Pre-Operative Care

Question 1

why do cardiovascular conditions need to be disclosed in a pre-op assessment and why?

Answer 1

there is an increased risk of an acute cardiac event when a patient is under anaesthesia

Question 2

why do respiratory conditions need to be disclosed in a pre-op assessment and why?

Answer 2

patient needs adequate oxygenation to prevent ischaemic complications during surgery

Question 3

what complications of renal disease can increase the risk of surgical complications?

Answer 3

anaemia, coagulopathy, biochemical disturbances

Question 4

when should extra care be taken when operating on a patient with severe renal dysfunction?

Answer 4

when giving IV contrast or during blood loss in theatre as can cause further damage to the kidneys

Question 5

what endocrine diseases need to be considered when operating on a patient and why?

Answer 5

diabetes and thyroid disease

the medications used to treat these conditions may have to be changed peri-operatively

Question 6

what is post operative nausea and vomiting (PONV)?

Answer 6

nausea and vomiting that occurs within the first 48 hours post-op often caused by opioid anaesthesia

Question 7

what is the eating regimen pre-op?

Answer 7

stop eating and drinking 6 hours prior

stop clear fluids 2 hours prior

Question 8

why should a patient not eat or drink prior to surgery?

Answer 8

an empty stomach reduces the risk of pulmonary aspiration, which can lead to aspiration pneumonia

Question 9

what is the pneumonic for commonly discontinued medications pre-operatively?

Answer 9

CHOW:
Clopidogrel
Hypoglycaemics
Oral contraception or HRT
Warfarin

Question 10

what is the protocol for clopidogrel prescriptions pre-op?

Answer 10

should be stopped 7 days pre-op to reduce bleeding risk

Question 11

true or false: aspirin should be stopped pre-op

Answer 11

false.

aspirin has a minimal effect on surgical bleeding and can be continued

Question 12

what is the protocol for type I diabetic patients pre-op?

Answer 12

• patient should be taken into theatre in the early morning as will be NBM from night time
• patients should miss morning insulin and be started on an IV sliding scale
• patient should also be given IV dextrose while NBM and BM should be monitored

Question 13

what is the protocol for type II diabetic patients pre-op?

Answer 13

• metformin should be stopped the morning of surgery
• other diabetic drugs should be stopped 24 hours pre-op
• patient should be placed on IV sliding scale and dextrose the same as type I diabetics

Question 14

what is the protocol for pre-op patients on OCP or HRT?

Answer 14

should be stopped 4 weeks before surgery due to DVT risk

Question 15

what is the protocol for pre-op patients on warfarin?

Answer 15

stopped 5 days before surgery to reduce bleeding risk

• therapeutic LMWH given instead
• INR <1.5 needed for surgery to go ahead, PO vitamin K may be given to help lower INR

Question 16

what is the protocol for pre-op patients on long-term steroids?

Answer 16

these should be continued, as the risk of an Addisonian Crisis increases if stopped

Question 17

what three things should be prescribed to a patient pre-operatively?

Answer 17

• low molecular weight heparin (LMHW)
• TED stockings
• antibiotic prophylaxis

Question 18

why is a pre-op patient given LMWH?

Answer 18

this is done to reduce the risk of VTE

Question 19

when would you not prescribe TED stockings?

Answer 19

if a patient is undergoing vascular surgery or has peripheral vascular or neuropathic conditions

Question 20

why is a pre-op patient given prophylactic antibiotics?

Answer 20

in order to reduce the risk of infection peri and post-operatively

Question 21

what specific surgeries would a patient need ‘bowel preparation’ for?

Answer 21

if the patient is having one of the following colorectal surgeries:

• left hemi colectomy
• sigmoid colectomy
• abdo-peroneal resection
• anterior resection

Question 22

what is ‘bowel preparation’ and what specific drugs are given?

Answer 22

giving a patient laxatives or enemas to clear out their bowels prior to surgery.
phosphate enemas most commonly given

Question 23

how is the difficulty of intubation assessed?

Answer 23

by giving the patient a Mallampati grade

Question 24

what is assessed in Mallampati grading?

Answer 24

• facial deformities
• degree of mouth opening
• presence of teeth and dentition
• oropharynx and visibility of their uvula
• range of movement of the neck

Question 25

what investigations are normally conducted pre-operatively?

Answer 25

• blood test
• imaging
• urine dip
• pregnancy testing

Question 26

what specific blood tests are done and why?

Answer 26

• FBC to assess for any undiagnosed anaemia or thrombocytopenia (these can increase risk of CVS events)
• U&Es to assess baseline renal function and inform on IV fluid management intra-operatively
• LFTs to assess liver metabolism as it can inform of drugs prescribed
• Clotting screen to assess risk of bleeding or risk of clots
• X-match and G&S in the event of a transfusion needed

Question 27

what specific imaging is done and why?

Answer 27

• ECG preformed for patients with a history of CVD or if they are undergoing major surgery, done to provide a baseline of cardiac activity
• CXR if the patient is a smoker or has had a cardiorespiratory illness