Preoperative assessment in patients presenting for elective surgery

Preoperative assessment of patients undergoing elective surgery is vital to ensure patients have underlying comorbidities identified, appropriate investigations performed and are optimized prior to the day of surgery. Anaesthetic pre-assessment is usually initiated at the pre-assessment clinic. A thorough assessment should include a careful history and examination as well as assessment of both the airway and functional capacity. This article provides a systematic approach to the assessment process.     

Day of surgery cancellations after nurse-led pre-assessment in an elective surgical centre: the first 2 years

We describe a nurse-led pre-assessment system at an elective surgical centre. A targeted referral system was used by trained nurses to direct referrals to a supervising consultant anaesthetist or to the surgical team. Of 2726 patients pre-assessed in the first 2 years, 105 patients (3.9%) were cancelled or postponed for medical optimisation after pre-assessment. There were 137 cancellations (5.0%) on the day of surgery, despite pre-assessment, but only 36 were for anaesthetic or medical reasons. Only eight of these 36 were considered a 'failure' of the pre-assessment system. These results are much better than the cancellation rate of about 11% in the Trust as a whole. There were 18 transfers of patients postoperatively from the elective centre to another hospital. A review suggested that four of these transfers could have been reasonably predictable from the patients' medical history. We conclude that a pre-assessment clinic has an important role to play in minimizing cancellations on the day of surgery and also in reducing the number of patients transferred to other hospitals. This last conclusion has an important implication for the planning of systems in hospitals that perform only elective surgery.     

Comparison of the automated Dinamap blood pressure monitor with the mercury sphygmomanometer for detecting hypertension in the day case pre-assessment clinic

Patients will be rejected from surgery by nurse-led pre-assessment clinics and will need to be assessed by their general practitioners if their blood pressure is higher than a pre-determined value. We have assessed the accuracy of the Dinamap automatic blood pressure recorder compared with manual mercury sphygmomanometry for detecting pre-operative hypertension in the day case pre-assessment clinic under everyday conditions. Two hundred consecutive patients attending for day case surgery pre-assessment had their blood pressure measured using the automated and the manual methods. We found that the Dinamap over-read systolic blood pressure by a mean of 8.38 mmHg and under-read diastolic pressure by a mean of 1.68 mmHg when compared with manual readings. Of the patients 6.5% would have been inappropriately diagnosed as hypertensive using the Dinamap and thus potentially rejected from day surgery and inappropriately referred to their general practitioner.     

Urinary point-of-care test for smoking in the pre-operative assessment of patients undergoing elective plastic surgery.

Self-reported information about smoking habit and cigarette consumption can be inaccurate and subject to bias in the clinical setting. Accurate assessment of a given smoking history at point-of-care is valuable. We describe the use of a comprehensive smoking questionnaire and the use of a disposable biomarker test to verify and quantify the exposure to tobacco smoke. This point-of-care test (SmokeScreen) is a 6-min, easy-to-use urine test that measures nicotine and its breakdown products. One hundred consecutive patients attending plastic surgery pre-assessment clinic filled in the questionnaire and gave a consented urine sample. Qualitative and semi-quantitative assessment of tobacco consumption was observed by a simple sample colour change set against a standardised colorimetric chart for nicotine metabolite containing urine. The questionnaire self-reported smoking prevalence was 30% with 98% test specificity. The cotinine validated smoking prevalence was 54% with a 26% self-denial rate. Half the patients (n = 15) who admitted smoking on the questionnaire underreported the amount they smoked daily, as quantified by biochemical measurement. Objective biochemical assessment shows that 26% of self-reporting non-smokers via self-completed questionnaire studies are actual smokers attending this pre-assessment clinic. When patients did report smoking there was consistent underreporting of cigarette consumption.     

Preoperative assessment of patients for vascular surgery

Effective preoperative evaluation of patients undergoing major vascular surgery presents a significant multidisciplinary challenge. A focussed preoperative evaluation targeted to organ systems can help mitigate the combined effects of inherently high-risk surgical procedures undertaken in an increasingly comorbid patient population. Careful history and examination supported by appropriate investigations and specialist input remains the cornerstone of this process, with risk increasingly quantified by dedicated scoring systems. In addition, the role and evidence base for objective assessment of functional capacity continues to build with cardiopulmonary exercise testing (CPET) now widely employed in vascular pre-assessment across the UK. When employed in a timely manner, complete preoperative assessment allows more informed decision-making surrounding surgery, frank discussion of risk with the patient and effective utilization of critical care resources if required.     

