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Peri-operative medicine > Pre-operative assessment > Flashcards

Pre-operative assessment Flashcards

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1
Q

What questions is it important to ask about in an anaesthetic history?
What 2 types of reactions to anaesthetic drugs do you need to ask about?
What 3 medical conditions do you need to ask about?

A

Anyone in family or personal history had bad reaction to anaesthetics?
Any post op nausea or vomiting?
Anaphylaxis
Difficult or failed intubation
Malignant hyperthermia
Suxamethonium apnoea
Acute porphyrias, myasthenia gravis, neuromuscular disease, GORD or hiatus hernia,

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2
Q

How do you work out a patients pre-operative cardiac risk? What level is a risk to post-op cardiac event?

A

METS - over 4 indicated by inability to climb 2 flights of stairs is at risk of post op cardiac event

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3
Q

What does an anaesthetist need to know about angina pre op?

A

Is it stable or unstable, unstable need to know functional impair, exacerbating or relieving factors, frequency

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4
Q

What does an anaesthetist need to know about MI pre op?

A 
When
STEMI or NSTEMI
How was MI treated - PCI, thrombolysis, CABG, stents
How many vessels were involved
Has functional capacity changed
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5
Q

What does the level of cardiac impairment effect in management of a patient?

A

BP control- inotropes
Level of monitoring in op - arterial lines and CVL
Post op care - HDU or ICU

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6
Q

What heart disease is spinal anaesthesia contraindicated in?

A

Severe aortic stenosis

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7
Q

What is dual antiplatelet therapy?

A

Aspirin and P2Y12 inhibitor

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8
Q

Difference between a STEMI and an NSTEMI in terms of anatomy?

A

STEMI is full thickness infarction whereas NSTEMI is subendocardial MI/partial thickness

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9
Q

Why do drug eluting cardiac stents need DAPT? How long do they need it for? Why is this an issue for anaesthetists?

A

DES will undergo stenosis without taking DAPT for the initial 6-12 months that the artery is recovering around the stent
Issue as you dont want to stop DAPT in this time period and risk stenosis of the vessel, can you prolong surgery? if not you need fine tuned management plan

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10
Q

Difference between anticoagulants and antiplatelets?

A

Anticoagulants are heparins, direct thrombin inhibitors, Factor Xa inhibitors and Vitamin K antagonists
Antiplatelets are COX inhibitors, ADP/P2Y12 inhibitors, phosphodiesterase inhibitors, glycoprotein 2a3b inhibitors

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11
Q

Example of a LMWH anticoagulant?

A

Enoxaparin

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12
Q

Example of a direct thrombin inhibitor anticoagulant?

A

Dabigatran

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13
Q

2 examples of a direct factor Xa inhibitor?

A

Rivaroxaban and Apixaban

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14
Q

Example of a vitamin K antagonist?

A

Warfarin

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15
Q

Example of a COX inhibitor?

A

Aspirin

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16
Q

Example of a P2y12 inhibitor?

A

Clopidogrel

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17
Q

Example of a phosphodiesterase inhibitor?

A

Dipyridamole

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18
Q

Example of a glycoprotein 2a3b inhibitor?

A

abciximab

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19
Q

How long pre op does aspirin need to be stopped?

A

Doesnt

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20
Q

How long does clopidogrel need to be stopped pre op?

A

7 days

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21
Q

How long does warfarin need to be stopped for pre-op? goal INR?

A

4-5 days (goals INR at 1.4)

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22
Q

How long before op do Dabigatran, Rivaroxaban and Apixaban need to be stopped?

A

18-96 hours

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23
Q

How long since your last dose of Enoxaparin can you administer neuraxial anaesthesia?

A

12 hours or more

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24
Q

what can you assess about a patient that would increase their risk of post operative pulmonary complications?

