Perioperative Medicine Introductory Booklet For Students - vFINAL

Table of Contents
POA history taking
Suggested timetable
Assessments
Core guidelines
Starvation
NICE tests
CVS: Echo, Angiogram, Stents, Hypertension
New diagnosis AF
Pacemakers
Respiratory: Pulm function tests, COPD, Pulm Hypertension
Obstructive Sleep Apnoea
Diabetes
Cognitive Dysfunction
Anaemia
Drug management
Infection control
Nutrition
Exercise
Functional exercise testing
Additional Intermediate guidelines

Risk Stratification
Enhanced Recovery
Goal Directed therapy
Post op complications
Examples of typical co morbidities

POA History taking
Hypertension
 When was it diagnosed
 Is it well controlled
 GP reading within last 12 months
 Do you take your medication
 Have you seen a cardiologist
 Complications – renal, brain, heart
Angina/Chest Pain
 Do you have angina/ chest pains. In older patients angina can present as
SOB
 Are you under care of cardiologist. Who and when seen?
 Is it stable i.e. is it the same or is it increasing in frequency
 Is it unstable i.e. worsening severity or frequency
 Does it occur at rest
 When was the last episode
 DO you use GTN, how long does it take to relieve symptoms
 When does angina/chest pains occur eg on exertion, at rest, woken at
night
 Further details location and type of pain, associated symptoms
 Exercise tolerance
 Chase all letters from GP and cardiology
Heart Attack
 When was your heart attack,
 Did you require angiogram and stenting
 Are you still taking aspirin/clopidogrel /other antiplatelet
 Are you under the care of a cardiologist. Who and when seen?
Irregular heart rhythm

 Do you have AF or other irregular heart rhythm
 Do you have a pacemaker
 Date and details of last check – including battery life, type of PPM,
underlying rhythm
 Do you get palpitations
 How long do they last, does anything relieve them
 Any LOC/dizziness/blackouts/CP/SOB
Feinting /Dizziness
 How often do they occur
 Have you ever been investigated
 Have you ever had a drop attack
 Do you get SOB or CP at the time
 Any LOC/incontinence
 Any vertigo/tinnitus
Heart murmur
 Are you aware you have a heart murmur
 Have you had rheumatic fever
 Have you had a valve replacement
 Where/when was this done
 When were you last reviewed by a cardiologist
 Type of valve
 Any anticoagulants
 Have you had a recent echo
Heart failure
 Do you know you have heart failure
 DO your ankles swell
 Is it pitting – ankles, calf, thigh, sacrum
 Is it longstanding/recent occurrence
Asthma/COPD
 Is your asthma well controlled
 When was your last attack
 What triggers your asthma
 Have you ever required a hospital admission/ITU /HDU admission
 Are you under the care of a respiratory physician. Who and when seen?
 Last oral steroids
 Do you have home nebs/oxygen
 What is normal peak flow
 Recent chest infections
 Current cough/sputum/audible wheeze
 Chase all letters from chest physician and GP
SOB
 Can you walk up 1 flight stairs
 SOB uphill or on flat
 How far can you walk
 How many pillows do you need to sleep
 Wake at night SOB/SOB lying flat/SOB on dressing
Heavy Snoring
 Do you snore heavily at night? If yes continue to STOP BANG
 Do you have sleep apnoea
 Have you ever had sleep studies
 Use CPAP at night
 When CPAP last reviewed
 DO you wake with a morning headache, or require daytime nap?
Diabetes
 Diagnosed when
 Type
 Treatment/tablets/insulin/diet
 Well controlled
 Any hospital admissions
 Under care of GP or hospital
 Last HbA1c
 BM range
 Complications – renal, heart, brain, peripheral neuropathy
Stroke/TIA
 When did you have your CVA/TIA
 Did you require hospital admission
 Fully investigated CT head , echo, and carotid dopplers
 Cause – hypertension. emboli/vasculitis /other
 Were you left with any neurology
 Any problems swallowing/coughing/communication
 Did you require speech therapy/occupational /physiotherapy
 Are you still under care of stroke team. When and who seen
 Treatment – aspirin, clopidogrel
 Chase all letters neurologist and GP
Epilepsy
 When were you diagnosed
 Are you under care of neurologist. Who and when last seen?
 When was last fit
 Frequency and type of fits
 Is it stable
 Medication
Parkinsons
 How affect you, when was it diagnosed
 Drug treatment
 Stable or on/off symptoms difficult to control
 Deep brain stimulator in situ?
 Are you under care of neurology/parkinsons nurse? Who and when last
seen?
 Chase neurologist and GP letters
Dementia
 Known or unknown history of dementia
 Caused by
 Treatment
 Baseline MTS, or other scoring system
 Referral to dementia nurse
 Care required – including relevant ‘my name is’ information.
Thyroid
 Hyper/hypothyroid
 Treatment
 When levels last checked
 Any change appetite/change in level activity/intolerance heat/cold
Liver
 Any jaundice/hepatitis
 Cause
 Treatment
 Complications
 Alcohol
Anaemia
 What is cause of your anaemia
 Have you ever required a blood transfusion, if so antibodies known?
 Current treatment
 Been investigated properly?
DVT/PE
 Date and where in body – calf, IVC, PE
 Precipitating factors i.e. cancer, long haul flight, post op, immobility,
clotting disorder
 On long term anticoagulants
 Under care of haematology. Who and when last seen?
Kidney/urinary issues
 Impaired renal function known or unknown?
 Nephrotoxic drugs
 What caused problems, treatment.
 Are you under care of renal team. Who and when last seen?
Neck/jaw problems
 C Spine issues or reduced mobility C Spine
 Mouth opening >3cm
 Previous intubation issues
 Chase old anaesthetic charts and letters
Suggested Timetable
Index case
Identify high-risk index cases e.g. colorectal resection, ♯NOF, revision hip,
cystectomy.
Follow Preop/Periop/Post Op
CBD with named consultant
Periop opportunities
Nurse POA filter clinic for fast/basic history taking practice
Notes review with anaesthetic consultants
Anaesthetic High Risk clinics
ERP follow up /Ortho education class
CPEX
PACU/ward post op surgical rounds
Cardiac training (as needed)

