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Perioperative Medicine Introductory Booklet For Students - vfinAL
Perioperative Medicine Introductory Booklet For Students - vfinAL
Suggested timetable
Assessments
Core guidelines
Starvation
NICE tests
CVS: Echo, Angiogram, Stents, Hypertension
New diagnosis AF
Pacemakers
Respiratory: Pulm function tests, COPD, Pulm Hypertension
Obstructive Sleep Apnoea
Diabetes
Cognitive Dysfunction
Anaemia
Drug management
Infection control
Nutrition
Exercise
Functional exercise testing
Angina/Chest Pain
Do you have angina/ chest pains. In older patients angina can present as
SOB
Are you under care of cardiologist. Who and when seen?
Is it stable i.e. is it the same or is it increasing in frequency
Is it unstable i.e. worsening severity or frequency
Does it occur at rest
When was the last episode
DO you use GTN, how long does it take to relieve symptoms
When does angina/chest pains occur eg on exertion, at rest, woken at
night
Further details location and type of pain, associated symptoms
Exercise tolerance
Chase all letters from GP and cardiology
Heart Attack
When was your heart attack,
Did you require angiogram and stenting
Are you still taking aspirin/clopidogrel /other antiplatelet
Are you under the care of a cardiologist. Who and when seen?
Chase all letters from GP and cardiology
Feinting /Dizziness
How often do they occur
Have you ever been investigated
Have you ever had a drop attack
Do you get SOB or CP at the time
Any LOC/incontinence
Any vertigo/tinnitus
Heart murmur
Are you aware you have a heart murmur
Have you had rheumatic fever
Have you had a valve replacement
Where/when was this done
When were you last reviewed by a cardiologist
Type of valve
Any anticoagulants
Have you had a recent echo
Chase all letters from GP and cardiology
Heart failure
Do you know you have heart failure
DO your ankles swell
Is it pitting – ankles, calf, thigh, sacrum
Is it longstanding/recent occurrence
Asthma/COPD
Is your asthma well controlled
When was your last attack
What triggers your asthma
Have you ever required a hospital admission/ITU /HDU admission
Are you under the care of a respiratory physician. Who and when seen?
Last oral steroids
Do you have home nebs/oxygen
What is normal peak flow
Recent chest infections
Current cough/sputum/audible wheeze
Chase all letters from chest physician and GP
SOB
Can you walk up 1 flight stairs
SOB uphill or on flat
How far can you walk
How many pillows do you need to sleep
Wake at night SOB/SOB lying flat/SOB on dressing
Heavy Snoring
Do you snore heavily at night? If yes continue to STOP BANG
Do you have sleep apnoea
Have you ever had sleep studies
Use CPAP at night
When CPAP last reviewed
DO you wake with a morning headache, or require daytime nap?
Diabetes
Diagnosed when
Type
Treatment/tablets/insulin/diet
Well controlled
Any hospital admissions
Under care of GP or hospital
Last HbA1c
BM range
Complications – renal, heart, brain, peripheral neuropathy
Stroke/TIA
When did you have your CVA/TIA
Did you require hospital admission
Fully investigated CT head , echo, and carotid dopplers
Cause – hypertension. emboli/vasculitis /other
Were you left with any neurology
Any problems swallowing/coughing/communication
Did you require speech therapy/occupational /physiotherapy
Are you still under care of stroke team. When and who seen
Treatment – aspirin, clopidogrel
Chase all letters neurologist and GP
Epilepsy
When were you diagnosed
Are you under care of neurologist. Who and when last seen?
When was last fit
Frequency and type of fits
Is it stable
Medication
Parkinsons
How affect you, when was it diagnosed
Drug treatment
Stable or on/off symptoms difficult to control
Deep brain stimulator in situ?
Are you under care of neurology/parkinsons nurse? Who and when last
seen?
Chase neurologist and GP letters
Dementia
Known or unknown history of dementia
Caused by
Treatment
Baseline MTS, or other scoring system
Referral to dementia nurse
Care required – including relevant ‘my name is’ information.
Thyroid
Hyper/hypothyroid
Treatment
When levels last checked
Any change appetite/change in level activity/intolerance heat/cold
Liver
Any jaundice/hepatitis
Cause
Treatment
Complications
Alcohol
Anaemia
What is cause of your anaemia
Have you ever required a blood transfusion, if so antibodies known?
Current treatment
Been investigated properly?
DVT/PE
Date and where in body – calf, IVC, PE
Precipitating factors i.e. cancer, long haul flight, post op, immobility,
clotting disorder
On long term anticoagulants
Under care of haematology. Who and when last seen?
Kidney/urinary issues
Impaired renal function known or unknown?
Nephrotoxic drugs
What caused problems, treatment.
Are you under care of renal team. Who and when last seen?
Neck/jaw problems
C Spine issues or reduced mobility C Spine
Mouth opening >3cm
Previous intubation issues
Chase old anaesthetic charts and letters
Suggested Timetable
Index case
Identify high-risk index cases e.g. colorectal resection, ♯NOF, revision hip,
cystectomy.
Follow Preop/Periop/Post Op
CBD with named consultant
Periop opportunities
Nurse POA filter clinic for fast/basic history taking practice
Notes review with anaesthetic consultants
Anaesthetic High Risk clinics
ERP follow up /Ortho education class
CPEX
PACU/ward post op surgical rounds
Peri-Op
CARBOHYDRATE LOADING: (clear carbohydrate rich drink the night before
surgery, and three hours prior to surgery). Evidence for this shows
20% reduction in length of stay when included within an ERP
Up to 50% reduction in insulin resistance
50% reduction in loss of lean body mass
Reduction of patient discomfort, thirst, hunger, anxiety, fatigue
Post op
Eat and drink as soon as possible unless specific reason not to.
“Perioperative fasting in adults and children: guidelines from the European Society
of Anaesthesiology”. European Journal of Anaesthesiology: August 2011 - Volume
28 - Issue 8 - p 556–569
https://www.esahq.org/guidelines/guidelines/published/esa-guideline-on-pre-
operative-fasting
GENERAL BLOODS and
INVESTIGATIONS
“AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease”
- Nishimura, RA et al. 2014 AHA/ACC Valvular Heart Disease Guideline
www.content.onlinejacc.org/article.aspx?articleid=1838843
2. CORONARY STENTS
Incidence of perioperative major coronary events is determined by time between
MI and/or coronary stent and surgery.
