What information is relevant to the 'pre-med' visit ? And what information will actually help you plan your case and affect your management ? The plan is not to replicate the full clerking etc but to guide you to the essentials for your work.
Remembering the 'pre-med' visit is a crucial time for assessment and learning for you and the patient. It forms the basis of your planning with the consultant. It also is a great reassurance to the patient and family who will likely never have heard of our department.
Cardiac Pre-assessment
The Basics !
- Age
- Baseline HR, BP, Saturations on ____ O2, Hx of AF.
- General anaesthetic and airways assessment
- Specific cardiac history
- Chest pain history
- SOB
- Orthopnoea
- Ankle swelling
- Exercise tolerance on the flat and on an incline (usually ask how far they can walk on the flat without getting SOB/CP and how may flights of stairs can they manage)
- Smoker/Ex-smoker
All patients will likely have had:
- An ECHO - record the results particularly LV function, valvular abnormalities and EF
- Angio results
- Pulmonary function tests
- Carotid Doppler results
- ECG
- CXR / CT
- Bloods- check they have been G+S and that no antibodies present - If they are present please discuss with blood bank that blood is available.
- Record pre-op drugs and allergies
Planning:
Patients can have all their medication but it is wise to avoid ACEi and anti-platelets on day of surgery. If clopidogrel has been continued pre-op, please discuss with the cardiothoracic team that platelets are available post-op.
Inform the patient that:
- They will have 2 drips and an arterial line inserted awake under local anaesthetic.
- They will then be gently drifted off to sleep and have an ETT inserted which will remain post-op when they are transferred to CICU asleep.
- They will be warmed up, their pain controlled and they will slowly be woken up with the ETT in-situ. Once the nursing staff are happy with their breathing and they are fully awake the ETT will be taken out. They may well have a sore throat afterwards.
- Whilst they are asleep they will have a line in the neck (CVP) and if they have renal impairment it is likely they will have a vascath post-induction.
- Warn them of a risk of bruising, bleeding, small risk of nerve damage and pneumothorax.
- Explain they will already have chest drains in that will rectify the issue should they get a pneumothorax.
Address and answer their questions and concerns
Consider a pre-med ( and have look at the consultant preference sheet )