Chest pain clinic, understand primary indications for angio, follow patient
through ETT to angio
Echo Clinic with cardiac technicians
Valve clinic for indications to refer for valve replacements
Angio suite
Geriatric training (as needed)

Orthogeriatric Ward round
POA geriatric clinic
MuDAS session
Investigations if not seen previously

Lung function tests
Sleep Study/Clinic
Functional capacity testing
Cardiac echo, angio, ETT
Obstetric POA clinic for intermediate trainees

Assessments
Core Trainee Guidelines for Perioperative Medicine
Compulsory Activity No. Assessment

Index case
(High risk patient, follow whole perioperative
1-2
pathway pre, intra and post op) CBD/CEX
Emergency and elective cases
POA clinic attendance 4
Preop patient reviews
4 CBD/CEX
Covering recommended core topics
ECG Interpretation DOPS
Intraoperative monitoring
1 DOPS
eg: Art line, Doppler, BIS
Intraoperative emergency case
management 1 CBD/CEX/DOPS
ASA 1-2
Dementia, Frailty 1
Assessment and management.
Post op / PACU ward round 1
Recommended Core topics to be covered

Anaemia
Antiplatelet drugs
Cardiac issues and pacemakers
DM Perioperative management
Dementia management
Fragmin bridging
OSA
Intermediate Trainee Guidelines for Perioperative Medicine
Recommended Activity No. Assessment

Index case
(High risk patient, manage whole
1-2
perioperative pathway pre, intra and post op) CBD/CEX
Emergency and elective cases
POA clinic attendance
4 DOPS/CBD/CEX
Including CPEX interpretation
Preop patient reviews
Covering recommended core topics 4 CBD/CEX
And present management plan
Intraoperative emergency case
management 1 CBD/CEX/DOPS
ASA 2-4
Intraoperative monitoring
1 DOPS
eg: TEG, Doppler, Lidco, BIS, TOE
Assess and manage dementia, frailty, TEP, 1
DNACPR
Post op / PACU ward round
1
Plan appropriate post op care and handover
Recommended Intermediate topics to be covered

Informed consent
Anaemia
Antiplatelet drugs
DM Perioperative management
Dementia management
Enhanced recovery
Fragmin bridging
Goal Directed fluid therapy
OSA
Risk stratification
STARVATION GUIDANCE
Pre-Op
Adults and children: should drink clear fluid until 2 hours before anaesthetic,
solid food not for 6 hours.
Should not cancel if chewing gum, sweets
No evidence for ranitidine/antacids/metoclopramide prior to elective surgery
Peri-Op
CARBOHYDRATE LOADING: (clear carbohydrate rich drink the night before
surgery, and three hours prior to surgery). Evidence for this shows
 20% reduction in length of stay when included within an ERP
 Up to 50% reduction in insulin resistance
 50% reduction in loss of lean body mass
 Reduction of patient discomfort, thirst, hunger, anxiety, fatigue
Post op
Eat and drink as soon as possible unless specific reason not to.
“Perioperative fasting in adults and children: guidelines from the European Society
of Anaesthesiology”. European Journal of Anaesthesiology: August 2011 - Volume
28 - Issue 8 - p 556–569
https://www.esahq.org/guidelines/guidelines/published/esa-guideline-on-pre-
operative-fasting
GENERAL BLOODS and
INVESTIGATIONS
NICE guidelines on pre-operative investigations

