Why is pre operative checklist important?
Thepre-operative assessmentis an opportunity to identify co-morbidities that may lead topatient complications during theanaesthetic, surgical, or post-operative period. Patients scheduled for elective procedures will generally attend apre-operative assessment 2-4 weeks before the date of their surgery. Show In this article, we shall look at the components of an effective pre-operative history, examination, and routine investigations that can be performed. Pre-Operative HistoryThe pre-operative history follows the same structure as typical history taking, with the addition of some anaesthetic and surgery specific topics. History of the Presenting Complaint Abrief historyof why the patient first attended and whatprocedurethey have subsequently been scheduled for. One should also confirm the side on which the procedure will be performed (if applicable) There may be aspects of the disease or condition requiring surgery that are important for the anaesthetist to be aware of; for example, head and neck surgery may indicate the presence of abnormal airway anatomy. Past Medical History A full past medical history (PMH) is required, with the following specifically asked about:
Other specific questions it may beuseful to ask themselves the following questions:
Past Surgical History Has the patient had anyprevious operations? If so, what, when, and why? If the patient is having a repeat procedure, this can significantly change both the surgical time and ease of operation, and hence influence the anaesthetic technique used Past Anaesthetic History Has the patienthad anaesthesia before? If so, for what operation and what type of anaesthesia? Were there any problems? Did the patient experience anypost-operative nausea and vomiting? Drug History Afull drug historyis required, as somemedicationsrequire stopping or altering prior to surgery. Ask about any knownallergies, both drug and non-drug allergies Family History Whilst most hereditary conditions relating to anaesthesia are extremely rare, such as malignant hyperthermia, it is important to ask about any known family history of problems with anaesthesia Social History Ensure to ask the patient aboutsmoking history, alcohol intake, and any recreational drug use Other important social factors to make note of include:
Pre-Operative ExaminationIn the pre-operative examination, two distinct examinations are performed; thegeneral examination(to identify any underlying undiagnosed pathology present) and theairway examination(to predict the difficulty of airway management e.g. intubation). If appropriate, the area relevant to the operation can also be examined. Perform afull general examination, looking closely for any obvious cardiovascular (in particular undiagnosed murmurs or signs of heart failure), respiratory, or abdominal signs. Ananaesthetic examination, including anairway assessment (typically using the Mallampati score),will also be performed by the anaesthetist prior to any surgery American Society of Anaesthesiologists GradeOn all anaesthetic charts, a patient will be given an American Society of Anaesthesiologists (ASA) grade after their pre-operative assessment, which has been subjectively assessed and based on the criteria below. A patients ASA grade directly correlates with their risk of post-operative complications and absolute mortality. ASA GradeDefinitionAbsolute Mortality (%)INormal healthy patient0.1IIMild systemic disease0.2IIISevere systemic disease1.8IVSevere systemic illness that is a constant threat to life7.8VMoribund,who is not expected to survive without the operation9.4ESuffix added if an emergency operation-Pre-Operative InvestigationsThe nature of theexact investigationsrequireddepends on a number of factors, including co-morbidities, age, and the nature of the procedure. The urgency of the surgery will also dictate which conditions need further investigation and management prior to surgery. For example, elective surgery is often delayed for poorly controlled blood glucose levels in diabetic patients, to allow time for optimisation Each specifichospitalis likely to providelocal guidelines, howeverit is useful to understand the tests than could be done pre-operatively and have an appreciation as to why eachmay be requested. NICE produce acolour traffic light tablewhich can further guide your investigative decisions. Blood Tests
Group and Save versus Cross-MatchGroup and Save (G&S) and Cross-Match (X-match) are two tests that are slightly different in their aims:
Cardiac InvestigationsAn ECG is often performedin individualswith ahistory of cardiovascular diseaseor for thoseundergoing major surgery. It can indicateany underlying cardiac pathology and provide a baseline for comparison if there are post-operative concerns for cardiac ischaemia. An echocardiogram (ECHO) provides very useful information for the anaesthetist as it helps to risk stratify and tailor the intra-operative care of the patient. It may be considered if the person has (1) a heart murmur (2) ECG changes (3) signs or symptoms of heart failure. For patients with untreated ischaemic heart disease, or symptoms of angina, myocardial perfusion scans are often performed to look for inducible ischaemia. Respiratory InvestigationsIf a patient has a chronic lung condition e.g. COPD,spirometrymay be of use in assessing current baseline and predicting post-operative pulmonary complications in these patients. Patients may also be referred for spirometry if there are symptoms and signs of undiagnosed pulmonary disease. Plain film chest radiographs(CXR) are less commonly performed routinely pre-operatively and should be used only when necessary Other TestsUrinalysis Especially for urological procedures, a urinalysis must be performed to assess if there is any evidence or suspicion of ongoing urinary tract infection MRSA Swabs All patients will have swabs taken from the nostril and perineum for MRSA colonisation. If this is isolated, decontamination hair and body wash, along with topical ointment applied to the nostrils, will be given. Cardiopulmonary Exercise Testing High-risk patients undergoing major surgery may be referred for cardiopulmonary exercise testing (CPET). This usually involves a graded intensity period on a stationary bicycle whilst wearing a mask, as well as ECG monitoring. It provides useful information, such as the VO2max and anaerobic threshold, which can be used to risk-stratify patients for post-operative complications and need for higher level care environments |