Mortality rates of stent thrombosis are high. 40-60%
Preop
If early interruption of DAPT is needed always involve cardiologist,
surgeon, and anaesthetists prior to surgery.
Defer all non-urgent, non-cardiac surgery for 12 months post MI if possible.
If surgery is urgent defer recent BMS for 30 days, DES for 6 months.
Continue DAPT peri-operatively where possible, if not possible then continue
Aspirin alone, to prevent stent thrombosis.
https://www.uptodate.com/contents/noncardiac-surgery-after-percutaneous-
coronary-intervention.
www.ceaccp.oxfordjournals.org/content/10/6/187.full
3. CORONARY or CT ANGIOGRAPHY
Preop Indications
Revascularisation before non-cardiac surgery is only recommended for
patients in whom revascularisation is indicated regardless of surgery.
4. HYPERTENSION
Preop
GP should refer patients for elective surgery with mean BP in primary care in the
past 12 months <160/100 mmHg.
Pre-op assessment clinics need not measure the BP for elective surgery whose
BP are documented below 160/100 mmHg in the GP referral letter.
Patients may be referred for elective surgery if they remain hypertensive despite
optimal antihypertensive treatment or if they decline antihypertensive
treatment.
Pre-operative assessment staff should measure the blood pressure of patients
who attend clinic without evidence of blood pressures less than 160/100 mmHg
being documented by primary care in the preceding 12 months.
Elective surgery should proceed for patients who attend the pre-operative
assessment clinic if their blood pressure is <180/110 mmHg when
measured in clinic.
However hypertension has been implicated in development of postoperative
haemorrhage in neuro, thyroid and opthalmic surgery. Hypertension is
recommended to be optimally managed in these specialities.
Post op AF prevention
The following are potentially preop modifiable risk factors for the development
of postoperative AF:
Alcohol consumption
Obesity
Anaemia
Hypertension
Use of inotropes
Poor cardiac function
Electrolyte disturbances – Potassium and Magnesium
Post op Pain
Dehydration
Periop
Co-ordination with anaesthetist, cardiologist, pacemaker technician and surgeon
is key to avoiding perioperative complications in these patients.
Recommend Bipolar diathermy for all PPM patients
Never use Monopolar diathermy close to PPM device
Never use Magnet over unknown device
Post op
Check 12 lead ECG in recovery
Keep ICD dependent patients monitored till Shock function is switched back on
by Cardiac tech in recovery post op.
If there were any concerns regarding PPM damage during surgery ensure cardiac
tech checks PPM prior to discharge.
Low risk patients can have their PPM checked after discharge.
2016 British Heart Rhythm Society: Guidelines for the management of patients
with cardiac implantable electronic devices (CIEDs) around the time of surgery.
http://www.bhrs.com/files/files/Guidelines/160216Guideline,
%20Peri-operative%20management%20of%20CIEDs.pdf
RESPIRATORY
2. COPD
COPD is a progressive inflammatory condition resulting in expiratory airflow
limitation.
Patients with COPD are at increased risk of developing perioperative
complications and have an increased mortality.
Preop
Stop smoking
Optimal symptom control – refer for lung functions tests with reversibility
testing, and respiratory physician review if in doubt whether treatment is
optimal (ie: if patient has audible wheeze in the POA clinic!)
Check Preop ABG if hypoxia or CO2 retention suspected
Respiratory physiotherapy is crucial for sputum clearance
Prophylactic antibiotics can be considered
Preop respiratory training
Periop
RA preferred if at all possible, avoid GA if possible.
Optimal ventilator settings to reduce post op respiratory complications include:
6-8ml/kg tidal volume, and PEEP<6cmH2O.
Periop
Anaesthetic aims in Pulm HTN are to avoid
Increased PVR,
Marked decreases in venous return or SVR,
Myocardial depression
RV failure
Maintain normal heart rate
www.aagbi.org/sites/default/files/228%20Anaesthesia%20for%20the%20Pati
ent%20with%20Pulmonary%20Hypertension[1].pdf
OBSTRUCTIVE SLEEP APNOEA
Patients with obstructive sleep apnoea are at a 2-3x increased risk of
perioperative complications.
Diagnosed and classified by number of apnoeas/hypoapnoeas (AHI index)
occurring every hour during a sleep study.
AHI Index < 4 normal, 5-14 mild, 15-30 moderate, > 30 Severe OSA.
Preop
High-risk populations include obese, large tonsils, male, smoker, cervical fixation,
Use STOP BANG screening tool with Epworth Sleepiness Score for diagnosis
Send for investigations: overnight pulse oximetry or full sleep study,
Check CO2 levels if suspect hypoventilation in addition
Screen for Pulmonary HTN
Management plans include:
Investigate cases of suspected OSA preop, unless surgery is urgent in
which case arrange for HDU admission post op for CPAP
When OSA is newly diagnosed start CPAP treatment and delay elective
surgery. Allow period of time to ensure treatment compliance.
Established OSA patients require assessment for symptoms, and
compliance with treatment.
Periop
Associated with 8x incidence of difficult intubation
Anaesthetic technique adjustments include
Avoiding GA, use RA, avoid LT Opiates, avoid Benzodiazepine
Ensure patient brings in own CPAP machine to hospital
Post Op
It is essential to continue CPAP in the post-operative period, starting in
recovery.
Increased risk continues for first 3 nights post op.
May not require HDU post op if stable on own CPAP machine, and close
monitoring available.
OSA is NOT AN ABSOLUTE CONTRAINDICATION to day case surgery
www.ceaccp.oxfordjournals.org/content/11/1/5.full
http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1917935
DIABETES
Patients with diabetes have greater complication rates, mortality rates and
length of hospital stay.
Management focuses on:
Preop
Patient education and involvement
Patients should retain control and continue to self-administer their own
medication
Pre-optimisation of DM – aim for HBA1C <69mmol/mol (delay elective surgery
until improved control)
Where possible aim for admission on same day of surgery and schedule
surgery for the start of the theatre list
Periop
Aim is to avoid hypo- or hyperglycaemia during the period of fasting and the
time during and after the procedure, until the patient is eating and drinking
normally.