A 
COPD
Smoking
Age
Myasthenia gravis
Anatomical abnormalities like kyphosis 
Nutritional status
Sleep apnoea
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25
What happens in a patient with reactive airways?
They get bronchospasm and can't be ventilated so need a period in ICU
26
How do you work out pack years as a smoker?
number of packs a day x years as a smoker
27
How long after stopping smoking does it take to clear carbon monoxide out of your system?
12-24 hours
28
How long after stopping smoking does your upper airway reactivity improve?
2-10 days
29
How many months after stopping smoking does your post operative complications reduce?
5-6 months
30
What occurs in diabetics that may make intubation difficult?
Stiff joint syndrome causing glycosylation of collagen effecting the TMJ and atlanto-occipital joints
31
Why do diabetics tend to experience a longer hospital stay?
Prone to infection and anastomoses break down
32
What HbA1c level pre op leads to a delayed elective surgery?
Over 69 mmol/L
33
How is insulin given to a patient with diabetes pre operatively whilst fasting? If they are receiving this pre-op how does their insulin regime alter post op?
Variable rate IV insulin infusion | Need a 30-60 minute overlap to prevent DKA
34
What should blood glucose levels be intra-operatively for a diabetic patient?
6-10mmol/L
35
What does GORD lead to in surgery?
Aspiration pneumonitis
36
9 situations that can increase your risk of GORD during surgery?
``` Pregnancy Hiatus hernia Diabetes Opioids Alcohol Obesity Gastric outlet obstruction Pain and anxiety Bowel obstruction ```
37
What methods can be put in place to minimise the risk of aspiration under anaesthesia?
``` Fasting Positioning of patient upright Use of different anaesthesia methods - spinal NG tube to suction out contents Quick induction anaesthesia ```
38
How many hours before a procedure are you unrestricted by food or liquid intake? can have a small meal? can have breast milk? can only have fluids? NBM?
``` 8 hours 6 hours 4 hours 2 hours clear liquid From 2 hours to procedure ```
39
What does atlantoaxial instability increase your risk of?
Acute subluxation and spinal cord compression
40
What joint issue can cause difficulties for airway management by anaesthetists?
TMJ
41
When can MSK issues become a problem for anaesthetists?
``` Contractures - IV access TMJ - airway management Difficult positioning Dry eyes - corneal abrasions immunosuppression - proper aseptic technique ```
42
What is ankylosing spondylitis and what joints does it primarily effect? What is usually needed for intubation?
Fibrosis and ossification of sacroiliac joints and spine as well as some extra articular disease Usually need a fibreoptic intubation method through the nose
43
What is ASA grade?
An assessment tool used by anaesthetists to assess functional capacity of a patient to undergo surgery
44
What are some examples of minor surgeries performed?
Skin lesion excision | Breast abscess drainage
45
What are some examples of Intermediate surgeries that are performed?
hernia repair varicose vein excising tonsillectomy knee arthroplasty
46
What are some examples of major surgeries that are performed?
``` GI TAH Thyroidectomy Total joint replacement Thoracic surgery Vascular surgery ```
47
What are the ASA grades? What ASA grades used for day surgery?
``` ASA 1 - fit and healthy (day case) ASA 2 - mild systemic illness (day case) ASA 3 - severe systemic illness ASA 4 - severe systemic illness with constant threat to life ASA 5 - Expected to die ASA 6 - brain dead organ retrieval ```
48
ASA 3 and 4 are the only groups that you consider 2 investigations for minor surgery, what are they?
Kidney function | ECG if none available from last 12 months
49
ASA 1 testing for intermediate surgeries?
None routinely
50
ASA 2, two tests you consider for intermediate surgery?
Renal function if at risk of AKI | ECG if they have CV, diabetes or renal comorb
51
What management and considerations are taken for an ASA grade 3 or 4 undergoing intermediate surgery?
You would do a renal function and ECG You would consider FBC if CV or renal disease You would consider haemostasis analysis if chronic liver disease or on anticoagulants You would consider seeking advice from senior anaesthetist if respiratory disease
52
What management would an ASA 1 get for major surgery?
FBC renal function if risk of AKI ECG if over 65 and non available
53
What management would ASA 2 get for major surgery?
FBC Renal function ECG
54
What management would ASA 3 get for major surgery both compulsory and considered?
FBC ECG Renal function Haemostasis considered if chronic liver disease or clotting status needed Lung function consider senior anaesthetist review if known respiratory disease
55
What test would you do on women pre op?
Pregnancy test
56
When is an ECHO done pre op?
When there is a murmur or SOB, risk of arrhythmia
57
4 things that increase the risk of VTE in acute surgical or trauma patients?
Surgery longer than 90 minutes Surgery longer than 60 minutes on pelvis or lower leg Acute inflammatory condition or intra-abdominal condition Expected marked reduction in mobility
58
When a patient first comes to hospital, how do you perform a VTE risk assess?
Thrombosis risk - 1 point then consider LMWH | Bleeding risk - 1 point then dont use LMWH unless thrombosis risk outweighs
59
What patient factors increase the risk of thrombosis?
``` Age over 65 Obesity Active cancer or cancer treatment Dehydration Known thrombophlebitis Significant medical comorbidities Personal history of VTE HRT Oestrogen contraception Pregnancy or 6 weeks post partum ```
60
What is the usual dose and form of VTE prophylaxis used for patients?
Enoxaparin 40mg SC OD
61
When would you only use 20mg SC OD of Enoxaparin for prophylaxis against VTE?
when their weight is under 40kg or their eGFR is under 30mls/min
62
When would you use 60mg SC OD of Enoxaparin for VTE prophylaxis?
When the patient is over 100kg
63
What non-pharmacological methods of VTE prophylaxis are there?
Anti-embolism stockings Early mobilisation Hydration Intermittent pneumatic compression devices
64
Patient factors that increase the bleeding risk?
``` Active bleeding Bleeding disorders - liver disease and haemophillia Thrombocytopenia below 75 Anticoagulants being used Acute stroke Uncontrolled systolic hypertension ```
65
Admission related bleeding risk factors?
Neurosurgery, spinal or eye High bleeding risk Neuroaxial anaesthesia expected in next 12 hours or in the last 4 hours

Peri-operative medicine (8 decks)

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