Patient Checklist

The process of going for surgery depends on a patient’s country of origin. In the UK’s National Health Service a family doctor (General practitioner, GP) will act as the “gatekeeper”, only referring patients to a specialist if they think the condition merits it or on the insistence of a patient. Primary care can help optimize patients’ fitness before surgery by offering advice on smoking cessation, exercise and weight reduction, and by optimizing treatment of chronic conditions such as diabetes and anaemia. Private hospitals, if contacted directly, will put patients in touch with specialists but they will still usually require a letter from their own doctor especially if the costs are to be covered by health insurance.

Assuming the patient’s condition merits it, the process of preparation for surgery starts with the specialist taking a history and examining the patient. They should ensure the patient is fully informed about their proposed procedure and the interventions that will need to be undertaken. Every patient should be given sufficient information that they can understand their own individual risk and thus make an informed decision about whether to proceed to surgery.

The specialist’s examination and history is likely to focus on their specialty. A more detailed preoperative assessment (POA) will be obtained by either the patient’s family doctor, or a specially trained pre assessment nurse (PAC, pre assessment clinic) or the anesthesiologist (anaesthetist). The timing of this is usually a week before surgery is scheduled. At this time the patient may be tested for MRSA using skin swabs applied to the groin and in the nose. Occasionally it is on the day of surgery if the proposed procedure is relatively minor. A detailed description of the perioperative period and the role of the anaesthetist is available from here: http://www.aagbi.org/sites/default/files/preop2010.pdf accessed August 4, 14

Estimating risk

Examples of conditions that are important to identify in the pre-operative history are conditions that may have an adverse impact on the outcome of either surgery or anaesthesia. An almost universal scale of severity of comorbidity is the ASA status.

ASA Physical Status Classification System

Every patient’s level of risk will be estimated, usually by classifying him or her according to the system adopted by the American Society of Anesthesiologists for assessing preoperative physical status.

Every patient’s level of risk will be estimated, usually by classifying him or her according to the system adopted by the American Society of Anesthesiologists for assessing preoperative physical status.
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The higher the number awarded, the greater the chance of prolonged hospital stay or postoperative complications. Patients classified as ASA IV and above are not normally candidates for elective surgery, only emergency surgery. Healthy patients can be seen up to the day of surgery.

Examples of conditions that add to the classification numbers are: A previous history of heart failure, coronary artery disease, history of a myocardial infarction, poorly controlled hypertension, symptomatic irregularities of the heartbeat (make you breathless or feint), hormone disorders (low thyroid), respiratory problems (shortness of breath), anaemia and insulin dependent diabetes.

The range of a preoperative investigations and referrals depend on how well the patient is. If in good health, none is usually required. If the patient has a raised ASA classification and the proposed surgical procedure is major then they will be investigated to a greater degree. A combination of nine variables provide independent prognostic information:2

    • Age
    • Sex
    • Socioeconomic status
    • Aerobic fitness
    • Diagnosed ischaemic heart disease (myocardial infarction and angina)
    • Diagnosed heart failure
    • Diagnosed ischaemic brain disease (stroke and transient ischaemic attacks)
    • Diagnosed kidney failure
    • Diagnosed peripheral arterial disease
If the patient is found to have a previously unknown condition (like diabetes or profound anaemia), has a significant past medical history (blood clots or recent heart attack) or is on medication that may need to be modified due to surgery (anticoagulants), then it is likely that the patient will be referred to an appropriate specialist to determine the cause and extent of the problem before surgery can go ahead.

It is not just the patients current condition that is important, so too is the past medical history and that of the family, especially if untoward effects occurred as a result of anaesthesia (scoline apnea or malignant hyperthermia).

Most hospitals perform a preoperative history and examination based on simple checklists. Only if this system flags up a relevant condition does a more in-depth process begin. The patient may fill in the medical history checklist. This can be reviewed with the help of a doctor or nurse if the meaning is not clear. Googling “preoperative medical history checklist images” reveals examples of such checklists.