Otherwise If only one meal missed: Adjust normal medication and aim CBG 6-10
mmol/L)
Aim intraop CBG 6-10 mmol/L (check prior to induction and then hourly until
eating and drinking)
Post op
Restart regular Oral DM medications and SC Insulin once patient has restarted
oral intake.
Use caution when restarting Metformin (check eGFR >50)
www.aagbi.org/sites/default/files/Diabetes%20FINAL%20published%20in%2
0Anaesthesia%20Sept%2015%20with%20covers%20for%20online[1].pdf
COGNITIVE DYSFUNCTION
Understand the definitions and differences between:
Dementia
Delirium/acute confusional state
POCD
Preop
May or may not be able to consent to surgery/anaesthesia.
Informed consent issues need to be discussed and efforts always made to speak
to family and find out what they think patient would have preferred before
became unable to consent.
Ensure DNACPR and escalation limits are in place preop if appropriate
Periop
Do not omit Aricept, and beware drug interactions
Simple anaesthetic strategies to prevent cognitive impairment are effective if
implemented eg:
Avoid GA if possible,
Avoid Bzp, anticholinergics and long acting opiates
Prevent hypotension,
Institute monitoring to avoid ‘Triple low’ effect
https://www.ncbi.nlm.nih.gov/pubmed/26967259
Post op
The long-term implications of cognitive impairment are significant, and reduce
life expectancy
POCD can be reversible or irreversible
Look for causes of Acute Confusional State and institute treatment.
Refer to the dementia team prior to discharge
Simple strategies on post op wards to improve outcomes include
own family or carer present
‘my name is’ programme and information availability
sleep cycle hygiene
avoidance opiates and benzodiazepines
avoidance constiapation
removal urinary catheters
frequent orientation on ward
stable ward and nursing staff
http://bjaed.oxfordjournals.org/content/bjaed/early/2016/05/16/bjaed.mkw0
38.full.pdf
ANAEMIA
Preop anaemia and Blood transfusion is independently associated with adverse
outcome.
Anaemia needs to be identified as early as possible in the pathway.
Definitions
WHO definition of anaemia is Hb <130g/L in men, <120g/L in women
Anaemia with ferritin <30mcg/L = Iron deficiency
Anaemia with ferritin 30-100mcg/L, TSAT <20%, CRP raised= Functional Iron
deficiency
When in doubt check B12, folate, Iron studies
Treatment thresholds
Consider all the following before deciding if treatment necessary:
Optimal aim is Preop Hb >130g/L in men, >120g/L in women,
Hb >120 & 110g/L respectively may be acceptable depending upon
clinical urgency
The peri-op transfusion trigger
Estimated peri-op blood loss
Post op transfusion trigger
Management
Oral iron is first line treatment for iron deficiency if surgery is non urgent
IV Iron indicated for:
Functional Iron deficiency
Iron deficiency with no response to oral iron after 3-4 weeks, Short time
frame to surgery, Patient on PPI patient has IBS, Or inability to tolerate
oral iron
Also remember to check preop phosphate after IV Iron administration
Other treatment options include B12, folate and erythropoietin.
There is little place for preop blood transfusion – no evidence of benefit.
AAGBI: “The use of blood components and their alternatives 2016”. Anaesthesia.
Volume 71, Issue 7 (July 2016) p829–842
http://onlinelibrary.wiley.com/doi/10.1111/anae.13489/full
www.ceaccp.oxfordjournals.org/content/13/3/71.full
DRUGS
All the information you need can be found in the UKCPA: See BUCKS O
DRIVE UK: “Clinical Pharmacy Association - Handbook of perioperative
medicines”
NB: Incorrect info regarding all alpha-blockers in drug handbook – do not stop
alpha-blockers prior to cataract surgery. Effect of alpha-blocker on eye is
permanent with regards to floppy iris syndrome. Inform ophthalmic surgeon if
patient ever taken alpha-blocker.
BETA-BLOCKERS
Patients with IHD and other associated risk factors (see RCRI) are at high risk of
peri-operative cardiac events. Postoperative troponin rise is common, not always
associated with cardiac symptoms, and independently associated with
postoperative mortality.
Preop management
Continue B-Blocker in patients currently taking B-Blocker (Class 1)
Consider starting B-Blocker pre-op in high-risk patients, but start several
days before surgery to assess tolerability (Class 2B), and titrate dose to
heart rate, avoiding hypotension if possible.
Use bisoprolol, or atenolol rather than metoprolol (Class 2b)
Do not start on day of surgery
Antiplatelet drugs
1. Aspirin
Irreversible inhibition of COX1 and COX2; antithrombotic effect is
primarily due to the inhibition of COX1
Dose: 75-300mg
Stop: 7 days before intervention (but most commonly continued)
2. Phosphodiesterase inhibitors
Dipyridamole prevents degradation cAMP and inhibs PDE 5
Used in TIA and CVA when aspirin is contraindicated
Stop 24 hours before surgery
Cilostazol inhibs PDE 3, is rarely used.
3. ADP receptor blockers
Irreversibly bindsthe ADP receptor preventing the binding of ADP to its
specific platelet receptor and activating the platelet.
Clopidogrel Dose: 75-300mg
Stop: 7 days before intervention
Ticlopidine. Has serious side effects, not licensed in UK.
Prasurgel. Third generation thienopyridine. Dose: 10mg
Stop 7 days before surgery. Higher risk of bleeding complications
4. Reversible, non-competitive antagonist of the ADP receptor
Ticagrelor Dose: 90mg BD
Stop: 5 days before intervention
Cangrelor (An ATP analogue), short acting IV infusion. Not yet FDA
approved
5. Glycoprotein IIb/IIIa Receptor antagonists
Abciximab , monoclonal antibody
Dose: IV bolus or infusion
Stop: 48 hours prior to intervention
Also Tirofiban, Eptifibatide also ultra short acting IV infusions. Stop
8hrs before intervention. Show increased bleeding complications. Are
reserved for specific populations.
