Preoperative Assessment

Preoperative Assessment

Anaesthetic Assessor: Dr Sarah Jenkins

Anaesthetic Assessor Grade: Consultant Anaesthetist

Patient Information

Medical record number: NHS 482 910 3847

Title: Mr

Patient name: Arthur Pendelton

Date of birth: 14/05/1956

Age: 68

Gender: Male

Surgery

Right total hip replacement (THR)

Reason for Surgery

Severe right hip osteoarthritis causing refractory pain and reduced mobility

Medical History

Essential hypertension, Type 2 diabetes mellitus, gastro-oesophageal reflux disease (GORD), and right knee arthroscopy (2015).

• Heart disease, including a pacemaker: no
• Previous myocardial infarction: no
• Hypertension: yes
• Angina: no
• Stroke: no
• Diabetes: yes (Type 2, diet and oral hypoglycaemic controlled)
• Epilepsy: no
• Jaundice: no
• GORD/hiatus hernia: yes
• Kidney disease: no
• Arthritis: yes
• Asthma: no
• Chronic respiratory disease: no
• Thyroid disease: no
• Sickle cell status: negative
• Pregnancy status: n/a

Current medications:

• amlodipine 5 mg PO OD
• ramipril 10 mg PO OD
• metformin 500 mg PO BID
• omeprazole 20 mg PO OD
• paracetamol 1,000 mg PO QID PRN
• No herbal products

Allergies: Penicillin (generalised maculopapular rash)

Disabilities/communication: Mild bilateral presbycusis; wears hearing aids, communicates well with aids in situ.

Issues with earlier anaesthetics: none

Social History

Ex-smoker (quit 20 years ago, 15 pack-year history). Alcohol: 4–6 units/week. Retired postal worker. Lives in a two-storey house with his wife, who is fit and well and able to support him postoperatively. Independent with ADLs.

Baseline Observations

• Pulse: 72 bpm, regular
• Temperature: 36.6 °C
• Conscious level: Alert
• Blood pressure: 136/82 mmHg
• ECG: Normal sinus rhythm, 72 bpm, normal axis, no ST-T wave changes
• Respiratory rate: 14 breaths per minute
• Oxygen saturation: 97% on air
• Weight: 88 kg
• Height: 1.76 m
• BMI: 28.4 kg/m2
• MRSA status: negative

National Early Warning Score (NEWS2) Assessment

Respiratory Rate (RR)

• 3 - ≤ 8
• 1 - 9-11
• 0 - 12-20
• 2 - 21-24
• 3 - ≥ 25

Scale 1: Oxygen Saturation (SpO2)

• 3 - ≤ 91%
• 2 - 92-93%
• 1 - 94-95%
• 0 - ≥ 96%

Scale 2: Oxygen Saturation (Sp02)

• 3 - ≤ 83%
• 2 - 84% - 85%
• 1 - 86% - 87%
• 0 - 88% - 92% or ≥ 93% on air
• 1 - 93% - 94% on Oxygen
• 2 - 95 - 96% on Oxygen
• 3 - ≥97% on Oxygen

Any Supplemental Oxygen

• 2 - Yes Oxygen
• 0 - No Air

Temperature (°C)

• 3 - ≤ 35.0
• 1 - 35.1-36.0
• 0 - 36.1-38.0
• 1 - 38.1-39.0
• 2 - ≥ 39.1

Systolic Blood Pressure (SBP)

• 3 - ≤ 90
• 2 - 91-100
• 1 - 101-110
• 0 - 111-219
• 3 - ≥ 220

Heart Rate (HR)

• 3 - ≤ 40
• 1 - 41-50
• 0 - 51-90
• 1 - 91-110
• 2 - 111-130
• 3 - ≥ 131

Level of Consciousness (AVPU)

• 0 - A (Alert) including normal confusion
• 3 - C (Confusion) New onset of confusion or worsening normal
• 3 - V (Voice)
• 3 - P (Pain)
• 3 - U (Unresponsive)

Total NEWS Score: 0

Baseline observations are within normal physiological limits with RR 14/min, SpO2 97% on air, HR 72 bpm, and BP 136/82 mmHg, yielding a total NEWS2 score of 0.

Family History

Father died of myocardial infarction aged 78; mother had Type 2 diabetes mellitus. No family history of malignant hyperthermia or suxamethonium apnoea.

