Pre-operative Assessment Study Guide the patient with needed

REVISED: 2018 information.

In the past many patients were
admitted to hospital 1-2 days prior to
their surgery. During this time they were
seen by their anesthesiologist, had
opportunity to discuss their anesthetic
and any pre-operative work up needed
was done. In the era of increasing fiscal
constraints most patients are now
admitted on the morning of their
procedure and time for pre-
optimization is not available unless
surgery is cancelled. This works for the
majority of patients, but what about
patients with significant health
concerns? For this reason the pre-
operative assessment clinic (PAC) has
been developed to address our more
complex patients. This is a clinic where
patients are seen weeks to months prior
to their surgery so that additional
consults, tests and pre-optimization can
occur. The PAC nurses use screening
tools and algorithms, and their own
experience to determine who needs to
be seen in the clinic. Our surgical
colleagues’ are also able to directly refer
their patients for assessment.
During your anesthesia rotation, you will
have opportunity to practice the
knowledge and skills you will acquire in
this study guide, both in the OR and in
the preoperative assessment clinic.
The study guide is set up with
information on the left hand side of the
page and tasks or readings to assist you
on the right hand side of the page. The
answers to the questions can be found
at the back of the study guide for you.
The aim of the guide is to assist you in
learning about pre-operative
assessment.
If you have any concerns or questions
please contact either Dr. Melinda Davis
or Niza Delic at 403-944-2298.

Pre-operative assessment has three

main functions:

1. It offers opportunity to
determine a patient’s medical
and surgical problems.
2. It allows for further
investigation, consultation and
treatment in patients who are
not well optimized. *Created by: Edited by: Dr. Chris Young
3. It allows the anesthesiologist
June 2018
time to discuss with the patient
anesthetic options and provide

1
I. Gathering Information
The Anesthetic History
Read: Ottawa Anesthesia
Primer – Chapter 3
Determining patient problems is one of
the most important aspects of the pre-
operative assessment of a surgical
patient. An anesthetic history must be When conducting your
thorough and focus on both current and systems review for the cardiovascular
previous patient problems. Part of your system what patient symptoms would
job is also similar to a detective. You cause you concern? What are the
need to search out the medical possible etiologies?
conditions the patient was not even
aware of. For example the 50-year-old
male may not realize that his arm pain
when he works out is actually coronary
artery disease. The anesthetic history
has many components. These include:

2014 ACC/AHA Guideline

a. Presenting complaint/History of
on Perioperative Cardiovascular
Presenting Illness.
Evaluation and Management of
b. Past medical history with
Patients Undergoing Non-cardiac
systems review
Surgery Circulation. 2014; 130:e278-
c. Functional capacity
e333.
d. Previous Surgical and anesthetic
Canadian Cardiovascular Society
history (including family history)
guidelines on Perioperative Cardiac
e. Medications
Risk Assessment and Management for
f. Allergies
Patients Who Undergo Non-cardiac
g. Review of Old Charts
Surgery
Canadian Journal of Cardiology
33(2017) 17e32
2
An easy way to remember this is the
acronym AMPLE:
A – allergies
M – medications
For each of the following activities what
P – past medical history & past
is the metabolic equivalent (MET’s)?
anesthetic history
a. Swimming– METS
L – last meal (NPO status)
b. Walk around the house– METS
E – Events (hx of presenting illness) &
c. Climb 1 flight of stairs– METS
exam

The information you acquire during your

history will help you determine what
pre-operative investigations, consults List four reasons the

and medications are needed. This is the anesthetic history of the patient and

groundwork for your patient’s family is important

assessment. a.
b.
c.
d.

Not all surgeries carry the same

anesthetic risk. Review the ACC/AHA
and the CCS Guidelines to look at high,
medium and low risk surgical
procedures.