www.nice.org.uk/guidance/ng45/chapter/Recommendations
CARDIOVASCULAR
1. ECHO
Preop Indications
Murmur with age> 60, symptoms or abnormal ECG
Suspected pulmonary HTN,
New signs or symptoms of cardiac failure (check BNP also)
Known AS (no echo in last year)
No evidence in routine pre-op assessment or for stable cardiac disease

Ejection fraction poorly correlated with outcome
Dynamic Echo has a role in identifying inducible ischemia in at risk patients only
“AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease”
- Nishimura, RA et al. 2014 AHA/ACC Valvular Heart Disease Guideline
www.content.onlinejacc.org/article.aspx?articleid=1838843
2. CORONARY STENTS
Incidence of perioperative major coronary events is determined by time between
MI and/or coronary stent and surgery.
Mortality rates of stent thrombosis are high. 40-60%
Preop
If early interruption of DAPT is needed always involve cardiologist,
surgeon, and anaesthetists prior to surgery.
Defer all non-urgent, non-cardiac surgery for 12 months post MI if possible.
If surgery is urgent defer recent BMS for 30 days, DES for 6 months.
Continue DAPT peri-operatively where possible, if not possible then continue
Aspirin alone, to prevent stent thrombosis.
Future developments include:

Short-acting, reversible ADP blockers and
Modified thromboelastography as point-of-care platelet function
monitoring.
New biomatrix stents
New studies investigating safety of early DAPT interruption
https://www.uptodate.com/contents/noncardiac-surgery-after-percutaneous-
coronary-intervention.
www.ceaccp.oxfordjournals.org/content/10/6/187.full
3. CORONARY or CT ANGIOGRAPHY
Preop Indications
Revascularisation before non-cardiac surgery is only recommended for
patients in whom revascularisation is indicated regardless of surgery.
The latest ACC/AHA guidelines recommend against coronary revascularisation

before non-cardiac surgery. In other words:
Never refer patients for angiogram just because they are having major non-
cardiac surgery
Indication for coronary angiogram includes:

Positive ETT, including CPET
STEMI
Non-STEMI and unstable Angina
Angina unresponsive to medical therapy
4. HYPERTENSION
Preop
GP should refer patients for elective surgery with mean BP in primary care in the
past 12 months <160/100 mmHg.
Pre-op assessment clinics need not measure the BP for elective surgery whose
BP are documented below 160/100 mmHg in the GP referral letter.
Patients may be referred for elective surgery if they remain hypertensive despite
optimal antihypertensive treatment or if they decline antihypertensive
treatment.
Pre-operative assessment staff should measure the blood pressure of patients
who attend clinic without evidence of blood pressures less than 160/100 mmHg
being documented by primary care in the preceding 12 months.
Elective surgery should proceed for patients who attend the pre-operative
assessment clinic if their blood pressure is <180/110 mmHg when
measured in clinic.
However hypertension has been implicated in development of postoperative
haemorrhage in neuro, thyroid and opthalmic surgery. Hypertension is
recommended to be optimally managed in these specialities.
2016 AAGBI Guideline: The measurement of adult blood pressure and

management of hypertension before elective surgery
www.aagbi.org/sites/default/files/The%20measurement%20of%20adult%20bloo
d%20pressure%20and%20management%20of%20hypertension%20before%20ele
ctive%20surgery%202016(1).pdf
2014 ACC/AHA Guideline: Perioperative Cardiovascular Evaluation and