Review of Systems

A: Patent, good mouth opening (> 3 finger breadths), thyromental distance > 6.5 cm, full cervical spine mobility, normal jaw flexion/protrusion, trachea central. B: Equal chest expansion, vesicular breath sounds bilaterally, no added sounds. C: HS I + II + 0, capillary refill < 2 seconds, no peripheral oedema. D: Alert, oriented, PEARL. E: Lumbar spine palpable landmarks (L2–L5) clear, no skin infection over back or right hip.

ASA II

Mallampati Class II

Own teeth, Crown on upper left molar (UL6), no loose teeth or dentures.

Cardiovascular: Nil chest pain, palpitations, orthopnoea, or PND. Respiratory: Nil cough, wheeze, or haemoptysis. GI: Acid reflux well controlled on omeprazole, nil dysphagia.

Sleeps on 2 pillows, no nocturnal breathlessness, comfortable lying flat on one pillow for 45 mins, mild SOB on climbing 1 flight of stairs, no SOB at rest; max walking distance 200 m (limited by right hip pain, not cardiorespiratory). STOP-BANG score: 3 (Snoring: No, Tired: No, Observed apnoea: No, Pressure: Yes, BMI > 35: No, Age > 50: Yes, Neck > 40 cm: No, Gender: Male) – Intermediate risk.

Laboratory and Diagnostic Tests

Pelvic X-ray (10/09/2024): Severe loss of joint space, subchondral sclerosis, and osteophytosis of the right hip. HbA1c: 52 mmol/mol.

Investigations - Blood Test Results: Routine preoperative bloods normal.

Date: 15/10/2024

Urea: 5.4 mmol/L

Creatinine: 84 µmol/L (eGFR > 60 mL/min/1.73m2)

Sickle: Negative

PTT: 29.5 s

INR: 1.0

FEV 1: 2.85 L (94% predicted)

FVC: 3.60 L (96% predicted)

K+: 4.3 mmol/L

Na+: 139 mmol/L

Cross-Match: Not required (Group & Save only)

Group & Save: O RhD Positive, antibody screen negative (2 valid samples confirmed)

PLT: 245 x 10^9/L

WCC: 6.8 x 10^9/L

Hb: 142 g/L

Technique Explained and Agreed

Subarachnoid (spinal) block using hyperbaric bupivacaine 0.5% with intrathecal diamorphine, combined with target-controlled infusion (TCI) propofol sedation. Backup plan for general anaesthesia (GA) discussed if spinal fails or is inadequate.

L3/L4 or L4/L5 interspace, sitting position.

Fascia iliaca compartment block (FICB) or local infiltration analgesia (LIA) by surgeon intraoperatively.

Oral multimodal analgesia postoperatively (PCA not routinely required following intrathecal diamorphine, but available as rescue).

Diclofenac suppository avoided due to age and concomitant ACE inhibitor use; regular IV/PO paracetamol and PRN oral opioids prescribed instead.

Level 0/1 Post-Anaesthesia Care Unit (PACU) recovery, stepping down to standard orthopaedic ward care.

Discussed common and serious risks: hypotension, nausea and vomiting (PONV), itching, urinary retention, post-dural puncture headache (PDPH), failure of block requiring conversion to GA, transient or permanent nerve damage, haematoma, infection, and dental damage (specifically noting UL6 crown).

Standard AAGBI monitoring (ECG, NIBP, SpO2, capnography). No invasive arterial or central venous monitoring required.

Admission and Plan

Admit to Surgical Day of Surgery Admission (DOSA) lounge on 24/10/2024 at 07:00 (first on morning list). Fasting instructions given: nil by mouth (no food/milk) from 02:00 on day of surgery; clear fluids (water only) permitted until 06:00. Medication instructions: OMIT ramipril and metformin on the morning of surgery. TAKE amlodipine and omeprazole as normal with a sip of water before 06:00. Monitor capillary blood glucose 2-hourly on admission.

DVT Prophylaxis: TEDS, intraoperative Flowtrons, and enoxaparin 40 mg SC postoperatively (plus 28 days extended prophylaxis as per orthopaedic protocol).

omeprazole 20 mg PO and paracetamol 1,000 mg PO on the morning of surgery.

Consent

Verbal consent obtained for spinal anaesthesia with sedation, fascia iliaca/local infiltration block, and backup general anaesthesia; patient information leaflet provided.

Other Information

Standard surgical site infection prophylaxis: teicoplanin 800 mg IV and gentamicin 240 mg IV at induction (as per trust penicillin-allergy orthopaedic guidelines).

Single-consultant case (Mr D. Patel, Consultant Orthopaedic Surgeon).

Bair Hugger forced-air warming device and fluid warmer.