References

Medication History

Patients’ current list of medications is important as it provides further information about any concurrent illness. Some may interfere with anaesthetic and analgesic drugs. Unfortunately many patients taking over-the-counter medicines and herbal or nutritional remedies omit to mention them (Complementary and alternative drugs, CADs). They consider them not “strong enough” or “natural” and thus not relevant. Unfortunately this is a mistake that will have serious consequences for some individuals. In one study 49.8% of the population regularly used CADs.1

Herbal medications should be stopped at least 7 days before surgery, owing to the uncertainly over their actual contents and adverse effects on clotting. (Table 2)

Some prescribed medications may represent a problem for either surgery or anaesthesia. 2 Deciding to stop or continue them should only ever occur following discussion with your surgeon or anaesthetist as the consequence of stopping drugs inappropriately may be disastrous.

Common drugs that have been associated with withdrawal or rebound symptoms when discontinued preoperatively include selective serotonin reuptake inhibitors (SSRIs), beta-blockers, clonidine, statins, and corticosteroids.

In general, most non-steroidal anti-inflammatory drugs may be stopped at least 3 days before surgery as they may interfere with clotting. This is not always the case, for example if you have cardiac stents stopping aspirin may be dangerous.

ACE inhibitors (ramipril) and angiotensin receptor blockers may significantly intensify the hypotensive effects of anaesthesia. Careful consideration must be given to whether to continue them perioperatively or not.

Among psychotropic drugs, SSRIs, benzodiazepines and antipsychotics are generally safe to continue perioperatively but the anaesthetist should be made aware.

Table 2: Examples of Common Complementary and alternative drugs, (CADs) and Potential Clinical Effects 3 4

CAD
Possible effects
Aloe VeraDiarrhea and low blood sugar
Black cohosh Liver dysfunction
Chamomile Anticoagulation
EchinaceaAnticoagulation, hepatotoxicity, effectiveness of corticosteroids
Ephedra (Ma huang)Hypertension, palpitations, arrhythmias, tachycardia, enhanced sympathomimetic effects with MAOIs
FeverfewPlatelet inhibition, CNS stimulation (potential vasoactive agent interactions)
GarlicInhibited platelet aggregation, enhanced fibrinolysis activity
GingerInhibits thromboxane synthetase; bleeding
GingkoVasodilation of cerebral and peripheral arteries (increase in cerebral blood flow, resulting in an increase in intracranial pressure)
Platelet-activating factor is inhibited; increase in bleeding time
GinsengHypertension, CNS stimulation, possible ↑ in anesthetic requirements
KavaMay potentiate CNS depressant effects of barbiturates, benzodiazepines, and opioids
LicoriceCan cause sodium and water retention, edema, hypertension, hypokalemia
Saint John's WortMay cause hepatic enzyme inhibition and exaggerate CNS depressant effects of opioids and barbiturates

May decrease hepatic production of plasma cholinesterase and require reduced dosages of succinylcholine

May have exaggerated blood pressure responses to sympathomimetic drugs
ValerianCan potentiate sedative effects of benzodiazepines, barbiturates, and opioids
VohimbeMay increase anesthetic needs, cause tremors, increased skeletal muscle activity
Excessive doses can cause rapid pulse, high blood pressure, tingling sensations and dissociative states

References

    • 1. Lucenteforte E, Gallo E, Pugi A, Giommoni F, Paoletti A, Vietri M, et al. Complementary and Alternative Drugs Use among Preoperative Patients: A Cross-Sectional Study in Italy Evidence-Based Complementary and Alternative Medicine. Volume 2012 (2012), Article ID 527238. Accessed 29 October 14
    • 2. Whinney C. Perioperative medication management: General principles and practical applications. doi: 10.3949/ccjm.76.s4.20 Cleveland Clinic Journal of Medicine November 2009 vol. 76 Suppl 4 S126-S132
    • 3. Cupp MJ, Herbal Remedies: Adverse Effects and Drug Interactions. Am Fam Physician. 1999 Mar 1;59(5):1239-1244.
    • 4. Nutrition.gov http://www.nutrition.gov/dietary-supplements/herbal-supplements accessed 29 October 14

Fasting guidelines

Fasting guidelines may be controversial. Their purpose is to avoid either vomiting or passive regurgitation into the back of the mouth where the stomach contents may access the lungs and impair oxygen uptake. Conditions that increase this rare but avoidable risk include anxiety, ascites, esophageal surgery, narcotic use, pain, hiatus hernia, gastro esophageal reflux disease (GORD), bowel obstruction, diabetes, neurologic problems (seizures, head injury), pregnancy, recent dialysis and
a full stomach.

