Fitness for Anaesthesia & Surgery

• What medical conditions may affect fitness for surgery?

  Diabetes

  CKD

  Obesity

  Peripheral arterial disease

  Chronic lung conditions (COPD, asthma)

  Frailty

  Cardiovascular disease
• What lifestyle choices can affect fitness for surgery?

  Alcohol

  Smoking

  Illicit drug use

  Sedentary lifestyle

  Poor diet
• What are the risks of obesity in terms of surgery?

  Airways often difficult to manage

  • obesity reduces functional residual capacity of lungs
  • less reserve to utilise during decreased ventilation or physiological stress
  • O2 sats can drop very quickly

  Difficult IV access

  Cardiovascular monitors are less accurate (esp. non-invasive BP -> may need an arterial line)
• What are the risk of cardiac conditions in terms of surgery?

  Risk of peri-operative MI

  (due to plaque instability & anaesthetic effects on CV system (vasodilation))
• What are the risks of OSA in terms of surgery?

  Need to consider if the patient wears CPAP machine & if they are able to lie flat
• What are the risks of reflux in terms of surgery?

  Risk of aspiration

  Reduced by fasting & PPIs until day before surgery

  Do they have any condition/meds which may affect gastric emptying
• What are the risks of frailty in terms of surgery?

  Increased risk of post-op delirium & cognitive decline

  Pts with pre-existing dementia have increased risk of developing delirium

  More prone to adverse effects on anaesthesia

  • bradycardia
  • hypotension
  • respiratory depression
  • cognitive impairment
  • aspiration pneumonia
• NEED TO ADD ABOUT CHRONIC LUNG CONDITIONS FROM SLIDES.
• What is done in a pre-operative assessment clinic?

  Take a history

  Perform examination

  Check what operation they are coming in for (time & length)

  Order/check necessary investigations

  Inform patient of anaesthetic plan

  Answer patient's questions
• What is important in a pre-operative assessment history?

  Medical diagnoses

  Previous surgery

  Drug history

  Any potential undiagnosed medical condition?

  Allergies?

  Previous anaesthetic history (when? what for? any previous problems? FHx of anaesthetic problems, loose teeth? dentures?)
• What can be used to assess & classify pre-anaesthesia medical co-morbidities?

  ASA physical status classification

  Can be used with other factors to help predict perioperative risks

  • type of surgery
  • frailty
  • level of function/deconditioning
  • NELA (national emergency laparotomy audit)
  • surgical outcome risk tool
• ASA classification

  Grade I - healthy pts (non-smokers & no/minimal alcohol)

  Grade II - pts w/ mild systemic disease (well-controlled diabetes/HTN, smoker, BMI 30-40 & mild lung disease)

  Grade III - pts w/ severe systemic disease (poorly controlled diabetes/HTN, COPD, BMI >40, Hx of ACS/stroke/TIA > 3 mths ago)

  Grade IV - pts w/ severe systemic disease, threat to life (MI/stroke/TIA < 3 mths, severe valve dysfunction, severe reduced EF, sepsis)

  Grade V - pts not expected to survive operation (ruptured AAA, massive bleed)

  Grade VI - pt declared brain-dead, organs removed for transplant
• What are the different grades of surgery?

  Minor (excising skin lesion or draining superficial abscess)

  Intermediate (primary repair of inguinal hernia, cholecystectomy, tonsillectomy, knee arthroscopy)

  Major/Complex (total abdominal hysterectomy, endoscopic resection of prostate, lumbar dissection, total joint replacement)
• What are the possible complications of endotracheal tube placement?

  Sore throat, cuts, damage to teeth

  Hoarseness (temp/permanent damage to vocal cords)

  Increased BP or HR

  Asthma exacerbation

  Brain damage and/or death secondary to inability to intubate
• When does warfarin need to be stopped before surgery?

  5 days

  May require bridging with LMWH (depending on risk of VTE)

  In emergencies, check INR (may require reversal)
• When does clopidogrel need to be stopped before surgery?

  7 days before surgery
• When do ACE inhibitors need to be stopped before surgery?

  Withhold on the morning of surgery
• When do DOACs need to be stopped before surgery?

  Depends on procedure, risk & creatinine clearance

  Normally 2-3 days before
• When do anti-convulsants need to be stopped before surgery?

  Do not need to be stopped
• When do diabetic medications need to be stopped before surgery?

  Omit oral hypoglycaemic agents on day of surgery

  Aim for first on the list to minimise starvation period

  Consider variable rate insulin infusion during perioperative period
• When do steroids need to be stopped before surgery?

  > 5 mg daily will be supplementary steroids during perioperative period (sick day rules)

  Dosage depends on normal regimen & duration
• When do hormonal therapies need to be stopped before surgery?

  Caese COCP/oestrogen HRT before surgery (at least the day before)