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Preoperative anaemia  Search Site

A patient scheduled for primary elective total knee replacement is found to be anaemic, On this page 
with a haemoglobin level of 90 g/ litre.  
Preoperative anaemia 
a) What perioperative consequences may be associated with preoperative anaemia? (5 ­ ©2017 Dr Ciara Armstrong 
marks)  
b) What physiological adaptations occur to offset the effects of anaemia? (6 marks)   Post anaesthetic care unit 
c) Describe perioperative events that may worsen the effects of the anaemia. (4 marks)   ­ ©2013 Dr David Stephenson 
d) What further blood tests may help in the classification of this anaemia? (5 marks)  
Enhanced recovery 
Click for model answer by Dr Ciara Armstrong ­ ©2012 Dr Najmiah Ahmad 

a) Smoking and anaesthesia 
¥ Increased requirement for blood transfusion ­ ©2012 Dr Bronagh McKay 
¥ Increased mortality risk
¥ Increased risk of cardiac events Risk associated with anaesthesia 
¥ Increased risk of non-cardiac complications (Respiratory, Urinary, Wound, Septic, Thromboembolic) ­ ©2012 Dr Pamela Eakin 
¥ Increased length of hospital stay
Cardiopulmonary exercise testing 
b) ­ ©2012 Dr Neil McLoughlin
Increased O2 Extraction
¥ Increased extraction by kidneys/skeletal muscle/skin
¥ Reduced mixed venous oxygen saturation

Increase in Cardiac Output

¥ Reduced blood viscosity
¥ Reduced systemic vascular resistance
¥ Sympathetic Stimulation viachemoreceptors

Redistribution of Cardiac Output

¥ Cardiac Output redistributed to organs with high oxygen demand (e.g. Brain/heart)

Altered affinity of Hb for oxygen

¥ Right shift in oxygen dissociation curve due to increase in 2,3-DPG and Hydrogen ions
¥ Reduced affinity of Hd for oxygen favours release to issue at higher partial pressures

Intra-cellular Adaptations
¥ Erythopoietin
¥ Vascular endothelium growth factor
¥ Metabolic switch to anaerobic utilisation of glucose

c)
Factors reducing Oxygen delivery
¥ Reduced cardiac output secondary to hypovolaemia/cardiac depressing drugs
¥ Reduced oxygen saturations secondary to atelectasis, post-op pneumonia, thromboembolism
¥ Reduced Hb secondary to surgical blood loss or inhibition of erythropoiesis
¥ Increased affinity of Hb for oxygen secondary to hypothermia induced left shift in oxygen dissociation curve.

Factors Increasing Oxygen Requirements

¥ Pain
¥ Fever
¥ Shivering
¥ Stress response

Post anaesthetic care unit 

With regard to the 2013 AAGBI recovery/post anaesthetic care unit guidelines: 

(a) What suggestions are made for facilities and access for each PACU bedspace
contributing toward patient safety? 
(b) What staffing recommendations are made with regards to numbers and training? 
(c) What are the anaesthetist’s responsibilities before transferring a post­anaesthesia
patient to a recovery area? 
(d) What is the minimum information to be recorded for patients in the post anaesthesia
care unit? 
(e) What are the minimum criteria for discharge of patients from the PACU or recovery
area to ward­level care? 

Click for model answer by Dr David Stephenson

What suggestions are made for facilities and access for each PACU bedspace contributing toward patient safety?
Specific guidelines set out by DoH detail the layout of health buildings, and specify dimensions and layout within each
hospital area (including bed ratios, health and safety aspects, lighting etc.)
PACU itself should be in a position central within the theatre complex, with separate access to the wards
Each bed should have:
12 electrical sockets (6 each side)
1 oxygen pipeline outlet
1 medical air outlet
2 vacuum outlet
1 examination light
A push button emergency call system
Physiological monitoring system
Access to an occasional use anaesthetic machine with scavenging
Access to difficult airway equipment, capnography, nerve stimulation, drugs and resuscitation equipment etc. should be
immediately available

