Thanks to everyone who contributed to the discussions about Molly Adams, a 32 year old woman who had ulcerative colitis, and who we were assessing peri-operatively. We also had some interesting debates on the place of protocols in healthcare.
You can see the highlights of the discussion on Twitter in the storify.
This week’s question setter was Dr Gautam Kumar, Anaesthetic Registrar, UCLH. Our expert was Dr David Walker, ITU and Anaesthetic Consultant, UCLH.
Information available at the start of the week:
Molly Adams, a 32 year-old woman, is seen in colorectal surgery clinic. She has been referred by the gastroenterologists for consideration of surgery. She has a history of ulcerative colitis which is active and severely debilitating, causing frequent episodes of abdominal pain and bloody diarrhoea. In addition, she constantly suffers with fatigue and tenesmus.
You are part of the anaesthetic team and want to optimise her pre- peri- and post-operative care.
Question 1: What further information do you want from the history to help you plan Mrs Adams’ pre-operative care?
Further information released during the week:
Mrs Adams has no other systemic manifestations of ulcerative colitis and no other past medical history. She is being treated with mesalazine and a TNF-inhibitor. She smokes 10 cigarettes a day and drinks alcohol rarely.
Blood tests show: Hb 90 g/L, WCC 4.3×10 9/L, Plts 230×10 9/L, Urea 4.7mmol/L, Creatinine 72μmol/L.
The surgeon and patient decide that she is an appropriate candidate for a total colectomy and she is listed for surgery in 4 weeks time.
Further questions discussed on Twitter:
Question 2: How would you manage Mrs Adams preoperatively up until the day of surgery?
Question 3. How can you help her recover as quickly as possible post-op?
Question 4. Are protocols necessary in healthcare?
- Preoperative investigation guidelines exist in order to ensure patient optimisation for surgery whilst avoiding added expense and time-wasting by unnecessary testing.
- It is important to diagnose and appropriately treat preoperative anaemia as this will reduce post-operative morbidity and mortality and reduce the need for intra-operative blood transfusion.
- Smoking cessation reduces cardiovascular and respiratory complications. Smokers should ideally stop at least 4 weeks pre-op but ciliary function improves and carbon monoxide levels reduce after 12hrs.
- Enhanced recovery, often referred to as rapid recovery, is a new, evidence-based model of care that creates fitter patients who recover faster from major surgery. It is the modern way for treating patients where day surgery is not appropriate
Background to the importance of managing patients well peri-operatively
- NCEPOD report into peri-operative care of surgical patients 2011 including data comparing UK and USA peri-operative mortality rates http://www.ncepod.org.uk/2011report2/downloads/POC_fullreport.pdf
- A useful site collating risk prediction scores and allowing risk to be estimated for individual patients (includes POSSUM and other validated scores) http://riskprediction.org.uk/
- Royal College of Surgeons, England guidance on improving the care of high risk surgical patients http://www.rcseng.ac.uk/publications/docs/higher-risk-surgical-patient/
- An overview of pre-op guidelines and management http://emedicine.medscape.com/article/1127055-overview
- A brief summary of pre–operatively care of the surgical patient http://www.surgwiki.com/wiki/Pre-operative_management
Making decisions about pre-op investigations and treatment
- NICE guidelines on preoperative investigation: http://publications.nice.org.uk/preoperative-tests-cg3
- Management of anaemia: why? http://www.ncbi.nlm.nih.gov/pubmed/21982521and how? http://www.transfusionguidelines.org.uk/docs/pdfs/rtc-scent_pre_op_guidelines.pdf
- Pre-op counselling improves satisfaction http://www.ncbi.nlm.nih.gov/pubmed/16534340 and outcomes http://www.ncbi.nlm.nih.gov/pubmed/19735761
- The importance of smoking cessation, peri-operatively, from Public Health England: http://www.lho.org.uk/viewResource.aspx?id=9776
- A brief tutorial written by an anaesthesiologist on smoking and perioperative care – including 3 sets of T/F questions to test your knowledge! http://www.frca.co.uk/Documents/221%20Smoking%20and%20Anaesthesia.pdf
- A background to enhanced recovery programmes by NHS Improvement http://www.improvement.nhs.uk/documents/er_better_journey.pdf
- Guidelines on enhanced recovery programmes from the Royal College of Anaesthetists http://www.rcoa.ac.uk/node/5994
Dr Gautam Kumar, Anaesthetic Registrar, UCLH, and Dr David Walker, ITU and Anaesthetic Consultant, UCLH, say:
Preparing a patient for anaesthesia requires an understanding of the patient’s pre-operative status, the nature of the surgery and the anaesthetic techniques required for surgery, as well as the risks that a particular patient may face during this time. Patients often have co-morbidities that require careful assessment and co-ordination.
Preparation for surgery may take weeks to achieve, and could therefore potentially cause delay and cancellation of surgery if not done adequately. Pre-operative anaesthetic assessment services decrease cancellations on the day of surgery, improve the patient’s experience of their hospital admission, and may reduce complication rates and mortality. New national NICE guidelines have recently been released in order to standardise and stratify pre-operative investigations.
Protocols and evidence-based guidelines are becoming an important and indispensable part of quality healthcare because of their potential to improve quality and reduce cost of health-care. Effective communication and a team approach are vital in the pre-operative period. Complications and malpractice lawsuits are often attributable to poor preparation and failures in communication. Essential team members include anaesthetists, surgeons, physicians and general practitioners. Specialist anaesthetic pre-operative assessment nurses have been shown to be safe and effective at pre-operative screening and should be an integral part of the team.
Specific co-morbidities picked-up and treated in pre-assessment should be addressed in order to improve a patient’s peri-operative outcome. For example, preoperative anaemia, even to a mild degree, is independently associated with an increased risk of 30-day morbidity and mortality in patients undergoing major non-cardiac surgery. In this case, given the absence of any other history, Mrs Adams’ anaemia is most likely attributed to her bleeding and ulcerative colitis. Knowing whether the anaemia was microcytic would aid in the diagnosis. Active smoking has been shown to be a factor which increases peri-operative complications. The most noteworthy complications are those related to cardiovascular and respiratory events and wound healing. Information on these risks should be given in the preoperative visit with the patient. Preoperative abstinence must be strongly recommended because it has been shown to reduce postoperative morbidity. Doctors and nurses involved in preoperative patient management have a great opportunity to help patients to quit smoking permanently. For this case, it is entirely reasonable to postpone the procedure for 6-8 weeks provided that the patient is committed to stopping smoking. The patient’s GP is integral in this process as they will be able to link them in to treatment therapies and programmes. If the primary condition required more urgent surgery (e.g. cancer), then the risk of disease progression by postponing surgery has to be considered.
Overall, this patient is young and relatively fit and healthy. She is ideal to undergo treatment following an enhanced-recovery programme in order to reduce her length of post-operative stay. Different interventions of the programme are based on varying levels of evidence but placed together can reduce morbidity and post-operative complications. Some of these interventions include:
- Preoperative: Same-day admission, no bowel-prep, reduced starvation and carbohydrate loading, DVT prophylaxis day before procedure
- Intraoperative: Minimally invasive surgery, no NG tubes, use an epidural, optimise fluid therapy.
- Postoperative: Planned mobilisation, remove catheters early, manage pain but avoid opiates if possible, no wound drains, therapy support (stoma and physio.)
* some hospitals are still using g/dL as units for Haemoglobin in which case the result would be 9.0 g/dL