The role of a multidisciplinary pre-assessment clinic in reducing mortality after complex orthopaedic surgery

INTRODUCTION

This paper describes an audit loop. The aim of this study was to audit the effect of a specialised preoperative anaesthetic assessment clinic after hip and knee arthroplasty and revision arthroplasty.

PATIENTS AND METHODS

We studied patients undergoing hip and knee surgery (arthroplasty and revision arthroplasty). We collected data concerning postoperative admissions to the high dependency unit (HDU), intensive care unit (ICU) and post-anaesthesia care unit (PACU) (planned and unplanned rates of admission, length of stay). We also noted mortality.In the first part of the study (April 2005 to March 2006) we studied 298 patients. All patients were assessed independently by an anaesthetist on the day of surgery. A multidisciplinary preoperative assessment clinic commenced in April 2006. After this date all patients were assessed preoperatively by a multidisciplinary anaesthetic lead team. In the second part of the study (May 2006 to April 2009) a further 1,147 arthroplasty patients were studied. Data were again collected regarding HDU, ICU, PACU and mortality, as noted above.

RESULTS

We found statistically significant (p=0.001) reductions in the admissions to PACU (22% down to 10%) and in mortality (6.1% down to 1.2%) after the introduction of the pre-assessment clinic. There was also a statistically significant (p=0.01) reduction in the HDU length of stay (2.1 days to 1.6 days), ICU un-planned admissions (1.3% to 0.4%) and the ICU length of stay (2.3 to 1.9 days). We estimated cost savings of nearly £50,000 in the second part of the study. This is based on the average decrease in HDU and ICU length of stay.

CONCLUSIONS

We recommend the use of a multidisciplinary pre-assessment clinic for complex orthopaedic surgery.     

'One-stop' inguinal hernia surgery--day-case referral, diagnosis and treatment

BACKGROUND: Patients with unilateral inguinal hernias are conventionally seen at an out-patient appointment before being placed on a waiting list for surgery. Many patients are also required to attend a pre-assessment clinic prior to admission. AIM: To establish whether patients fit for day surgery inguinal hernia repair could be assessed and treated at a single hospital appointment. PATIENTS AND METHODS: Patients referred with unilateral inguinal hernias were sent an information sheet and health questionnaire by post. General practitioners were asked to help patients complete the medical details. Patients suitable for day surgery were sent a single appointment for assessment and treatment by an open, tension-free Lichtenstein mesh repair. RESULTS: Ninety-eight patients were sent an appointment for 'one-stop' inguinal hernia treatment. Ninety-two patients (93.5%) underwent inguinal hernia repair and were discharged on the same day without complication. CONCLUSIONS: Patients with unilateral primary inguinal hernias who are under 70 years old and ASA grade I or II can been seen, assessed and treated on the same day. 'One-stop' inguinal hernia surgery reduces the number of patient visits to the hospital and could be expanded to incorporate many more hernia repairs and other day case procedures.     

Direct optometrist referral of cataract patients into a pilot 'one-stop' cataract surgery facility

OBJECTIVES: To determine the feasibility of a) direct optometrist referral of patients with cataract, and b) combined assessment with same day cataract surgery ('one stop' cataract surgery). METHODS: Evaluation of 169 patients referred directly by optometrists into a pilot 'one stop' cataract surgery facility. RESULTS: Of 169 referrals, 160 patients (94.7%) were given confirmed appointments for the 'one stop' cataract service and 9 patients (5.3%) were appointed conventionally. Of 160 patients attending the 'one stop' cataract service, 154 patients (96.3%) underwent cataract surgery at the same visit, in 4 patients (2.5%) cataract surgery was indicated but deferred and in 2 patients (1.3%) cataract surgery was not indicated. The referral was supplemented with information regarding the patient's medical history forwarded by the general practitioner for 3 patients (1.8%). There were no systemic or sight-threatening complications. 151 patients (98.1%) achieved a visual acuity of 6/12 or better at a mean of 31 days post-operatively. CONCLUSION: Optometrists can accurately predict the need for cataract surgery and refer directly into a pilot 'one stop' cataract surgery facility, without the need for general practitioner involvement. 'One stop' cataract surgery is feasible; benefits to the patient include the abolition of the need to visit the general practitioner for consultation and referral, and the hospital for pre-assessment.     