(b) What staffing recommendations are made with regards to numbers and training?
Numbers:
At least 2 staff must be present if patient in PACU (one must be registered practitioner)
At least one to one care until patient regained airway control / CVS & RS stability / and communicating
Anaesthetist supernumerary to theatre requirements must be immediately available for patients in the PACU
Should be a consultant anaesthetic lead for PACU
Training:
All staff should be appropriately trained in post anaesthesia care management
All staff should be up to date with standards, including resuscitation training, pain management etc.
There should be regular team rehearsal of common emergency scenarios
At least one member of staff with ALS should be present at all times
Staff should consider rotations within other critical care areas such as HDU / ICU

(c) What are the anaesthetist’s responsibilities before transferring a post-anaesthesia patient to a recovery area?
They must ensure they are satisfied that the PACU staff are competent to take responsibility for the patient
Formal hand over of care
Ensure safe transfer from theatre to PACU, including transfer of appropriate monitoring systems and resuscitation
equipment if appropriate

(d) What is the minimum information to be recorded for patients in the post anaesthesia care unit?
See list in AAGBI safety guideline, 2013: Immediate Post-anaesthesia Recovery:
Level of consciousness
Patency of airway
Respiratory rate and adequacy
Oxygen saturation and administration
CVS: BP, HR, Rhythm
Pain intensity on an agreed scale
Nausea and vomiting
Drugs administered; IV infusions
Core temperature
Other parameters depending on circumstances e.g. Urinary output, surgical drainage volume
ASA status
Surgical procedure performed
Anaesthetic type
Names of surgeon and anaesthetist

NPSA guidance: minimum dataset of:

Name (first and last)
DOB
NHS number
Time of admission and fitness of discharge
Time and destination of discharge

(e) What are the minimum criteria for discharge of patients from the PACU or recovery area to ward-level care?
Responsibility of anaesthetist
Should be well-defined criteria – which may allow delegation of discharge to trained staff
Patient fully conscious, with protective airway reflexes, and able to maintain own airway
Breathing and oxygenation are satisfactory
CVS stability, and no persistent bleeding
Pain and nausea controlled, with regimes in place
Temperature within acceptable limits
Oxygen therapy prescribed as appropriate
IV cannula should be present, and flushed
All drains and catheters checked
All health records should be complete and medical notes present

Enhanced recovery 

a) What are the potential benefits of an enhanced recovery (“fast­track”) programme for a
patient undergoing major abdominal surgery? (25%) 
b) List the preoperative (25%), intra­operative (25%) and postoperative goals (25%) that
aim to achieve “fast track” status. 

Click for model answer by Dr Najmiah Ahmad

a)
Improve patient’s satisfaction, better understanding, better motivation to get better quicker
Patients involvement, joint responsibility in his/her care
Patients optimised before the start of surgery, reduce waiting time
Patients are kept as physiologically normal as possible
Patients receive evidence based care
Reduce risk of paralytic ileus, faster bowel recovery, reduce immobilization, reduce risk of thromboembolic
complications.
Reduce surgical stress response
Reduced risk of anastomotic breakdown
Reduce length of hospital care, without compromising safety
Develop fewer complications/ hospital associated infection
Return to normal activity quicker
Improved relationship between primary care and hospitals trusts
Better multidisciplinary team dynamics
Reduce cost

b)
Preoperative
Patient’s understanding and motivation through education
Patient’s optimisation by the PCT, e.g correction of anaemia, hypertension, diabetes, smoking cessation and alcohol intake
advice
Avoids bowel preparations
Avoids prolonged fasting. Patients allowed minimum required period of fasting, liquid 2 hrs, solids 6 hours
Carbohydrate drinks
Avoids premedications

Intra-op
Regional anaesthesia e.g spinal/epidural, low concentration to reduce motor block for early mobilization.
Short acting anaesthetic agents, TIVA remifentanil, propofol. Avoid long lasting opioids
Avoid agents that can cause paralytic ileus e.g opioids
Goal directed therapy to reduce over hydration, using cardiac output monitor. NICE recommends oesophageal doppler.
Laparoscopic technique or other minimal access technique e.g mini laparotomy
Avoid use of wound drain/nasogastric tube
Temperature control
Glucose control
Risk stratification for PONV and aggressive prophylaxis and treatment
Thromboprophylaxis

