1. Dr David Cain FRCA MRCP Speciality Registrar Anaesthesia and Intensive Care Medicine The Royal Marsden Hospital Preoperative Assessment

2. Contents Preoperative assessment v’s day of surgery assessment Why do we pre-assess patients? Quantifying perioperative risk Reducing perioperative risk / optimisation Functional guide to preoperative assessment Time for questions

3. The purpose of preoperative assessment To minimise the risk of surgery To allow patients to make informed decisions about their care To reduce patient anxiety To build up patient rapport To plan service provision

4. Investigations and optimisation. Will benefits from investigations or medical treatment out-weigh the delay in surgery? Preoperative assessment clinics Day of surgery assessment Opportunities for preoperative assessment

5. Perioperative risk Early, intermediate and late risk. “If you keep the air going in and out, and the blood going around the patient will be fine” Direct anaesthesia related mortality is uncommon. Surgery + Anaesthesia Patient system wide inflammatory changes system wide complications The specific biological mechanisms that link surgery to postoperative complications are unknown. (Oxygen delivery, leakage of gut bacteria, immune changes, blood clotting) Institutional factors

6. Quantifying perioperative risk Morbidity Complications Mortality

7. Postoperative morbidity Postoperative morbidity affects up to 50% of postoperative patients (POMS). For patients who develop a postoperative complication: - Total care costs ↑78% - Length of stay ↑114% (Khan, 2006; J Gen Int Med).

8. The mortality associated with postoperative complications (1) Persists for (at least) 8 years!

9. “High risk surgical population”. 12% of surgical patients account for 80% of postoperative mortality. (Pearse, 2006) The mortality associated with postoperative complications (2)

10. Predicting perioperative risk Individual risk v’s population risk? Associative? Mechanistic? Patient factors. Surgical factors. System based factors ASA Lees revised risk score (cardiac…) POSSUM (a model) Cardio pulmonary exercise testing – beyond the anaerobic threshold. Acute illness.

11. ASA I – healthy (0.05% mortality) II – mild systemic disease, not affecting function (0.4% mortality) III – severe systemic disease that limits function (4.5% mortality) IV – incapacitating systemic disease, life threatening (25% mortality)

12. Reducing perioperative risk Optimisation Preoperative resuscitation Institutional factors Intraoperative resuscitation Postoperative care

13. Reducing perioperative risk: ‘optimisation’ (1) Treatment of acute illnesses ‘Optimisation’ of chronic illnesses What is ‘optimal’ – balance with surgical risk e.g. coagulation. Cardiac: American (AHA/ACC) and European (ESC/ESA) guidelines. Anaemia, polycythaemia and [Hb} Fitness and deconditioning. Specialist review. Planning of timing of surgery, intraoperative care and postoperative care.

14. Pre-assessment guidelines Reducing perioperative risk: ‘optimisation’ (2)

15. Investigations: minor surgery Pre-assessment guidelines Reducing perioperative risk: ‘optimisation’ (3)

16. Investigations: major surgery Pre-assessment guidelines Reducing perioperative risk: ‘optimisation’ (4)

17. Practical guide to preoperative assessment Go to preoperative assessment clinics, make own decisions and discuss these with a consultant. Consider how tests will inform or change management. Read the guidelines. http://www.riskprediction.org.uk/ http://www.riskcalculator.facs.org/

18. Practical guide to day of surgery assessment Develop your patter. Avoid technical terms. Does the risk of surgery outweigh the benefits? Functional assessments. General anaesthesia or local anaesthesia? Airway. Facemask / Supraglottic device / Intubate / Emergency airway Is a rapid sequence intubation required? Breathing. Ventilation modes and settings. Circulation. Cannulation? A line. Central line. Cardiac output monitor. Analgesia. Systemic or regional. Postoperative care. Decision before operation. Feeding.

19. Practical guide to preoperative resuscitation (emergency case assessment) Surgical risk versus optimisation time Fit for the ward? Gas exchange. O 2, CO 2 Cardiac output: fluid challenge. [Hb] 7-8 g/dL – order blood! Coagulation – order products! Electrolytes. Destination – discuss with critical care Anaesthetic plan: Two big drips and a tube? Discussion with the patient

20. Reducing perioperative risk: intraoperative resuscitation Lung protective ventilation Optimise fluid balance (goal directed therapy?) Electrolytes and coagulation.

21. Reducing perioperative risk: Postoperative care All patients with a predicted mortality of 10% should be cared for in critical care environment

22. Preoperative assessment To minimise the risk of surgery To allow patients to make informed decisions about their care To reduce patient anxiety To build up patient rapport To plan service provision

23. Questions davicain@gmail.com

24. Further reading (guidelines and reports) Preoperative assessment ACC / AHA guidelines ESC / ESA guidelines NICE guidelines UK Reports Knowing the risk – NCEPOD The higher risk surgical patient: towards improved care for a forgotten group – The Royal College of Surgeons. National Audit Projects – The Royal College of Anaesthetists

25. Further reading (journal articles) Quantifying perioperative risk Barnett, S., & Moonesinghe, S. R. (2011). Clinical risk scores to guide perioperative management. Postgraduate Medical Journal, 87(1030), 535–41. Khuri, S. F., Henderson, W. G., DePalma, R. G., Mosca, C., Healey, N. a., & Kumbhani, D. J. (2005). Determinants of Long-Term Survival After Major Surgery and the Adverse Effect of Postoperative Complications., 32–48. Pearse, R. M., Harrison, D. a, James, P., Watson, D., Hinds, C., Rhodes, A., … Bennett, E. D. (2006). Identification and characterisation of the high-risk surgical population in the United Kingdom. Critical Care (10(3), R81. Mechanisms of operative risk: Ackland, G., Grocott, M. P., & Mythen, M. G. (2000). Understanding gastrointestinal perfusion in critical care: so near, and yet so far. Critical Care (4(5), 269–81. Angele, M. K., & Faist, E. (2002). Clinical review: immunodepression in the surgical patient and increased susceptibility to infection. Critical Care 6(4), 298–305

26. Further reading (journal articles) Lung protective ventilation Futier, E., Constantin, J.-M., Paugam-Burtz, C., Pascal, J., Eurin, M., Neuschwander, A., … Jaber, S. (2013). A trial of intraoperative low-tidal-volume ventilation in abdominal surgery. The New England Journal of Medicine, 369(5), 428–37. Goal Directed Therapy Hamilton, M. a, Cecconi, M., & Rhodes, A. (2011). A systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high-risk surgical patients. Anesthesia and Analgesia, 112(6), 1392–402. Grocott M, Dushianthan, A., Ma, H., Mg, M., Harrison, D., & Rowan, K. (2013). Perioperative increase in global blood flow to explicit defined goals and outcomes following surgery. Cochrane review. Transfusion targets Carson, J. L., Terrin, M. L., Noveck, H., Sanders, D. W., Chaitman, B. R., Rhoads, G. G., … Magaziner, J. (2011). Liberal or restrictive transfusion in high-risk patients after hip surgery. The New England Journal of Medicine, 365(26), 2453–62. Villanueva, C., Colomo, A., Bosch, A., Concepción, M., Hernandez-Gea, V., Aracil, C., … Guarner, C. (2013). Transfusion strategies for acute upper gastrointestinal bleeding. The New England Journal of Medicine, 368(1), 11–21.