7th_DayPac
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Transcript of 7th_DayPac
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Outlook Brief background history
Objectives of Pre-admission Clinics (PAC)
Who should be seen in PAC
Classification of physical status Patient assessment by organ system
Conclusion
Questions
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Background 1
1992: 6% DOSA (Liverpool Hospital) 6,700 elective admissions
1994: 35% DOSA
2003: 95% DOSA (RMH) > 10,000 elective admissions
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Background 2
Day Case Surgery at Royal Melbourne: Feb. 03 - Jan. 04
2,242 Day cases vs 7,083 Multiday cases
Endoscopies: 2,767 as day cases
5,009 Day cases of a total of 12,092 patients
41 % Day Cases
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Background 3
Mid 90 - PACs everywhere Australia leading the world
Love - hate relationship
Poor guidelines by colleges
Vast differences in organisation and
philosophy
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Objectives 1
Identifying potential anaesthetic difficulties Identifying existing medical conditions
Improving safety by quantifying risk
Allowing planning of peri-operative care
Explain and discuss
Allaying fear and anxiety
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Objectives 2
Reduce costs Increase efficiency of operating time
Increase patient comfort and satisfaction
Reduce cancellations
Reduce FTA
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Classification of Physical Status
AmericanSociety ofAnesthesiologists
ASA
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ASA 1
Class I Normal healthy patient
Class II Mild systemic disease
Class III Severe systemic disease
that limits activity, but is not
incapacitating
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ASA 2
Class IV Severe incapacitating
systemic disease with
constant threat to life
Class V Moribund Patient not
expected to survive 24hours with or without
surgery
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Predictors of operative
morbidity Age
Pre-operative ASA status
Type of surgery (minor vs. major)
Emergency vs. elective
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Day Case Eligibility
Social
medical
facilities and procedures
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Day Case Eligibility 2
Medical Procedure
Minimal bleeding
Minimal pain and nausea
Minimal post op airway compromise
No special nursing requirements
Rapid return to oral intake
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Day Case Eligibility 3
Medical cont. Patients should be fit or well controlled chronic
disease
BMI < 30 (35) Physiological status vs age
Routine rules apply to pre-operative assessment
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Day Case Eligibility:
Ever growing list of procedures: eg: Laparoscopic cholecystectomy
Hernias
VVs Orthopaedics
Plastics
Urology
Eyes
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Who should be seen Type of surgery (cataract vs. hemihepatectomy)
Age (? Over 60/65/70)
ASA III and IV
Language Patient request
Previous anaesthetic problems
Social circumstances (country patients, elderlyetc)
Repeat operations
Possible airway problems
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Who should assess
Anaesthetist vs Liaison nurses
RMH: 94% of all patients are seen by
anaesthetist
Patient questionnaire
Nurse assessment guided by protocols
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Organ systems
CVS
Respiratory
Renal
Hepatic
Haematological
Endocrine
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CVS Risk Factors Hypertension
Diabetes
Family History
Cholesterol
Smoking
Obesity
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Guidelines for Perioperative
Cardiovascular Evaluationfor Noncardiac Surgery
ACC/AHA Task Force
JACC 1996; 27:910-945Circulation 1996; 93:1278-1317
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Cardiac risk stratification for Noncardiac
Surgical ProceduresHigh (Reported cardiac risk often
>5% )
Emergent major operations,particularly in the elderly
Aortic and other major vascular
Peripheral vascular
Anticipated prolonged surgicalprocedures associated with large
fluid shifts and / or blood loss
Intermediate (risk generally
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Clinical Predictors of Increased
Perioperative Cardiovascular Risk (MI,
CHF, Death)Major
Unstable coronary syndromes
Recent MI ( >7 days but 30 days) with evidence of important ischemicrisk by clinical symptoms or noninvasive study
Unstable or severe angina (Canadian Cardiovascular Society Class III
or IV). May include stable angina in patients who are unusually
sedentary. Decompensated congestive heart failure
Significant arrhythmia
High-grade atrioventricular block
Symptomatic ventricular arrhythmias in the presence of underlying
heart disease
Supraventricular arrhythmias with uncontrolled ventricular rate
Severe valvular disease
ACC/AHA Task Force
JACC 1996; 27:910-945; Circulation 1996; 93:1278-1317
Clinical Predictors of Increased
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Clinical Predictors of Increased
Perioperative Cardiovascular Risk (MI,
CHF, Death)Intermediate
Mild angina pectoris (Canadian Cardiovascular Society Class I or II)
Prior myocardial infarction by history or pathological waves Compensated or prior congestive heart failure
Diabetes mellitus
Minor
Advanced age Abnormal electrocardiogram (LVH, LBBB, ST-T abnormalities)
Rhythm other than sinus(eg. atrial fibrillation)
Low functional capacity (eg. Unable to climb one flight of stairs with a bag of
groceries)
History of stroke
Uncontrolled systemic hypertension
ACC/AHA Task Force
JACC 1996; 27:910-945; Circulation 1996; 93:1278-1317
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Estimated Energy Requirements
for Various Activities
1 MET Can you take care of yourself?
Eat, dress, or use the toilet?