3
Systems Review
Specific patient conditions have the
potential to increase a patient’s peri-
Read: Ottawa
operative risk. We will focus on a few
Anesthesia Primer - pages
conditions in 4 systems.
15-22
A. CNS
a. Stroke
b. High ICP
B. Respiratory
a. Asthma For each of the

b. COPD chronic diseases listed on the

c. Obstructive sleep apnea left consider why it may

d. Upper respiratory and increase a patient’s peri-

lower lung infection operative risk?

e. Smoking
C. Cardiac
a. Angina/ recent MI
b. Hypertension
After an acute
c. Dysrhythmia
MI elective surgery should be
d. Hypovolemia
delayed until?
e. Valvular heart disease
a. 6 days post MI
f. CHF
b. 6 weeks post MI
D. GI/Renal/Endocrine
c. 6 months post MI
a. Reflux
d. 6 years post MI
b. Renal failure
c. Diabetes
Apfel Score:
This scoring system allows you to
estimate risk of post-operative
nausea and vomiting. It’s
important to remember that

4
 there are other factors that mouth. A complete airway exam has
contribute to PONV including the many components:
type of anesthetic used and the 1. Mallampati assessment
type of surgery, however these 2. Mouth opening
factors are not included in the 3. Thyromental Distance
Apfel score. 4. C-spine range of motion
Risk Factor Number of PONV Risk 5. Dentition
Risk Factors
0 10%
Female 1 21%
Non-smoker 2 39%
Previous 3 61%
PONV/motion
sickness
Post-op opioid use 4 79% Read: Ottawa Anesthesia
Primer – pages 55-61
II. Anesthetic Physical Exam

There are three main components to

the anesthetic physical exam.

Describe the four

A. Airway classifications of the mallampati
B. Cardio/pulmonary assessment. Which classes indicate a
C. Peripheral exam potentially difficult airway?

Airway Exam

The examination of the patient’s airway

is one of the most important aspects of
the anesthesia physical exam. Only an
anesthesiologist can thoroughly
examine an airway with an anesthetic in
mind. The examination of an airway is
much more than looking in the patient’s
5
1. Mallampati Assessment

This assessment is based on the degree

Can you think of a few
of visibility of the structures in the hypo
pre-existing conditions and acute
pharynx. The patient needs to be sitting
conditions that would reduce a patient’s
up and with the mouth open as wide as
mouth opening?
possible.

A normal Mallampati class does not

mean a patient’s airway will be
normal. It is only one of 5 components
in an airway exam.
What is the normal
2. Mouth Opening and TMJ distance for mouth opening (how many
movement fingerbreadths?

A person may have a normal mallampati

class but if they are unable to open their
mouth one can see how they may be a 3. Thyromental Distance
difficult airway. It could be impossible
to place a laryngoscope in the mouth. The thyromental distance is the
Chronic TMJ problems may reduce measurement between the thyroid
mouth opening or cause the jaw to notch and the mentum (lower aspect of
remain locked in an open or closed the chin).
position.

6
 4. C-spine range of motion and
instability

Can you think of some

The ability to flex and extend the neck is
chronic diseases/ patient conditions
necessary to place a patient in the
that would result in a decrease range of
sniffing position for laryngoscopy.
motion of the neck?
Limitations to the range of motion of
the neck, particularly extension may
make intubation difficult. This may be
due to changes from chronic disease or
an acute injury (c-spine fracture)
Can you think of some
pre-existing conditions that may have
Always remember a c-spine cannot be associated c-spine instability? Why is
cleared radiographically if there are this important?
distracting injuries. So if in doubt leave
the collar on.
5. Dentition

Assessment of a patient's teeth is the

last component of an airway exam.
When examining teeth we look for an
What is considered a
overbite or under bite that may add
normal thyromental distance? If this
difficulty to the airway. We look for
distance is short what does this mean?
capped, crowned or veneered teeth,
dentures and any missing teeth.
Damage to teeth is one of the most
common causes of anesthetic litigation
therefore discussing risk to dentition is
very important.

7
 Bag-Mask Ventilation:
The reason we ask about capped, Though we often emphasize skills to
crowned and veneers is they are more assess difficult laryngoscopy,
prone to damage or breaking during anesthesiologists intuitively
laryngoscopy! simultaneously assess predicted
difficulty of bag-mask ventilation. Bag-
mask ventilation is a life-saving skill that
all physicians should be able to perform.
Try practicing the airway exam with
your colleagues during independent The acronym BONES can help us
study time! remember features of difficult bag-mask
ventilation.
B – beard
O – obese/older age
N – no neck/neck stiffness
E – edentulous
S – stridor/snores
What teeth are the most
prone to damage during laryngoscopy?
Supraglottic Airway:
The acronym RODS can be used to
predicted the difficulty of inserting a
SGA.

