UPDATE 03/10/13- 97 Days to go! Simply… Lecture … · Communication Skills OSCE ... He states...
Transcript of UPDATE 03/10/13- 97 Days to go! Simply… Lecture … · Communication Skills OSCE ... He states...
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Pre-operative Assessment
Dr Will Dooley
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Plan
• Assessment structure• Investigation options• Exam format
• Reduce morbidity and mortality• Risk management• Keep surgeon/anaesthetist happy & reduce cancellations• Commonly examined in Finals…
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
What further investigations and management options would you consider?
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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) .
BackgroundMr Griffin has been admitted twice for urinary retention in the past year before being discharged an indwelling catheter with a leg bag. PR revealed smooth enlarged prostate. PSA was only marginally elevated.
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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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Douketis JD, Spyropoulos AC, Spencer FA et al. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141
“Bridging” Warfarin
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Other medications to consider• Aspirin/clopidogrel
• Stop 7 days pre-op (unless high risk such as valvular stent)
• Insulin• Consider sliding scale
• Oral hypoglyaemics / metformin• Avoid on day of operation (consider insulin)• Stop metformin 2 days before/2 days after (risk of lactic acidosis)
• Potassium sparing diuretics/ACEi• Avoid on day of operation
• Other meds e.g. steroids/oral contraceptive pill• Liaise with anaesthetic team if any concerns
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History structureCurrent state
• Baseline• Recent condition• What operation / anaesthetic planned
Past 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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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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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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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
D• BM• BMI
E
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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
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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
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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 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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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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Management
OrderIn addition to previously decided tests: • Pregnancy test• MRSA swabs
Book• Book on to CEPOD
1. Immediate (Life / limb threatening)
2. Urgent (Acute cases)
3. Expedited (Subacute cases)
4. Elective (Planned)
• Book post op care e.g. ITU/HDU
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Management
Optimise patient pre op• DM control- First on theatre list• VTE control- pre/post operatively • Review bloods e.g. anaemia
MDT involvement • Anaesthetic team• Social/OT for post op
Fasting rules• Last eat• Last drink
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