Post-op
Dedicated ERAS ward with trained nurses, high level of interest in the program
Early iv fluids discontinuation
Early oral intake, enteral feeding
Early drains and urinary catheters removal
Early mobilization
Multimodal analgesia, opiod sparing e.g paracetamol and NSAIDS. Adjuncts GABAPENTIN and PREGABALIN .
Setting daily specific rehabilitation goals involving physiotherapist.
Well set up telephone follow up service
Audit

Smoking and anaesthesia 

(a) What physiological changes are induced by smoking? (25%) 
(b) What perioperative systemic effects are associated with smoking?(30%) 
(c) What is the time course of beneficial effects of smoking cessation?(30%) 
(d) Discuss potential disadvantages to stopping smoking prior to anaesthesia and surgery
(15%) 

Click for model answer by Dr Bronagh McKay

(a)
- Respiratory
Reduced O2 carriage due to carboxyhaemoglobin
Shifting of the ODC to the left
Irritable upper and lower airways
Reduced ciliary function
Decreased FEV1
Increased closing capacity

- Cardiovascular
Hypertension
Ischaemic heart disease
Hypercoagulation

- Gastrointestinal
Peptic ulceration
Gastro-oesophageal reflux disease
Anastomotic breakdown

(b)

- Airway and breathing

Irritable upper airways causing breath holding and laryngospasm
Bronchospasm
Increased closing capacity causing small airway collapse
Retained secretions and increased risk of post-operative chest infections due to impaired ciliary function
Increased shunt so patient more vulnerable to hypoxaemia
Potential risk of aspiration due to gastro-oesophageal reflux disease

- Cardiovascular
Ischaemic heart disease more likely and patient more likely to have perioperative myocardial ischaemia
Reduced myocardial O2 supply due to coronary artery disease and carboxyhaemoglobin
Increased risk of arterial and venous thrombosis due to hypercoaguable state- polycythaemia due to chronic hypoxia

- Miscellaneous
Reduced PONV
Induction of cytochrome P450 system and potential for drug interactions
Decreased O2 delivery to tissues and decreased immune function cause poor wound healing and risk of anastomotic
breakdown

(c)

Within 12 to 24 hours there is clearance of carbon monoxide and increase in physical work capacity of 10 to 20%
With 2 to 10 days airway reactivity improves
Within 1 month the risk of perioperative pulmonary complication
Within 5 to 6 months the risk of postoperative complications decreases
Over years the risk of COPD, lung cancer, stroke and ischaemic heart disease reduces

(d)

Anxiety
Withdrawal causing a state of less arousal
Some studies have suggested that the irritant effects of smoking may be beneficial in causing expectoration. Therefore
after smoking cessation there may be sputum retention until ciliary function recovers.
Smokers have less PONV than non-smokers due to smoking activating the vomiting centre

Risk associated with anaesthesia 

(a) What is risk? (10%) 
(b) What respiratory, cardiac and neurological risks are associated with anaesthesia?
(60%) 
(c) List the perioperative cardiac risk factors as defined by ACC/AHA (30%) 

Click for model answer by Dr Pamela Eakin

(a)

Risk - the potential for unwanted outcome

(b)

Respiratory:
- LRTI
- atelectasis
- aspiration
- post-operative respiratory depression
- laryngospasm
- bronchospasm
- endobronchial intubation
- tension pneumothorax
- volutrauma
- barotrauma
- negative pressure pulmonary oedema.

