Transcript Perioperative

Perioperative Medicine
Topics
•Organisational Issues
•Perioperative Assessment
•Preanaesthetic Assessment
•Medications and Surgery
•Preoperative Investigations
•Patient Preparation
•Post-operative care
Perioperative Medicine Topics
•Organisational Issues
•Perioperative Assessment
•Preanaesthetic Assessment
•Medications and Surgery
•Preoperative Investigations
•Patient Preparation
•Post-operative care
The Iceberg of Poor Patient Preparation
Conceptual Basis
Patient outcomes and efficiency of care are maximised by
appropriate preprocedural preparation.
 Avoiding adverse outcomes
 Avoidance of cancellations
 Reducing time in hospital both pre- and post-procedure.
Increasing
 complexity of patient care,
 increasing comorbidities,
 need to address patient preferences and other patient factors,
 the complexity of managing the hospital system requirements,
requires a system integrating all these dimensions
The “Ideal” System for Surgery
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Preadmission patient assessment
Selective clinic review
Preadmission preparation
Day of Surgery Admission
Centralised Preoperative Care
Centrally organised & coordinated process
from booking to discharge and recovery
Preoperative Assessment & Preparation System
Patient Health Information
( Questionnaire, Interview, Old Records )
Triage
No Clinic
(Clerk/Nurse)
Anaesthetist
Clinic
(Standard)
READY
Day of Surgery
(Multidisciplinary)
PENDING
Phone Call Day Prior
Day Only
Clinic
Inpatient
Meeting the patient preoperatively
General Hints
 Know the procedures & paperwork
 Look and Behave like a Professional
 Plan the consultation before you meet the patient.
 Read the patients notes First!
 Check with the Nurses.
 Introduce yourself:- your name and your purpose clearly.
 Call the patient Mr/Mrs/Miss, at least at first
 Use confirmation questions rather than interrogation
 Give the patient and family time to ask questions
Perioperative Medicine Topics
•Organisational Issues
•Perioperative Assessment
•Preanaesthetic Assessment
•Medications and Surgery
•Preoperative Investigations
•Patient Preparation
•Post-operative care
Perioperative Medicine Topics
Perioperative Assessment
•What preparation is needed
•What might "go wrong"
•What are the procedure-specific tasks Pre- and
Post-op?
•What are the general tasks Pre and Post-op?
•What are the indicators of higher perioperative
risk
•Should this patient have the operation?
What is the point of patient assessment before Surgery?
 Identify potential to improve patient’s health
status (……and manage this…)
 Assess the risks associated with planned
procedure to enable risk/benefit assessment
 Modify the planned perioperative
management.
 Identify possible undesired events or
‘complications’ that may occur perioperatively
in order to plan detection and treatment of
patient if they do occur.
The Key Steps of the PreProcedural Process
 Gather Information
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Patient Health; Procedure; Hospital/system; Personal
Collation & Documentation of Information
 Review Patient Health
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Identify potential to improve patient’s health status
Optimise the Patient’s Health as much as realistically achievable in the timeframe available
 Analyse/Integrate (four perioperative dimensions)
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Assess the risks and benefits associated with planned procedure
Consider alternative perioperative management options and/or procedures.
 Decide on perioperative management plan.
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Resolve conflicting requirements.
Decide on plan of care
Identify possible undesired events or ‘complications’ that may occur perioperatively
Plan detection and treatment of ‘complications’ if they do occur.
 Explain/Educate
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Communicate plan to patient/proceduralists/theatre staff surgeon
What things are assessed before Surgery?
 CVS
 Cardiac Failure; IHD; Valves; Arrythmias
 Exercise Capacity
 Respiratory
 Asthma/CAL; Bronchiectasis; Smoking
 Diabetes
 Cerebrovascular & other neurological
 Haematology
 Anaemia; Bleeding/Clotting disorders; Warfarin
 etc etc etc
Balance the conflicting aims of optimising health and
what is realistically achievable in the timeframe available
Why does the patient’s “fitness” matter?…..
What happens in the Clinic?
• Patients are (ideally) seen 1-2 weeks preoperatively
• Specialist Nurse review
• Perioperative Medical consultation by Anaesthetist
(as a ‘Perioperative Physician’)
• Tests / Referral as appropriate
• Postponement if necessary (surgeon notified)
• Patient Education & Instruction
• Warning to Procedural Anaesthetist, Theatres etc as
needed.
But What happens before and after the clinic
visit (or instead of it) is just as important as
what happens in the clinic itself
Perioperative Medicine Topics
•Organisational Issues
•Perioperative Assessment
•Preanaesthetic Assessment
•Medications and Surgery
•Preoperative Investigations
•Patient Preparation
•Post-operative care
Perioperative Medicine Topics
Preanaesthetic assessment
•Assessment for anaesthesia
• What’s the point? – (Will it change
anything)
•“Is this Patient Fit for Anaesthesia?”
•General vs. Regional vs. Local,
•ASA score
•Airway Assessment
Who Assess the Airway?
The MOUTHS system for assessing airways
Mandible
Opening
Uvula
Teeth
Head & Neck
Shape/Silhouette
(My personal mnemonic)
The LEMON system for predicting
difficult intubation
• Look externally,
• Evaluate the 3-3-2
• Mallampati,
• Obstruction,
• Neck mobility
(A Different mnemonic)
What is the Mallampati score?