An assessment of the effectiveness of a pre-operative dental visit: an audit of the elective orthopaedic assessment clinic in relation to dental infection and joint arthroplasty

This paper outlines the audit that was conducted to gauge the efficiency of the Elective Pre-operative Assessment Clinic in the Department of Orthopaedics, Kilcreene Orthopaedic Hospital, Kilkenny, Ireland. The study was conducted in 1999 when 380 patients were seen. Of these, 328 were on the waiting list for joint replacement and 52 for other elective procedures. We found 204 patients fit for surgery on their first pre-assessment visit. Of the 328 patients awaiting joint replacement, 48 had dental caries or infected gums, and 28 were diagnosed with minor infective foci elsewhere in the body. These 76 patients had their operations postponed until the infection resolved. One hundred and twenty-four patients had co-morbid medical conditions for which they were referred to allied medical specialities for further opinion and/or treatment. These patients had their operations after the medical conditions were stabilised or treated. The study in question has proved that the Elective Pre-operative Assessment Clinic acts as an intermediary between the outpatient department where the patient’s name is added to the waiting list and the operation theatre by determining patient’s fitness for surgery. This fact is of primary importance as it aids in preventing possible and sometimes last-minute cancellations, thereby attesting to the effectiveness and efficiency of the pre-assessment clinic. The study results have initiated a number of improvements to our Elective Pre-operative Assessment Clinic policies, such as the introduction of a checklist card for patients on the waiting list for joint replacements. This checklist includes blood and radiological investigations, medical co-morbid conditions and points to rule out infective foci in the body.     

Principles of preoperative assessment and enhanced recovery optimization for thoracic anaesthesia

A comprehensive preoperative assessment is imperative for patients undergoing lung surgery, ideally by way of a multidisciplinary team approach. This not only allows for clinicians to risk stratify patients and gain informed consent, but also to explore avenues in optimizing patients prior to surgery and plan for the delivery of the most appropriate postoperative care. A tripartite risk assessment combining risks of operative mortality, perioperative adverse cardiac events and postoperative dyspnoea should be assessed and discussed with patients. Those patients who continue towards surgical management may then be optimized with patient education addressing nutritional status, smoking cessation and alcohol dependency as well as the management of anaemia and physiological prehabilitation. This article aims to review existing guidelines for preoperative assessment in thoracic surgery as well as the latest preoperative guidance for enhanced recovery specific to thoracic surgery.     

腹腔镜探查判断胆囊癌可切除性的临床意义

目的 初步评价腹腔镜探查在胆囊癌外科治疗中的应用价值.方法 自2007年1月至2010年3月在上海交大医学院附属新华医院普外科及第二军医大学东方肝胆外科医院腹腔镜科收治胆囊癌患者中,选择有手术切除可能的60例患者作为腹腔镜探查组,将同期符合相同条件行剖腹探查的192例胆囊癌患者作为对照组,比较两组手术切除率、腹腔广泛转移患者的手术时间及住院时间.计量资料采用t检验,计数资料采用x2检验.结果 腹腔镜探查组60例中27例患者的肝脏和(或)腹膜有肿瘤广泛转移,中止手术;33例转行剖腹探查,发现1例肝脏多处肿瘤转移、12例侵犯门静脉主干和(或)胰头、十二指肠,无手术切除可能,中止手术;其余20例中7例行胆囊癌姑息性切除,13例行胆囊癌根治性切除术.直接行剖腹探查组192例术中发现肝脏和(或)腹膜肿瘤广泛转移的82例及侵犯门脉主干和(或)胰头31例均中止手术,姑息性切除32例,根治性切除47例.两组手术切除率、腹腔广泛转移患者的手术时间及住院时间差异有统计学意义(x2=4.328,t=8.6501,t=5.8260;P＜0.05、P＜0.01、P＜0.01).结论 腹腔镜探查有助于手术决策的制定,减少不必要的非治疗性剖腹探查,能显著提高手术切除率,可以作为胆囊癌外科治疗中的常规操作.

Abstract：

Objective To evaluate the role of laparoscopic staging for the resectability of gallbladder cancer. Methods From Jan 2007 to Mar 2010,60 gallbladder cancer patients without of metastatic disease or main hepatic portal vessel invasion as assessed by preoperative imaging underwent staging laparoscopy for tumor resectability evaluation. Peritoneal and liver surface metastases were looked for and assessment of local spread was done if possible. Assessment was based on visual impression and biopsies were obtained routinely. T test and x2 test were used. Results At laparoscopy, 27 (45%) patients were found with disseminated disease on peritoneal cavity or the surface of liver, hence, senseless open surgery was avoided. The other 33 patients were converted to open laparotomy, among those 1 patient was found with disseminated metastasis in the liver and 12 patients with the invasion of main hepatic portal vessel,pancreatic head, duodenum did not undergo any further surgery. Finally 7 patients received surgical bypass procedure and 13 patients underwent radical resection. During the same period, 192 clinically diagnosed gallbladder cancer patients undergoing open laparotomy without laparoscopic pre-assessment served as control. Among those in control group 79 patients received radical or palliative resection. The resectability rate was significantly different between the two groups ( P ＜ 0. 05). Conclusion Staging laparoscopy in patients with gallbladder cancer is helpful in detecting liver and peritoneal metastases overlooked by preoperative imaging, avoiding unnecessary open explorations.     