Management of Patients Undergoing Noncardiac Surgery
www.content.onlinejacc.org/article.aspx?articleid=1893785&resultClick=3
NEW DIAGNOSIS AF
Preop
Management of new AF diagnosed in POA clinic is the same as per non-surgical
patient. Preop specifically you need to ensure
Rate control <100bpm
Cardioversion if needed/appropriate, medical or electrical
Echo to exclude structural defects
Anticoagulation management determined by CHA2DS2-VASC
Timing of surgery depends on urgency. Elective surgery should be delayed until
full diagnosis and management has been determined.
Post op AF prevention
The following are potentially preop modifiable risk factors for the development
of postoperative AF:
Alcohol consumption
Obesity
Anaemia
Hypertension
Use of inotropes
Poor cardiac function
Electrolyte disturbances – Potassium and Magnesium
Post op Pain
Dehydration
“Atrial Fibrillation: Management” - NICE

www.nice.org.uk/guidance/cg180/
PACEMAKERS
Preop
Must identify patient with PPM/ICD preoperatively
Information needed includes
Battery life > 6 months – 1year. Get replaced if not.
Type of PPM
ICD or CRT present or not
Underlying rhythm
Periop
Co-ordination with anaesthetist, cardiologist, pacemaker technician and surgeon
is key to avoiding perioperative complications in these patients.
Recommend Bipolar diathermy for all PPM patients
Never use Monopolar diathermy close to PPM device
Never use Magnet over unknown device
ICD function must be switched off during surgery

Only use a ring magnet to do this if instructed to do by the Cardiac physiologist
who knows the device. Otherwise get the cardiac tech to reprogramme the
switch off in recovery preop, whilst monitored. You will need to have a method
of external defibrillation at hand in case of tachyarrythmia throughout surgery.
Identify PPM dependency:

These patients (ie: underlying rhythm asystole or CHB.) need external pacing
readily available throughout surgery in case of damage or malfunction of PPM.
Post op
Check 12 lead ECG in recovery
Keep ICD dependent patients monitored till Shock function is switched back on
by Cardiac tech in recovery post op.
If there were any concerns regarding PPM damage during surgery ensure cardiac
tech checks PPM prior to discharge.
Low risk patients can have their PPM checked after discharge.
MHRA 2006: “Guidelines for the perioperative management of patients with

implantable pacemakers or implantable cardioverter / defibrillators, where the use
of surgical diathermy is anticipated”
https://www.erbe-med.com/images/uk/Diathermy__Pacemakers-ICDs1.pdf
2016 British Heart Rhythm Society: Guidelines for the management of patients
with cardiac implantable electronic devices (CIEDs) around the time of surgery.
http://www.bhrs.com/files/files/Guidelines/160216Guideline,
%20Peri-operative%20management%20of%20CIEDs.pdf
RESPIRATORY
1. INDICATION FOR PULMONARY FUNCTION TESTS

Respiratory complications contribute significantly to perioperative morbidity
and mortality after surgery
Evidence based guidelines for PFTs prior to thoracic surgery are published
https://www.uptodate.com/contents/preoperative-evaluation-for-lung-
resection
Routine use of PFT is not recommended in non-thoracic surgery, but it may

be useful in optimizing the patients with respiratory disease before surgery.
www.ums.ac.uk/umj080/080(2)084.pdf
2. COPD
COPD is a progressive inflammatory condition resulting in expiratory airflow
limitation.
Patients with COPD are at increased risk of developing perioperative
complications and have an increased mortality.
Preop
Stop smoking
Optimal symptom control – refer for lung functions tests with reversibility
testing, and respiratory physician review if in doubt whether treatment is
optimal (ie: if patient has audible wheeze in the POA clinic!)
Check Preop ABG if hypoxia or CO2 retention suspected
Respiratory physiotherapy is crucial for sputum clearance
Prophylactic antibiotics can be considered
Preop respiratory training
Periop
RA preferred if at all possible, avoid GA if possible.
Optimal ventilator settings to reduce post op respiratory complications include:
6-8ml/kg tidal volume, and PEEP<6cmH2O.
If GA, then artificial ventilation can be challenging due to:

On-going infection if present (bronchiectasis)
Chronic Hypoxia and reduced ventilator drive (CO2 retention) issues
Reduced lung volumes, increased dead space, and increased V/Q
mismatch
Presence of controlled/ uncontrolled bronchospasm resulting in high
airway pressures
Pulmonary hypertension and risk of a failing RV
Post op
Adequate reversal of neuromuscular blockade
Early treatment of suspected infection
Incentive spirometer or CPAP
Early and regular chest physiotherapy with mobilisation
Do not routinely need HDU post op
Patient education is vital
www.ceaccp.oxfordjournals.org/content/14/1/1.full.pdf+html
3. INDENTIFICATION OF PULMONARY HTN

Preop
Identification is important and is based on history, examination, ECG and
chest x-ray.
If Pulmonary HTN is suspected, TTE is first line investigation. TTE utilizes
Doppler across a tricuspid regurgitant jet, to estimate pulmonary artery
pressure, but as a diagnostic test has limitations in accuracy.
Right heart catheterization is required to confirm the diagnosis. A
vasodilator challenge forms part of this assessment.
High-risk patients include:

COPD
Multiple Pulmonary Emboli
Severe OSA
End stage lung disease
Periop
Anaesthetic aims in Pulm HTN are to avoid
Increased PVR,
Marked decreases in venous return or SVR,
Myocardial depression
RV failure
Maintain normal heart rate
www.aagbi.org/sites/default/files/228%20Anaesthesia%20for%20the%20Pati
ent%20with%20Pulmonary%20Hypertension[1].pdf
OBSTRUCTIVE SLEEP APNOEA
Patients with obstructive sleep apnoea are at a 2-3x increased risk of
perioperative complications.
Diagnosed and classified by number of apnoeas/hypoapnoeas (AHI index)
occurring every hour during a sleep study.
AHI Index < 4 normal, 5-14 mild, 15-30 moderate, > 30 Severe OSA.
Preop
High-risk populations include obese, large tonsils, male, smoker, cervical fixation,
Use STOP BANG screening tool with Epworth Sleepiness Score for diagnosis
Send for investigations: overnight pulse oximetry or full sleep study,
Check CO2 levels if suspect hypoventilation in addition
Screen for Pulmonary HTN
Management plans include:
Investigate cases of suspected OSA preop, unless surgery is urgent in
which case arrange for HDU admission post op for CPAP
When OSA is newly diagnosed start CPAP treatment and delay elective
surgery. Allow period of time to ensure treatment compliance.
Established OSA patients require assessment for symptoms, and
compliance with treatment.
Periop
Associated with 8x incidence of difficult intubation
Anaesthetic technique adjustments include
Avoiding GA, use RA, avoid LT Opiates, avoid Benzodiazepine
Ensure patient brings in own CPAP machine to hospital
Post Op
It is essential to continue CPAP in the post-operative period, starting in
recovery.
Increased risk continues for first 3 nights post op.
May not require HDU post op if stable on own CPAP machine, and close
monitoring available.
OSA is NOT AN ABSOLUTE CONTRAINDICATION to day case surgery
http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1917935
DIABETES
Patients with diabetes have greater complication rates, mortality rates and
length of hospital stay.
Management focuses on:
Preop
Patient education and involvement
Patients should retain control and continue to self-administer their own
medication
Pre-optimisation of DM – aim for HBA1C <69mmol/mol (delay elective surgery
until improved control)
Where possible aim for admission on same day of surgery and schedule
surgery for the start of the theatre list
Periop
Aim is to avoid hypo- or hyperglycaemia during the period of fasting and the
time during and after the procedure, until the patient is eating and drinking
normally.
Indication for Sliding scale (VRII)

If two or more meals missed, ie major surgery with delay to re-feeding
Poorly controlled diabetes
Emergency patients
Otherwise If only one meal missed: Adjust normal medication and aim CBG 6-10
mmol/L)
Aim intraop CBG 6-10 mmol/L (check prior to induction and then hourly until
eating and drinking)
Management of intra-operative Hyper-glycaemia:

Type 1 DM: Administer SC rapid acting insulin (max 6 IU) (Assume 1 IU
will drop CBG by 3mmol/L)
Type 2 DM: Administer SC rapid acting insulin 0.1IU/Kg (max 6IU)
Management of intra-operative Hypo-glycaemia:

Administer 50-100ml Glucose 20%
Post op
Restart regular Oral DM medications and SC Insulin once patient has restarted
oral intake.
Use caution when restarting Metformin (check eGFR >50)
www.aagbi.org/sites/default/files/Diabetes%20FINAL%20published%20in%2
0Anaesthesia%20Sept%2015%20with%20covers%20for%20online[1].pdf
COGNITIVE DYSFUNCTION
Understand the definitions and differences between:
Dementia
Delirium/acute confusional state
POCD
Preop
May or may not be able to consent to surgery/anaesthesia.
Informed consent issues need to be discussed and efforts always made to speak
to family and find out what they think patient would have preferred before
became unable to consent.
Ensure DNACPR and escalation limits are in place preop if appropriate
Document causative agent if known

Refer to dementia and geriatric team to plan in patient and discharge
support in advance.
Use hospital passport and leaflets for family advice
Baseline AMT (Abbreviated Mental Test Score) Score is essential to
document preop in case of post op deterioration.
AMT Questions are as follows:

How old are you
What is the time (nearest hour)
Address for recall at end of test, repeated by patient
What year is it
What is the name of this place/location
Can the patient recognise two relevant people ( eg nurse/doctor)
What was the date of your birth
When was the second world war
Who is the present prime minister
Count backwards from 20 to 1
Total Score /10.
Less than 8 indicates cognitive impairment
Periop
Do not omit Aricept, and beware drug interactions
Simple anaesthetic strategies to prevent cognitive impairment are effective if
implemented eg:
Avoid GA if possible,
Avoid Bzp, anticholinergics and long acting opiates
Prevent hypotension,
Institute monitoring to avoid ‘Triple low’ effect
https://www.ncbi.nlm.nih.gov/pubmed/26967259
Post op
The long-term implications of cognitive impairment are significant, and reduce
life expectancy
POCD can be reversible or irreversible
Look for causes of Acute Confusional State and institute treatment.
Refer to the dementia team prior to discharge
Simple strategies on post op wards to improve outcomes include
own family or carer present
‘my name is’ programme and information availability
sleep cycle hygiene
avoidance opiates and benzodiazepines
avoidance constiapation
removal urinary catheters
frequent orientation on ward
stable ward and nursing staff
Alzheimers society has useful information.

http://ceaccp.oxfordjournals.org/content/12/3/105.full
http://bjaed.oxfordjournals.org/content/bjaed/early/2016/05/16/bjaed.mkw0
38.full.pdf
ANAEMIA
Preop anaemia and Blood transfusion is independently associated with adverse
outcome.
Anaemia needs to be identified as early as possible in the pathway.
See O DRIVE for Bucks Healthcare Guideline – “Anaemia investigation and

treatment pathway”
Definitions
WHO definition of anaemia is Hb <130g/L in men, <120g/L in women
Anaemia with ferritin <30mcg/L = Iron deficiency
Anaemia with ferritin 30-100mcg/L, TSAT <20%, CRP raised= Functional Iron
deficiency
When in doubt check B12, folate, Iron studies
Treatment thresholds
Consider all the following before deciding if treatment necessary:
Optimal aim is Preop Hb >130g/L in men, >120g/L in women,
Hb >120 & 110g/L respectively may be acceptable depending upon
clinical urgency
The peri-op transfusion trigger
Estimated peri-op blood loss
Post op transfusion trigger
Management
Oral iron is first line treatment for iron deficiency if surgery is non urgent
IV Iron indicated for:
Functional Iron deficiency
Iron deficiency with no response to oral iron after 3-4 weeks, Short time
frame to surgery, Patient on PPI patient has IBS, Or inability to tolerate
oral iron
Also remember to check preop phosphate after IV Iron administration
Other treatment options include B12, folate and erythropoietin.
There is little place for preop blood transfusion – no evidence of benefit.
AAGBI: “The use of blood components and their alternatives 2016”. Anaesthesia.
Volume 71, Issue 7 (July 2016) p829–842
http://onlinelibrary.wiley.com/doi/10.1111/anae.13489/full
BCSH: “British Committee for Standards in Haematology Guidelines on the

Identification and Management of Pre-Operative Anaemia”. Anaesthesia. Volume
171, Issue 3 (November 2015) p322–331
http://onlinelibrary.wiley.com/doi/10.1111/bjh.13623/full
DRUGS
All the information you need can be found in the UKCPA: See BUCKS O
DRIVE UK: “Clinical Pharmacy Association - Handbook of perioperative
medicines”
NB: Incorrect info regarding all alpha-blockers in drug handbook – do not stop
alpha-blockers prior to cataract surgery. Effect of alpha-blocker on eye is
permanent with regards to floppy iris syndrome. Inform ophthalmic surgeon if
patient ever taken alpha-blocker.
BETA-BLOCKERS
Patients with IHD and other associated risk factors (see RCRI) are at high risk of
peri-operative cardiac events. Postoperative troponin rise is common, not always
associated with cardiac symptoms, and independently associated with
postoperative mortality.
Preop management
Continue B-Blocker in patients currently taking B-Blocker (Class 1)
Consider starting B-Blocker pre-op in high-risk patients, but start several
days before surgery to assess tolerability (Class 2B), and titrate dose to
heart rate, avoiding hypotension if possible.
Use bisoprolol, or atenolol rather than metoprolol (Class 2b)
Do not start on day of surgery
European Society of Cardiology: “Guidelines in non-cardiac surgery”

http://eurheartj.oxfordjournals.org/content/ehj/35/35/2383.full.pdf
2014 ACC/AHA: “Guideline on Perioperative cardiovascular evaluation”.