What is the Laryngoscopy
view?
(Cormack & Lehane Categories)
Mallampati Score
Cormack & Lehane Category
Perioperative Medicine Topics
•Organisational Issues
•Perioperative Assessment
•Preanaesthetic Assessment
•Medications and Surgery
•Preoperative Investigations
•Patient Preparation
•Post-operative care
Perioperative Medicine Topics
Medications and Surgery
•Anticoagulants
•Hypoglycaemics and insulin
•Betablockers
•Antihypertensives
•Antiplatelet agents
•Others
Perioperative Medicine Topics
•Organisational Issues
•Perioperative Assessment
•Preanaesthetic Assessment
•Medications and Surgery
•Preoperative Investigations
•Patient Preparation
•Post-operative care
Perioperative Medicine Topics
Preoperative Investigations
•Blood tests
•Group & Screen; Cross Matching
•INR; HbA1C; Pregnancy
•Radiology
•ECG
•Echocadiography
•Myocardial Perfusion Imaging
(Stress; Sestamibi, Angiography etc)
•Cardiopulmonary Exercise Testing (CPX or CPET)
•If you think extra tests are needed:- Check with the registrar,
nurses or the procedural anaesthetist.
Perioperative Medicine Topics
•Organisational Issues
•Perioperative Assessment
•Preanaesthetic Assessment
•Medications and Surgery
•Preoperative Investigations
•Patient Preparation
•Post-operative care
Perioperative Medicine Topics
Patient Preparation
•Fasting
•Appropriate fluids while fasting
•Bowel prep - who needs it, what to
prescribe
•Skin Preparation, Shaving
•DVT Prophylaxis
What do I do for the patient preoperatively?
Confusing Patient Preparation Issues
 Fasting - 3hrs water, 6hrs solids
 IDDM - Check BSLs, Half normal insulin.
 Warfarin - Omit 4/5 doses, Clexane cover for some patients
 Aspirin - Controversial & Confusing - check with surgeon!
 Clopidogrel - Withold for 7-10 days BUT NOT FOR STENTS
 DVT Prophylaxis – “The most overlooked part of patient care”
 Smoking - NRT Patches, refer to Quitline
 EtOH abusers - Alcohol Withdrawal Score, Refer to D&A.
If in Doubt, Check!
Full protocols available
from Perioperative Service
Postoperative Patient Care
What is likely to happen to the patient
postoperatively?
Perioperative Medicine Topics
•Organisational Issues
•Perioperative Assessment
•Preanaesthetic Assessment
•Medications and Surgery
•Preoperative Investigations
•Patient Preparation
•Post-operative care
Perioperative Medicine Topics
Post-operative care
•Appropriate fluids in context of
surgery/blood loss
•When to transfuse
•Analgesia - PCA's and nerve infusions
•Post-op tests
•When to restart preop medications that
have been stopped.
What is going to happen to the patient postoperatively?
 Procedure-specific Issues
 Specific monitoring, therapy or other care tasks,
and ‘specific’ complications related to the
particular procedure that has been performed
 General Postoperative Management
 Monitoring, therapy, and care tasks that may be
encountered in any patient having surgery
 “Complications”
 Response to problems/complications
What is going to happen to the patient postoperatively?
General Postoperative Patient Care
• ‘Normal’ response to surgery
• Stress Response; Systemic Inflammation
• Observations
• Vitals signs; Pain; Mental status; Emotions etc
• ‘Fluid & Electrolytes
• Maintenance; Replacement of losses; “third space loss”
• Thromboprophylaxis
• A major preventable cause of hospital deaths
• Chronic Medications
• Maintain most medications – some are critical!
• Pain Management
• Optimise:- Multimodal strategies & The analgesic ladder
• Discharge & Convalescence
• Patient Expectations and Systematic Organisation
What is going to happen to the patient postoperatively?
• “Complications”
• Respiratory
• Atelectasis, Infection, Respiratory Failure
• Cardiovascular
• Dysrythmias, LVF; Myocardial Ischaemia; AMI
• Mental Status
• Confusion & Delirium (treat and find the cause!)
• Renal Function
• Observations; ??Cause???
• Infection
• Local or systemic; May be insidious
• Gastrointestinal
• PONV; Bowel obstruction; feeding
• etc etc etc
• “More harm is done when you do not look than by
not knowing what is in the book”
What are the Hot Topics in Perioperative Medicine?
• Intravenous Fluids
• Too much Salt; Colloids; IV Access; Goal-Directed Fluid
Therapy; GIFTASUP
• Blood
• Antiplatelet agents; Transfusion Triggers; Iron therapy;
Patient Blood Management
• Checklists etc; ERAS programs
• Integrity of Process as a major determinant of outcome
• “Failure to Rescue”
• MET Failures; DETECT; Between the flags etc. Emergency
Response Systems
• Critical Care Access
• Triage by biomarkers or CPET; ICU Outreach; HDU
Resources; Alternative Models of Critical Care
• Patient Preparation
• Patient selection; Identification of futility; Prehabilitation;
Appropriate expectations; Active Recovery
Any Questions?