6. PAR 1 blockers
Vorapaxar, recently approved for marketing. Long half life. No data
High bleeding risk procedures where Low bleeding Risk procedures where
anticoagulation should be interrupted anticoagulation can be usually be continued
Any procedure involving a vascular organ e.g. Minor dental procedures including extractions &
lungs liver kidney bladder or spleen root canal work (most procedures can take place
Cardiac & Genitourinary surgery providing INR <4) – check INR within 72 hours
Bowel & polyp resection & all colonoscopy of procedure
procedures for pts aged > 55years where Cataract surgery (INR <2.5 acceptable in most
biopsy or polypectomy likely. Endoscopic cases)
procedures involving PEG placement, Skin biopsy (if INR< 2.5 is required then omit
dilatation o oesophagus, treatment of varices, warfarin for 1-2 days prior to procedure)
endoscopic US with fine needle aspiration; Diagnostic upper/ lower endoscopy with or
ERCP without biopsy (providing INR within
Major surgery associated with extensive therapeutic range); diagnostic colonoscopy if
tissue injury eg cancer surgery, orthopaedic aged <55
surgery, reconstructive plastic surgery Implantation pacemaker or ICD defibrillator-
Bronchoscopy (may need to omit 1-2 doses)
Any Neuro & spinal surgery including catheter ablation, coronary angiography and
epidurals; vitreoretinal surgery other vascular interventions, -can usually
perform the procedure without interrupting
warfarin
Joint injections & soft tissue injections
2. If you need to stop warfarin then Next consider whether it is SAFE to stop warfarin?
If the risks of clot formation in the perioperative period are high then fragmin bridging is needed to reduce the period of time the patient
is exposed.
If the risks are low, fragmin bridging is not needed, and you can simply stop warfarin.
Preop instructions
Post op instructions
Surgical Prophylaxis
Surgical site infection is common (5–20%) and is associated with significant
morbidity and mortality.
Crucial immune mechanisms such as neutrophil phagocytosis of bacteria are
impaired during the perioperative period.
RCT and systematic reviews show antibiotic prophylaxis to be effective in
preventing infections after many types of surgery.
Preop
Advise stop smoking and reduce weight
Treat concomitant infections wherever possible
Guidance exists for elimination of UTI prior to urological surgery, and prior to
joint implants, although this is not yet national guidance See BUCKS O DRIVE
Periop
For effective prophylaxis, appropriate antibiotics should be given before skin
incision as recommended by the WHO surgical safety checklist.
Potentially modifiable perioperative factors include: Temp, BM, Surgical site
bundles, Skin prep, Organ perfusion
http://ceaccp.oxfordjournals.org/content/11/5/151.full
Preop
Check BMI if <20 then is likely malnourished.
Establish history of recent weight loss.
Use Tools to evaluate nutritional status eg: MUST score (Do not use BMI alone)
Assess protein status (serum albumin, transferrin, prealbumin)
Beware specific nutritional deficiencies eg: Vit D
Identify malnutrition and patients at risk, but in general do not delay surgery
International guidelines recommend preop nutritional support for severe
malnutrition BMI<18.5
High protein oral supplements are most suitable for patients with wounds or
malignancy
Preop parental nutrition is associated with increased infectious complications
and mortality
Post op
The risk of post op malnutrition depends upon preop nutritional status,
complexity of surgery, and degree of post op hypermetabolism.
Consequences of malnutrition include:
Increased susceptibility to infection
Poor wound healing (10)
Increased risk decubitus ulcers
Bacterial overgrowth GIT
Immune system dysfunction
Early enteral nutrition is therefore essential. Feed (orally) all unless there is
a contraindication, it’s a component of ERAS protocols
Post op TPN is not indicated unless bowel function is not anticipated to return
within 10 days
Preop exercise
In order to address both aerobic fitness and sarcopenia, the programme should
consist of both muscle strength and aerobic training.
Only 2 randomised controlled trials to date to show outcome benefit post op
www.aomrc.org.uk/publications/reports-guidance/exercise-the-miracle-cure
Patient History
Consider and define Metabolic Equivalents (Patients should be able to perform
>4 METs, which is equivalent to climbing at least one flight of stairs, if they are to
consider undertaking major surgery)
Studies show subjective reports of activity by patients do not correlate well with
objective measurements. Patients frequently overestimate activity levels.
Risk prediction indices can assign individual patients to a category of risk for a
specified adverse outcome in a defined population, This will then assist to guide
the appropriate post operative care required and potentially improve outcomes.
There are a number of tools, all of which have limitations and can be compared
in terms of
Performance (how well they identify post op outcomes),
Generalisibility (across surgical populations),
Utility (ease of use by clinical team), and
Clinical effectiveness (provide clinically useful information).
Risk tools can also be divided depending upon whether they are a scoring
system, or a risk prediction model. There are 8 such tools in use to date:
1. ASA
Is familiar to all anaesthetists
Good interdisciplinary understanding
Simple easy to use
High score correlates to poor outcome
Subjective inter rater reliability is poor
No emphasis on either severity, or urgency of surgery.
2. Charlson Comorbidity Index
Designed for medical not surgical patients
Is the method used to adjust HES mortality data in the UK.
Both the type and number of co morbidities are taken into account.
Poor predictor of mortality in the surgical setting
5. P-POSSUM
Risk prediction model using 18 variables
Widely validated in several countries and across different surgical
populations.
Moderate to high discrimination accuracy.
Recommended tool by NELA group.
Limitations include requirement for intra operative data therefore
requiring some preop estimation
6. NSQIP
Multivariable model (21 risk factors) used to predict morbidity and
mortality within 30 days post op
>1 million patients’ data used to construct model, and ongoing updates.
High discrimination accuracy for both morbidity and mortality
The ability to influence patient care and improve outcomes is promising.
Few limitations to performance.
Not validated outside NSQIP hospitals
7. SORT Tool
UK developed tool using snapshot data from 2011 NCEPOD audit
Requires 6 pre op variables and planned surgical procedure.