Circulation 2014;130:e278-333
http://content.onlinejacc.org/article.aspx?articleid=1893784
Perioperative Antiplatelet
Management
Both continuation and discontinuation of antiplatelet therapy can be associated
with significant risks.
A team-based approach to risk stratification is critical to optimizing the
perioperative approach to antiplatelet therapy
Antiplatelet drugs
1. Aspirin
Irreversible inhibition of COX1 and COX2; antithrombotic effect is
primarily due to the inhibition of COX1
Dose: 75-300mg
Stop: 7 days before intervention (but most commonly continued)
2. Phosphodiesterase inhibitors
Dipyridamole prevents degradation cAMP and inhibs PDE 5
Used in TIA and CVA when aspirin is contraindicated
Stop 24 hours before surgery
Cilostazol inhibs PDE 3, is rarely used.
3. ADP receptor blockers
Irreversibly bindsthe ADP receptor preventing the binding of ADP to its
specific platelet receptor and activating the platelet.
Clopidogrel Dose: 75-300mg
Stop: 7 days before intervention
Ticlopidine. Has serious side effects, not licensed in UK.
Prasurgel. Third generation thienopyridine. Dose: 10mg
Stop 7 days before surgery. Higher risk of bleeding complications
4. Reversible, non-competitive antagonist of the ADP receptor
Ticagrelor Dose: 90mg BD
Stop: 5 days before intervention
Cangrelor (An ATP analogue), short acting IV infusion. Not yet FDA
approved
5. Glycoprotein IIb/IIIa Receptor antagonists
Abciximab , monoclonal antibody
Dose: IV bolus or infusion
Stop: 48 hours prior to intervention
Also Tirofiban, Eptifibatide also ultra short acting IV infusions. Stop
8hrs before intervention. Show increased bleeding complications. Are
reserved for specific populations.
6. PAR 1 blockers
Vorapaxar, recently approved for marketing. Long half life. No data
“Perioperative management of antiplatelet therapy”. BJA (2013) 111, i3-i17

www.bja.oxfordjournals.org/content/111/suppl_1/i3.full
Perioperative Warfarin Management
1. First decide whether warfarin needs to be stopped for surgery, or
whether it is safe to operate whilst remaining anticoagulated. Use the
following table to guide you.
High bleeding risk procedures where Low bleeding Risk procedures where
anticoagulation should be interrupted anticoagulation can be usually be continued
Any procedure involving a vascular organ e.g. Minor dental procedures including extractions &
lungs liver kidney bladder or spleen root canal work (most procedures can take place
Cardiac & Genitourinary surgery providing INR <4) – check INR within 72 hours
Bowel & polyp resection & all colonoscopy of procedure
procedures for pts aged > 55years where Cataract surgery (INR <2.5 acceptable in most
biopsy or polypectomy likely. Endoscopic cases)
procedures involving PEG placement, Skin biopsy (if INR< 2.5 is required then omit
dilatation o oesophagus, treatment of varices, warfarin for 1-2 days prior to procedure)
endoscopic US with fine needle aspiration; Diagnostic upper/ lower endoscopy with or
ERCP without biopsy (providing INR within
Major surgery associated with extensive therapeutic range); diagnostic colonoscopy if
tissue injury eg cancer surgery, orthopaedic aged <55
surgery, reconstructive plastic surgery Implantation pacemaker or ICD defibrillator-
Bronchoscopy (may need to omit 1-2 doses)
Any Neuro & spinal surgery including catheter ablation, coronary angiography and
epidurals; vitreoretinal surgery other vascular interventions, -can usually
perform the procedure without interrupting
warfarin
Joint injections & soft tissue injections
2. If you need to stop warfarin then Next consider whether it is SAFE to stop warfarin?
If the risks of clot formation in the perioperative period are high then fragmin bridging is needed to reduce the period of time the patient
is exposed.
If the risks are low, fragmin bridging is not needed, and you can simply stop warfarin.
Indication for Warfarin Therapy