Fasting guidelines for adults and children
(Royal College of Nursing pre-operative fasting guidelines, 2005)

Adults
Pre-operative fasting in adults undergoing elective surgery – ‘the 2-6 rule’:

    • ‘2’ – Intake of water up to 2 h before induction of anaesthesia
    • ‘6’ – A minimum pre-operative fasting time of 6 h for food (solids, milk and milk-containing drinks)
    • The anaesthetic team should consider further interventIons for patients at higher risk of regurgitation and aspiration
Post-operative resumption of oral intake in healthy adults:
Patients should be encouraged to drink when ready, providing there are no contraindications.

Children
Pre-operative fasting in children undergoing elective surgery – ‘the 2-4-6 rule’:

    • ‘2’ – Intake of water and other clear fluid up to 2 h before induction of anaesthesia.
    • ‘4’ – Breast milk up to 4 h before
    • ‘6’ – Formula milk, cow’s milk or solids up to 6 h before
    • The anaesthetic team should consider further interventions for children at higher risk of regurgitation and aspiration.
Contents
Minimum Fasting Period
Clear liquids 2 hours
Breast milk4 hours
Infant formula 6 hours
Nonhuman milk 6 hours
Light meal6 hours

References

    • Royal College of Nursing pre-operative fasting guidelines, 2005

Diagnostic Testing

There is often controversy regarding the necessity of laboratory studies especially in health adults. Routine preoperative laboratory screening is not cost-effective or predictive of postoperative complications.

    • Electrocardiography: if older than 80; if older than 60 and surgical severity at ≥3; any cardiovascular disease; severe renal disease (drug abuse, hypertension, renal disease, circulatory disease, thyroid disease, diabetes, significant pulmonary disease), if there is a history of previously undiagnosed heart murmur, a history of moderate to severe sleep apnea, or chronic airway obstruction (may be at risk for right-sided heart strain)
    • Full blood count: if older than 60 and surgical severity ≥ grade 2; all adults if surgical severity ≥ grade 3; severe renal disease.
    • Urea, electrolytes and creatinine: if older than 60 and surgical severity ≥ grade 3; all adults if surgical severity grade 4; any renal disease; severe cardiovascular disease.
    • Pregnancy test for women who may be pregnant
    • Sickle-cell test on families with homozygous disease or heterozygous trait; ancestry that is African, Afro-Caribbean, Asian, Middle-Eastern, east Mediterranean
    • Chest X-ray: patients scheduled for critical care
Surgical severity (from NICE pre-operative testing)
Grade 1 examples:
Diagnostic endoscopy or laparoscopy, breast biopsy.
Grade 2 examples: Inguinal hernia, varicose veins, adenotonsillectomy, knee arthroscopy.
Grade 3 examples: Total abdominal hysterectomy, TURP, lumbar discectomy, thyroidectomy.
Grade 4 examples: Grade 4 examples: Total joint replacement, artery reconstruction, colonic resection; radical neck dissection.

Hospitals tailor their guidelines to the specialty they serve based on the above criteria. Recent tests within two months of surgery are sufficient.

Exceptions

    • Patients using diuretics or digitalis require a current (7 days) serum potassium level and blood glucose levels should be obtained on the day of surgery for medication dependent diabetics.
    • Patients who are on dialysis should have had serum chemistry, hemoglobin and hematocrit, BUN and creatinine, PT/INR and PTT since the last dialysis, and preferably on the day of surgery.
    • A full blood count (FBC) and biochemistry screen are helpful if a patient is receiving chemotherapy.
    • Routine pregnancy testing is routine for women of childbearing age even when using contraceptives

In addition, not all patients are candidates for surgery outside of the hospital, such as at a freestanding surgery center. Patients who have serious medical problems such as cardiac disease, severe respiratory problems, or bleeding disorders that are not adequately managed should have procedures done in the hospital setting.2

Patients are normally contacted prior to hospital admission with written instructions on how to prepare for the surgery. These include instructions on preoperative fasting, which medications to take or omit and skin preparation with chlorhexidine antiseptic. Information regarding length of hospital stay and sometimes anesthesia and postoperative care may also be available.