R – restricted mouth opening

Practice your airway O – obstruction
assessment skills with your patients in D – distorted airway anatomy
the operating room. Ask your S – stiff lungs/neck
preceptor to check your findings.

8
Cardiopulmonary Assessment
A thorough cardiopulmonary
assessment is also important pre-
Read:
operatively. The cardiovascular and Ottawa Anesthesia Primer –
pulmonary systems are subject to many pages 16-19
changes under anesthetic. Individuals
with acute or chronic disease in these
systems may be at higher risk when
undergoing an anesthetic. When
examining a patient you should include: Conduct your cardio-
pulmonary exam in a quiet
A. Vital signs location. It may be difficult
B. Cardiac to auscultate subtle
a. Auscultation of carotids murmurs in a noisy
b. Auscultation for murmurs environment.
and heart sounds
c. Check pulses
C. Respiratory
a. Auscultation of bilateral
lung fields

9
Peripheral Exam
The peripheral examination is important
when considering patient positioning
during surgery, the placement of lines
or regional anesthetic techniques.
Chronic diseases such as rheumatoid
arthritis or ankylosing spondylitis may
make positioning or line placement
difficult. By assessing the patient pre-
operatively anatomical problems can be
considered ahead of time and alternate
techniques or positions arranged.
Can you think of some
anatomical problems or chronic disease
conditions that may make placing a
spinal difficult?
III Pre-operative Investigations
The types of pre-operative
investigations needed are dependent on
two factors:
a. The patient
b. The surgery
Patient factors consider the patient’s
current underlying medical conditions
and investigation of any new symptoms.
An example would be conducting
pulmonary function tests (PFT’s) on a
patient with COPD. This will help the
anesthesiologist determine whether the
patient’s lung function is stable enough
to proceed.
The type of surgery also plays a key role.
A minor surgical procedure such as a
carpal tunnel release may not require
any pre-operative testing. A major
surgery such as an abdominal aortic
aneurysm may require numerous tests.
10
 A. Laboratory Investigation: CBC,
electrolytes etc.
B. Diagnostic imaging: Chest x-
Read: Ottawa Anesthesia Primer – ray, CT scan
pages 26-29 C. Pulmonary Lab: Arterial blood
gas
Fleisher LA, Beckman JA, Brown KA, et D. Cardiac lab: Echocardiogram,
al. American College of Thallium
Cardiology/American Heart Association For pre-operative cardiac testing the
Task Force on Practice Guidelines. American heart association and the
Circulation 2007; 116:1971-96 Canadian Cardiovascular Society give
us guidelines to help determine what
investigations are needed considering
non-cardiac surgery. Read the
In keeping with Choosing Wisely, there AHA/ACC guidelines listed earlier
has been a move away from screening referenced
style investigations of all patients
regardless of their comorbidities or
surgical procedure (i.e. all patients used
to have CBC, lytes, Cr, INR, PTT and an
For the four categories of
ECG for even minor procedures). For
investigations on the list above, record
any investigation chosen, the question
as many examples of investigations as
must be asked “how will this result
possible.
change perioperative management?”
There are many types of pre-operative
investigations one may consider. A few
examples are:

11
 For each of the following
patients list the pre-op investigations
Consults
you would order.
We sometimes need to ask for others’
opinions on a patient. For example a
1. 72 yr old female with
cardiologist’s advice may be helpful in
rheumatoid arthritis and
determining whether a patient with
decreased range of motion of
coronary artery disease requires cardiac
neck. She is coming for hip
intervention prior to a non-cardiac
surgery.
surgery
2. 25 yr old female with poorly
controlled asthma coming for a
tubal ligation
3. 68 yr old male with history of
rheumatic fever and a new
murmur coming for gallbladder
surgery

IV Pre-optimization

Now that we have taken our history, For each patient you see

done our physical and reviewed our think about whether another

investigations what is next? We now specialist’s advice would be helpful.

ask if there is anything we are able to do Review this with your consultant.

to improve our patient prior to surgery?

