
- Determine level of post-op care (day case, overnight, ITU)
- Fully inform patients; e.g. NBM
12
Q
What is taken in a history in pre assessment
A
• PMHx of: MI, diabetes, HTN, rheumatic fever, epilepsy, jaundice
- existing illnesses - drugs and allergies
- be alert to chronic lung diseases, high BP, arrhythmias, and murmurs
- assess any specific risks e.g. is this patient pregnant
- is the neck/jae immobile and teeth stable
- has there been any previous anaesthesia - if so were there any complications such as nausea and DVT
- family history may be relevant - e.g. in malignant hyperpyrexia, dystrophia myotonic, porphyria, cholinesterase problems and sickle cell disease
13
Q
What happens in an examination in pre assessment
A
- ABCDE
- assess cardiorespiratory system, exercise tolerance
- is the neck stable for intubation e.g. in arthritis it might not be
- is VTE prophylaxis needed
- for unilateral surgery mark the correct arm/leg/kidney
14
Q
What should you do before administering anaesthetics
A
- Determine the patient’s comorbidities – i.e. ASA Grade
- Determine the grade of surgery – 1 to 4 (minor to major+)
- Follow national or local guidelines, +/- individual advice
15
Q
What does an ASA grade stand for and what is it used for
A
American Society of Anaesthesiologists’ (ASA) classification of Physical Health is a widely used grading system for preoperative health of the surgical patients,
16
Q
What are the grades for ASA
A
- grade 1
- grade 2
- grade 3
- grade 4
- suffix E
- ASA 5
- ASA 6
17
Q
Describe the ASA grades
A
- grade 1 = normal health patient - wihtout any clinically important comorbidity and without clinically significant past/present medicial history
- grade 2 = a patient with mild systemic disease (any alcohol consumption puts you here)
- grade 3 = a patient with severe systemic disease
- grade 4 = a patient with severe systemic disease that is a constant threat to life
- suffix E = Emergency
- ASA 5 = moribund patient not expected to survive the next 24 hours
- ASA 6 = brain dead
18
Q
Name the surgery grades
A
- Grade 1 = minor
- Grade 2 = intermediate
- Grade 3 = major
- Grade 4 = major +
19
Q
give examples of surgery grades
A
Grade 1 = minor
- excision of lesion of skin;drainage of breast abscess
Grade 2 = intermediate
- primary repair of inguinal hernia, excision of varicose veins of leg, tonsillectomy, adenotonsillectomy, knee arthroscopy
Grade 3 = major
- total abdominal hysterectomy; endoscopic resection of prostate, lumbar disectomy, thyroidectomy
Grade 4 = major +
- total joint replacement, lung operations, colonic resection, radical neck dissection
20
Q
How do the NICE guidelines work
A
- need the ASA grades
- tests running down the side
- marks them not routine, consider, and yes
21
Q
Do not routinely offer an
A
Do not routinely offer resting echocardiography before surgery. Consider resting echocardiography if the person has:
- a heart murmur and any cardiac symptom (including breathlessness, pre-syncope, syncope or chest pain) or signs or symptoms of heart failure.
Before ordering the resting echocardiogram, carry out a resting electrocardiogram (ECG) and discuss the findings with an anaesthetist.
22
Q
In which case should you offer an echo before surgery
A
- a heart murmur and any cardiac symptom (including breathlessness, pre-syncope, syncope or chest pain) or signs or symptoms of heart failure
23
Q
What do you need to inform the patient before surgery
A
- NBM(nil by mouth) (6 hours food, 4 hours breast milk, 2 hours clear fluids)
- Stopping anticoagulants (warfarin / anti platelets)
- Smoking cessation and chewing gum (opinions vary so seek opinions)
- Check consent, understanding and provide a date if possible
24
Q
How do you calculate risk
A
P-POSSUM
- use physiological parameters and operative parameters
25
What does the P Possum scale provide
Provides an indication of morbdity and mortality risk
26
For major surgery you always need a
FBC - for every ASA grade
27
How do you pre assess an emergency patient
* Take a full history and examine the patient thoroughly
* look for undiagnosed co-morbidities and uncontrolled co-morbidities
* Investigations:usually full set of bloods (and ECG if age>60 or cardio- respiratory disease) as minimum, further tests if time allows.
