Pre-operative Assessment · Clinical Skills OSCE Station Please EXAMINE from this 85yo life long...
Transcript of Pre-operative Assessment · Clinical Skills OSCE Station Please EXAMINE from this 85yo life long...
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Pre-operative Assessment
Dr Will Dooley
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Plan
• Exam format• Structure for history and examination• Options for investigations
• Commonly examined in Finals…• Reduce morbidity and mortality• Reduce cancellations
Why is it important??
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How do you structure a pre-op assessment?
Please perform a pre-operative assessment on this 85yo life long smoker who has been booked for transurethral resection of prostate (TURP) .
• History • Examination• Investigation• Management
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Communication Skills OSCE Station
Please TAKE A HISTORY from this 85yo life long smoker who has been booked for transurethral resection of prostate (TURP) .
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85yo for TURP
Mr Griffin has suffered two "mini-strokes" in the past two years, since which he taken “blood thinning tablets”. He has never had a heart attack and has had no previous operations. He has smoked twenty cigarettes a day since aged 15. He is a retired shopkeeper.
He lives in a warden controlled flat and has ‘meals-on-wheels’. He can get around the home with a frame but is limited by his breathing. He states his breathing has been “bad for years” and he has a cough productive of clear sputum all year round. He states he gets a bad acidic taste when he ties his laces.
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History structureCurrent state
• Baseline / Recent conditionPast Medical History
• Especially cardiovascular and respiratory / sleep apnoea symptoms• Current control of medical conditions
Past Surgical History / Previous anaesthetic• Any anaesthetic or surgical complications
Drug history• Including allergies
Family history• Anaesthetic e.g. malignant hyperthermia
Social history• Smoking• Dependence• Exercise Tolerance
Anaesthetic specifics• Dentition / Dentures
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DRUGS TO STOP
DRUGS TO ALTER
DRUGS TO ADD
DRUGS TO CONTINUE
DISCUSS WITH ANAESTHETIST / SURGEON
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DRUGS TO STOP
• Aspirin/Clopidogrel: 7 days before, unless high risk
• Metformin: 2 days either side of surgery
• Diuretics & ACE-inhibitors: On day of surgery
• Combined oral contraceptive pill / HRT: 4 weeks pre op if high VTE risk
• Psychiatric drugs – Monoamine Oxidase Inhibitors (MAOI) 2 weeks before
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DRUGS TO ALTER
• Insulin: consider sliding scale
• Steroids: may need to change to IV steroids
• Anti-coagulation…
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“Bridging” Warfarin5 days before stop WarfarinStart LMWH if high riskStop LMWH day before 1 day before check INRContinue op if INR < 1.5 Consider vit K if INR >1.5
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DRUGS TO CONTINUE
• IF IN DOUBT, ASK THE ANAESTHETIST / SURGEON
• Anti-hypertensives• Antacids / PPI• Anti-arrythmics• Anti-anginals• Anti-depressants (other than MAOI)• Benzodiazapines• Bronchodilators• Parkinson / Epilepsy medications• Thyroid medications
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DRUGS TO ADD
• Pre-operative - Bowel prep
• Intraoperative - TEDS stockings
• Post-operative - LMWH
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Clinical Skills OSCE Station
Please EXAMINE from this 85yo life long smoker who has been booked for transurethral resection of prostate (TURP) .
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ExaminationA• Any intubation concerns (including dentures)• Review mouth opening (Mallampati classification)
B• Examine respiratory system
C• Examine cardiovascular system• Any signs of heart failure or respiratory distress
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Practical Skills OSCE Station
What investigations would you order for this patient?
Anything else you may consider doing?
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NICE Guideline
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InvestigationsBedside
• ECG
• Random blood glucose
• Urine Analysis
• Peak Flow
Bloods• FBC
• U+E
• Clotting– e.g. PT / APTT / INR
Imaging• Chest X-ray
Special tests (for ASA 2/3 consider):• Arterial Blood Gas
• Lung Function Tests
• Echocardiogram
MRSA Swabs
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NICE Guideline
?Nice
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Which tests?