This is where pre-optimization has a
role. The goal is to have the patient in
the best condition possible prior to
coming to the operating room.
12
Pre-medication

Some patients require the addition of SBE prophylaxis

recommendations.
medications prior to coming to the
Circulation. 2007; 116:1746-1754
operating room. This may be to
optimize a chronic condition (such as
improving control of hypertension) or to
help decrease peri-operative risk (B-
For interest only, you may
Blockers in coronary artery disease). want to read a good summary article
There are many examples of pre- that address the use of beta blockers in
medications: the peri-operative setting. Br. J.
Anaesth. 2008; 101(2):135-138.
A. SBE prophylaxis (endocarditis)
B. B-blockers (decrease peri-
operative cardiac mortality)
C. Anti-reflux medication
D. Addition of anti-hypertensive
E. Medication for asthma
F. Anti-anxiety medication
G. Anti-emetics
H. Stress dose steroids

Read: Ottawa Anesthesia

Primer – Chapter 4

13
 Match each patient listed
on the left with an appropriate pre-
medication on the right. You will not
use all of the answers.

A. Ventolin 2.5 mg neb 30 minutes

A. 32 yr old female with history of
pre-op.
reflux coming for a tubal
B. Ampicillin 2 g IV 30 minutes
ligation
pre-op
B. 25 yr old male with chronic
C. Ativan 1mg sl 20 minutes pre-
prednisone for colitis coming
op
for a colectomy. He has a
D. Maxeran 10 mg IV 30 minutes
penicillin allergy.
pre-op
C. 36 yr old asthmatic coming for
E. Metoprolol 25 mg po BID
a hernia repair.
starting one week pre-op
D. 52-year-old male with prior MI
F. Hydrocortisone 100 mg IV 30
coming for a hip replacement.
minutes pre-op.
E. 32 yr old who had a repair of a
G. Ancef 1 g IV 30 minutes pre-op.
PDA 15 years ago and is coming
H. No pre-med required
for a knee scope.

14
Continuation of Chronic Medications

As a rule, the majority of patient’s

What if she was on long-
medications should be continued up
acting and short-acting insulin? How
until the day of surgery. This is
would you advise her to manage her
particularly important with
insulin before surgery?
cardiovascular, respiratory and pain
medications. There are a few
exceptions:

A. Anticoagulants (Warfarin,
Coumadin, Heparin, Fragmin) Mr. Smith is on coumadin
B. Diabetes Medications (oral and for chronic atrial fibrillation. How many
insulin) days pre-op should he stop? Are there
C. ACE inhibitors or ARBs special orders for him on the morning of
D. Herbal medications. surgery?

These medications may need to be held

or their doses altered depending on the
patient.

Why hold ACEs and ARBs

prior to surgery? Are there any
exceptions to this rule?
Mrs. Smith takes
metformin three times per day for her
diabetes. When should she stop taking
it prior to surgery? Write orders to
cover her diabetes peri-operatively.

15
 V Peri-operative Risk
Assessment
There are many available classification Read: Ottawa Anesthesia

schemes to assess a patient’s pre- Primer – page 28 and

operative physical condition. The most https://www.asahq.org/resources/clini

commonly quoted are the ASA cal-inforation/asa-physical-status-

classification (devised by the American classification-system

society of Anesthesia in 1941), and the

Revised Cardiac Risk Index (RCRI). Pre-
op risk prediction is a developing area of
medicine with several new scoring tools
For each of the following
and algorithms being developed and
patients assign an ASA class.
evaluated on different subsets of
patients.
VI Controlled hypertension
VII Healthy patient for an
ASA
emergency appendectomy
The ASA is the oldest and easiest to use.
VIII Unstable angina
IX COPD
X Ruptured abdominal aortic
aneurysm.

Practice assigning an
ASA class to the patients you see in the
OR.

16
Revised Cardiac Risk Index
The RCRI was created in 1999 as a
modification of an older (1977) score.
The patient you are
It uses 6 independent variables to
assessing for a bowel resection is over
identify patients at risk of cardiac
70, had an MI over 6 months ago, has
complications. The risk increases with
hypertension, and chronic renal
the number of variable present.
impairment (creatinine 190
1. History of ischemic heart disease
micromol/L). What is his preoperative
2. History of congestive heart failure
cardiac risk according to the RCRI?
3. History of cerebrovascular disease
(stroke or transient ischemic attack)
XI Fasting Guidelines
4. History of diabetes requiring
Fasting guidelines are recommendations
preoperative insulin use
in place for elective surgery to help
5. Chronic kidney disease (creatinine >
reduce the risk of gastric aspiration.
177 micromol/L)
They are used regardless of the type of
6. Undergoing suprainguinal vascular,
anesthetic (general, regional, local). The
intraperitoneal, or intrathoracic
minimum fasting duration for elective
surgery.
surgery is:
Risk of MI, cardiac death or non-fatal
cardiac arrest:
• 8 hours post meal (meat, fried or
0 predictors = 0.4%,
fatty foods)
1 predictor – 0.9%,
• 6 hours post a light meal (toast,
2 predictors = 6.6%,
milk, infant formula)
> 3 predictors = >11%
• 4 hours post breast milk
• 2 hours post clear fluids.
Practice applying the ASA and the
RCRI classifications to your patients in
With emergent or urgent surgery the
the pre-operative clinic. Review your
risk of delaying the surgery must be
findings with an attending.
weighed against the risk of aspiration.