User friendly
Better discrimination than ASA
Prediction for mortality only, hence less applicable to low risk and
elective procedures
www.riskprediction.org.uk/index-pp.php
www.riskcalculator.facs.org/RiskCalculator/PatientInfo.jsp
ENHANCED RECOVERY
Enhanced recovery is a combination of elements of care for elective surgery that
aims to:
Optimise pre-operative preparation for surgery
Avoid iatrogenic problems such as postoperative ileus
Minimise the stress response to surgery
Speed recovery and return to normal function
Early recognition of abnormal recovery and intervention if necessary
Preop
Optimise patient health in community (correct anaemia, stop smoking, manage
HTN)
CPEX testing where appropriate
Initiation of appropriate care pathway and early discharge planning
Preop patient information eg: Joint School
Periop
Day of surgery admission
Patient optimisation:
VTE prophylaxis
No bowel prep
Carbohydrate loading
Reduced starvation times
Optimal intraop care:
Optimise fluid balance using goal directed fluid therapy
Pain control: regional anaesthesia, Minimally invasive surgery
Prophylactic anitemetic
Postop
Early oral fluid and food and stop IV fluid as early as possible
No post op NG tubes or drains
Planned early mobilisation
Avoid systemic opiates where possible
Early initiation of community care and support where needed: eg physio, stoma
nurse
Telephone follow up post discharge
“Enhanced recovery: more than just reducing length of stay?”. Br. J. Anaesth.
(2012) 109 (5):671-674.
“Fast track surgery versus conventional recovery strategies for colorectal surgery”.
Cochrane Database Syst Rev. 2011 Feb 16;(2):CD007635. doi:
10.1002/14651858.CD007635.pub2.
http://www.rcoa.ac.uk/system/files/CSQ-ERP-Summ2012.pdf
www.frca.co.uk/Documents/204%20Enhanced%20recovery%20after%20surge
ry%20(ERAS).pdf
GOAL DIRECTED THERAPY
An important aspect of perioperative care is fluid management
Excessive fluid administration can harm patients significantly. Hypervolaemia
increases intravascular hydrostatic pressure, damaging endothelial glycocalyx,
increasing permeability and contributing to interstitial oedema. This is all
associated with increased morbidity, prolonged ileus, and delayed hospital
discharge.
Perioperative challenges
Pneumoperitoneum (laparoscopic surgery) and head down positions make GDFT
indices difficult to interpret.
Pulse pressure variation indices require constant intrathorcacic pressures and
TV above 7ml/kg for accurate interpretation.
GDFT is more effective when patients present hypovolaemic (ie emergency
patients) and less effective in the euvolaemic elective setting
Post op
Reduced Urine Output is a consequence of the normal neuroendocrine responses
to surgery and does not imply hypovolaemia.
Disconnect IV fluids and do not restart unless there is a clinical indication
Eat and drink as soon as able.
Oesophageal Doppler
Cardiac output can be estimated using Doppler ultrasound to determine the
flow of blood through the aorta
(Currently the recommended method of CO monitoring by NELA)
www.ceaccp.oxfordjournals.org/content/12/1/5.full
Complications can be general or specific to the operation, and are not always
preventable
Issues
1. Prevention
2. Early identification and early rescue
NB: elevation of serum troponin following non-cardiac surgery is
the strongest predictor of 30-day mortality.
Scoring systems:
Postoperative Morbidity Score (POMS)
The POMS is an 18-item tool that addresses nine domains of morbidity relevant
to the post-surgical patient (pulmonary, infection, renal, gastrointestinal,
cardiovascular, neurological, wound complications, haematological and pain).
For each domain either presence or absence of morbidity is recorded on the basis
of precisely defined clinical criteria
In essence it is a Simple method to detect and quantify post op complications, the
design is suited to all surgery, Validated across a range of elective surgery and
POMs complications have been shown to correlate with ASA and P POSSUM
mortality scores
www.ucl.ac.uk/anaesthesia/StudentsandTrainees/Intro_to_postop_Complication
s
Clavien dindo
Widely used throughout surgery for grading adverse events which occur as a
result of surgical procedures
The therapy used to correct a specific complication is the basis of the Clavien-
Dindo Classification in order to rank a complication in an objective and
reproducible manner
http://www.orthopaedicscore.com/scorepages/oxford_knee_sc
ore.html
http://www.orthopaedicscore.com/scorepages/oxford_hip_score.html
CO-MORBIDITIES
Bariatric
Cancer
Elderly
Frailty
Jehovahs Witness
Lifestyle factors
Parkinsons Disease
Renal
Rheumatoid Arthritis
BARIATRIC
Major weight loss can lead to partial/complete resolution of a range of
conditions including, diabetes mellitus, ischaemic heart disease, and
hypertension.
www.aagbi.org/sites/default/files/Obesity07.pdf
www.sobauk.co.uk/downloads/single-sheet-guideline
www.ceaccp.oxfordjournals.org/content/10/4/99.full
CANCER
Various perioperative factors are implicated in tumour growth, including
anaesthetic agents and analgesia.
Effects may be mediated via tumour cell signalling, the immune response or
neuroendocrine stress response effects.
Largely based on animal studies
Further evidence is awaited, until then the BJA consensus statement
acknowledges ‘insufficient evidence to support a change in clinical practice’.
Volatile agents
Conflicting studies, majority in vitro
Enhanced expression of tumourigenic markers: proliferation marker (eg: IGF-1
and isoflurane), angiogenic marker (eg: VEGF after isoflurane) as well as
proliferation and migration of cancer cells.
Nitrous oxide
No effect
NSAIDS
Inhibition of cox 2 may lead to reduced resistance of cancer cell to apoptosis and
their reduced production of prostaglandins.
Current evidence suggests merit in using perioperative NSAIDS to lessen cancer
recurrence.
Opioids
Inhibit the function of NK cells, and stimulates cancer cell proliferation via
multiple angiogenesis and tumour cell signalling pathways.
Supplemental oxygen
Possible proangiogeneic effect on micro metastases
Dexamethasone
Does not affect overall rates of cancer cell survival.
Other in vitro studies suggest:
Thiopentone reduces NK cell activity
Ketamine reduces NK cell activity
Pain increasing immunosuppression.
Blood transfusion conflicting results suggesting liberal strategies may be
beneficial in early post op morbidity, but longer term there is an
association between transfusion and increased cancer recurrence.
