SCE: Preparing the elderly for OT
A common SCE scenario: The elderly patient with multiple medical
problems, who needs to go to theatre semi-urgently e.g. for an acute
abdomen. “How are you going to prepare this patient for theatre ?”
One possible approach:
Global opening statement: e.g. “This patient has multiple active
problems, which need to be addressed immediately”.
Brief statement to cover triage / monitoring etc., without wasting time by
lapsing into “Emerg-speak” e.g. “I’d confirm that he was in a safe place,
on supplemental O2 and fully monitored”.
Likely problems which may be presented to you:
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A set of lousy ABGs e.g. severe COAD.
 /  K+.
 /  Na+.
 /  BSL.
Coagulopathy -DIC.
-Warfarin.
Renal failure.
Fluid deficit.
MI / cardiogenic shock.
Arrhythmia.
Going through your preparation for theatre:
A good way is to go system by system, thinking for each system in terms
of likely pathology, investigations and interventions.
e.g.
SYSTEM
PATHOLOGY
INVESTIGATIONS
INTERVENTIONS
CVS
Hypotension
MI / LVF
Arrhythmia
Dehydration
ECG
FBC / U&E
Cardiac enzymes
Gp. & hold
IV access
Fluids
Inotropes
CVL / IDC
Resp
COAD
Pneumonia
PE
 GCS
Perf’ed viscus
Ileus
Gastric dilat’n
Warfarin Rx
DIC
Renal failure
ABG
CXR
O2
Bronchodilators
Antibiotics
CNS
G-I
Haem
G-U
Metabolic / E-lytes
/ BSL
NGT
Antibiotics
Coags
MSU
Urine Na+ (?)
Urinary ketones
ABG
Blood products
Warfarin reversal
IDC / Supra-pubic
Correction
(How fast ?)
(How much ?)
Anticipate specific questions like:
 “Tell me about your fluid management”.
 “Would you reverse the anticoagulation, and if so then how ?”
 “What are your aims regarding BSL control in this hyperglycaemic
patient leading up to and during his operation ?”
 “What antibiotics would you use ?”
 “What inotrope would you use ?”
Other important points:
 Try to demonstrate that you are anticipating and actively looking for
specific problems.
 Remember that CVL and IDC go together in the same sentence, just
like ETT and NGT (i.e. if you put in a CVL, make sure that you put in
an IDC with an hourly-measures bag).
 You may be asked to consider the issue of consent e.g. in the confused
elderly patient.
 When treating with antibiotics, say which ABs and why.
 Have alternative antibiotic choices ready; the most likely problem will
be Penicillin allergy. (e.g. Vancomycin in G-I sepsis, to cover
Enterococcus faecalis if Amoxycillin-allergic)
 Remember to discuss with other people: - Surgeons.
- Anaesthetists.
-  ICU.
- Family.
-  GP.
 Notify other people EARLY.
 Don’t forget analgesia !
 Order set-ups early e.g. CVL, IDC etc.