17
 Prevention of Aspiration
There is no way to completely eliminate
Read: CAS fasting the risk of aspiration. There are some
guidelines measures that will reduce the risk
www.cas.ca • Pre-optimization
• Anesthetic technique
• Post anesthetic care

If Mr. Smith had eggs and

bacon for breakfast at 7 am and has
arrived for his elective surgery at what
For the three
time would it be safe to proceed?
categories above, list preventative
measures that fail in each one.

Full Stomach Considerations

Some patients even if fasted for the

recommended time are still considered
an aspiration risk. This may be due to
many factors. Some examples include
emergency surgery, medications or
anatomy.
The main predisposing factors fall into 6
categories:
• Decreased LOC
• Impaired Airway Reflexes For the six categories

• Abnormal Anatomy on the left, list examples of

predisposing factors that may
• Gastro esophageal reflux
increase the risk of aspiration
• Increased intragastric pressure
• Delayed gastric emptying
18
Study Guide Question Answers

Question page 2: When conducting your systems review for the

cardiovascular system what patient symptoms would cause you concern?
What are the possible etiologies?

The review of systems for cardiac is done to look for evidence of cardiac
dysfunction. A positive answer to any of the following questions could be
cause for concern
a. Do you ever get chest pain? What brings it on? How long does
it last? Can you describe it? Your concern here is that the
patient is experiencing angina and may have coronary artery
disease.
b. Do you ever get palpitations? Does you heart ever race out of
control? Have you had to come to emergency with it? Does it
make you lose consciousness? Here your concern is malignant
arrhythmia.
c. Do you get short of breath when you lie flat? How many
pillows do you sleep on? Do you have trouble with ankle
swelling? Here you are looking for symptoms of congestive
heart failure.
d. For a patient with a murmur you want to look for evidence that
the murmur is hemodynamically significant. Do you get dizzy
or pass out? Do you get short of breath with activity? Do you
feel your heart race out of control?

19
Question page 3: For each of the following activities what is the metabolic
equivalent (MET’s)?

A. Swimming (greater than 10 MET’s)

B. Walk around the house (one MET)
C. Climb 1 flight of stairs (4 MET’s)

METS are a useful way of assessing and communicating functional

capacity. You will see in the AHA/ACC guidelines that this is used to
determine the pre-op testing a patient requires for cardiac risk
stratification. Functional capacity has been de-emphasized in the most
recent Canadian guidelines (CCS) however, it was felt to be difficult to
determine accurately and did not contribute to risk prediction.

Second question page 3: List four reasons the anesthetic history of the
patient and family is important?

a. Previous difficult airway

b. Family history of Malignant Hyperthermia
c. Family history of Pseudocholinesterase deficiency
d. Adverse event in a prior anesthetic (eg. Allergic reaction, postoperative
nausea and vomiting, MH, or Pseudocholinesterase deficiency)

20
First question page 4: For each of the chronic diseases listed on the left
consider why it may increase a patient’s peri-operative risk?

Find answers in Ottawa Anesthesia Primer – Chapter 3

Second question page 4: After an acute MI elective surgery should be

delayed until?
A. 6 days post MI
B. 6 weeks post MI
C. 6 months post MI
D. 6 years post MI
Answer B & C – traditional teaching has been to wait six months
post MI. New literature suggests 4 – 6 weeks is okay, provided the
patient has no further residual myocardium at risk.
The indication for surgery is important to appreciate. Truly
elective surgery will allow the treating team to make different
choices than in the case of urgent or emergent surgery.

