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Preoperative assessment and management

Clinical Discipline(s)/Organ System(s)
Anaesthesiology, Cardiovascular System, Endocrinology, Respiratory System
Progress Test Topic(s)
Homeostasis
Description
A 74 year old NZ European woman with diabetes is admitted for removal of a bowel tumour, and will require a general anaesthetic. You are on your anaesthetic attachment and are shadowing the anaesthetic registrar. You both go to see the patient preoperatively to assess her fitness for surgery and plan the anaesthesia.
Applied Science for Medicine 
   - Anatomy of mouth (including teeth and tongue), pharynx, larynx, vocal cords, trachea, vertebral column, meninges, spinal cord, jugular veins
   - Controls of consciousness and pain pathways, neuromuscular junction, ventilation, cardiac output, body fluid compartments
   - Physiological responses to surgery and anaesthetic
   - Science of osmosis and diffusion
   - Pharmacology of benzodiazepines, opioids, paracetamol, metoclopramide, ondansetron, flumazenil, naloxone, low molecular weight heparin, insulin, aspirin, clopidogrel
   - Outline the pharmacology of inhalation anaesthetic agents, propofol, thiopental, muscle relaxants, local anaesthetic
   - Toxicology of local anaesthetic, opioids
   - Define 'triad of anaesthesia', total intravenous anaesthesia (TIVA) and definitive airway
Clinical and Communication Skills 
   - Obtain an anaesthetic history from a patient awaiting an operation
   - Perform an examination of cardiovascular and respiratory systems, upper airway and neck including a full preoperative airway assessment
   - Recognise high risk anaesthesia patients (signs of airway obstruction, difficult intubation, cardiovascular risk assessment/American Society of Anaesthesiologists (ASA))
   - Arrange appropriate preoperative investigations
   - Perform bag-valve-mask ventilation, airway manoeuvres, use airway adjuncts, prescribe insulin regimen for 'nil by mouth' patient, thromboembolic risk assessment, ECG
   - Interpret monitoring of vital signs, full blood count, coagulation screen, renal function tests, chest X-ray
   - Indications for laryngeal mask, tracheal intubation, cricothyroidotomy, tracheostomy, rapid sequence induction, awake intubation, central venous cannulation, echocardiogram, pulmonary function tests/spirometry, arterial pressure monitoring, catheterisation for urine output monitoring, BIS (bispectral index monitoring for awareness), ultrasound-guided regional anaesthesia
   - Management of airway of a breathing and apnoeic patient, massive blood transfusion, anaphylaxis, aspiration pneumonia, perioperative thromboembolic risk, perioperative diabetes mellitus, perioperative fluid and electrolyte balance, perioperative nutrition
   - Awareness of advanced airway issues (such as aspiration risk, failed intubation, bronchospasm, laryngospasm), malignant hyperpyrexia, intraoperative myocardial ischaemia, patient undergoing a high-risk anaesthetic
   - Explain to a patient: general anaesthetic, regional anaesthetic, awake intubation
   - Awareness of WHO preoperative checklists
   - Role of surgeon, anaesthetist and anaesthetic technician
   - Complications of oropharyngeal airway, nasopharyngeal airway, laryngeal mask airway, tracheal intubation, central line insertion, general anaesthesia, spinal anaesthesia, epidural catheter, other regional anaesthesia
   - Insert a peripheral venous catheter
   - Awareness of commonly used sites for central venous access
Personal and Professional Skills 
   - Awareness of power dynamics regarding an older person in hospital
   - Effectively communicate to provide information about anaesthesia and to obtain consent
   - Demonstrate empathic and compassionate approach regarding pre-operative anxiety
   - Reflect on the mind-body link between pre-operative anxiety and post-operative recovery
Hauora Māori 
   - Inequities by ethnicity in adverse events during hospitalisation
   - Appropriate engagement and consultation with whānau
   - Awareness of differing disease risk profiles for Māori (and other disadvantaged populations) compared with non-Māori in New Zealand
   - Cater for differential health literacy needs of Māori patients and whānau
   - Understand inequities in access to health services, quality of medical care and health outcomes for Māori (and other disadvantaged populations) compared with non-Māori in NZ
   - Acknowledge the disproportionate impact of illness on whānau employment/income and therefore availability and models of caregiving
   - Consider access to cultural/spiritual support for patient and whānau
Population Health 
   - Epidemiology in New Zealand of malignant hyperpyrexia
Conditions to be considered relating to this scenario
Common
aspiration pneumonia, airway management failure, damaged teeth, airway trauma, diabetes mellitus, deep vein thrombosis
Less common but 'important not to miss'
malignant hyperpyrexia, anaphylaxis, pulmonary embolism