Fentanyl reduces NK cell activity, less than morphine.
ACE inhibitors may increase breast cancer recurrence
Epo - Surgically related Handling of tumour / Increased local/systemic
growth factors after surgery / Peri-op immune suppression due to
surgery / Decrease in anti-angiogenesis factors from primary tumour
β-blockers promote Anti-angiogenesis
Statins also Anti-angiogenic & anti-inflammatory
Tramadol improves NK cell action
Preop
Optimise Polypharmacy
Undertake a Baseline cognitive score
Assess for frailty, mobilisation and need for physio/OT.
Assess help required for ADL
Nutritional assessment
Social circumstances.
Assess mental health
Assess falls and pressure ulcer risk
Ensure Hearing and Visual aids are available to patient at all times.
Prehabilitation to improve aerobic capacity and muscle mass
Discuss DNACPR and TEP in advance of surgery
Post op care
Early mobilisation
Optimise rehabilitation with physio and OT input prior to discharge
Postoperative delirium is common, but under diagnosed, in elderly surgical
patients. Treat any underlying cause. It increases complications and delays
rehabilitation.
Peri-operative pain is common, but underappreciated, in elderly surgical
patients, particularly if they are cognitively impaired
Administer opioid-sparing analgesia where possible.
Avoid sedatives
Intra op Care in the elderly
www.aagbi.org/sites/default/files/perioperative_care_of_the_elderly_2014.pdf
http://ceaccp.oxfordjournals.org/content/14/6/273.full
https://www.uptodate.com/contents/frailty - H598978312
JEHOVAH’S WITNESS
Wherever possible, consultant staff should be directly involved throughout the
care of Jehovah’s Witness patients.
In an emergency, an anaesthetist is obliged to care for a patient in accordance
with the patient’s wishes.
Properly executed Advance Directives must be respected and special Jehovah’s
Witness consent forms should be widely available for use as required.
All Jehovah’s Witnesses must be consulted individually, whenever possible, to
ascertain what treatments they will accept, and their acceptance or rejection of
treatments recorded and witnessed.
In the case of children, local procedures for application to the High Court for a
‘Specific Issue Order’ should be reviewed and available for reference.
A ‘Specific Issue Order’ or equivalent should only be applied for when it is felt to
be entirely necessary to save the child in an elective or semi-elective situation.
In a life-threatening emergency in a child unable to give competent consent all
life-saving treatment should be given, irrespective of the parents’ wishes.
https://www.aagbi.org/sites/default/files/Jehovah's%20Witnesses_0.pdf
Anaesthetists must consider the acute and chronic effects of alcohol at all stages
of the patient pathway.
Alcohol withdrawal is a potentially life-threatening complication that must be
diagnosed and actively managed.
www.frca.co.uk/Documents/221%20Smoking%20and%20Anaesthesia.pdf
www.ceaccp.oxfordjournals.org/content/9/1/10.full
PARKINSONS DISEASE
Parkinson's disease (PD) is associated with additional perioperative morbidity
and mortality.
Abrupt withdrawal or omission of anti-parkinsonian medication can have
serious consequences. Make sure patients continue their medications at all times,
even when NBM. If patient is not swallowing or absorbing then discuss with
pharmacy to convert to NG administration or patches.
The transdermal dopamine agonist rotigotine is especially useful.
Preop
Identify patients at risk for AKI using the ‘any stage’ AKI score, developed
in 2014, and validated. It is a 14 variable, online tool.
Consider measuring biomarkers pre and post op, and the associated evolving
evidence including Cystatin C, Neutrophil Gelatinase-Associated Lipocalin
(NGAL), H/L/I type Fatty aid Bimdimg Protein (FABP), Troponin, Insulin like
growth factor Binding protein 7, and Tissue inhibitor of metalloproteinase
2(TIMP 2)
Periop
Optimisation of perioperative renal perfusion using GDFT is likely to be
beneficial to avoid renal hypoperfusion.
ANP – use of low dose ANP associated with improved outcomes in Cochrane
review 2009. High dose however associated with poorer outcomes, hypotension
and arrhythmias. Mechanism of action not fully understood.
Post op
Early RRT is more beneficial as increased mortality seen when RRT is
commenced late.
Specialist nephrology follow up required post op , as this will improve long term
outcome for patients who have sustained an episode of AKI during/after surgery.
SCORING AKI:
Stage Serum creatinine Urine output
1 1.5 – 1.9 x baseline <0.5mg/kg/hr for 6 hours
or
>0.3mg/dl(>26.5 μmol/l)
increase in 48hrs
2 2.0 – 2.9 x baseline <0.5mg/kg/hr for 12 hours
3 3.0 x baseline <0.3mg/kg/hr for 24 hr or
or anuria for 12 hours.
increased serum creatinine
to >4.0mg/dl (>353μmol/l)
or
initiation of RRT.
www.frca.co.uk/Documents/266%20Rheumatoid%20Arthritis%20and%20Anaest
hesia%20-%20Part%201.pdf
Questions
RENAL QUESTIONS:
4. Glomerular filtration:
a. Occurs at a rate of 125ml/min
b. Is mainly controlled by the capillary endothelium
c. Results in a filtrate with the same osmolality as plasma
d. Favours filtration of negatively charged molecules
RENAL ANSWERS:
1. F, F, T, F
The kidneys are situated at the level of T12 – L3 but are retroperitoneal organs
measuring approximately 12cm from end to end. Each kidney has two clearly
distinguishable regions; the cortex and the medulla. The abdominal aorta is
slightly to the left of the midline while the IVC is slightly to the right; therefore
the left kidney has a slightly shorter renal artery but longer renal vein.
2. T, F, F, T
There are two different types of nephrons; cortical and juxtamedullary.
Regardless of the type of nephrons, all of the glomeruli are within the cortex of
the kidney. The juxtaglomerular apparatus is situated after the loop of Henle, i.e.
in the distal tubule. All of the collecting ducts pass through the medulla and drain
the urine that is produced into the calyces.