* Risk score
* May need to seek advice from physicians (cardiology, geriatrics etc)
* Discuss with ananaesthetist early
* Informed consent
* Plan post-operative care
28
What investigations do you carry out in a pre-operative assessment
- FBC, U&Es, finger prick blood glucose
- cross match and group & save - blood type
- specific blood tests
- CXR
- ECG - if older than 55 years or poor exercise tolerance or history of heart disease
- Echo - if suspicion of poor LV function
- pulmonary function tests - if known pulmonary disease/obesity
- lateral cervical spine X-ray - if history of RA, ankylosing spondylitis, Down syndrome
- MRSA screen
29
what specific blood tests might you carry out in a pre operative assessment
- LFT in jaundice, malignancy or alcohol abuse
- Amylase in acute abdominal pain
- Blood glucose if diabetic
- Drug levels as appropriate
- Clotting studies if liver or renal disease, DIC, massive blood loss or if on valproate, warfarin, heparin
- HIV, HBsAg in high-risk patients after counselling
- Sickle test in those from Africa, West Indies or Mediterranean
- TFT in those with thyroid disease
30
What are the aims of pre-operative assessment
1. To provide diagnostic and prognostic information
2. to ensure patient understands the nature, aims and expected outcome of the surgery
3. to allay anxiety and pain
31
if you are on anticoagulation what should you avoid pre surgery
- avoid epidural, spinal and regional block
32
Do you stop taking warfarin before surgery
Minor surgery – can be undertaken without stopping (if INR<3.5 it may be safe to proceed)
Major surgery – stop for 3-5d pre-op; vitK ± FFP or Beriplex® may be needed for emergency reversal of INR; one elective option is conversion to heparin (when re-warfarinizing give LMWH until INR is therapeutic as warfarin is initially prothrombotic)
33
Do you stop taking warfarin before surgery
– decision to stop based upon patient’s risk of VTE and bleeding risk associated with procedure
- No clinically important bleeding risk – can be performed just become next DOAC dose or 18-24h after last dose, and dosing restarted 6h post-op
- Low bleeding risk procedure – omit DOAC 24h pre-op
- High bleeding risk procedure – omit DOAC 48h pre-op
34
can aspirin be continued in surgery
- Aspirin can usually be continued
35
What happens to anticonvulsants before surgery
- given as usual pre-op
| - post op give drugs IV until able to take orally
36
how are beta blockers given before surgery
- continue up to and including on the day of surgery as this precludes a labile cardiovascular response
37
What happens to the contraceptive pill before surgery
- Stop 4 weeks before major/leg surgery
- ensure alternative contraception is used
- restart 2 weeks after surgery
38
should you continue digoxin before surgery
- continue up to and including the morning of surgery
- check for toxicity - ECG and plasma level
- do potassium and calcium
39
What preparation should take place before surgery
- starve patient: NBM >2 hours pre-op for clear fluids and >6 hours for solids
- is any bowel or skin preparation needed, or prophylactic antibiotics
- Start VTE prophylaxsis - graduated compression stockings, LMWH
- ensure necessary pre-medications, regular medications, analgesia, anti-emetics, antibiotics are all prescribed
- book any pre, intra, or post-operative X-rays or frozen sections
- book post op physio
- if needed - site IV cannula, catheterise and insert a Ryle's tube
40
What dose of LMWH is given before surgery
- Moderate risk: 20mg - 2 hour pre-op then 20mg/24 hr
- high risk(e.g. orthopaedic surgery) - 40mg pre op then 40mg/24hr
- heparin 5000U SC 2hr pre-op then every 8-12hr SC for 7d or until ambulant