Walk indoors around thehouse?
Walk a block or two on level
ground at 2-3 mph or 3.2-4.8
km/h?
4 METs Do light work around the houselike dusting or washing
clothes?
MET = metabolic equivalent
4 METs Climb a flight of stairs or walk up
a hill?Walk on level ground at 4 mph or6.4 km/h?
Run a short distance?
Do heavy work around the houselike scrubbing floors or lifting or
moving heavy objects?Participate in moderaterecreational activities like golf,bowling, dancing, doubles tennis,or throwing a baseball orfootball?
10 METs Participate in strenuous sportslike swimming, singles tennis,
football, baseball, or skiing?
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Stepwise Approach to Preoperative Cardiac
Assessment2. Coronary
revascularization
within 5 years ?
Recurrent
symptoms
or signs ?
Urgent or
Elective
Yes
Yes
No1. Need for
noncardiac
surgery
3. Recent
coronary
evaluation
No
Recent coronary
angiogram or
stress test ?
Postoperative risk
stratification and risk
factor management
Operating
Room
4. Clinical
predictorsEmergency Yes
No
Favorable AND no
change in symptoms
Unfavorable
OR change in
symptoms
ACC/AHA Task Force
JACC 1996; 27:910-945; Circulation 1996; 93:1278-1317
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Stepwise Approach to Preoperative Cardiac
Assessment4. Clinical
predictors
6. Intermediate
clinical
predictor
7. Minor or no
clinical
predictor
5. Major
clinical
predictor
Advanced age
Abnormal ECG
Rhythm other than sinus
Low functional capacity
History of stroke
Uncontrolled systemic
hypertension
Mild angina pectoris
Prior myocardial
infarction
Compensated or prior
CHF
Diabetes mellitus
Unstable coronary
syndromes
Decompensated congestive
heart failure
Significant arrhythmia
Severe valvular disease
ACC/AHA Task Force
JACC 1996; 27:910-945; Circulation 1996; 93:1278-1317
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Stepwise Approach to Preoperative Cardiac
Assessment
5. Major
clinical
predictor
Major Clinical Predictor
Unstable coronary
syndromes
Decompensated congestive
heart failureSignificant arrhythmia
Severe valvular disease
ACC/AHA Task ForceJACC 1996; 27:910-945; Circulation 1996; 93:1278-1317
Consider delay
or cancel
noncardiac surgery
Consider
coronary
angiography
Medical
management and
risk factormodification
Subsequent care
dictated by
findings andtreatment results
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Stepwise Approach to Preoperative Cardiac
AssessmentFunctionalcapacity
Surgical
risk
Noninvasive
testing
Invasive
testing
6. Intermediate
clinical
predictor
Moderate or
excellent
(>4 METs)
Intermediate
or low surgical
risk procedure
High surgical
risk procedure
Low surgical
risk procedure
8. Noninvasive
testing
Postoperative
risk stratification
and risk factor
reduction
Low risk
High risk
Poor
(
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Stepwise Approach to Preoperative Cardiac
AssessmentFunctionalcapacity
Surgical
risk
Noninvasive
testing
Invasive
testing
Poor
(4 METs)
Intermediate
or low surgicalrisk procedure
High surgical
risk procedure
Low surgical
risk procedure
8. Noninvasive
testing
Postoperative
risk stratification
and risk factor
reduction
Low risk
High risk
7. Minor or no
clinical
predictor
Consider
coronary
angiography
Operating
room
Subsequent
care dictated
by findings and
treatment results
ACC/AHA Task ForceJACC 1996; 27:910-945; Circulation 1996; 93:1278-1317
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Respiratory 1 Guidelines not as clear
Poor respiratory function increases the
risk of perioperative complications
Respiratory function can often be
optimised
Asthma much better controlled today
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Respiratory 2 Often determines anaesthetic technique
GA vs. regional
Epidural for pain relief
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Respiratory 3 History of asthma/COAD/Malignancy
Exercise tolerance Can you climb 2 flights of stairs?
Drug history Inhalers, nebuliser, steroids
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Respiratory 4 Hospital admissions
Frequent infections
Previous operations
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Respiratory 5 CXR
Respiratory Function Tests
Arterial Blood Gases
Exercise Testing
Occlusive Vascular Tests
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Respiratory 6
Referral to Physician
Optimisation of condition
Steroids
Reschedule
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Diabetes History (Type, how long)
Treatment
How well controlled
Complications (IHD, PVD, Neuropathies,
Renal Impairment,
retinopathy)
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Renal History
Medication
Severity
Dialysis
Crea / Urea
Complications (Hypertension, Anaemia
IHD, fluid overload)
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Hepatic History
Infection / alcohol / drug abuse
LFT / coagulation
Complications (generally poor conditions,
CVS, RS)
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Conclusion Preadmission clinics are here to stay
Essential for economy and patient safety
Systematic approach to patient assessment
Patient assessment in context of surgery Protocols for common situations
Specialised nurses will take lead role in patientsassessment and triage
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Conclusion Team approach needed in assessment
and preparation of the sick patient
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Any Questions?
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