Dr Mark Edwards MRCP FRCA Locum Consultant in Anaesthesia University Hospital Southampton Preoperative Assessment and Resuscitation

Contents Why pre-assess patients? Risk Structured approach Forming a plan Optimisation Consent

Why bother? The labour suite… 2:03am - bleep: “Emergency C-section for fetal bradycardia!!” 2:05am - arrive on labour ward, screaming patient being wheeled into theatre Me: “Are you fit and well?”Her: “Yes!” Me: “OK with anaesthetics?”Her: “Yes!” Me: “Open your mouth!”Her: “Aaaargh!” Me: “Need to get baby out quick, OK if we knock you out?” Her: “Just f***ing do it!!”

Why bother? 2:07am – in theatre, drugs from fridge, monitoring attached, sodium citrate given. 2:09 am – urinary catheter in, abdo prepped and draped, scalpel in surgeons hand. 2:10 am – thio, sux, tube, cutting 2:11 am – baby out! 2:48 am – mother awake and happy.

So…. Pre-assessment should be tailored to the situation… …but if time allows it’s good to: 1.Build a rapport 2.Assess and manage risk 3.Formulate a plan 4.Get consent for your plan

Rapport Good introduction Explanation of events Trust Open discussion

Risk “High-risk” surgical population: –12% of surgical patients account for more than 80% of postoperative deaths Postoperative morbidity affects up to 50% of postoperative patients Assess patients’ perioperative risk of mortality / morbidity: –modify risk factors –“proper” informed consent

Risk More Risk Surgical factorsPatient Factors“System” factors Minor surgery e.g. on the body surface, short duration Usually fit and well, young and active. Planned surgery / experienced staff / easy access to high quality post- op critical care. Moderate surgerySome minor illness, well controlled. Major surgery e.g. intra-abdominal, intra-thoracic, major orthopaedic, long duration. Multiple cardiorespiratory or other morbidities, not well controlled, elderly patients. Emergency surgery / junior or fatigued staff / no or poor critical care facilities.

Risk Surgical: –Likely degree of “surgical stress”? –Get to know the procedure –Get to know the surgeon –Discuss it with the team

Risk: Patient Factors Age Co-morbidities + their treatments: –BP –Ischaemic heart disease –Heart failure –Chest disease –Renal failure –Diabetes NB these may be covert!!

Risk: Patient Factors Exercise tolerance Difficult airway Aspiration risk Allergies ….small print hereditary problems related to anaesthesia

Risk Scores Integrated way of defining patient ±surgical risk American Society of Anesthesiologists: –ASA: 1 – healthy, no systemic disease –ASA: 4 – severe systemic disease, constant threat to life. Others: RCRI (cardiac risk), POSSUM (patient and surgical risk), Surgical Risk Scale (SRS).

Anaesthetic Preassessment: structured like any other medical approach History (Anaesthetic, PMH, DH, allergies, SR incl exercise) Examination (CVS, RS, airway) Investigations (triggered by Hx and Ex)

Investigations: minor surgery

Investigations: major surgery

“Special” Investigations Advanced cardiac testing: –ECHO – resting function –Stress testing Respiratory: –ABGs, PFTs – not good predictive ability Cardiopulmonary exercise testing: –Objective, detailed stress test –Association with outcome e.g. anaerobic threshold <11 mlO 2 /kg/min more morbidity after major surgery.

Optimisation Get patient in the best physiological state possible in the time available Optimise chronic comorbidities: –Cardiac / respiratory / metabolic –Specialist referral? –Rarely involves new treatments just for the perioperative phase

Preoperative resuscitation 10pm: emergency laparotomy ?perforation 77yrs, angina, COPD Bloods & ECG done Cool peripheries Lactate 4.1 Hb 8.5 UOP 10ml/hr

Preoperative resuscitation Preoperative optimisation of tissue oxygen delivery –DO 2 >600ml/min: more survival –Fluid, blood, inotropes to achieve targets Who needs it? –Major surgery, high risk patient –Emergency surgery Guided by: –Bedside: examination, UOP, CVS status –ABGs: lactate, base deficit –Cardiac output monitor

The Plan Preoperative: –?adequate information –?optimisation – comorbids / resuscitation –Practicalities – blood, ITU bed etc. Intraoperative: –RA vs GA, ventilated or spont. breathing? –Airway device? –Invasive monitoring? –Plans A, B and C!

The Plan Postoperative: –Location – ward, HDU, ITU? –Level of care tailored to perioperative risk –Immediate or late extubation? –Extra details e.g. CPAP for patients with sleep apnoea

Consent Verbal – but document the conversation Discuss: –common but minor complications e.g. sore throat –rarer but more serious events e.g. nerve damage after epidural (approx 1:20,000) Open, sensitive discussion if risks of “perioperative insult” are high

Summary Good preoperative assessment allows: –Happier patient –Stratification of risk –Opportunity to optimise patients – chronic or acute –A sensible plan to be made –Informed consent to occur