References

    • 1. National Institute for Clinical Excellence. Pre-operative tests, the use of routine pre-operative tests for elective surgery. London: NICE, 2003
    • 2. Warner MA, Shields SE, Chute CG. Major morbidity and mortality within one month of ambulatory surgery and anesthesia. JAMA. 1993;270:1437.

Anesthesia

Most hospitals employ theatre checklists before a patient leaves the ward, on arrival in theatre and after a patient is put to sleep. This safety checklist for office-based surgery is an example. 1 All places of surgery should have the same attention to detail.

Until relatively recently surgical procedures requiring general anaesthesia were almost always conducted in well-equipped hospital environments in the presence of trained nurses and doctors. In the UK small hospitals and clinics, including dental surgeries have been actively discouraged from undertaking procedures requiring the services of an anaesthetist. The primary motivation was patient safety and secondarily economies of scale when equipment purchases are being made. Across the Atlantic this process is in reverse. With the pressure of economics and the bureaucratic burden of hospital regulations there has been a trend to move towards an office based surgical service including procedures requiring general anaesthesia. Whilst licensing regulations may be less stringent in an office-based practice, it is important that patients receive the same level of medical expertise and contemporary technology that would be found in larger hospitals. However, more recent data have shown that care in ambulatory settings is comparable to hospitals and ambulatory surgery centers, especially when offices are accredited and their proceduralists are board-certified.2 There is a lack of state and federal oversight of office-based facilities. Increased regulation and standardization of care, such as the use of checklists and professional society guidelines, can help promote safer practices. 3 The demand for cosmetic surgery is considered one of the driving factors in the exponential growth of office-based anesthesia. 4

Both the American physician based and nurse based professional bodies for anesthesia have issued guidelines and check lists that are designed to enhance patient safety.

In addition SAMBA’s Office Based Anesthesia Committee explores the particular issues related to administering anesthesia in a physician’s office outside of a hospitals or surgery centers. 5

    • Is the office accredited for surgery and anesthesia?
    • Does the doctor have credentials to perform the surgery in a hospital or outpatient surgery center?
    • Will a qualified anesthesiologist or certified registered nurse anesthetist (supervised by an anesthesiologist or other qualified physician) give the anesthesia? (You should meet this person before your surgery, and she should remain with you until you wake up.)
    • Is the anesthesia equipment equivalent to that used in a hospital or ambulatory surgical facility?
    • Does the doctor have the necessary equipment and drugs to handle any emergencies?
    • Which hospital will you be admitted to if complications occur?
    • Will qualified and trained staff monitor your recovery?
    • Is the recovery area equipped similarly to one in a hospital or ambulatory surgery facility?
    • Will a physician decide if you are ready to be discharged? (A nurse could follow a doctor’s orders based on objective criteria.)
    • Is someone in the office certified in advanced cardiac life support (ACLS)?
    • If a child is having the surgery, is someone trained in pediatric life support? Are equipment and drugs specifically for children available?

Several Web sites provided by The American Association of Nurse Anesthetists and The American Society of Anesthesiologists, Association of Anaesthetists of Great Britain and Ireland, 7 The Royal College of Anaesthetists, 8 Australian & New Zealand College of Anaesthetists, 9 Canadian Anesthesiologists’ Society 10 and many others carry similar information. All these Web sites provide excellent educational information for the public as well as brochures that can be obtained for personal use.

References

General Information

The patient should carry the results of laboratory or X-ray investigations to the place of surgery on the day of surgery. Acute deterioration in health should be notified to the hospital (colds or flu) especially if symptoms develop after contact with ill friends or family.

Patients often complain about the long wait if they are subjected to one. Patients easily understand reasonable explanations regarding changes in operating list schedules due to equipment issues.

After Surgery

At the end of any surgical intervention the patients who have been sedated will be allowed to awaken by discontinuing the sedative drugs. This also applies to patients who have received a general anaesthetic. The effects of sedative and anaesthetic drugs wear off by simply discontinuing their administration to the patient. They are not usually reversed. Administering an antidote usually actively reverses muscle relaxants. Some anesthetists avoid giving the antidote as these drugs may produce colic and a dry mouth. If no antidote is to be given then the degree of residual muscle relaxation is tested for by means of a nerve stimulator before the patient is allowed to wake up.

