Perioperative Medicine: Risk, Optimisation and Complications
Risk assessment
Candidates must be able to stratify risk using clinical judgement plus tools: ASA physical status, functional capacity (metabolic equivalents), and procedure-specific risk. A patient who cannot climb two flights of stairs has poor functional capacity and warrants escalation. Know the difference between cardiac risk indices and the value of biomarkers (NT-proBNP, troponin) in selected patients.
Optimisation before theatre
Address anaemia (iron studies, treat before elective surgery), glycaemic control, smoking cessation, anticoagulation management (bridging is rarely needed for most agents), and medication review (ACE inhibitors, SGLT2 inhibitors, beta-blockers). The trap: assuming every cardiac patient needs a beta-blocker started perioperatively - starting one on the day of surgery increases stroke and mortality risk.
Common complications to name
Postoperative nausea and vomiting (risk factors: female, non-smoker, history of PONV/motion sickness, opioids, volatile anaesthesia), postoperative delirium (elderly, cognitive impairment, sensory deprivation), surgical site infection, venous thromboembolism, acute kidney injury, and perioperative myocardial injury. For each, know the prevention bundle and the first-line management.
Worked rule of thumb
Use the Apfel score for PONV prophylaxis: count the four risk factors; 0-1 give no prophylaxis, 2 give two agents, 3-4 give three or more, ideally from different classes (dexamethasone, ondansetron, droperidol, NK1 antagonist).
The recovery phase
Never forget handover: pain plan, fluids, oxygen, mobilisation, and clear escalation criteria. A structured handover is often the highest-yield mark in a long case.