3. T, F, F, F
Renal blood flow is around 400ml/100g/min, which higher than either coronary
or cerebral blood flow. This blood flow is unevenly distributed with the vast
majority supplying the cortex. The high flow rate and preferential distribution to
the cortex is necessary to drive glomerular filtration, rather than to meet
metabolic demands.
4. F, T, T, F
In health the glomerular filtration rate is 125ml/min. The main barrier to
glomerular filtration is the glomerular basement membrane. This is made from
connective tissue, which is negatively charged and so tends to oppose the
filtration of negatively charged molecules e.g. plasma proteins. Small molecules
such as electrolytes, urea and glucose are freely filtered so that the ultrafiltrate
produced by the glomerulus has the same osmolality as plasma.
5. F,T,T,F
Diffusion does not require any external energy. Active transport does require
energy to move solute against their concentration gradient. Glucose reabsorption
is an example of secondary active transport. All reabsorption starts with the
action of the Na+ /K+ ATPases acting to lower intracellular Na+ concentration.
6. F,F,T,F
There is a single layer of epeithelial cells lining the nephron lumen. 70% of the
glomerular filtrate volume, but 100% of the glucose is reabsorbed in the
proximal tubule. Bicarbonate is reabsorbed in the proximal tubule.
7. F,T,T,F
There are two types of loop of Henle; long and short. The ascending limb of all
the loops of Henle is impermeable to water. By the end of the loop of Henle the
tubular fluid is hypotonic. The purpose of the vasa recta is to deliver nutrients to
the medulla without removing the solutes that have accumulated there.
8. T,F,F,F
All collecting ducts pass through the renal medulla to drain into the renal pelvis.
Collectively they receive 23L of tubular fluid per day. In their natural state they
are impermeable to water. They become permeable to water due to the action of
ADH. This allows most of the water to be reabsorbed resulting in a low volume,
concentrated urine.
RA QUESTIONS:
RA ANSWERS:
1 F,F,T,F,T
RA is a multisystem disorder and is not limited to the bones and connective
tissue. Axial skeleton involvement does occur, but more commonly affected
joints include the wrists, fingers, neck, shoulders, elbows, hips, knees, ankles and
feet. Approximately 70% of cases are associated with the HLA-DR4 subtype, and
only 80% of patients are seropositive for rheumatoid factor. Environmental
factors may also play a role, including as yet, unidentified viral or bacterial
agents.
2 T,F,T,F,T
Long standing RA patients can develop Sjogrens syndrome with dry eyes and
mouth. RA causes restrictive (not obstructive) lung disease due to pulmunory
fibrosis and costochondral arthritis limiting chest wall movement. Anaemia is
common; anaemia of chronic disease (normochromic) and anaemia due to
gastric bleeding secondary to drugs (microcytic). RA is associated with
rheumatoid cachexia, and weight gain is rare. RA patients have an increased
susceptibility to infections as a result of the immunosupressive effects of the
drugs used to manage their disease.
3 T,F,T,T,F
The drugs that are useful to treat symptoms of RA are paracetamol, NSAIDs and
corticosteroids. The others modify the disease process, prevent exacerbations
and long term disability, but do not treat symptoms.
4D
Hoarse voice in a patient with longstanding RA, should lead to suspicion of
cricoarytenoid arthritis, which is variable in frequency and often unrecognised.
Other symptoms include stridor, a sense of pharyngeal fullness when speaking
and swallowing or dyspnoea. Pre operative nasoendoscopy may aid in diagnosis.
If cricoarytenoid involvement is suspected, avoid endotracheal int inubation in
favour of supraglottic airway devices. If intubation is essential, use the smallest
internal diameter tracheal tube possible. Problems occur post extubation, when
the oedema combined with an already narrow airway can cause complete
obstruction. Consider the use of an airway exchange catheter at extubation, and
observe patient in a high dependency area for some time post extubation. In
severe cases, a preoperative tracheostomy may be required.
5 T,F,T,T,F
Regional anaesthesia in the form of neuraxial blocks or peripheral nerve blocks
should always be considered as it avoids airway manipulation, provides good
postoperative pain relief and reduces polypharmacy. However, regional and
neuraxial blocks may be technically difficult due to spinal arthritis and loss of
anatomical landmarks from contractures or deformities. LMAs and other
supraglottic airway devices should be used where possible as they require
minimal neck manipulation for insertion and cause lesser trauma and
subsequent laryngeal oedema compared with a tracheal tube. AFOI is the
technique of choice in patients with an expected difficult airway or known
cervical spine instability needing intubation. Cervical spine involvement is not
always symptomatic.
6 F,T,T,F,T
The most common type of AAS is anterior AAS, occurring in 80% cases. Anterior
AAS is worsened by flexion. Subluxation exists when the distance between the
atlas and the odontoid peg exceeds 4 mm in patients older than 44 and 3 mm in
younger patients; this can be diagnosed by plain radiography of the neck. Severe
cervical spine instability may necessitate an AFOI or a tracheostomy under local
anaesthesia for safe management of the airway.
ELDERLY QUESTIONS:
2. You are seeing a 68yo man in the pre-anaesthetic clinic before his right
total knee replacement. He weighs 70kg and apart from his osteoarthritis
is fit and well. You discuss with him the options of a general anaesthetic
with multi-modality analgesia and enoxaparin postoperatively as well as
the option of an epidural for both the anaesthetic and post operative pain
management. What is incorrect regarding the epidural?
A. It will shorten his hospital stay and accelerate his rehabilitation –give him
better pain relief particularly for the CPM machine
B. It will give him better pain relief
C. It will reduce his risk of myocardial ischaemia
D. There will be little difference in his risk of thromboembolism
E. If he has no sedation, his risk of post-operative delirium and cognitive
impairment will be reduced
6. Which one of the following drug not associated with post-op delirium in
elderly patient?
A. Digoxin
B. thiazides
C. Midazolam
D. amitryptyline
E. Glycopyrrolate
7. 70 year old man with small cell lung ca, post-op lobectomy, in Recovery
room, desaturating. Shoulder abduction and hip flexion weakness, weak
but sustained handgrip. 8mg cisatracurium given 90 minutes earlier,
reversed with 2.5mg neostigmine and 1.2mg atropine. What is the most
likely diagnosis?