During the surgery the patients airway is protected either by a small plastic tube placed just in the mouth (Guedel), a laryngeal mask airway (LMA) or a tube (Endotracheal tube or ET tube) placed in the trachea usually via the mouth but sometimes via the nose. The latter is usually placed with the help of muscle relaxants and is required when the surgery requires a patient’s chest to be ventilated mechanically. This tube is never removed before a patient can breath for himself or herself and is only removed by a trained anaesthetist or intensive care nurse. Extubation is commonly done in the operating theatre where the drugs and equipment are readily at hand should they be, rarely, required. Patients are transferred at this point to the recovery or post anaesthesia care ward (PACU).

Patients themselves often spit out other types of airway protection mentioned above. A slight sore throat may ensue for 24 hours. In the UK the point at which a patient asks for any pain relief is technically the point at which responsibility for the patient becomes the recovery nurse’s. However the anaesthetist should always be available in the hospital until all their patients have been discharged from the recovery ward or admitted to an intensive care ward. In certain of the United States the PACU is considered an intensive care ward and strict patient to staff ratios are, or should be, observed. The position of office based recovery areas is less well defined.

PACU

The PACU is where patients’ vital signs are observed and recorded postoperatively in the same manner as during the operation. Patients are also observed for nausea, pain, low body temperature, and adequacy of urine output and completeness of fluid or blood replenishment. Wounds are inspected for excess bleeding and thrombo-prophylaxis measures are implemented.

Medication can be given to minimize both pain and nausea. Patients should be made aware preoperatively of the possibility of both these side effects of anaesthesia. Alcohol tolerant individuals fair better than alcohol naive persons. Predicting the degree of postoperative pain that a patient should anticipate is impossible.

For example a patient having bilateral knee replacements by the same surgeon, performing the same technique one after the other on the same day may reveal one severely painful joint and one with no pain at all. If pain is severe, intravenous doses of strong painkillers (morphine) may be injected in small repeated doses after short intervals until the pain is brought rapidly under control. At the same time non-steroidal anti-inflammatory drugs may be commenced and intravenous paracetamol (acetaminophen, Tylenol) given.

This may involve other drugs such as clonidine and is called multi-modal analgesia. This multi-modal technique for postoperative pain relief is time consuming but effective and is less prone to induce nausea and vomiting. Patient will be returned to the ward once they are warm, clean, dry and comfortable. The average stay in PACU is approximately 45 minutes.

Pain relief on the ward may be achieved by a similar multi-modal method via the oral route or by intravenous painkillers administered via a CPU controlled syringe driver regulated by the patient on demand (PCA patient controlled analgesia). Most anaesthetists will review their patients on the ward at the end of an operating list and before going home. A resident doctor trained in advanced life support is usually on call for emergencies in good hospitals. Day case patients undergoing minor or even non-painful intermediate surgery will be discharged to the care of a responsible adult.

The use of dangerous machinery or vehicles of any type is forbidden. Patients who try to mislead staff and attempt to drive themselves home may be reported to police authorities immediately for driving under the influence of intoxicating substances otherwise the hospital may be held equally culpable in the event of an accident. 1 The American Society of Anesthesiologists’ (ASA) Practice Guidelines for Postanesthetic Care indicate that the following should be mandatory for all patients who have just received general anesthesia, regional anesthesia, or moderate or deep sedation: “As part of a recovery room discharge protocol, all patients should be required to have a responsible individual accompany them home,” to increase patient comfort and satisfaction and to reduce adverse outcomes. 2

A period of at least 24 hours with an accompanying adult is usually recommended for patients who have had an anaesthetic.

“Preoperative preparation of the patient is extremely important. This is the time when the patient can be properly prepared physically and emotionally for a planned procedure. Proper preparation of the patient scheduled to undergo a surgical procedure can optimize patient care, comfort, and satisfaction. During this time, any factors that may affect the risk of anesthesia or the proposed procedure can be identified, minimizing surgical delays, preventable cancellations, whilst reducing morbidity, and mortality.” 3

References

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