普外科术后不良结局风险评估工具研究现状

普外科手术是最常见的手术之一,其术后不良结局主要集中在一部分高危患者。风险评估工具可以识别出这部分高危患者,为后续的临床干预和资源配置提供参考。目前存在多种评估工具,且具有各自的优缺点,充分了解这些工具是临床应用的前提。通过回顾目前一般常用评估工具、针对急诊普外患者的评估工具和机器学习方法在评估工具上的应用,阐明风险评估工具的基本特征、应用现状和发展趋势。     

Psychiatric assessment

Psychiatric disorders and behavioral disturbances may complicate the postsurgical outcome in patients and de novo psychiatric symptoms have been reported. In numerous, but not all epilepsy surgical centers, a psychiatric assessment is included as part of the presurgical evaluation of potential candidates for surgery. Affective disorders and psychosis are the most frequently reported postsurgical psychiatric disorders. There are no absolute psychiatric contraindications to surgery. Specific preexisting psychiatric conditions may need cautious consideration because there may be a risk of postsurgical psychiatric complications. Routine pre- and postsurgical psychiatric evaluations in patients undergoing epilepsy surgery are urgently needed. Clinicians involved in the care of surgical candidates should be aware of the possible psychiatric complications following surgery.     

衰弱与老年心脏手术关系的研究进展

衰弱是老年人多个生理系统储备功能减退,致机体易损性增加及维持自体稳态能力降低的一种老年综合征。近年来,众多研究已证实将衰弱作为老年心脏手术患者的术前评估可预测其术后再入院、不良心血管事件及死亡等不良预后。该文就衰弱的概念、衰弱与心脏手术的关系、老年心脏手术患者合并衰弱的评估及干预策略等进行系统综述,旨在为老年心脏手术患者的危险分层及围术期管理提供决策依据。     

Assessment of elective patients

This article outlines an approach to preoperative assessment of patients presenting for elective surgery. The main focus is on assessment of patients with cardiovascular disease undergoing non-cardiac surgery, with regard to risk assessment, preoperative investigations and perioperative management of cardiovascular medications. Assessment of patients with common respiratory diseases, including obstructive sleep apnoea, is also discussed. The current utility of cardiopulmonary exercise testing in risk assessment and perioperative care planning is summarized. Finally, use of brain natriuretic peptide as a biomarker in risk stratification is considered.     

Intraoperative margin assessment reduces reexcision rates in patients with ductal carcinoma in situ treated with breast-conserving surgery

BACKGROUND: Reported rates of reexcision for margin control after breast-conserving surgery for ductal carcinoma in situ (DCIS) range from 48% to 59%. The optimal technique for intraoperative margin assessment in patients with DCIS has yet to be defined. We sought to determine whether intraoperative multidisciplinary evaluation using gross tissue assessment and sectioned-specimen radiography reduces the need for reoperation for margin control in DCIS. METHODS: A prospectively compiled database was used to identify patients who had DCIS diagnosed by core needle biopsy and were treated with breast-conserving surgery at our institution between July 1999 and July 2002. All patients had intraoperative gross margin assessment and specimen radiography of both the whole and sliced specimen for calcifications. RESULTS: Four hundred two patients with DCIS were evaluated at our institution during the study period. Of these, 160 had excisional biopsy for diagnosis prior to referral, 92 had mastectomy as their initial procedure, 40 were seen for a second opinion only, and 1 patient refused surgery. The remaining 109 patients formed the study population. The median age was 55 years (range 34 to 81). The median pathologic size of DCIS was 1.2 cm (range 0.2 to 8.0 cm). Fifty-nine patients had positive (less than 1 mm) or close (less than 5 mm) margins on intraoperative assessment. Final pathology agreed with intraoperative assessment of a positive or close margin in 43 of the 59 patients (P = 0.00005). Seventy-five percent of those thought to have a positive or close margin at the time of surgery (n = 44) underwent intraoperative reexcision. Of the total 109 patients, 31 (34%) had an intraoperative reexcision that resulted in a change in margin status from positive on intraoperative evaluation to negative on final pathologic evaluation (P < 0.00001). A second procedure for margin control was necessary in only 24 patients (22%). The decision to excise additional tissue at the first surgery on the basis of intraoperative assessment resulted in significantly fewer second procedures for margin control (P = 0.029). CONCLUSIONS: In patients with DCIS, intraoperative margin assessment by gross pathological examination and sliced specimen radiography significantly affects intraoperative decision making, and excision of further tissue on the basis of intraoperative assessment results in a substantial decrease in second procedures for margin control.     

