Surgery and Perioperative Care: Resuscitation, Timing and Complications
The Surgery and Perioperative Care domain tests resuscitation of the injured and acutely unwell patient, operative decision-making, and prevention of complications around surgery. Stems often hinge on timing - of fever, of antibiotics, of reoperation.
Core rules
- Primary survey ABCDE; hypotension after trauma is haemorrhagic until proven otherwise. Activate massive transfusion with balanced 1:1:1 components and give tranexamic acid within 3 hours of injury.
- Acute abdomen: repeated examination by the same clinician; pain out of proportion to findings suggests mesenteric ischaemia; free air under the diaphragm means perforation.
- Postoperative fever follows a timeline: days 1–2 atelectasis; 3–5 pneumonia and urinary infection; 5–7 wound and line infection; after 7 days collections, DVT and drug reactions ("wind, water, wound, walk, wonder").
- Wound healing: proliferation is driven by fibroblasts laying down type III collagen; vitamin C is required for hydroxylation and zinc for epithelialisation; diabetes, steroids and malnutrition impair healing.
- Preoperative risk: Revised Cardiac Risk Index (ischaemic heart disease, heart failure, cerebrovascular disease, insulin-treated diabetes, creatinine >2 mg/dL) plus functional capacity; ≥4 METs generally permits surgery without further cardiac testing.
- VTE prophylaxis by Caprini score, using LMWH plus mechanical methods in high-risk patients.
- Anaesthetic emergencies: malignant hyperthermia is treated with dantrolene and stopping the trigger; suxamethonium is avoided in major burns after 24 hours because of hyperkalaemia.
Worked example
A 24-year-old man is 6 hours after appendicectomy with HR 128, BP 92/60, urine output 10 mL/h and a distended abdomen. Postoperative tachycardia is not assumed to be pain. The differential is hypovolaemia, sepsis, haemorrhage and anastomotic leak. He is resuscitated with crystalloid and blood products as indicated, catheterised, and sent for CT with contrast once stabilised; a falling haemoglobin or peritonism prompts immediate reoperation.
Traps
- Attributing postoperative tachycardia and oliguria to pain and giving opioids instead of assessing volume status.
- Over-resuscitating with crystalloid in trauma, worsening coagulopathy and oedema.
- Missing necrotising fasciitis because pain seems disproportionate to skin findings.
- Forgetting tetanus status and antibiotic timing in open fractures.