Pre-Operative Assessment and Post-Operative Care
Adam Eslick
Staff Specialist
Department of Anaesthetics and Perioperative Medicine
Learning Objectives
• Pre-Operative Assessment: What are we trying to achieve?
• What really matters for pre-operative patients?
• Referring patients to Anaesthetics
• What is the role of specialty consults peri-operatively?
• What do Anaesthetists care about?
• What really matters post-operatively?
Perioperative Medicine is a big topic…
Goals of Pre-Operative Assessment
• Patient Safety
• Facilitate Operating Theatre/Hospital Efficiency
• Early Planning for Post-Operative Rehabilitation
• Advanced Care Directives/Goals of Treatment
Pre-Operative Care: What really matters
• Optimisation of important, unstable disease• Cardiovascular
• Respiratory
• Endocrine
• Neurology
• Renal
• Haematological
Pre-Operative Care: What really matters
• Optimisation of unstable, important disease
• Tests
Pre-Operative Care: What really matters
• Optimisation of important, unstable disease
• Tests• Common Sense: Why are we doing this?
• Tests to facilitate surgery: • Group and Screen, Imaging etc…
• Screening Tests: • ECG, CXR, Spirometry, Sickle Cell, (?? Troponin)
• Tests to facilitate pre-op optimisation and risk stratification:• FBC, Electrolytes, Albumin, Coags, beta-hCG, Echocardiography, PFTs, HbA1c….
Pre-Operative Care: What really matters
• Optimisation of important, unstable disease
• Tests
• Fluids• This really matters
• Fasting is bad for you
• Inpatient management so much harder than outpatient management
Pre-Operative Fluid Management: A Diversion
• Fluids• Euvolaeamia is the goal
• Heart Failure, Renal Failure, Bowel Prep
• Electrolytes• Na+ = 1mmol/kg/day
• K+ = 0.5 – 1mmol/kg/day
• Mg++ = 10-15mmol/day
• Glucose = 50-100g/day
• Nutrition• Major Cavity Surgery
Fasting???
• Historical• Dehydration is bad• Aspiration is very, very bad…• Fasting Times
• 6 hours solids• 4 hours breast milk• 2 hours clear fluids
• Delayed Gastric Emptying• Diabetes, Autonomic dysfunction• Renal Failure• Head Injury• Opioids• Trauma, Pain• Raised Intra-Abdominal Pressure
Pre-Operative Care: What really matters
• Optimisation of important, unstable disease
• Tests
• Fluids
• Management of Diabetes• This really matters
• Common problem
Diabetes Mellitus: Another Diversion
• Common: • 10-15% of surgical population.
• Up to 30% of emergency surgery population.
• Significant: • Perioperative mortality up to 50% higher than non-diabetic population.
• Hyperglycaemia is an independent risk factor for surgical site infection.
• Evidence for SSI in Spinal, Vascular, Colorectal, Cardiac, Breast, Trauma, Orthopaedic, Neurosurgery, Upper GI.
• Increased risk of AMI (100% increase)
• Increased risk of AKI (100% increase)
• Increased risk of UTI, Pneumonia (> 100% increase)
Perioperative Management of Insulin
• Listen to the patient
• Ultra-Long Acting Insulin (once daily)• Lantus, Levemir• Reduce dose by 20% Day -1 and Day 0. • Continue with Insulin Infusion (80%)
• Twice Daily Insulin• Novomix 30, Humalog Mix, Levemir or Lantus used BD• Leave unchanged on Day -1• Halve the usual morning dose on Day 0
• Short and Intermediate Acting• Actrapid, Novorapid, Humulin, Apidra, Isophane• Leave Unchanged on Day -1• Calculate total morning dose, give half
Perioperative Management of Oral Hypoglycaemics – Practical Guide
• Drugs that can cause hypoglycaemia when fasting• Sulphonylureas – Gliclazide, Glipizide, Glibenclamide• Meglitinides – Repaglinide, Nateglinide
• Continue Day -1, Withhold Day 0, Restart when eating normally
• Drugs that can cause ketoacidosis when fasting• SGLT-2 Inhibitors – Dapaglifozin, Canaglifozin
• Continue Day -1, Halve Morning Dose on Day 0, Restart when eating normally
Perioperative Management of Oral Hypoglycaemics – Practical Guide• Drugs that may be continued when fasting
• DPP-IV Inhibitors – Sitagliptin, Vildagliptin, Saxagliptin, Linagliptin• GLP-1 analogues – Exenatide, Lixisenatide• Glitazones – Pioglitazone, Rosigllitazone• Acarbose• Continue Day -1 and Day 0• Restart post-operatively when eating normally
• Metformin• Controversial• Contrast, Renal Impairment: Withhold on Day 0 and for 48 hours thereafter
Insulin Infusions
• Poor Control
• Complex medical regimes (eg Insulin + 2 oral hypoglycaemics)
• Repeated Surgery
• Major Surgery
• Emergency Bookings
• Use 10% Dextrose 40mL/hr if volume is a problem
Pre-Operative Care: What really matters
• Optimisation of important, unstable disease
• Tests
• Fluids
• Management of Diabetes
• Drugs
• Insulin Management
• Anticoagulants and Antiplatelet agents
• ACE inhibitors and Angiotensin II Receptor Blockers (…pril, …artan)
• MAO-A Inhibitors• Tranylcypromine, phenelzine, isocarboxacid, moclobemide + LINEZOLID
Pre-Operative Care: What really matters
• Optimisation of important, unstable disease
• Tests
• Fluids
• Management of Diabetes
• Drugs
• Pain Management• This really matters• Aggressive management of pain perioperatively is one of
the few interventions shown to reduce the risk of persistent post-surgical pain
• Acute Pain Service can help• Long-Term analgesic therapy should NOT be stopped.