Intraoperative Touch Preparation Cytology for Margin Assessment in Breast-Conservation Surgery: Does It Work for Lobular Carcinoma?

Background Breast carcinoma is the most frequently diagnosed malignancy in women of the North America. The combination of breast-conservation surgery and radiotherapy has become a standard of treatment for most breast cancers. It is critical to obtain clear margins to minimize local recurrence. The literature suggests that intraoperative touch preparation cytology (IOTPC) can be useful in evaluation of margins. Invasive lobular carcinoma (ILC) accounts for 10% to 15% of all breast cancers. Obtaining clear margins in ILC can be more challenging. Literature shows the positive margin rate for ILC to be as high as 60%. This report describes our experience with IOTPC for margin assessment in ILC by a single surgeon at Beth Israel Medical Center. The purpose of this study is to determine whether IOTPC is reliable for ILC. Methods A prospective review of 73 patients who underwent breast-conservation surgery with the use of IOTPC for margin assessment at Beth Israel Medical Center was performed. Pathology revealed ILC in 12 of these patients (16.4%), who are the subjects of this study. The lumpectomy specimens were oriented by the surgeon intraoperatively and were submitted fresh to pathology for cytologic assessment. IOTPC consisted of touching the corresponding margin onto the glass slide. The principle of this technique is that if cancer cells are present, they will stick to the slide, whereas fat cells will not. Six slides were prepared for each lumpectomy specimen. Air-dried samples were stained immediately by the Diff-Quik method and examined under the microscope by a cytopathologist. Results Twelve patients with ILC underwent breast-conservation surgery with IOTPC for assessment of 72 margins. Ten patients had lobular carcinoma only, and the remaining two patients had a combination of lobular and ductal carcinoma. There was a correlation between IOTPC and final pathology in 60 of 72 margins, which accounted for 83.3% of the cases. IOTPC for assessment of margins in patients undergoing breast-conservation surgery for ILC has a sensitivity of 8.3%, specificity of 98.3%, positive predictive value of 50%, and negative predictive value of 84.3%. Conclusions On the basis of our experience, IOTPC is of limited value for intraoperative assessment of margins for ILC. Poster presentation at the Sixth Annual Meeting of the American Society of Breast Surgeons, March 16–20, 2005, Los Angeles, California.     

Preoperative assessment for cardiac surgery

Anaesthetic challenges in cardiac surgery are multifaceted. Since patients present with compromised cardiovascular reserve and multiple comorbidities, a thorough preoperative assessment and meticulous anaesthetic plan is essential. This targets anaesthetic history, physical examination and analysis of investigations, routine and specific to the cardiovascular system. Special models exist for risk stratification to aid perioperative planning, surgical decision making, benchmarking and quality assurance. This article provides an overview of history, examination and preoperative management of patients undergoing cardiac surgery. Scoring systems and practical investigations are reviewed.     

Preoperative assessment for cardiac surgery

Anaesthetic challenges in cardiac surgery are multifaceted. Since patients present with compromised cardiovascular reserve and multiple co-morbidities, a thorough preoperative assessment and meticulous anaesthetic plan is essential. This targets anaesthetic history, physical examination and analysis of investigations, routine and specific to the cardiovascular system. Special models exist for risk stratification to aid perioperative planning, surgical decision making, benchmarking and quality assurance. This article provides an overview of history, examination and preoperative management of patients undergoing cardiac surgery. Scoring systems and practical investigations are reviewed.     

应用衰弱评估预测老年病人围手术期风险研究进展

老年病人随着生理储备能力下降即自身衰弱程度加重,围手术期并发症的发生风险增高。当前的手术病人风险分级方法均无法准确的评估老年病人的生理储备能力,需要衰弱评估作为补充。现有的衰弱评估方法多来自国外,主要包括衰弱表型量表（FP）、5项改良衰弱指数量表（5-mFI）、衰弱筛查量表（the “FRAIL” scale）,每种方法各有其优点,如指标可量化、注重手术风险因素、适于快速筛查等,其中以5-mFI最适合应用于外科术前评估。但这些方法应用于外科术前评估时,又各有其不足,如需要工具辅助、项目定义不明确、未评估生活自理能力等。在未来的研究中,需要外科医生予以衰弱评估更多关注。