PRE-OPERATIVE ASSESSMENT FOR ORTHOPEDIC SURGERY

Pre operative evaluation for orthopedic surgery

1. Preoperative assessment and preparation for anaesthesia

2. Session outline Preoperative assessment: History taking Physical examination Surgical urgency Investigations

3. Introduction: what is POA?

4. Introduction  What are the aims of POA? Reduce morbidity and mortality associated with surgery Assess pre-existing medical conditions Plan preoperative and postoperative management of these conditions Prevent unnecessary cancellations Ensure the patient is fully prepared for surgery Reduce length of hospital stay Inform the patient of the proposed procedure and gain consent

5. Introduction Why is POA important? Induction is d angerous without correct preparation Anaesthetic has profound effect on CVS and RS Pre-existing medical conditions can have a dramatic influence To enable you to adequately prepare for an anaesthetic type To minimizes the risk to the patient Structured approach: Take a few moments to outline on a piece of paper a plan for a preoperative assessment.

6. Preoperative assessment 1: History taking History of present compliant? Determine surgical urgency Influence of anaesthetic technique Determine the acceptable starvation period Surgical condition which have systemic effect. E.g. bowl ca

7. Anesthesia fitness chart

8. Preoperative assessment 1: History taking Medical History – CV disease For cardiovascular disease, ask: Exercise tolerance Palpitations Collapse/syncope Ankle swelling History of MI/Hypertension/raised cholesterol/diabetes Known valvular or congenital heart disease

9. Preoperative assessment 1: History taking Medical History – RS disease For respiratory disease, ask: Exercise tolerance Cough/sputum/haemoptysis Smoking history Wheeze Exposure to industrial dusts Weight loss Night sweats Fever

10. Preoperative assessment 1: History taking Medical history: exercise tolerance

11. Preoperative assessment 1: History taking Medical history: other conditions Malnourished Dehydration Elderly (>75 years) Diabetes mellitus Endocrine dysfunction Chronic renal failure Nephrotic syndrome Obstructive jaundice

12. Preoperative assessment 1: History taking Medical history: Anaesthetic history Note details of previous anaesthetics and any problems encountered Examine previous anaesthetic charts if available Note last exposure to halothane anaesthesia Medical history: family history Malignant hyperthermia Suxamethonium apnoea Porphyria Haemoglobinopathies

13. Preoperative assessment 1: History taking Medical history: Drug history Allergies and addiction Pregnancy Reflex

14. Preparation What should you prepare prior to anaesthetising a patient for surgery? Patients Drugs and blood products Equipment check Communicate with ward Communicate with theatre team

15. Preoperative assessment 2: physical examination Look at your patient as a whole to decide how sick he/she is Assess the degree of hydration Check peripheral perfusion (is he cold to touch?). Check for cyanosis (central and peripheral). Check for jaundice

16. Preoperative assessment 2: physical examination Cardiovascular System and respiratory Examination  Look  Listen( Auscultate)  Feel  Look Other systems

17. Preoperative assessment 2: physical examination Airway assessment Airway assessment aims to predict:  Difficult mask ventilation (with or without adjuncts/aids)  Difficult placement of LMA Difficult intubation  Difficult surgical access to trachea (rarely required)

18. Preoperative assessment 2: physical examination  Poor management of the difficult airway can result in:  Dental trauma  Airway trauma  Pulmonary aspiration  Hypoxia  Death

19. Preoperative assessment 2: physical examination Successful intubation requires: Good mouth opening Extension of the upper cervical spine The ability to move soft tissue within the mandible out of the way

20. Preoperative assessment 2: physical examination Quick airway assessment Mallampati test Mouth opening (interinciser ga p ) Jaw slide Neck movement

21. Preoperative assessment 2: physical examination

22. Preoperative assessment 2: physical examination M outh opening Neck movement

23. Preoperative assessment 2: physical examination Jaw slide Thyro and sterno - mental distance

24. Difficult ventilation Which features are associated with difficult mask ventilation? Overweight/Pregnant Bearded or Burns/Trauma to face Edentulous (lack of teeth) Snoring/Obstructive Sleep Apnoea/space occupying lesion of oropharynx or larynx Elderly

25. Difficult intubation Which features are associated with difficult intubation? Protruding/awkward teeth Space occupying lesion of oropharynx and larynx Facial trauma or burns Obesity Previous tracheostomy/tracheal stenosis Pregnancy