Pre-Operative Care: What really matters
• Patient and Carer Expectations
• Consent
• Advanced Medical Directives
• Goals of Treatment
Refer to Anaesthetics…
• What is the goal of the referral?• Courtesy• Assist with pre-operative optimisation• Collaborative assessment of fitness for surgery• Participation in multi-disciplinary planning and assessment
• What are the goals of the anaesthetist when seeing patient pre-operatively?• Maximise patient safety, pre-operative optimisation• Facilitate OT efficiency• Provide information to the patient and family about anaesthetic plan• Expectations, Consent, Advanced Directives
What is the role of Specialty Consults?
• Pre-Operative Optimisation
• Answer Specific Questions
What is the role of Specialty Consults?
• Pre-Operative Optimisation
• Answer Specific Questions
• NOT to Assess Fitness for Surgery
What makes up an Anaesthetic Assessment?
Surgical Factors
AnaestheticFactors
Patient Factors
Anaesthetic Assessment: Patient Factors
• Age
• Focused Medical History
• General Medical History
• Functional Status
• Medications
• Allergies
• Smoking, Alcohol, Other Drugs
• Airway Assessment
Anaesthetic Assessment: Patient Factors
• Age• < 2 or > 70…75…80 years
• Focused Medical History• Cardiorespiratory (inc OSA)• Endocrine/Diabetes/Obesity• Renal Disease• Major Haematological Disease• Major Neurological Disease
• General Medical History
• Functional Status
• Medications
• Allergies
• Smoking, Alcohol, Other Drugs
• Airway Assessment
• Disease Processes with direct implications for Anaesthesia Practice• Myaesthenia Gravis• Muscular Dystrophy• Myotonica dystrophica• Multiple Sclerosis• Major Burns• Phaeochromocytoma• Carcinoid Syndrome• Rheumatoid Arthritis (involving neck/jaw)• Ankylosing Spondylitis• Mastocytosis• Malignant Hyperthermia (or family Hx)• Suxamethonium Apnoea• Halothane Hepatitis• Structural Airway disease
ASA Score
• Designed to compare workload of hospitals
• Never intended to serve as a prognostic marker
• ASA 1 – A healthy individual
• ASA 2 – Minor disease only (eg well controlled asthma, hypertension on a single agent)
• ASA 3 – Significant co-morbidities which impact on a patient’s daily life (egMorbid Obesity + DM + Coronary Artery Disease)
• ASA 4 – Significant co-morbidities which pose a constant threat to life (egIschaemic Heart Disease complicated by ischaemic cardiomyopathy with intermittent VT).
• ASA 5 – A moribund patient, not expected to survive 24 hours without surgery
ASA Score - Modifiers
• ASA 6 – A patient undergoing organ donation
• E – Emergency Surgery
• T – Trauma Surgery
Cardiac and Respiratory Investigations
• Impressive shift to minimise investigations
• ACC/AHA Guidelines almost universally adopted
• Respiratory Guidelines being developed• Often need an anatomical and physiological approach
• 3 legged-stool.
Airway Assessment
• History• Medical conditions• Previous Anaesthetics• Anaesthetic Charts, Letters
• Examination• Mallampatti Score• Thyromental Disease• Neck circumference• Teeth• Mouth Opening• Mandibular advancement• Macroglossia• Facial structure, beard
• Investigations• Lateral Neck X-Ray• CT Neck• Nasoendoscopy
Obligatory Ridiculous Photo
Post-Operative Care: The Big Issues
• Where to physically care for patients
• Pain
• Fluids, Electrolytes and Nutrition
• Diabetes Management
• Mobilisation, Physiotherapy, DVT Prophylaxis
• Nausea and Vomiting
• Post-Op Investigations
• Returning to baseline function, medications etc….
Pain Management: Issues• Oral analgesia vs Parenteral analgesia
• Who needs a PCA? For how long?
• What adjunct analgesics are available:• Paracetamol• NSAIDs• Tramadol• Amitriptylline, Pregabalin, Gabapentin, Duloxetine, others….• Ketamine
• How do I manage Local Anaesthetic techniques:• Epidurals• Nerve/Sheath infusions• Wound infusions
Resources• Oxford Handbook of Anaesthesia
• Pre-Procedure Preparation Toolkit, NSW Health 2007
• Perioperative Diabetes Management Guidelines, Australian Diabetes Society, 2012
• Peri-Operative Management of the surgical patient with diabetes 2015. Anaesthesia 70: 1427-1440.
• Preoperative Assessment A Cardiologists perspective. Australian Prescriber 2014: 37: 188-91.