Summarise core details
- Patient details
- Operation (and anaesthesia if required)
- Background
NB: look through past notes/documents to confirm details.
Current health
- Recent/current illnesses (within 2 weeks)
- Full systems review
- Baseline exercise tolerance (what makes them stop: SOB/chest pain/claudication)
- Symptoms of sleep apnoea (paroxysmal nocturnal dyspnoea, excessive sleepiness, morning headaches)
- Smoking/alcohol use
Medical and drug history
- Medical conditions: ask specifically about hypertension, diabetes (should be put first on list), asthma/COPD, cardiovascular disease, liver disease. Determine if conditions are adequately controlled.
- Drug history (including allergies!)
Anaesthetic history
- Previous anaesthetics and reactions
- Family anaesthetic history
Examination
- Neck movement limitation/jaw opening limitation/dentures
- Airway assessment: use Mallampati classification and note BMI
- See all soft palate and uvula
- See half of uvula
- See a small gap at end of soft palate
- Can only see hard palate
- Back examination (if having spinal/epidural): look for skeletal malformations
- General: GCS, limb movements
- Hands: cyanosis, warm peripheries, cap refill, peripheral pulses
- Neck: JVP, carotid bruits
- Chest: heaves/thrills, chest expansion, percussion resonance, lung and heart sounds
- Abdomen: tenderness, masses/organomegaly, bowel sounds
- Calves: swelling/tenderness, oedema
Investigations
Tests that may be required for patients having surgery include:
- Blood tests: FBC, U&Es, LFTs, clotting, group and save
- ECG
- Other tests may be considered in advance
- Pregnancy test (if chance of pregnancy)
- Echocardiogram (if murmur/heart failure/cardiac symptoms)
- Spirometry (if significant lung disease)
- Pacemaker check(if have pacemaker)
- TFTs (if on known thyroid disease)
Reference: NICE ‘NG45 Routine preoperative tests for elective surgery’ 2016
Preparation
Correct investigation abnormalities
For an immediate pre-operative assessment (day prior to the operation)
- Correct INR if abnormal (>1.4)
- Aggressive correction (if on warfarin for AF): 5-10mg IV vitamin K, then repeat INR in 6 hours – if still high, discuss with haematology regarding giving prothrombin complex concentrate pre-operatively
- Cautious correction (if on warfarin for artificial heart valve/recent PE): discuss with senior and haematology – will usually require reversal of warfarin and cover with unfractionated heparin infusion, which will be stopped 4 hours pre-operatively and restarted after
- If INR raised due to liver disease: 10mg IV vitamin K, then repeat INR in 6 hours – if still high, discuss with haematology who may advise FFP/cryoprecipitate
- Blood transfusion if Hb <9g/dL, or <10g/dL if elderly/cardiovascular/respiratory disease
- Consider platelet concentrate transfusion if platelets <50×109/L (discuss with haematology if cause unclear)
- Correct electrolyte abnormalities
Note, if there are significant abnormalities, bloods must be repeated again pre-operatively (e.g. at 6am) to show they have been corrected.
For an early pre-operative assessment (>1 week pre-operatively)
- INR may be corrected by stopping warfarin as below
- Anaemia should be investigated and the cause treated – e.g. with iron tablets/infusion for iron-deficiency anaemia
If there are any concerns, contact the consultant or an anaesthetist.
Medications
- IV fluids: only prescribe fluids overnight (when NBM) if instructed by consultant, or if patient needs variable rate insulin infusion, or is dehydrated
- New medications
- Operation preparation: give drugs required for specific operation (specified in pre-operative checklist), e.g. bowel prep for colorectal
- VTE prophylaxis: prophylactic LMWH should usually be given the night before the operation, but omit any doses when the operation is due to start in <12 hours
- Antiemetics and analgesia: as required
- Regular medicines
- Vital drugs should usually be taken on the day of the operation: cardiovascular medications (excluding antihypertensives), antipsychotics, Parkinson’s medications, inhalers, glaucoma medications, immunosuppressants, thyroid medications, drugs of dependence (e.g. benzodiazepine)
- Most other drugs should not be taken on the day of the operation (restarted the day after)
- Some medications must be stopped/changed pre-operatively:
Medications that should be stopped/changed pre-operatively
Medication | Time to stop pre-operatively | Details |
Warfarin | 5 days | Therapeutic-dose LMWH can be prescribed in the interim in most cases; patients with high risk indication (e.g. mechanical heart valve) may need to be admitted for unfractionated heparin infusion |
Direct oral anticoagulants | 24 hours for minor surgery; 48 hours for major surgery | |
Therapeutic-dose LMWH | 24 hours | |
Unfractionated heparin infusion | 4 hours | Restart post-operatively |
Aspirin/clopidogrel/dipyridamole/ P2Y12-receptor inhibitors | 7 days ideally (but risk/benefit decision) | If patient has a cardiac stent or other high risk indication, liaise with cardiology and surgeon to make decision regarding stopping |
Insulin | Avoid morning dose | Prescribe variable rate insulin infusion with surgical fluid [5% dex/0.45% NaCl/0.15% KCl @ 80ml/h] from midnight the night before (unless minor surgery) |
Oral hypoglycaemics | Avoid on day of operation | Prescribe variable rate insulin infusion as above if blood glucose not well controlled. Also avoid metformin for two days after (due to risk of lactic acidosis). |
Diuretics/ACE inhibitors | Avoid on day of operation | |
Long-term corticosteroids | Change to equivalent dose hydrocortisone | Liaise with anaesthetist |
COCP | 4 weeks | Restart 2 weeks after |
Forms
- VTE prophylaxis Proforma
- Consent form (complete this only if you have sufficient knowledge, if not call registrar/consultant)
Fasting and admission
- Fasting guidelines
- ‘2-6 rule’ = NBM for 2 hours pre-operatively; clear fluids only for 6 hours pre-operatively
- If you are unsure of the operation time, prepare the patient for 8am (e.g. say clear fluids only from 2am, NBM from 6am).
- Pre-operative patients only generally need admission the night before if they are diabetic (and therefore require a variable rate insulin infusion from midnight); or if they need specific medications which must be given overnight; or if INR/Hb/platelets need correction