26. Preoperative assessment 3: surgical urgency Why for anaesthetist? To communicate with surgeon To minimize the overall risk Aware the risks associated with the surgical urgency Risk – benefit analysis Consensus b/n the team and family

27. Preoperative assessment 3: surgical urgency There are four categories: Immediate life, limb or organ saving Urgent Expedited Elective

28. Preoperative assessment 3: surgical urgency Surgical grades Examples Grade 1 (minor) Excision skin lesion; drainage breast abscess Grade 2 (intermediate) Inguinal hernia; varicose vein(s); tonsillectomy; arthroscopy Grade 3 (major) Hysterectomy; TURP; lumbar discectomy; thyroidectomy Grade 4 (major+) Joint replacement; thoracic operations; colonic resection; radical neck dissection

29. The ASA classification of general preoperative health  Extended version ASA 1 : Healthy patient. ASA 2: Healthy patient with remarks. ASA 3 : Patient with moderate clinical illness. ASA 4: Severely ill patient. ASA 5 : Patient with an immediately life-threatening condition.  Add E for emergency Original version ASA I: A normal healthy patient ASA II: A patient with mild systemic disease ASA III: A patient with severe systemic disease ASA IV: A patient with severe systemic disease that is a constant threat to life ASA V: A moribund patient who is not expected to survive without the operation ASA VI: A declared brain-dead patient whose organs are being removed for donor purposes

30. Preoperative Assessment 4: Investigations The decision to order tests will depend on: Age of the patient General health/co-morbidities of the patient Medications Presenting condition Urgency of surgery Nature of surgery planned Facilities available for testing

31. Age Healthy patients over 60 years old may need the following if major surgery is planned: Electrocardiogram (ECG) Full blood count (FBC) Renal function tests (U&E) The type of surgery planned is a major determinant of preoperative investigations.

32. Full blood count (FBC) Full blood count (FBC) Measure when: The history or examination indicates anaemia The proposed operation is expected to cause substantial blood loss Measure in patients with: Jaundice Malignancy Infection HIV Significant blood loss Also measure in patients with cardiac/renal/respiratory disease.

33. Blood test (Group save and cross much) Group and save According to hospital guidelines for elective surgery Significant or continuing blood loss but patient not shocked Cross match When blood is required Immediately if blood loss >30% circulating blood volume (1.5 L in adult) If blood loss >50% circulating blood volume (2.5 L in adult); use O negative blood until crossmatched blood becomes available

34. Blood test (coagulation screen) Measure when the patient : Has hepatic disease Is on warfarin or anticoagulants History of inappropriate excessive bleeding If there is a family history of bleeding disorders Severe sepsis Major haemorrhage

35. Blood glucose Measure if the patient has: Diabetes Glycosuria Steroid treatment Altered conscious level

36. Radiograph Chest Chest X rays (CXR) are not routinely ordered Usually limited to patients listed for major surgery with Substantial cardiac or respiratory disease, Heavy smoking or exposure to TB They may be requested as part of the surgical work up of the patient. Acute respiratory symptoms: May require as part of their management These should be treated before elective surgery

37. Radiograph Spine Cervical spine x-rays (AP, lateral) are indicated in History of arthritis Susceptibility in clinical examination Trauma / RTA Diabetes

38. Electrocardiogram Consider when patient scheduled for major surgery has: Cardiovascular risk factors or history of cardiovascular disease for example: hypertension, smoking, high cholesterol, significant family history, and obesity Signs of heart failure You suspect an arrhythmia from clinical examination Atypical abdominal pain or cardiac sounding chest pain

39. Echocardiography Do not routinely offer resting echocardiography before surgery. Consider resting echocardiography if the patient has: A heart murmur and any cardiac symptom (including breathlessness, pre- syncope, syncope or chest pain) or S igns or symptoms of heart failure. Before ordering the resting echocardiogram, carry out a resting electrocardiogram (ECG) and discuss the findings with surgeon

40. Pulmonary function test (Spirometry or PEFR ) To assess the reversibility of obstructive airways diseases Useful to quantify severity of ventilatory dysfunction To differentiate restrictive from obstructive defects. May be indicated: Those with equivocal clinical and radiological findings or unclear diagnosis. Patients in whom functional ability cannot be assessed Part of the assessment of patients for lung parenchymal resection

41. Renal function test Measure: For all major surgery Measure in patients on: On diuretics or cardiovascular drugs Measure in patients with: Infection Diabetes Dehydration Hypertension Poor urine output

42. Liver function tests Measure in patients with: Cardiac/hepatic disease Biliary disease Infection Alcohol abuse Jaundice