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Pre-operative Assessment Intra-operative Care Post-operative Care
4th year Anaesthesia MBChB tutorial
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Pre-Operative Assessment
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Considerations Patient Procedure Documentation / Notes Physical
General Airway Respiratory Cardiovascular Other relevant systems Psychological Procedure Type of surgery Elective or Emergency
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Pertinent History Current problem Co-morbid disease Medication history
Previous anaesthetics Relevant Family History Systemic Review Last oral intake
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Current problem and Co-morbidity
Recognise and correct any problems concept of pre-operative optimisation Urgency of surgery will dictate degree of optimisation possible Specifically look at: Fluid balance (negative or positive) Anaemia (acute or chronic) Infections (surgical or not) Bronchospasm and reversibility with bronchodilators (FEV1 >200ml and ↑ %) Cardiac Failure Diabetics and Glucose control Electrolyte Disorders
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Medication Allergies and drug intolerances
Non therapeutic: smoking, alcohol, illicit drug use Current therapy Maintenance therapy should be continued up until time of surgery Particularly Anti-diabetic Anti-failure Anti-hypertensive Steroids Asthma treatment
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How compliant is your patient?
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Previous Anaesthetics
Complications PONV (post-op nausea and vomiting) Bronchospasm Respiratory and/or Cardiac Arrest Allergy or Anaphylaxis Pharmacogenetic Disorders Scoline apnoea Malignant Hyperthermia Porphyria
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Nil per os Status Time since last meal to trauma/injury
Other risk factors for a full stomach Pregnancy Increased intra-abdo pressure: obesity, ascites, masses, bowel obstruction 5 F’s: fat, foetus, fluid, flatus and faeces Peptic Ulcer Disease, GORD, hiatus herniae Renal Failure Diabetics with autonomic neuropathy What is in the stomach? Starvation period Solids and Formula milk 6 hours Breast milk 4 hours Clear fluid 2 hours
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Examination Vital signs AIRWAY: assess potential difficulty with ...
Mask ventilation Intubation Heart Lungs Extremities Neurologic
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Airway Face Mouth Neck Trachea Overt tumours Syndromic
Maxillo/mandibular fractures Mouth Mouth opening Teeth Intra-abdominal pathology Neck Mobility: extension and flexion Sternomental and thyromental distances Trachea
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Obesity and the Difficult Airway
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Airway Tumours
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Mobility of Neck Ankylosing Spondylitis
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Funny Teeth
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No teeth
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Beards and Facial Hair
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Special Investigations
CXR ECG Lung Function Tests Blood tests FBC Glucose, U + E Coagulation Cross-match These must be guided by patient’s age and co-morbidity planned procedure
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Tailor your investigations to each individual patient
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ASA Status Class Definition I A normal healthy patient II
A patient with mild systemic disease and no functional limitations III A patient with moderate to severe systemic disease that results in some functional limitation, but not incapacitating IV A patient with sever systemic disease that is a constant threat to life and incapacitating V A moribund patient that is not expected to live for more than 24 hours with or without the surgery VI A brain-dead patient whose organs are being harvested E If the procedure is an EMERGENCY, the physical status is followed by and “E”
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Risk Stratification Class Mortality Rate I 0.06-0.08% II 0.27-0.4% III
% IV 7.8-23% V 9.4-51%
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Aims of the pre-op visit
Anaesthetic plan to accommodate: Baseline physiologic state medical and/or surgical illnesses Planned procedure Drug sensitivities Previous anaesthetic experiences Psychological preparation
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These groups of women will require different anaesthetic plans
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Different age-groups require age-appropriate anaesthesia
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The anaesthetic plan Premed Type of anaesthesia
General Regional Local Conscious sedation Intra-operative Management Monitoring Positioning Fluid management Special techniques: TIVA, hypotensive anaesthesia, planned wake-up Post-operative Care Pain control ICU: ventilation and haemodynamics
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Premed Anxiolysis Sedation Analgesia Anti-emesis Anti-sialogogue
Acid Aspiration prophylaxis Protection against Myocardial ischaemia Hypertension Bronchospasm
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Intra-operative Care
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Depth of Anaesthesia 1 Analgesia: From induction to LOC 2
Stage Description 1 Analgesia: From induction to LOC 2 Excitement: LOC to automatic breathing; characterised by excitement, breath-holding, vomiting, coughing, swallowing, hiccoughing 3 Surgical anaesthesia Light Until eyeballs become fixed Medium Increasing intercostal paralysis Deep Diaphragmatic respiration 4 Overdose: From diaphragmatic paralysis to apnoea and death. All reflex activity is lost and pupils are widely dilated. Medullary paralysis
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Depth of Anaesthesia: Reaction to surgical stimulation
Somatic Frank movement of extremities or laryngospasm Subtle Forehead wrinkling, vocalisation, irregular breathing, breath-holding Sympathetic Hypertension, tachycardia, sweating, lacrimation
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Loss of “protective” reflexes
Voluntary control of eye movement Eyelash reflex Lid reflex Swallowing, retching and vomiting Conjuctival reflex Muscular tone Corneal reflex Glottic reflexes and control of respiration Pupillary light reflex
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Monitoring of the anaesthetised patient
Circulatory Respiratory Neuromuscular Temperature Renal function Glucose and other electrolytes Hb and other coagulation tests Eye care and Pressure points
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POSt-operative Care
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Recovery Room Only transfer patient to recovery if:
A patent airway can be maintained Ventilation is adequate Cardiovascular function is adequate Use oxygen if necessary Handover in recovery ID Summary of patient and procedure Anaesthetic and any complications Instructions for analgesia, oxygen, fluids, anti-emetics
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Common post-op problems
Airway obstruction Hypoventilation Hypoxaemia Hypotension Hypertension Shivering Somnolence Delirium PONV Pain
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Fitness for discharge from Recovery
Aldrete Score Activity Respiration Circulation Consciousness colour Score every 15 minutes Once score of 10 achieved the patient may be discharged to the ward
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ICU Patient may require higher dependency care than the ward can offer: Ventilation Haemodynamic monitoring and Inotropes Renal Replacement Therapy Neurological Observations Epidural Care
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DOCUMENTATION
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Documentation Pre-operative note Intra-operative Anaesthesia Record
Post-operative notes
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Pre-operative Note All relevant details of pre-op visit should be documented Detailed Anaesthetic Plan as discussed with patient, including risks Invasive monitoring ETT and NGT Regional or neuraxial anaesthesia, and associated risks Informed consent Premedication and Maintenance Therapy
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Intra-operative Record
Functions Useful intra-op monitor of trends Reference for future anaesthetics Medico legal document: written in black ink Document Vital signs graphically every 5 minutes minimum Critical incidents Difficult airway and what strategy was used to overcome this Procedures Lines Intubation or other airway devices Monitoring Timing of important events Anaesthesia Surgical incision Positioning and Pressure Point Care
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Post-op notes The anaesthesiologists responsibility does not end until the patient has completely recovered from the effects of anaesthesia Post-op placement Recovery Room or ICU
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