• Depends on …
1. The Patient• Age • Co-morbidities and Risk grading
2. The Operation• Severity / complexity
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The patient…
American Society of Anesthesiologists
Mortality (%)
0.1
0.2
1.8
7.8
9.4
ASA Grade 1
ASA Grade 2
ASA Grade 3
ASA Grade 4
ASA Grade 5
ASA Grade 6
Normal Healthy Patient
A patient with mild systemic disease
A patient with severe systemic disease
A patient with severe systemic disease that is a constant threat to life
A moribund patient unlikely to survive 24hrs with or without surgeryA brain dead patient who’s organs are for donor purposes
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The patient…
** ASA BINGO **
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ASA 1 ASA 2
ASA 3 ASA 4
ASA 5 Patient with Asthma and well controlled DM Current smoker (10/day)BMI 35
Patient with HTNPoorly controlled with 3 anti-HTN medsHealthy. Non smokerBMI 29Minimal ETOH
Patient in resusRuptured aneurysmPMH: HTN/IHD
Patient with IHDMI 1 week agoOngoing valve dysfunction
Declared brain dead For organ donoation
ASA 6
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ASA Grade 2/3 – What is mild/severe?Angina
Hypertension
DM
COPD
Asthma
Renal disease
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The operation…Grading system of severity
Grade 1 Minor
Grade 2 Intermediate
Grade 3 Major
Grade 4 Major +
Neurosurgery
Cardiovascular surgery
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The operation…
** OPERATION BINGO **
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The operation…Grading system of severity
Grade 1 Minor
Grade 2 Intermediate
Grade 3 Major
Grade 4 Major +
Neurosurgery
Cardiovascular surgery
Excision of skin lesion
Drainage of breast abscess
Hernia repair
Varicose veins excision
Tonsillectomy
Total Abdominal Hysterectomy
Prostate resection Thyroidectomy
Total joint replacement
Lung operation
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The operation…Grading system of severity
Grade 1 Minor Excision of skin lesion, drainage of breast abscess
Grade 2 Intermediate Hernia repair, varicose veins excision, tonsillectomy
Grade 3 Major Total Abdominal Hysterectomy, prostate resection, thyroidectomy
Grade 4 Major + Total joint replacement, lung operation
Neurosurgery
Cardiovascular surgery
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Management
C epodP ost op careO ptimiseD ay of surgery
C P O D
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BOOK
• CEPOD 1. Immediate (Life / limb threatening)
2. Urgent (Acute cases)
3. Expedited (Subacute cases)
4. Elective (Planned)
• Post op care – involve the MDT• e.g. ITU/HDU – discuss with surgeon and anaesthetist
• Social care - involve PT/OT etc.
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OPTIMISE
• Act on pre-operative investigations
• DM control – first on theatre list
• VTE control – pre and post operative
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DAY OF THE SURGERY
Fasting rules• Last eat• Last drink
Pregnancy test
Consent
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How do you structure pre-op assessment?
• History• PC/PMH/PSH/DH/SH
• Examination• ABCDE
• Investigation• Bedside/bloods/imaging/special tests
• Management -• Optimisation• MDT involvement
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Summary
• Pre-operative care aims to reduce complications
• Level of investigation depends on patient and operation
• Optimise the patient pre-op within the MDT
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EXAMPLE CASE
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85yo for TURP
Mr Griffin has suffered two "mini-strokes" in the past two years, since which he taken “blood thinning tablets”. He has never had a heart attack and has had no previous operations. He has smoked twenty cigarettes a day since aged 15. He is a retired shopkeeper.
He lives in a warden controlled flat and has ‘meals-on-wheels’. He can get around the home with a frame but is limited by his breathing. He states his breathing has been “bad for years” and he has a cough productive of clear sputum all year round. He states he gets a bad acidic taste when he ties his laces.
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Examination
Tar staining
CV : Pulse irregularly irregularHS- I+II+ ES murmur loudest aortic region no radiation to carotid
RS : Widespread wheeze
Observations BP 125/80HR 78RR 14Sats 91%
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Atrial fibrillation
Rate: 78bpm (60-100bpm)Rhythm: Irregularly irregularAxis: LAD
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Investigations
INR in therapeutic range
Type 1 respiratory failure
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HyperexpansionFlat diaphragmsBullae
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Obstructive disease