Fourth Year

Anaesthesia
Clerkship
GUIDEBOOK
DEPARTMENT OF ANAESTHESIA

0
GUIDELINES FOR PREOPERATIVE INVESTIGATIONS FOR ELECTIVE SURGICAL
PROCEDURES

Step 1 What Grade of surgery is patient having?

Surg Age ECG FBC U&E

ery

Grad
e

1 Under No No No Minor:
16 E.g. Excision Skin Lesion/ breast lump,
drainage abscess, cystoscopy
1 16-49 No No No

1 Over YES No No
50s

2 Under No No No Intermediate:
16 E.g. hernia repair, excision varicose
veins, tonsillectomy, arthroscopy
2 16-49 No No No

2 Over YES No No
50s

3 Under No YES No Major:

16 E.g. Abdominal Hysterectomy, TURP,
thyroidectomy, lumbar discectomy
3 16-49 No YES No

3 Over YES YES YES

50s

4 Under No YES YES Major +:

16 E.g. Total Joint replacement, bowel
resection, lung operations, radical neck
4 16-49 No YES YES dissection
4 Over YES YES YES
50s

The above table forms the minimum preoperative investigations to be carried out in
all patients, including healthy patients (ASA I). Clotting studies, urinalysis, random

1
glucose and CXR are not indicated routinely unless deemed necessary on the basis
of history and/or clinical examination.

2
Step 2 Add additional investigations based on Co Morbid Conditions - In
addition to the above, preoperative tests are recommended in patients
with co-morbidities as listed below (all ages, all grades of surgery)

Cardiovascular Disease ASA grades 2, 3 and 4 ECG, U&E, FBC

e,g, hypertension, angina. Diuretic therapy

Respiratory Disease ASA 3/4 i.e. significantly CXR

limiting activity Consider pulmonary function tests.
ABG on Rm Air

Renal Disease- ASA grades 2,3,4 ECG, U&E, FBC

Diabetes -ASA grades 2,3,4 ECG, U&E, glucose

Liver Disease /bleeding LFTs, U&E, FBC, coagulation studies

diathesis/anticoagulant therapy

Anaemia of symptoms of/ FBC

Myelosuppression/malignancy

Lithium therapy, digoxin, antiepileptic drugs Drug level assays, U&E

Pregnancy possible based on history Pregnancy test

ASA 1 Normal Healthy Patient

ASA 2 Patient with mild systemic disease e.g. controlled angina,

hypertension or asthma where activity is not limited

ASA 3 Patient with severe systemic disease e.g. Unstable angina,

hypertension requiring multiple therapies, poorly controlled diabetic
with complications, respiratory disease that limits activity

ASA 4 Patients with severe systemic disease that is a constant threat to life

American Society of Anesthesiologists (ASA) Physical Status

Classification

3
 Acid Base Values

Low Normal High

pH 7.36 7.4 7.44

PaCO2 35 40 45

HCO3 22 24 26

Std HCO3 22 24 26

Base Excess -2 0 +3

Anion Gap 9 12 15

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Expected changes in Paco2 and [HCO3-] in Response to Acute and
Chronic Acid-Base Disturbances
Disturbances [HCO3-] versus Paco2

Acute respiratory HCO3-= 0.2 Paco2

acidosis

Acute respiratory HCO3-= 0.2 Paco2

alkalosis

Chronic respiratory HCO3-= 0.5 Paco2

acidosis

Metabolic acidosis Paco2= 1.3 HCO3-

Metabolic alkalosis Paco2= 0.75 HCO3-

change in value; [HCO3-], concentration of bicarbonate ion; Pco2, partial

pressure of carbon dioxide.
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Common Acid Base Disorders

Acute Respiratory Acidosis Chronic Respiratory Acidosis

CNS depression Chronic obstructive pulmonary

Nerves disease
Neuromuscular Junction Chronic bronchitis or emphysema
Muscle Interstitial fibrosis
Thoracic Cage Integrity Obesity with decreased alveolar
Airway Obstruction ventilation
Respiratory Alkalosis

Hypoxia-mediated hyperventilation
CNS-mediated hyperventilation
Pharmacologic
Septicemia
Pulmonary

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Common Acid Base Disorders
Metabolic Acidosis (Increased AG) Metabolic Acidosis (Normal AG)

Ketoacidosis : Diabetic, Alcohol, GI HCO3 Loss: Diarrhea, fistulas

Fasting Urologic Procedures: Ureteroileal

Lactic Acidosis: Shock, hypoxia, conduits
toxins Renal HCO3 Loss: Renal tubular
Renal Failure acidosis
Toxins Metabolized to Acids: Ingestions: Acetazolamide
Methanol, salicylates Parenteral Infusion: Aminoacids
Rhabdomyolysis Hypoaldosteronism
Hyperkalemia
Metabolic Alkalosis (Volume Contracted: Saline Responsive)

Vomiting/gastric suction
Diuretics
Colonic adenomas
Metabolic Alkalosis (Normal or Expanded Volume: Saline Resistant)

Hyperaldosteronism
Cushing's syndrome
Severe potassium depletion
Metabolic Alkalosis (Unclassified)

Milk-alkali syndrome
Carbenicillin therapy
Massive transfusion with citrate anticoagulant

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GUIDELINES ON HOW TO WRITE A CASE REPORT

Finding a suitable case:

This may be a rare or particularly difficult to manage disease state

Literature search

Collecting information related to the case, including consent if applicable.

Summarising and writing

How to write and present the Case Report

1. Introduction
2. Case reportthe real story
a. History
b. Clinical features
c. Investigations
d. Treatment and outcome
e. Progress
3. Discussion
a. review of literature
b. Arguments
c. Message
4. Recommendations, if any
5. References

Revising and editing

An example is provided with this email, ExampleOfCaseStudy