Preoperative assessment Flashcards
(29 cards)
Define emergency / urgent / elective surgery
Emergency - must be done within 1 hour
Urgent - must be done within 24 hours
Elective - No urgency - a pre-determined booked time
Describe the triage system used at GSH to assign urgency to unplanned surgeries
Red: (Immediate)
Unstable bleeding gunshot
Imminently threatened airway
Ruptured AAA
Orange: (1 - 3 hours)
Acute abdomen d/t bowel perforation
Ectopic pregnancy ruptured/about to
Yellow: (< 6 hours)
Stable appendicitis
Open fractures
Green (<24 hours)
Stable, closed fractures
Changing of dressings
Cancer surgery
Blue (Elective surgery)
What are the 6 components of informed consent
- Advance
- Writing,
- Informed (Describe, Risk/ben, conseq, alternatives)
- Voluntary (exclude duress),
- Legally competent,
- Witnessed: 3 signatures: 1 independent medical practitioner and 2 witnesses (not anaesthetist)
What are the legal ages for consent for various types of procedures in RSA
Medical Rx - 12 yrs Surgical Rx - 12 yrs HIV Test - 12 years TOP - no lower age Contraception - 12 years
Virginity - 16 yrs
Circumcision - 16 yrs
Sexual Intercourse - 16 yrs
Sterilization - 18 yrs
Interns cannot take consent - they are not independent medical practitioner
What should be done about informed consent in the following circumstances:
- Parent/Guardian not present or contactable
- Unconscious/Incompetent patient
The surgeon accepts the responsibility of consent but must notify the Medical Superintendent of the problem prior to surgery.
What is the heirarchy of an ‘authorized person’
- Proxy nominated in patients writing
- Person authorised by court/law
- Spouse
- Parent
- Grandparent
- Adult Child
- Brother or sister
Define the ASA classification
I - A normal healthy patient
II - Mild systemic disease without fxnal limitation
III - Severe systemic disease with fxnal limitation
IV - Systemic disease is a constant threat to life
V - Moribund: dead with or without surgery
VI - Brain-dead awaiting organ harvest
When should oral hypoglycaemics be stopped and why
The day before theatre to avoid hypoglycaemia in fasting patients
Insulin sliding scale with glucose monitoring often required
What should be done for patient’s on antifailure treatment including: diuretics/digoxin/K supplements
Check electrolytes
Which medications should be discontinued before surgery and when should these be discontinued
- Oral hypoglycaemics (Glibenclamide, gliclazide) - 1 day before (omit bolus and long acting insulin)
- Warfarin - 4-5 days before INR < 1.5
- ACEI (enalapril) - day before
- Enoxaparin > 12 hours before surgery
Should BB/CCB/Diuretics be continued before surgery
YES (check electrolytes)
Describe management of patients with adrenal insufficiency or patients who have been on > 5mg of prednisone daily (or equivalent) for > 4 weeks
- Hydrocortisone 200mg intraop
- Hydrocortisone 50 mg IM over next 24 hours
- Double regular dose of enteral steroid for 2 - 7 days depending on surgery and patient.
What alterations in chronic asthma therapy should be made prior to surgery
Continue all preventers and relievers
Consider 5 day of prednisone 4mg daily to optimise prior to surgery
Should NSAIDS be stopped prior to major surgery
This should be considered where any effect on coagulation may be critical
- Airway surgery
- Neurosurgery
Should statins be discontinued before surgery
No. They also have anti-inflammatory action
Why should antiviral agents not be stopped prior to surgery and what are the problems with this
Increased antiviral resistance
Interactions with anaesthetic agents
- Overall: Enhanced toxic effects of most anaesthetic agents
Should aspirin be continued perioperatively
yes
When should clopidogrel be stopped prior to surgery
Drug eluting stent placement
- Postpone elective surgery for 1 year
Other stents
- Postpone elective surgery for 1 month
Exceeding the above timeframes clopidogrel should be stopped 5 days before surgery (discuss and confirm with cardiologist)
Psychiatric therapy
Continue therapy bt be aware that there are many enzymes induced and inhibited –> drug interactions with the risk the SSRIs and risk of serotonin syndrome
Should the oral contraceptive be continued prior to surgery?
Ideally yes - stop for one month prior as it increases risk of VTE
OTC drugs pre-op
Ascertain which ones and look it up
What is the principle that should guide pre-operative investigations
Abnormal results –> there must be increased risk to patient
Normal results –> there must be reduced risk to patient
Who gets ward Hb
Everyone
Which age group automatically gets ECG, UE, URINE
> 45
