Perioperative care, critical care and complications
Domain 3 - Perioperative care, critical care and complications
This domain tests the trajectory of the surgical patient - risk assessment, optimisation, prophylaxis, and recognition and management of deterioration. EMQs here often hinge on timing: which complication fits which postoperative day, and which intervention must come first.
Core rules
- Preoperative risk: ASA physical status, the Revised Cardiac Risk Index, and functional capacity in metabolic equivalents (4 METs is the usual threshold for proceeding without further testing). Frailty and sarcopenia predict morbidity better than chronological age.
- Fasting: clear fluids 2 hours, breast milk 4 hours, light meal 6 hours. Prolonged fasting worsens insulin resistance and is not required in most ERAS pathways.
- VTE: risk-assess every patient (Caprini); LMWH plus mechanical prophylaxis for moderate-to-high risk, extended to 28 days after major abdominal or pelvic cancer surgery.
- ERAS: carbohydrate loading, no routine bowel preparation or drains, opioid-sparing analgesia, early oral intake and early mobilisation.
- Postoperative timeline: days 1–2 atelectasis and hypovolaemia; days 3–5 pneumonia, urinary infection and ileus; days 5–8 anastomotic leak; days 7–10 wound infection and dehiscence; beyond 1–2 weeks DVT/PE.
- Critical care: Sepsis-3 is suspected infection plus SOFA ≥2; qSOFA is a prompt, not a rule-out. Give 30 mL/kg balanced crystalloid for sepsis-induced hypoperfusion, then noradrenaline to a MAP of 65 mmHg. AKI is staged by KDIGO criteria; ARDS by the Berlin definition (PaO2/FiO2 ≤300, bilateral infiltrates, no cardiac cause).
Worked example
A 70-year-old man on day 5 after anterior resection has heart rate 118, temperature 38.4 °C, urine output 15 mL/h and lactate 4.2 mmol/L despite 1 L of fluid. Tachycardia out of proportion to pain, with rising CRP and oliguria, is a leak until proven otherwise. Send cultures, start broad-spectrum antibiotics, resuscitate and obtain CT with IV and oral contrast; free fluid, faecal contamination or deterioration means return to theatre, with percutaneous drainage reserved for a contained collection in a stable patient.
Traps
Attributing new tachycardia and confusion to pain or opioids; using qSOFA to exclude sepsis; giving hydroxyethyl starch; treating postoperative ileus with more morphine; repeating scans while the patient deteriorates instead of re-operating.