Cardiac:
- acute MI
- arrhythmias
- cardiac arrest
- hypotension

Neurological:
- post operative confusion
- CVA
- headache
- post operative cognitive dysfunction
- peripheral nerve damage
- meningitis (post neuroaxial block)

(c)

- Peri-operative cardiac risk factors:

Active Cardiac Conditions:

Unstable coronary syndromes
Decompensated heart failure
Significant arrhythmia
Severe valvular disease

- Major Risks:

History of heart disease

History of compensated or prior heart failure
History of cerebrovascular disease
Diabetes mellitus
Renal insufficiency

- Minor risk factors:

Age>70
abnormal ECG - LVH, LBBB, ST abnormalities
rhythm other than sinus
uncontrolled systemic hypertension

- Surgical factors

Vascular surgery (reported risk of cardiac death and non fatal MI >5%) - aortic and major vascular surgery, peripheral
vascular surgery.
Intermediate risk - Cavity surgery, carotid endarterectomy, head and neck surgery, orthopaedic surgery prostate surgery
Low risk - endoscopic procedures, superficial surgery, cataract operations, ambulatory surgery

Functional capacity
<4 METS

Cardiopulmonary exercise testing 

A 70 year old man with ischaemic heart disease presents to pre­anaesthetic assessment
prior to a right hemicolectomy for colonic carcinoma. He is referred for cardiopulmonary
exercise testing. 

(a) What is cardiopulmonary exercise testing? Describe the process (40%) 
(b) What benefits does it confer with regards to anaesthetic preassessment? (40%) 
(c) What is the anaerobic threshold? (20%) 

Click for model answer by Dr Neil McLoughlin

(a)

- Cardiopulmonary exercise testing (CPET) is a functional assessment of cardiopulmonary reserve. It has been used in the
assessment of elite athletes and for the diagnosis of dyspnoea for which it is now recognised as the gold standard. The
results of CPET can help to assess an individual’s risk of perioperative morbidity and mortality and plan their
postoperative care including critical care bed allocation.

- CPET is carried out as an outpatient procedure.

- The patient sits on a bicycle ergometer or walks on a treadmill and is connected to a 12 lead ECG, blood pressure cuff
and pulse oximeter.
- Inspired and expired gases are sampled by a metabolic cart via a mouthpiece or facemask, allowing oxygen consumption
and carbon dioxide excretion to be measured.
- The patient then begins pedalling on the bicycle whilst the resistance gradually increases, or walking on the treadmill
whilst speed and gradient gradually increase.
- The test lasts around 13 minutes, although a total of approximately 25 minutes is needed to allow setup of the test
including connecting the monitoring.

CPET measures three ventilatory variables:

- Oxygen consumption
- Carbon dioxide excretion
- Minute ventilation

(b)

- A report by the Improving Surgical Outcomes Group recognised that tests currently used for the pre-operative evaluation
of patients are expensive and poor at predicting actual risk.
- Many clinicians are able to quote average mortality and morbidity figures for individual procedures, but it is important
that these risks are individualised to patients to make assessment of risk more accurate.
- The results of CPET are not only useful for assessing risk but can also guide peri-operative care.
- Patients can be more appropriately triaged to peri-operative interventions, avoiding unnecessary use of critical care
resources whilst increasing critical care surveillance where appropriate.
- Pre-operative interventions include outpatient exercise, nutritional support and drug therapy.
- It is likely that risk assessments that include CPET results can guide the use of neoadjuvant chemotherapy and
radiotherapy and optimise the timing of surgery.
- Demand for level 2 and 3 critical care facilities can be anticipated weeks in advance of admission, allowing hospitals to
plan patient flow and the allocation of personnel throughout the week.

(c)

- The anaerobic threshold is the point at which aerobic metabolism is no longer adequate and anaerobic supplementation
begins.
- After the anaerobic threshold had been reached, aerobic metabolism does not cease, but anaerobic metabolism
supplements aerobic production of ATP as the work rate increases.
- AT is a marker of the combined efficiency of the lungs, heart and circulation. With increasing exercise, oxygen demand
will begin to exceed supply. Most patients will be able to pass their AT as it is normally reached about halfway through a
CPET.
- Peak VO2 represents the maximum VO2 that is measured, usually at the point that exercise is terminated.
- The AT however will not vary with patient motivation and therefore provides a reliable, repeatable, patient-specific
measurement of dynamic functional capacity.
- AT does not vary greatly with age, but will be reduced in proportion to the degree of organ impairment.

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