SU11.1-6 | Anaesthesia and Pain Management — Assignment

CLINICAL SCENARIO

Mr R, a 68-year-old retired teacher, is listed for an elective open right inguinal hernia repair. He has type 2 diabetes (on metformin), well-controlled hypertension, and takes aspirin and clopidogrel following a coronary stent eighteen months ago. He is an ex-smoker, walks half a kilometre to the shops without breathlessness, and lives with his wife. On examination his mouth opening reveals a Mallampati class III oropharyngeal view. He asks whether he can 'come in, have it done and go home the same day'.

1. Preoperative assessment and risk stratification

Conduct a structured preoperative assessment for Mr R. Assign and justify an ASA physical status grade. Explain what the Mallampati class III finding tells you (and explicitly state how it differs from the ASA grade). Identify the comorbidities that materially affect his risk.

Guidance: Make clear that ASA grades systemic disease while Mallampati predicts a difficult airway — the two must not be conflated.

2. Perioperative medication management

Set out a specific plan for each of his regular drugs — aspirin, clopidogrel, metformin and his antihypertensive — stating whether each is continued, withheld or bridged, and why. Highlight the bleeding-risk decision and who should be involved in it.

Guidance: The dual antiplatelet therapy after recent stenting is the central tension: balance stent-thrombosis risk against surgical bleeding, and name the need for cardiology/anaesthetic liaison.

3. Anaesthetic plan and airway considerations

Recommend an anaesthetic technique for this hernia repair (general, regional/spinal, or local infiltration) and justify it. If local infiltration is used, calculate a safe maximum dose of lignocaine for a 70 kg patient (plain and with adrenaline) and convert it to a volume of 1% solution. State how the Mallampati III finding influences your airway preparation.

Guidance: Show the arithmetic: plain lignocaine 3 mg/kg, with adrenaline 7 mg/kg; 1% = 10 mg/mL. Mention LAST and intralipid as the safety net.

4. Suitability for daycare surgery

Decide whether Mr R is suitable for same-day discharge. Apply the three groups of daycare selection criteria (patient fitness, procedure characteristics, social/geographic factors) to his specific situation, and state the discharge criteria he would need to meet before going home.

Guidance: Reach a clear yes/no/conditional decision and defend it against the criteria — do not leave it open-ended.

5. Post-operative pain plan and safety netting

Write a multimodal post-operative analgesia plan using the WHO ladder principle. Explain how pain should be assessed and reassessed, and describe the red-flag scenario in which escalating pain should trigger reassessment for a complication rather than simply more analgesia.

Guidance: Emphasise anticipate-and-prevent, regular multimodal dosing, and that disproportionate pain is a sign of bleeding/ischaemia/infection.