Question page 5: Describe the four classifications of the mallampati

assessment. Which classes indicate a potentially difficult airway?
Compare your responses with Ottawa Anesthesia Primer – page 59.
Mallampati class 3 or 4 airways are potentially difficult.

21
First question page 6: Can you think of a few pre-existing conditions and
acute conditions that would reduce a patient’s mouth opening?

Possible etiologies include:

a. TMJ problems
b. Jaw fracture or trauma to facial bones
c. Infection (Ludwig’s angina, cellulites)
d. Arthritis: Rheumatoid
e. Jaw wired shut (post surgical)

Second question page 6: What is the normal distance for mouth opening
(how many fingerbreadths)?

(should admit at least two fingerbreadths)

First question page 7: What is considered a normal thyromental distance?

If this distance is short what does this mean?

A normal thyromental distance is 3 fingerbreadths or 6.5 cm. Adults who

have a shorter distance may either have an anterior larynx or a short
mandible and may be a more difficult intubation.

22
Second question page 7: Can you think of some chronic diseases/ patient
conditions that would result in a decrease range of motion of the neck?

There are a number of patient conditions that may result in a decrease range
of motion of the neck.
a. Arthritis: Osteoarthritis, Rheumatoid arthritis, ankylosing
spondylitis, Osteophyte formation.
b. Trauma: Cervical spine fusion, c-spine collar
c. Obesity: Decrease range of motion from posterior fat pad.

Third question page 7: Can you think of some pre-existing conditions that
may have associated c-spine instability? Why is this important?

Pre-existing conditions that may be associated with c-spine instability

include
d. Rheumatoid arthritis
e. Ankylosing spondylitis
f. Down’s Syndrome
g. Multiple syndromes ( Fragile X, Turners etc)
This is important because the placement of the patient in the sniffing
position to intubate may result in movement of the cervical spine, pressure
on the spinal cord and paralysis of the patient.

23
Question page 8: What teeth are the most prone to damage during
laryngoscopy?

In general any capped, crowned or veneered teeth are at risk as they are not
as strong. Front top teeth (especially the incisors) are more at risk than
bottom or back teeth.

Question page 10: Can you think of some anatomical problems or chronic
disease conditions that may make placing a spinal difficult?

Anything that affects the alignment of the spine, the spaces between the
spinal bones or the ability to palpate them will make a spinal more difficult.

h. Palpation Difficulty: Obesity

i. Alignment: Scoliosis
j. Spaces between: Arthritis, Ankylosing Spondylitis, prior
surgical fusion, and osteophytes.

Question page 11: For the four categories of investigations on the left list as
many examples of investigations as possible.

k. Laboratory Investigations: ( CBC, Lytes, BUN, CR, Ca, MG,

PO4, liver functions, INR, PTT, albumin, pregnancy test, HIV,
Hepatitis Band C, cholinesterase, cross match )
l. Diagnostic Imaging: x-ray of any body part, CT, MRI,
ultrasound
m. Pulmonary Lab: PFT, ABG, Pulmonary physiology

24
 n. Cardiac Lab: ECG, ECHO, THALLIUM, Angiogram,
dobutamine echo.

Question page 12: For each of the following patients list the pre-op
investigations you would order.

A. 72 yr old female with rheumatoid arthritis and decreased range of

motion of neck. She is coming for hip surgery.
This patient needs labs for her rheumatoid arthritis and for her surgery.
The hip surgery will require a CBC, Crossmatch and an x-ray of her hip.
The rheumatoid arthritis will require c-spine flexion and extension films
with her neck movement, an echo if she has a murmur, and liver function
tests if she is on methotrexate.

B. 25 yr old female with poorly controlled asthma coming for a

tubal ligation
This patient requires no labs for her procedure. The poorly controlled
asthma should be assessed with PFT’s

C. 68 yr old male with history of rheumatic fever and a new murmur

coming for gallbladder surgery
This gentleman needs liver function tests for his gallbladder surgery. As
well with his history of rheumatic fever and a new murmur he needs an echo
pre-op.

25
Question page 14: Match each patient listed on the left with an appropriate
pre-medication on the right. You will not use all of the answers.

A. 32 yr old female with history of reflux coming for a tubal ligation

Metoclopramide 10 mg IV 30 minutes pre-op

B. 25 -yr- old male with chronic prednisone for colitis coming for a
colectomy. He has a penicillin allergy.
Hydrocortisone 100 mg IV 30 minute’s pre-op.

