Download Pre-Operative Assessment

Pre-Operative Assessment
Summarise core details
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Patient details
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Operation (& anaesthesia required)
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Background
NB. look through past notes/ e-documents to confirm details
Current health
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Recent/current illnesses (within 2 weeks)
Baseline exercise tolerance (what makes them stop: SOB/chest
pain/claudication)
Symptoms of sleep apnoea (PND, excessive sleepiness, morning headaches)
Smoking
Medical and drug history
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Medical conditions
o Ask specifically about hypertension, diabetes, asthma/COPD, CVD, IHD
o Determine if conditions are adequately controlled
Drug history (including allergies!!)
Anaesthetic history
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Previous anaesthetics and reactions
Family anaesthetic history
06.08.2013 15.42
Pre-operative assessment
48y male
Admitted for: Right hemi-hepatectomy
Background: Cholangiocarcinoma
-Admitted with painless jaundice July 2013
-CT during admission revealed likely cholangiocarcinoma
without metastasis
-CT-guided biopsy August 2013 confirmed moderatelydifferentiated cholangiocarcinoma
-Staging laparoscopy August 2013 confirmed no peritoneal
disease
Currently: Fit & well. No illnesses in last 2 weeks. No
SOB/chest pain/claudication on exertion. No symptoms of
sleep apnoea. Never smoked.
PMHx: -Type 2 diabetes: Dx 2000, well controlled on
metformin.
-No past surgery
DHx: -NKDA
-Metformin 500mg OD
Anaesthetic Hx: Never had general anaesthetic. No known
family reactions.
O/E: Anaesthetic: No neck movement/ jaw opening
limitation. No dentures. Mallampati type 1. No
skeletal malformations
RS:
No cyanosis, warm peripheries, cap refill <2s
Chest expansion normal
Resonant to percussion
Normal air entry, no wheeze or added sounds
Calves non-tender
CVS:
Pulses palpable, JVP normal, no carotid bruits
No heaves/thrills
HS I + II + 0
No peripheral oedema
Abdo: Jaundice ++. S.N.T. No masses/organomegaly.
Normal bowel sounds.
CONCLUSION: Fit for anaesthetic if bloods normal
PLAN: 1) All bloods (inc glucose + G&S)
2) Admit overnight for variable-rate insulin infusion
3) VTE prophylaxis & proforma
4) Drug cardex
Examination
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5) Consent form
6) Clear fluids only from midnight
NBM from 8am
Patient aware & insulin/ fluids prescribed
Anaesthetic assessment
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Neck movement limitation/ jaw opening limitation/ dentures
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Airway assessment: use Mallampati classification & note BMI
1. See all soft palate and uvula
2. See half of uvula
3. See a small gap at end of soft palate
4. Can only see hard palate
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Back examination (if having spinal/epidural): look for skeletal malformations
Multi-system examination
o General: GCS, limb movements
o Hands: cyanosis, warm peripheries, cap refill, peripheral pulses
o Neck: JVP, carotid bruits
o Chest: heaves/thrills, chest expansion, percussion resonance, lung & heart sounds
o Abdomen: tenderness, masses/organomegaly, bowel sounds
o Calves: swelling/tenderness, oedema
CTN
C. Mansbridge
FY1 General Surgery (bleep 5211)
Order investigations
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Routine tests (ASA have guidelines on exactly who needs what)
o Bloods within 1 week
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FBC (all patients; anaemia increases surgical risk)
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U&Es (all patients; assess risk of ARF post-surgery)
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LFTs (if liver/biliary operation or past liver problems; impairment may delay healing)
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Clotting (all patients)
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TFTs (if taking thyroxine)
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Group and save (all patients)
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Sickle cell screen (if Afro-Caribbean/Mediterranean/Middle Eastern/Asian ethnicity)
o ECG (if >50years or any heart problems)
Other tests may be necessary
o CXR (only if may need ICU care)
o Echocardiogram (if valvular disease/murmur)
o Spirometry (if lung disease)
© 2013 Dr Christopher Mansbridge at www.OSCEstop.com, a source of free OSCE exam notes for medical students’ finals OSCE revision
o Pacemaker check (if have pacemaker)
NB. Look at the patients electronic record to determine history and any previous results e.g. echocardiography etc
Check investigation results and correct if needed
For a day 1 pre-op assessment:
 Correct INR if abnormal (>1.4)
o Aggressive regime (if on warfarin for AF): 5-10mg IV vitamin K, then repeat INR in 6 hours – if still high, discuss with
seniors and who may advise giving prothrombin complex concentrate (or FFP) pre-op
o Cautious regime (if on warfarin for artificial heart valve/PEs): discuss with seniors – will probably require heparin
infusion cover
 Consider blood transfusion if Hb <9g/dL, or <10g/dL if elderly/cardiovascular/respiratory disease
