Perioperative Medicine
Perioperative questions test structured cardiac risk assessment, medication management around surgery, and recognition of the timing of postoperative complications.
Cardiac risk assessment
Use a validated index such as the Revised Cardiac Risk Index. Then follow a stepwise path: emergency surgery proceeds; an active cardiac condition (unstable angina, decompensated heart failure, severe aortic stenosis, uncontrolled arrhythmia) delays surgery for optimisation; good functional capacity (4 METs or more) proceeds without further testing; poor capacity with elevated risk warrants testing only if it will change management. Routine revascularisation before surgery is not indicated.
Medications
Continue beta-blockers and statins. Do not start a beta-blocker on the day of surgery. Hold ACE inhibitors and ARBs for about 24 hours to reduce intraoperative hypotension. Continue aspirin in patients with recent stents at high thrombotic risk; routine heparin bridging is no longer recommended except for mechanical mitral valves or very recent thrombosis.
Postoperative fever
Days 1–2: atelectasis and the operation itself. Days 3–5: pneumonia, urinary tract infection, catheter-related infection. Days 5–7: surgical site infection. Beyond a week: abscess, Clostridioides difficile, drug fever.
Worked example
A 72-year-old with a drug-eluting stent placed 8 months ago on aspirin and clopidogrel needs elective hip replacement. Continue both antiplatelets and proceed if bleeding risk is acceptable, or defer the operation until 12 months if it can wait - stopping antiplatelets risks stent thrombosis.
Traps that cost marks
- Ordering routine stress testing before low-risk surgery.
- Starting beta-blockers on the day of surgery.
- Bridging with heparin unnecessarily.