Preoperative, Perioperative and Postoperative Care
Preoperative, Perioperative and Postoperative Care tests risk stratification, anesthesia coordination, infection prevention, wound care, critical care, and recognition of complications. The exam expects you to know which tests change management and which merely delay surgery.
Risk assessment
- ASA physical status predicts perioperative risk but not procedure-specific risk. The Revised Cardiac Risk Index (RCRI) predicts major cardiac events: ischemic heart disease, heart failure, cerebrovascular disease, insulin-treated diabetes, creatinine >2 mg/dL, and high-risk surgery (intraperitoneal, intrathoracic, suprainguinal vascular).
- Do not order routine stress testing for asymptomatic patients before low- or intermediate-risk surgery. Continue beta-blockers; do not start them on the day of surgery.
- VTE prophylaxis by Caprini score: early ambulation, mechanical prophylaxis, or low-molecular-weight heparin. Time neuraxial anesthesia around heparin per protocol.
Infection, wound, and ERAS
- Surgical site infection prevention: appropriate antibiotic within 60 min, normothermia, euglycemia, avoid shaving with a razor, chlorhexidine skin prep.
- ERAS: preoperative counseling, avoid prolonged fasting (clear fluids 2 h), multimodal analgesia, opioid-sparing, early feeding and ambulation.
Worked example: A 68-year-old with stable angina, insulin-treated diabetes, and creatinine 2.2 mg/dL undergoes open colectomy. RCRI = 4 (ischemic heart disease, insulin-treated diabetes, creatinine >2 mg/dL, high-risk surgery). Reasoning: count only the six RCRI variables; stable symptoms do not mandate revascularization, but perioperative beta-blocker continuation, glucose control, and monitoring are priorities.
Traps: treating mild hypertension as a reason to cancel surgery; confusing RCRI with ASA; giving prophylactic antibiotics after incision; ignoring postoperative oliguria as hypovolemia rather than checking for obstruction or sepsis.