Perioperative Care, Anesthesia and Pain Management
Core concepts
Perioperative care covers risk assessment, optimization, fasting, prophylaxis, anesthesia choices, and pain management. Estimate cardiac and pulmonary risk using history, functional capacity, and surgery-specific risk; routine stress testing is not indicated for most stable patients. Follow evidence-based fasting: clear liquids up to two hours and light meals up to six hours before anesthesia in most elective cases. Provide VTE prophylaxis according to risk, normothermia, glucose control, and antimicrobial prophylaxis timed before incision. Enhanced recovery pathways reduce opioid use with multimodal analgesia, early feeding, and early mobilization. Recognize malignant hyperthermia and local anesthetic systemic toxicity. Multimodal pain care combines acetaminophen, NSAIDs when safe, regional blocks, and opioids only as needed.
Traps
Do not order unnecessary preoperative testing in asymptomatic patients. Do not assume every patient on steroids needs stress-dose steroids. Beta blockers should not be started abruptly on the day of surgery. Dual antiplatelet therapy requires a tailored plan, not routine stopping. Malignant hyperthermia requires dantrolene, not just cooling.
Worked example
A patient on chronic beta blockers undergoing elective surgery should continue them, but a beta blocker-naive patient should not start one on the morning of surgery solely for perioperative protection. Rule of thumb: continue chronic cardioprotective medications when safe, and avoid starting new high-risk medications on the day of surgery.