so after gathering all your information with an anesthetic assessment you find
a plethora of medical issues so what is your very next step so really your
very next step is can this patient's medical condition be improved so the first exercise
if it is yes then you refer to a specialist and facilitate optimization
but i want you now to think about some examples of optimizing a patient so first of all just in
your in your books i just want you to write down or tell your partners what would make you believe
that a patient with and you know whatever disease x disease is optimized or not and what would you
what would make you believe that the patient is not optimized or could or the patient's
disease could be improved so i just want you to take 30 seconds to have a quick chat about that
if a patient's disease will be optimized if they're on the medications that they should be
on you know beta blocker for atrial fibrillation or amiodarone or or if they're on the appropriate
amount of insulin and their endpoint markers the bsl's are normal absolutely right the other things
i think about then are has this patient seen a regular specialist and that's always a good
indication if someone hasn't seen a cardiologist or a specialist in years then i'm a bit concerned
that they might not be optimized plus they might be symptomatic if they're not optimized so what
would make you suspect that the patient's disease could be improved i guess as you say if they're
if they're symptomatic and and um showing signs of whatever their co-morbidity is like heart failure
if you thought someone was in heart failure with fluid overload you'd want to make sure that you
could improve their fluid status by um you know getting fruitimida or um referring hydrology for
an echocardiogram prior to the procedure fantastic and a lot of this will be a gut feeling right so
if you think that this patient is not quite right it's very fair for you to say look i don't think
this patient's optimized to your consultant and then proceed with you know how you think you'd
optimize so why don't we go through that uh a 60 year old male presents for an elected black
colleague he said he had a mild heart attack 12 months ago with no intervention hasn't seen
a cardiologist after his hospital admission and seems lost to follow up so he's on no meds very
good exercise tolerance but what could you or what would you do to optimize this patient so just take
30 seconds to talk out loud what you could do what medications you could specifically give or
any other management you could do before you would go ahead it's for an elective black colleague and
has a history of possibly a mild heart attack 12 months ago and hasn't seen a cardiologist
since and it's on no medications so things we can organize i guess to assess this patient would be
starting with an ecg a stress echo and a referral to cardiology to see if he needs to be
if any intervention needs to be done or it's absolutely perfect so this elective so i've got
lots of time for optimization so you'd probably just send them to their cardiologist for review
because you're not really sure what's going on and often these patients should be on some medications
as well now let's just alter that situation let's say it's an urgent operation let's say
it's in maybe a more urgent uh lap collie um because of ascending collagen or whatever it is
what would you what medications could you then potentially give given this operation just to make
it potentially safer for this patient if we could trial them on anti-platelets or if we had time
an angiogram i don't know yeah that's true and obviously because they're having surgery i
wouldn't want to do the antiplatelet straight away but then i'd to think about getting anti-platelets
straight away after the operation like say within that 24-48 hours based on how bad the surgery
bleeding risk is that absolutely is appropriate i may start aspirin straight away though so that
would that could be useful especially if it's a low bleed wrist surgery like a lap collie and
maybe if they you know in consultation with the cardiologist maybe i would start to be the blocker
again these aren't things that you'd necessarily do but as a junior being being able to pick this
up and just make a bit of a judgment call where you're you know offering value i think is a very
useful skill to have and i just want you to give you the confidence in this section to think about
how you could optimize these patients so that's what i've said you do a full workup if they're
elective review echo and your consider treatment regular follow-up and then if it's an urgent case
aspirin be the blocker make sure they've got good analgesia and then postoperatively do they
need to be on any other uh anti-platelets like clopidogrel and there's some new guidelines with
dual antiplatelet therapy from the accha which say that essentially everyone who's had even
a mild uh you know a a mild non-stemi should be on a dual anti-platelets for at least 12 months um
and again it's very much cardiology territory so for this next one uh asthma so this patient 20
year old female presents with rf wrist structure from a fall prior to the general anaesthetic
you auscultate and notice wheezing she reports well-controlled aspen normally what do you do
an rf is probably going to be an emergent case or possibly non-immersion but either way if it is
non-emergent and i've got time i'll consider doing further workups such as i guess lung function
tests but if it's not then we need to proceed quickly yes um or sub acutely um i'll make sure
i rule out an effective process if that's okay see what medication she's on for asthma normally
and then optimize the medicines essentially so whether that be her preventer optimize her
short acting things but that's good right why isn't so i like the fact i like the way
you're thinking so now imagine this patient is in your anaesthetic bay you've just seen
the patient you definitely have to go ahead with this rest fracture almost definitely
um and what can you do right there in the anaesthetic room before you go to theater
you've got like five minutes 10 minutes to do this what could you give her i would give
her some salbutamol that's exactly what i want you to give so i'd give a nebulized salbutamol
ipratropium bromide mix put it in the nebulizer hudson mass combination and then do that again
think about what this is as a junior register this is actually very simple skill to do but it
can be just really really useful for the patient but also show a lot of insight to your consultant
so you know find that wheezing patient and sort that out before they go in and just think how
bad it is if you didn't treat this the patient has bronchospasm on induction which is pretty common
in even you know non-asthmatics but if they're asthmatic uncontrolled with weeds and a smoker
you're almost guaranteed of bronchospasm which is definitely not a place you want to be in
and these days people aren't listening to lungs that much so you know it's just not a thing that's
uh i'm seeing a lot of my trainees do even my even my colleagues doing so again something you
can do really easily now this patient a 30 year old male presents for inguinal hernia repair
reports significant reflux today what can you do to mitigate the risk and that's right you
may have not heard of this um so it's sodium in citrate uh metacrime you could give to just
increase gastric emptying um ppis yep over days to you know over hours to days may may work as well
um and just for your own information uh the fact that someone gets reflux significant reflux most
synthesis would rarely postpone an operation that probably if you're significant and you could feel
liquid coming up they'd just do a rapid sequence induction and intubate instead of putting an lma
in but that's great that's the way i want you to think i want you to think what can i do right now
to solve this and whether it's a ppi or something fast tracking that's great um again just a few
more tools for you to do this with just know that there's not a lot of good evidence for this
but again again as a trainee i want you to have have an insight into this and then be able to
offer it to show that insight now that was the optimization stuff so you've done a history you've
seen some problems that you maybe not aren't so happy with and you realize the patient could be
better than what they are for this elective or this emergent operation and you can actually do
things any questions before you move on to the next section um just to click on here with the
wrapper sequence induction if someone has to be refluxed then they were when would you make all
that you would decide to wrap do rapid sequence induction would you assess if your treatment like
the um sodium citrate has worked or because that's what we would just in terms of in our group when
you would do a rapid seat not a lot of evidence for this so uh if it's reflux that means there's
an esophageal sphincter problem which you're not going to solve with sodium citrate anyway but i'm
going to decrease the acidity of it and that will happen pretty instantly instantly um so that's
how that will happen um some really good questions here someone said regional technique is an option
absolutely that that's that's absolutely an option with this as well if the patient wasn't anxious
and didn't need sedation yep if they needed sedation then i'd be less less i'm concerned
um would i use cricoid pressure with an rsi or not that's a whole other section cracker pressure has
no evidence of benefit but you'd want to offer that because it's still part of the culture
that you'd use cricoid for the rapid sequence i don't think there's ever ever really been any
good evidence for that so when do you go ahead with elective surgery it's when the patient's
comorbidities are stabled and well controlled or optimized and then you've got to think about this
next you