DRROBSTEPHENSConsultantinAnaesthesia

UCLHospitals

AnIntroductiontoAnaesthesia2019

Contents •  Preoperative assessment vs day of surgery assessment • Why do we pre-assess patients? • Quantifying perioperative risk • Reducing perioperative risk •  Seeing elective patients on the day •  Seeing emergency patients before surgery • Questions

Preoperative assessment vs day of surgery assessment

• PreopAssessmentClinics•  Assessment,tests,Lotsofinformationgathered&given•  PMHx,DHx,Allergies?Okfordaysurgery•  Triage-somepatientsseeaDr•  7xmorelikelytodieifnotdone

• Dayofsurgeryassessment•  AllPatientsbeforecomingtotheatre•  Brief,patientstressed•  Essentials

KnowingtheRiskNCEPOD

Why pre-assessment?

• builduppatientrapport,reduceanxiety,qns• getinformationaboutthem• telltheminformation• allowpatientstomakeinformeddecisionsabouttheircare

• minimisetheriskofsurgery• Planning-ICUpostop,warnAnaesthetists,bridgingplanetc

Perioperative risk =Thechanceofdeathand/orcomplicationsaroundthetimeofsurgery30days

•  Deathduringsurgeryisuncommon

•  Butmanypeoplehavecomplicationsaftersurgery

• Why-specificbiologicalmechanismsareunknown.

…Oxygendelivery,leakageofgutbacteria,immunechanges,bloodclotting,autonomicdysfunction,cardiacdamage

Perioperative risk Patient+Surgery+Anaesthesia systemicinflammatorychanges

systemiccomplications&Death

Lotsofscoresystems

HowUrgent?

CVSRSGINSInfectiousOther

Complications = Postoperative morbidity

•  Postoperativemorbidityaffectsupto50%ofpostoperativepatients(POMS)=complications

•  Complicationrate~7xchanceofdying

•  Forpatientswhodevelopapostopcomplication: -Totalcarecosts↑ -Lengthofstay↑

-Suffering

Khan,2006;JGenIntMed

The mortality associated with postoperative complications

Persistsfor8+years!

Predicting perioperative risk • Individualriskvspopulationrisk?• Patient/Surgical/Hospitalbasedfactors• ASA• ‘SORT’surgery• ‘POSSUM‘• Leesrevisedriskscore(cardiacrisk)• Cardiopulmonaryexercisetesting–individualfitness

ASA physical status American Society Anesthesiology

death

I–healthy,nonsmoker/drinker 0.05%

II–mildsystemicdisease,notaffectingfunction 0.4%

III–severesystemicdiseasethatlimitsfunction 4.5%

IV–incapacitatingsystemicdisease,lifethreatening 20%

V–moribund,notexpectedtosurvivewithoutsurgery 30+%

VI–brainstemdeadawaitingorgandonation

E=emergency

Doesn’tincludeTypeofsurgeryUrgencyAnaesthesiastuffdirectly

Agreement?

Predicting perioperative risk • Individualriskvspopulationrisk?• Patient/Surgical/Hospitalbasedfactors• ASA• ‘SORT’surgery• ‘POSSUM‘• Leesrevisedriskscore(cardiacrisk)• Cardiopulmonaryexercisetesting–individualfitness

SORT Surgery

•  SurgicalOutcomeRiskTool• www.sortsurgery.com

SORT Surgery •  SurgicalOutcomeRiskToolwww.sortsurgery.com

SORT Surgery

P-POSSUM

• PhysiologicalandOperativeSeverityScorefortheenUmerationofMortalityandMorbidity.

• www.riskprediction.org.uk

Reducing perioperative risk

OptimisationPreoperativeresuscitation

Institutionalfactors

Intraoperativeresuscitation

Postoperativecare

Reducing perioperative risk: ‘optimisation’

•  GoodPreassessment:HxExaminationIx

•  Treatmentofacuteillnesses

•  ‘Optimisation’ofchronicillnesses

• Whatis‘optimal’–balancewithsurgicalriske.g.coagulation

•  Cardiac:American(AHA/ACC)

•  Anaemia,polycythaemiaand[Hb]

•  Fitnessvsdeconditioning•  Specialistreview•  Planningoftimingofsurgery,intra+andpostoperativecare

•  ‘Enhancedrecovery’

Pre-assessment guidelines Reducing perioperative risk: ‘optimisation’

Preoperative Tests Willtheychanceyourmanagementoradvice?NICEsay-dependsonSurgery,Age&Comorbidities

Consider

• Urine Pregnancy Dipstick• Bloods FBC U&Eglucose,SickleDexOther•  ECG RiskFactors >65 Majorsurgery• X-Ray CXRonlyifnewproblems•  Special ECHOCPET

Practical guide to preoperative assessment

• Gotopreoperativeassessmentclinics,•  makeowndecisionsand•  discussthesewithaconsultant•  Talkwithpatients-whataretheirconcerns?

• How/willthesetestswillchangemanagement?•  especiallyifitdelayssurgery/expensive/painful

• Readtheguidelines:PreoperativeTestsNICE2016•  Trycalculatingtherisks

•  SORTandPOSSUMforeachpatient

Practical guide to day of surgery assessment 1 •  Introduceyourself! Developyourownchat.Avoidtechnicalterms.

•  “haveyoueverhadananaestheticbefore”•  Don’tforgetHx Exam Investigations Mx

•  What’sthesurgery?‘Major’?