 Consider platelet pool if platelets <50x109/L (discuss with seniors)
 Correct electrolyte abnormalities
If there are significant abnormalities, bloods must be repeated again pre-op e.g. at 6am to show they have been corrected
For an early pre-op assessment (>1 week pre-op):
 INR may be corrected by stopping warfarin as below
 Anaemia should be investigated and the cause treated – e.g. with iron tablets for iron-deficiency anaemia
If there are any concerns, contact the consultant or an anaesthetist
Forms to fill out
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Drug cardex
o Regular medications (starting day after operation unless they are vital e.g. anti-arrhythmics)
o Only prescribe fluids overnight (when NMB) if instructed by consultant or if patient needs variable rate insulin infusion
or is dehydrated
o Drugs required for specific operation (specified in pre-operative checklist) e.g. bowel prep for colorectal
o Omit warfarin/asprin/clopidogrel/insulin/diuretics/ACEi/other medications specified by anaesthetist at the correct
times (more detail below)
o Write up (starting from the date of the operation):
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Paracetamol 0.5-1gram 4-6 hourly, max 4grams, PO/IV (regular QDS)
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Codeine 30-60mg 4-6 hourly, max 240mg, PO (PRN)
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Cyclizine 50mg TDS, max 150mg, PO/IV (PRN)
And for big operations also
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Ondansetron 4mg BD PO/IV (PRN)
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Fortisip 125ml QDS (also give pre-operative high calorie drinks)
VTE prophylaxis performa and prescription: LMWH must be given the night before the operation, but omit any doses when the
operation will start in <12 hours
Consent form (do it if you have sufficient knowledge, if not call registrar/ consultant)
Information to give patients
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Stopping medications prior to surgery (the below is generally done in an early pre-op assessment by, or in discussion with, an
anaesthetist)
o Warfarin
5 days (but LMWH should be prescribed in interim)
o Asprin/clopidogrel/dipyramidole
7 days (but never stop without clear instruction if drug-eluting cardiac stent or
other high risk indication)
o Therapeutic-dose clexane
48 hours (but may need heparin infusion if high risk indication)
o Insulin
Avoid morning dose (& prescribe variable-rate insulin infusion with surgical fluid
[5% dex/ 0.45% NaCl/ 0.15% KCl @ 80ml/h] from midnight the night before if
not minor surgery)
o Oral hypoglycaemics
Avoid on day of operation(and also avoid metformin for a few days after due to
risk of lactic acidosis) & prescribe variable-rate insulin infusion as above if blood
glucose not well controlled)
o Diuretics/ACEi
Avoid on day of operation
o Stop any other medications advised by anaesthetist
o Only give vital regular medications on the day of the operation e.g. anti-arrhythmics, anti-hypertensives (not listed
above) if SBP is high
Fasting guidelines
o “2-6 rule” = NBM for 2 hours pre-op; clear fluids only for 6 hours pre-op
N.B. if you are unsure the operation time, prepare the patient for 8am (e.g. say clear fluids only from midnight, NBM
from 6am)
Patients only need to stay in overnight the night before if they are diabetic (and therefore require a variable-rate insulin infusion
from midnight) or they need specific medications pre-op which must be given overnight or INR/Hb/plt may need correcting
© 2013 Dr Christopher Mansbridge at www.OSCEstop.com, a source of free OSCE exam notes for medical students’ finals OSCE revision
Pre-Operative Assessment Checklist
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Check there is access to CT/MR scans (if patient is from another hospital)
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Write a pre-op assessment in the notes
o Admitted for
o Background
o Current health
o PMHx
o DHx
o Anaesthetic Hx
o O/E
o Plan
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Investigations
o All bloods (+ sickle cell if not Caucasian)
+ follow-up
o ECG if >50y or heart problems
o Check any other investigations ordered by anaesthetist are done / order any other investigations necessary
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Prescription chart
o Specific pre-operative drugs
o Regular medications (start day after operation unless vital)
o LMWH (including dose night before unless operation will start <12 hours)
o Analgesia and anti-emetics post-op
o Check advice for others/ drugs to stop in anaesthetist assessment (if they’ve done one)
o If diabetic: variable-rate insulin infusion from midnight + surgical fluid [5% dex/ 0.45% NaCl/ 0.15% KCl @ 80ml/h]
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Add the patient to your team’s list
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VTE assessment
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Consent form
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Patient information
o Drugs to stop taking/check they were stopped
o Stay overnight if diabetic, need pre-op drugs during night or Hb/INR/plt may need correcting
o Clear fluids only after midnight, NMB after 6am
© 2013 Dr Christopher Mansbridge at www.OSCEstop.com, a source of free OSCE exam notes for medical students’ finals OSCE revision