Preoperative Assessment

1. Preoperative Assessment Dr Abhirup Lobo (Intern)

2. Preoperative assessment • Assess patient’s health • Anticipate problems • Informed consent • Education Goal??? To reduce a patient’s morbidity and mortality By-product? Reduces unnecessary cancellations

3. HOPC • What’s the problem? • Is it acute or chronic? • What are the symptoms? • Local vs. systemic • Why is the patient having this operation? • Why now?

4. Past surgical history Includes past anaesthetic history • Reactions to anaesthetic • PONV • Difficult airways/IV • Rare: Malignant hyperthermia • Post surgical complications

5. Past medical history – by system • Cardiovascular (IHD inc angina, HF, AF, strokes/TIAs) • Respiratory (COPD, asthma, past/current PE) • Haematology (anaemia, bruising/bleeding) • Renal (renal failure/disease) • Liver (Hep B/C, IVDU, past jaundice) • Endocrine (Diabetes – hypo/hyperglycemia, BSLs, complications – renal, eye, foot) • Arthritis

6. Family history • Reactions to anaesthetic: • Malignant hyperthermia

7. Medications Continue: • Antihypertensives • Beta-blockers • Statins Consider: • Anticoagulants inc aspirin, warfarin, clopidogrel • Diabetic meds: insulin, oral hypoglycemics • Other medications of concern: • Steroids • OCP

8. Medications (cont’d) Allergies Analgesia - NSAIDs

9. Social history • Premorbid function inc ADLs • Occupation • Social supports • Smoking • Alcohol • Drugs + tolerance to opioids

10. Examination • Vitals • Airway assessment • Done by the anaesthetist in PAC • dentition • neck mobility • sex • Obesity • Beard!! • Mallampati score (score ≥ III) • Thyromental distance (unreliable)

12. Mallampati score

14. What’s the ASA? • ASA I Healthy patient • ASA II Mild systemic disease with no functional limitation - for example, controlled hypertension • ASA III Severe systemic disease with definite functional limitation - for example, chronic obstructive pulmonary disease • ASA IV Severe systemic disease that is a constant threat to life - for example, unstable angina • ASA V Moribund patient who is not expected to survive for 24 hours with or without surgery - for example, with an abdominal aortic aneurysm Suffix E Emergency procedure

15. Focussed examination • Cardiovascular • Respiratory Consider: • Abdominal exam • Neurological exam • Joint exam • Vascular exam

16. Investigations • Bloods • Imaging • Other How much should you test?

18. The end of the consult • So what happens at the end of the consult? • Check for informed consent (inc form) • Instructions before the operation • Information about the surgery, recovery and likely return to full activity

19. Case example 1 • 20yo male with no past medical history • Presents for removal of lipoma • Famhx: an aunt died due to an “anaesthetic reaction”

20. Case example 2 • 70yo female presents for total hip replacement • PMHx: AF, TIAs • Medication: Warfarin

21. Case example 3 • 65yo male presents for elective TURP • PMHx: IHD, CABGx2, COPD • Smoking: 40 pk year hx

22. Post-op complications Dr Abhirup Lobo (Intern)

23. Case 1 55yo female presents with fever of 38.0⁰C post-THR. She has no relevant past medical history. On examination, • Vitals: PR80 reg, BP145/80, RR20, Sats 95% RA • Resp exam: bibasal crackles What’s the cause of her fever?

24. Fevers, <24h - Atelectasis • Response to surgical trauma • Necrotising wound infections – much less likely.

25. Case example 2 74yo male presents with fever of 38.4⁰C post-cholecystectomy. He has no relevant past medical history. On examination, • Vitals: PR95 reg, BP135/80 RR20, Sats 92% RA Without further examination. What is your differential diagnosis? What investigations will you order?

26. Fevers 24h-72h • Pulmonary causes eg. atelectasis, pneumonia inc aspiration • Catheters!! • UTI related to foley catheter • Thromboplebitis from IV cannula

27. Case example 3 You are the doctor on call overnight. You get paged about “Mr Hyatts”. The page reads: “42yo male. 6d post op (L femur # ORIF). Temp is now 38.0 ⁰C and pt is tachycardic – not responding to fluids.” What is your differential diagnosis?

28. Fever >72h • DVT!!! • Infection • Wound • UTI • Pulmonary

29. 5 W’s • Wind • Water • Wound • Walking • Wonder drugs

30. Case example 4 60 yo male presents d5 post laparotomy with urine output of 20mL/hour. He has been ambulating. His catheter was removed earlier in the day. What do you have to think about?

31. Hx • Ex • Fluid balance • Pre-renal vs. Obstruction Mx: • Does the pt need rehydration? • Does the pt need a catheter?

32. Case example 5 42 yo female presents with SOB 5 hours post-partial thryoidectomy. PHx: childhood asthma Meds: Pravastatin Smoking: 0.5pk/d for 20y What are your differentials?

33. Case example 5 cont’d On examination, the pt is in respiratory distress and is using her accessory muscles of respiration. From the end of the bed, you can hear a loud harsh sound whenever she tries to take a breath. PR 110 reg, BP 150/80, RR24, T36.5, Sats 91% RA Her wound is dressed. CVR exam: NAD

34. Case example 5 What’s your differential diagnosis? Is this an emergency? What are you going to do?

35. Case example 6 The nurse on 3SW pages you urgently regarding a 20yo male 3d post appendicectomy with a red, purulent wound. What predisposes you to a wound infection?

36. Predisposing factors • Type of surgery • Pt characteristics