•  Functionalassessments>1-2Flightstairsormore

•  Daysurgery? ‘24hrrules’

patient surgery

urgency

anaesthesia

Practical guide to day of surgery assessment 2

•  Painpostop-chat–Paracetamol/NSAID/Opioids

•  Discuss&Document Common/Likelythings•  Pain cannula N&V throat Transfusion•  Blocks ICU Mobility/Exercises

•  NormalDrugstoday?(Diabetes/ACEI/Anticoagulation/CVS)

•  Drink2hrs Food6hrs watersipsuntilsurgery

Practical guide to day of surgery assessment 3

Plan•  Doestheriskofsurgeryoutweighthebenefits??Alternatives•  Generalanaesthesiaorlocalanaesthesia?•  Airway–Whattype

Intubate?/Emergencyairway

Isa‘rapidsequenceintubation’required?

•  Breathing.Ventilationmodesandsettings.

•  Circulation.Lines:Bleeding/Art/CVP?Cardiacoutputmonitor.

•  DrugsAnalgesia.Systemicorregional.

•  Postoperativecare.Decisionbeforeoperation.Feeding.

Practical guide to preoperative resuscitation Urgent or emergency case assessment

Don’tforgetthebasics•  Hx/Exam/Investigations/Mx.

•  1Flightstairs?• What’sthesurgery?Urgency?

•  Riskchat+tact+kindness• Whatdoesthepatientexpect/want?

•  Surgicalriskversusoptimisationtime

•  AOK?•  BGasexchangeOK?O2,

•  C[Hb]<90g/L–orderblood+products!•  CCardiacoutput:fluidchallengesCSL•  DDrugsthey’reon?•  Electrolytes.•  Destination:Fitforthewardafter?•  Destination:?discusswithICU•  Anaestheticplan:‘Twobigdripsandatube?’

•  Discussionwiththepatientagain

Practical guide to preoperative resuscitation Urgent or emergency case assessment

Reducing perioperative risk: intraoperative resuscitation

•  Lungprotectiveventilation–Futier2013• Optimisefluidbalance(goaldirectedtherapy?)•  Electrolytesandcoagulation.

Reducing perioperative risk: Postoperative care

Allpatientswithapredictedmortalityof10%shouldbecaredforincriticalcare

Patientsthatdidn’tgotopreassesment

7xchanceofdeath

Summary

• PreassessmentvsDayofsurgery• RiskScores-ASASORTP-POSSUM• Reducingperioperativerisk• PreoperativeTests UBEXS• Preassessment–practicalites• Dayofsurgery–electives• Dayofsurgery-Urgent

Questions

robcmstephens@googlemail.com

Further reading: guidelines and reports Preoperativeassessment

•  ACC/AHAguidelines2015•  NICEguidelineswww.nice.org.uk/guidance/ng45/resources•  SORTsurgeryandPOSSUM

UKReports

•  Knowingtherisk–NCEPOD•  Thehigherrisksurgicalpatient:towardsimprovedcareforaforgottengroup–TheRoyalCollegeofSurgeons.

•  NationalAuditProjects–TheRoyalCollegeofAnaesthetists

Further reading: journal articles Quantifyingperioperativerisk

•  Barnett,S.,&Moonesinghe,S.R.(2011).Clinicalriskscorestoguideperioperativemanagement.PostgraduateMedicalJournal,87(1030),535–41.

•  Khuri,S.F.,Henderson,W.G.,DePalma,R.G.,Mosca,C.,Healey,N.a.,&Kumbhani,D.J.(2005).DeterminantsofLong-TermSurvivalAfterMajorSurgeryandtheAdverseEffectofPostoperativeComplications.,32–48.

•  Pearse,R.M.,Harrison,D.a,James,P.,Watson,D.,Hinds,C.,Rhodes,A.,…Bennett,E.D.(2006).Identificationandcharacterisationofthehigh-risksurgicalpopulationintheUnitedKingdom.CriticalCare(10(3),R81.

Mechanismsofoperativerisk:

•  Ackland,G.,Grocott,M.P.,&Mythen,M.G.(2000).Understandinggastrointestinalperfusionincriticalcare:sonear,andyetsofar.CriticalCare(4(5),269–81.

Further reading: journal articles Lungprotectiveventilation

• Futier,E.,Constantin,J.-M.,Paugam-Burtz,C.,Pascal,J.,Eurin,M.,Neuschwander,A.,…Jaber,S.(2013).Atrialofintraoperativelow-tidal-volumeventilationinabdominalsurgery.TheNewEnglandJournalofMedicine,369(5),428–37.

GoalDirectedTherapy

• Hamilton,M.a,Cecconi,M.,&Rhodes,A.(2011).Asystematicreviewandmeta-analysisontheuseofpreemptivehemodynamicinterventiontoimprovepostoperativeoutcomesinmoderateandhigh-risksurgicalpatients.AnesthesiaandAnalgesia,112(6),1392–402.

• GrocottM,Dushianthan,A.,Ma,H.,Mg,M.,Harrison,D.,&Rowan,K.(2013).Perioperativeincreaseinglobalbloodflowtoexplicitdefinedgoalsandoutcomesfollowingsurgery.Cochranereview.

Transfusiontargets

• Carson,J.L.,Terrin,M.L.,Noveck,H.,Sanders,D.W.,Chaitman,B.R.,Rhoads,G.G.,…Magaziner,J.(2011).Liberalorrestrictivetransfusioninhigh-riskpatientsafterhipsurgery.TheNewEnglandJournalofMedicine,365(26),2453–62.

• Villanueva,C.,Colomo,A.,Bosch,A.,Concepción,M.,Hernandez-Gea,V.,Aracil,C.,…Guarner,C.(2013).Transfusionstrategiesforacuteuppergastrointestinalbleeding.TheNewEnglandJournalofMedicine,368(1),11–21.