Pre-operative assessment

Question 1

Define pre-operative assessment.

Answer 1

History and examination at least 24 hours before surgical procedure

Question 2

Give 6 reasons for why pre-op assessment is important.

Answer 2

1. To identify existing medical problems, their management and any implications.
2. To understand all surgical and procedural problems and their implications.
3. To determine current drug therapy.
4. To identify risk factors for morbidity and mortality and if possible apply measures to reduce risks, e.g. cardiac, respiratory, aspiration, renal, haematological, endocrine.
5. To prepare an appropriate anaesthesia and analgesia plan including regional technique, airway management and invasive monitoring.
6. To plan postoperative recovery, e.g. HDU or ICU.
7. To obtain consent for the plan and discuss routine and specific risk-benefits and address concerns.
8. If necessary, to seek a second opinion or advice from another specialist or refer to another specialist.
9. To prevent on-the-day cancellations

Question 3

What would you ask in the PMHx and PSHx in a pre-op history?

Answer 3

Brief
- Presenting complaint
- Procedure to be done
- Confirm site of the procedure

Past medical history
- CVS: Hypertension, history of an acute cardiac event during anaesthetic procedure
- Respiratory disease
- Renal disease; anaemia, coagulopathies
- Endocrine disease; DM, thyroid disease

Past surgical history
- Previous operations
- What procedures
- Site
- Reason
- Complications

Question 4

What do you ask in the anaesthetic hx?

Answer 4

Any anaesthesia prior to this
Any complications
Well being post operatively
Post op nausea and vomiting

Question 5

What would you ask on drug, family and social history?

Answer 5

Drug hx
- Some meds must be stopped, altered prior to surgery
- Any drug allergies

Family hx
- Conditions that lead to muscle rigidity despite neuro muscular blockade
- Malignant hyperthermia

Social hx
- Smoking
- Alcohol
- Substance abuse

Question 6

What 2 things do you examine during examination?

Answer 6

1. General examination relating with the pathology
2. Airway examination to assess how difficult intubation will be

Question 7

On airway examination, what does the mnemonic LEMON stand for?

Answer 7

Look externally
Evaluate; the 3-3-2 rule
Mallampati
Obstruction
Neck mobility

Question 13

What is the purpose of the American Society of Anesthesiologists (ASA) Physical Status Classification?

Answer 13

The purpose of the system is to assess and communicate a patient’s pre-anaesthesia medical co-morbidities.

Question 14

What are the 6 ASA grades?

Answer 14

Grade I - A normal healthy patient
Grade II - A patient with mild systemic disease
Grade III - A patient with severe systemic disease
Grade IV - A patient with severe systemic disease that is a constant threat to life
Grade V - A moribund patient who is not expected to survive without the operation
Grade VI - A declared brain-dead patient whose organs are being removed for donor purposes

Question 15

List 4 pre-op investigations that can be done.

Answer 15

FBC

Electrolytes and Urea

LFTS

Clotting profile

Imaging; X-Rays, ECG

Question 16

What advice do you give to patients? (3)

Answer 16

Fasting at least 6 hours before procedure for solids in paediatrics, 8 hours for heavy meals in adults, 6 hours for fruits/vegetables

2 hours for clear fluids like water

Other fluids 4 hours

Question 16

What should be included in your management plan?

Answer 16

• Reassure the patient
• Advise
• Prescribe
• Refer
• Observe

Question 17

Name 2 drug you might need to stop or start before surgery.

Answer 17

STOP
Clopidogrel 7 days prior
Hypoglycaemics
OCPs -4 weeks
Warfarin 5 days

START
Low molecular weight heparin
Antibiotic prophylaxis