A. Eaton-Lambert syndrome
B. Myasthenia Gravis
C. Steroid myopathy
D. Brachial plexus injury
E. Guillaine -Barre syndrome
ELDERLY ANSWERS:
1. D
Sedation, dry mouth, orthostatic hypotension and cardiac conduction defects –
WRONG, these are all anticholinergic symptoms, which are side effects of TCA\
2. E
If he has no sedation, his risk of post-operative delirium and cognitive
impairment will be reduced – it has not been shown anywhere in the literature
that regional anaesthesia decreases the risk of both post-op delirium and post-op
cognitive decline.
3. E
A. Large prostatic glands have rich venous networks that promote intravascular
absorption of irrigation solution
B. The hydrostatic pressure of the irrigation solution is an important
determinant, depends primarily on the height of the irrigation solution pole.
When the height of the pole exceeds 60cm, the absorption of irrigation solution
is greatly enhanced
C. fluid absorption increases with the extent of the resection as the exposure is
prolonged
D. performing TURP with a low fluid pressure, below the critical pressure for IV
absorption, would limit the risk. This can be achieved by applying a suprapubic
evacuation instrument … or a special channel in a resectoscope .
E. Irrigating fluids have unique pathophysiological properties, but it does not
influence the rate of absorption
4. E
Mortality is same for both spinal & GA but there are advantages with spinal
anaesthesia such as
1. Monitoring the patient mentation allows us to detect sings of TURP in Spinal
anaesthesia
2. Peripheral vasodilation reduces venous return(>60% blood volume in venous
capacitance vessels),reduces pulmonary oedema ,subsequently the water is
being excreted by kidney,if it's working
3. Reduces blood loss due to drop in pressure
4. Post-op analgesia reduces sympathetic stimulation caused by pain
5. B
a) tell surgeon to release clamp – releasing the clamp is only indicated if the
altered mental state is noticed after clamping but prior to opening of the artery
b) tell surgeon to place shunt – If neurological deficit develops, tell the surgeon
who will place a shunt. Recovery should be rapid once the shunt is in place – if it
is not, convert to GA
c) induce GA – converting to GA is only indicated if there are legitimate concerns
that the patient will not remain still during shunt placement .
it only takes a vascular surgeon a few minutes to place a shunt,
d) give midazolam –this arguably makes confusion and combativeness worse
6. E
Al of them have got anticholinergic effects except Midazolam. anticholenergic
effects worsens delirium and dementia. glycopyrollate is anticholenergic but
doesn't cross BBB. Midazolam causes paradoxical excitation in elderly patients.
1.Delirium - Clinical features: Alteration of consciousness, Visual hallucinations,
delusional thoughts. Anxiety and distress. predisposing factors: UTI or chest
infection, alcohol withdrawal. drugs with anticholinergic actions are implicated
in delirium.
2.Dementia - Organic brain lesion, irreversible, failure of cholinergic
transmission, patients are very sensitive to anticholinergic drugs, delirium may
occur in the patients with dementia.
3.Parkinson's disease - deficiency of dopaminergic neurons in extrpyramidal
system
4.Postoperative cognitive decline - long term, possibly permanent, disabling
deterioration in cognitive function following surgery.
7. A
Eaton-lambert syndrome Is a autoimmune disorder, in which antibodies are
formed against presynaptic voltage-gated calcium channels, in the
neuromuscular junction. It is associated with Small cell carcinoma of lung, affects
males more than females, manifests as proximal limb weakness, and shows a
poor response to anticholinestserases.
8. E
Renal mass in renal cortex is reduced by 30 % at the age of 80, glomeruli are in
cortex . Renal blood flow is reduced by 10% per decade(maintain renal
perfusion, normovolemia). Progressive reduction of creatinine clearance-watch
our drugs eliminated through kidney (pancuronium 75%,rocuronium 25%)
Creatinine value is normal or low normal due to less muscle mass, not a good
predictor for kidney function in renal patients.
9. C
N Ach receptors reduced in NMJ and muscle mass is reduced.
Muscle mass progressively decreases in elderly people, and body fat increases
Total body water is decreased so:
1. The volume of distribution for water soluble drugs is decreased, which leads to
greater plasma concentrations. Lower doses of drugs are needed.
2. Volume of distribution for lipid soluble drugs is increased, and plasma
concentrations may be reduced. Elimination time is prolonged.
3. Duration of action is also affected by decline in hepatic function, reduction in
GFR and so clearance.
Distribution and elimination are also affected by altered protein binding. Level of
Albumin decreases with age (binds acidic drugs e.g., barbiturates,
benzodiazepines, opioid agonists).
Alpha1 - acid glycoprotein increases (which binds basic drugs e.g, local
anaesthetics).
MAC of inhalational agents is reduced by 4% per decade of age, after 40 years.
Onset of action is faster if cardiac output is depressed and is delayed if there is
significant ventilation/perfusion abnormality.
IV induction is slowed with low cardiac output.
10. D
1.The arterial system less compliant due to a loss in elastic tissue -increases after
load and BP
The venous system also less compliant, with a reduction in the strength of
smooth muscle contraction
2.The ventricle hypertrophies due to age & increased afterload.
3.Ventricular hypertrophy reduces ventricular compliance and increases LVEDP
and reduces early diastolic filling of the ventricle.
4.In the elderly due to vagal predominance , heart rate falls during exercise,
LVEDV increases (by 20–30%) but amount of blood ejected from left ventricle is
not proportionately increased,(refer starlings curve)
PARKINSON’S QUESTIONS:
PARKINSON’S ANSWERS:
1. F,F,F,T,F
2. F,F,T,T,T
3. T,F,T,T,T
4. F,T,T,F,F
Levodopa and selegiline can be used orally as single agents to treat Parkinson’s
disease. Entacapone is used in conjunction with levodopa- DDI. Pethidine should
not be used in patients on MAO type B inhibitors.
5. T,F,T,T,T
Rigidity is a feature of PD. PD results in excess saliva/ sialorrhoea. Orthostatic
hypotension can be due to PD itself, or due to the effects of dopaminergic or
anticholinergic agents used in PD. Respiratory muscle rigidity may result in a
restrictive ventilatory defect.
6. F,F,F,T,F