D. 36 yr old asthmatic coming for a hernia repair.

Salbutamol 2.5 mg neb 30 minutes pre-op

E. 52-year-old male with prior MI coming for a hip replacement.

Nil. Historically this patient would have been started on a beta blocker.
There may still be consideration for this if there is sufficient time for it to
be slowly introduced and titrated up but this is controversial.

F. 32 yr old who had a repair of a PDA 15 years ago and is coming

for a knee scope.
No pre-med required (first as the PDA repair was remote second as a
knee scope is a clean procedure).

26
First question page 15: Mrs. Smith takes metformin three times per day for
her diabetes. When should she stop taking it prior to surgery? Write orders
to cover her diabetes peri-operatively.

Mrs. Smith is on oral hypoglycemics. Her risk of developing ketoacidosis is

therefore small. We generally have patients not take their oral
hypoglycemics on the morning of surgery. She needs a chemstrip on arrival
to hospital and a sub cutaneous insulin sliding scale written out if her blood
sugar goes above 10.

Second question page 15: What is she was on long-acting and short-acting
insulin? How would you advise her to manage her insulin before surgery?

Long-acting insulin: take half of her normal dose the evening before
surgery. She won’t require the full dose because she won’t be eating for part
of the day
Short-acting insulin: do not take any short-acting insulin because she will
not be eating pre-operatively (see NPO guidelines)

Third question page 15: Mr. Smith is on coumadin for chronic atrial
fibrillation. How many days pre-op should he stop? Are there special orders
for him on the morning of surgery?

Coumadin should be stopped 4 days pre-op. On the morning of surgery he

needs an INR to be sure his coagulation is back to normal.

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Fourth question page 15: Why hold ACEs and ARBs prior to surgery? Are
there any exceptions to this rule?

Why hold: to avoid intra-operative hypotension (see 2016 CCS guidelines)

Exceptions: some physicians may elect to continue ACEs/ARBs pre-
operatively in patients who remain relatively hypertensive despite using
antihypertensives

Question page 16: For each of the following patients assign an ASA class.

A. Controlled hypertension ASA II

B. Healthy patient for an emergency appendectomy ASA IE
C. Unstable angina ASA IV
D. COPD ASA III
E. Ruptured abdominal aortic aneurysm. ASA VE

Question page 17: The patient you are assessing for a bowel resection is
over 70, had an MI over 6 months ago, has hypertension, and chronic renal
impairment (creatinine 190 micromol/L). What is his preoperative cardiac
risk according to the RCRI?

This patient has 3 predictors – history of ischemic heart disease, creatinine

> 177 micromol/L, intraperitoneal surgery. This gives him a risk estimate of
11% for cardia death, non-fatal cardiac arrest, or MI.

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Question page 18: If Mr. Smith had eggs and bacon for breakfast at 7 am
and has arrived for his elective surgery at what time would it be safe to
proceed?

This would qualify as a heavy meal therefore 8 hours after it. He will be
ready at 15:00. The practicalities moving patient order on a busy elective
list can be challenging.

Second question page 18: For the three categories on the left list
preventative measures that fall in each one.

Pre-optimization: Fasting, prokinetic meds like metoclopramide,

medications to reduce acid content like ranitidine. NG tube placement and
emptying of gastric contents, if able wait until fasting guidelines are met.

Anesthetic: Avoiding GA, use of an endotracheal tube, doing a rapid

sequence induction.

Post anesthetic: Extubate patient awake and on their side,

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Third question page 18: For the six categories on the left list examples of
predisposing factors that may increase the risk of aspiration.

A. Decreased level of consciousness: Drug overdose, anesthesia, head

injury, CNS pathology, trauma or shock
B. Impaired airway reflexes: prolonged tracheal intubation, local anesthetic
to the airway, myopathies, CVA, decrease LOC
C. Abnormal anatomy: Zenkers diverticulum, esophageal stricture
D. Decreased Gastroesophageal competence: NG tube, elderly patient,
pregnancy, hiatal hernia, obesity, curare
E. Increased intragastric pressure: pregnancy, obesity, bowel obstruction,
large abdominal tumors, ascites
F. Delayed gastric emptying: narcotics, anticholinergics, fear, pain , labor,
trauma, pregnancy, renal failure, diabetes

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