Pre-Operative Assessment & Management

<Management>

<Index>

 

 

-  Assessment

-  Preparation

-  Fasting

-  Diabetics

-  Meds

-  Bowel Prep

 

 

Assessment

<Up>

 

-  Indications for surgery

-  Previous surgery/anaesthetics

-  Reactions to anaesthetic

-  Prev intubation

-  Complications, medications, drug reactions/allergies

-  PMH

-  Nuero: stroke, seizure, raised ICP, spinal disease

-  Cardio: CAD, AMI, CCF, HTN, valve disease, dysryhtmias, PVD

-  Resp: smoking, asthma, COPD, URTI, OSA

-  Gastro: GORD (risk for aspiration pneumonia), liver disease

-  Renal: CRF, dialysis

-  Haem: anaemia, dyscrasias, coagulopathies

-  MSK: RA, OA, cervical tumours/infections, Downs, scleroderma, obesity (bull neck), myasthenia

-  Endocrine

-  DM: reflux

-  Thyroid: thyroid storm

-  Adrenal: Addisonian crisis

-  Pregnancy, obesity, drug dependance

-  Family Hx

-  Malignant hyperthermia, drug reactions, pseudocholinesterase

-  Exam

-  Airway exam

-  Regional assessment for blocks

-  Exam Resp, Cardio & Neuro

-  Nutrition, hydration, mental status

-  ASA Score

-  American Society of Anaesthesiologists (ASA) ass of fitness for surgery

-  Category 1

-  Normal healthy pt

-  Category 2

-  Mild systemic disease

-  Category 3

-  Severe systemic disease

-  Category 4

-  Severe systemic disease, w constant threat to life

-  Category 5

-  Moribund pt who is not expected to survice wo surgery

-  Category 6

-  Brain dead pt undergoing organ harvest

 

 

 

Preparation

<Up>

 

-  Consent

-  Pre-op Abx: as per unit protocol

-  Bloods: FBE, INR, APTT, U&E +/- Group & Hold

-  Catheter: fluid balance levels

-  Fasting

 

 

 

Fasting Guidelines

<Up>

 

-  Nil my mouth (NBM)

-  Often FFM (Fast From Midnight) for next day op OR early breakfast (0600) with FFB (Fast From Breakfast)

-  Solids

-  6 hrs for light meals (toast, crackers)

-  8 hrs for meat or fried foods

-  Liquid

-  2 hrs for clear fluids

-  4 hrs for breast milk or jelly

-  Diabetics (DM)

-  BSL 2/24

-  Oral hypoglycaemics

-  Withhold on morning of proc

-  If on Metformin +/- withhold 48hrs prior to any contrast or surgery +/- after

-   Particularly in renally impaired (consider NAC)

-  Insulin

-  Mixed Insulin (Mixtard..)

-   Fast from midnight (FFM)

-   1/2 usual morning dose insulin

-  If Levemir/Lantus at night then NO insulin in am

-   5% Dextrose IV 10/24

-   Usual therapy before next meal

-  Basal Bolus Regimen

-   Normal evening insulin

-   Withhold morning short acting insulin

-   Usual therapy post-op before next meal

-   Akin to skipping a meal (& therefore insulin)

-  If unsure of time of op or NBM as Mx & insulin dependant

-   Insulin & Dextrose infusion APP until after 1st meal

-  Actrapid 50units & 10% Dextrose 1L 12/24

 

 

 

Pre-Op Medications

<Up>

 

-  Fasting pt can still have meds

-  Start

-IE: Abx

-Adrenal suppression: steroid coverage

-DVT: Heparin subcut, Enoxaparin

-GORD: sodium citrate

-Analgesics

-Abx prophylaxis

- Continue

-Anticonvulsants

-Cardiac meds: anti-arythmics, antihypertensives

-IV meds

-  Stop

-  Prior to surgery

-  Anticoagulants

-   Aspirin & Clopidogrel 5/7

-   Warfarin 2/7+ w INR prior to Sx

-  If strict indication (DVT or heart valve) cover w Enoxaparin

-   Enoxaparin

-  Cease 12hrs pre-op

-  Restart 6hr+ post op

-  Particulate liquids: Mylanta, Aganol

-  Morning of surgery

-  DM: oral hypoglycaemics

-  Depression: antidepressants

-  Adjust

-  Insulin, Prednisolone, bronchodilators

 

 

 

Bowel Prep

<Up>

 

-  All pts for colon Sx, laparascopic bowel resection & ant. Resection

-  3L Go-Lytly & 2 Pico Lax tablets

-  Colonoscopy