Thrombosis Mechanical Atrial Fibrillation VTE Perioperative Bridging therapy with LMWH
Risk Heart Valve Recommendations
(MVR)
LOW CHA2DS2VASc score 0-3 & no VTE more than 12 months ago Pre op. Stop warfarin 5days preop. No further
previous history TIA/CVA or anticoagulation required.
rheumatic heart
disease/mitral stenosis Post op start prophylactic dalteparin 6-12 hours post op
INTERMEDIATE AF with CHA2DS2VASc score VTE between 12 weeks and 12 Pre op start prophylactic dose dalteparin
4-5 & no previous history months;
TIA/CVA or rheumatic heart Recurrent VTE Post op Start prophylactic dalteparin 6 -12 hours hrs post
disease/mitral stenosis VTE associated with active op & restart warfarin.
cancer Continue dalteparin until INR >2
HIGH Any aortic MVR AF & rheumatic heart disease VTE within last 6-12 weeks. Preop bridging with treatment dose Dalteparin starting day
with target INR /mitral stenosis Any indication with target INR -3.
2-3 or 2.5-3.5. AF with previous history 3-4 Post op recommence treatment dose as son as haemostasis
TIA/CVA or systemic achieved.
embolism
AF & CHA2DS2VASc score 6
or more
VERY HIGH Any mitral MVR AF with history CVA/TIA VTE within last 6 weeks (avoid Preop bridging with treatment dose Dalteparin indicated
or any MVR with within the last 6 months surgery if possible). Severe starting day -3.
target INR 3-4 thrombophilia disorder eg Post op recommence treatment dose as son as haemostasis
antiphospholipid, anti- achieved.
thrombin deficiency (contact
haematology for advice)
3. The next table informs you how to institute fragmin bridging once you
have determined it is necessary.
Preop instructions
DAY -5 DAY -4 DAY -3 DAY -2 DAY -1

DAY 0 = DAY of
PROCEDURE
For those at INTERMEDIATE risk of periop thrombosis
Last Omit Start daily Administer Administer No dalteparin
dose of warfarin prophylactic Dalteparin dalteparin morning of
warfarin dose prophylactic prophylactic surgery.
Dalteparin dose dose. Administer
Check INR
prophylactic
dalteparin no
sooner than 6
hours post op
For those at High and VERY HIGH risk of periop thrombosis
Last Omit Start daily Dalteparin Half dose No dalteparin
dose of warfarin therapeutic 200iu/kg 100IU/kg morning of
warfarin dose Dalteparin or surgery.
Dalteparin Omit Administer
200units/kg dalteparin.
prophylactic
Check INR
dose
dalteparin no
sooner than 6
hours post op
Post op instructions
DAY +1 +2 +3 POST PROCEDURE
For intermediate risk of perioperative thrombosis

Continue daily prophylactic dalteparin until full anticoagulation with warfarin is
re-established
Ensure patient has an appointment for INR follow up /to be seen in local
anticoagulant clinic within 5-7 days of discharge
For High and VERY HIGH risk of perioperative thrombosis
Continue prophylactic dose dalteparin until full anticoagulation is re-
established.
Recommence therapeutic dalteparin and then warfarin only when surgical
haemostasis has been achieved.
Continue dalteparin until INR >2.
Ensure INR follow up 3-5 days post hospital discharge is in place.
INFECTION CONTROL
MRSA and MSSA
Department of Health 2014 screening guidance identifies 2 high-risk groups as a
focussed and cost effective approach to an otherwise universal MRSA pre
admission screening.
All patients admitted to high-risk units (vascular, renal/dialysis,
neurosurgery, cardiothoracic surgery, haematology/oncology/bone
marrow transplant, orthopaedics/trauma, and all intensive care units).
All patients previously identified as colonised with or infected by MRSA.
Other high-risk groups for screening (local policy) include:

Recent hospital admission
Living in Nursing home
First line relative MRSA positive
https://www.gov.uk/government/publications/how-to-approach-mrsa-
screening
It is also important to understand the difference between preop suppression and

treatment
http://www.buckshealthcare.nhs.uk/Downloads/Patient-leaflets-Infection-
Control/MRSA%20eradication%20therapy%20patient%20instruction%20leafle
t.pdf
Surgical Prophylaxis
Surgical site infection is common (5–20%) and is associated with significant
morbidity and mortality.
Crucial immune mechanisms such as neutrophil phagocytosis of bacteria are
impaired during the perioperative period.
RCT and systematic reviews show antibiotic prophylaxis to be effective in
preventing infections after many types of surgery.
Preop
Advise stop smoking and reduce weight
Treat concomitant infections wherever possible
Guidance exists for elimination of UTI prior to urological surgery, and prior to
joint implants, although this is not yet national guidance See BUCKS O DRIVE
Periop
For effective prophylaxis, appropriate antibiotics should be given before skin
incision as recommended by the WHO surgical safety checklist.
Potentially modifiable perioperative factors include: Temp, BM, Surgical site
bundles, Skin prep, Organ perfusion
NICE CG74: “Surgical site infections: prevention and treatment”

https://www.nice.org.uk/guidance/CG74/chapter/1-Guidance
NUTRITION
Malnutrition is prevalent in surgical patients - Studies show 50 % hospitalised
patients are malnourished
Patients lose on average 5.4 % body weight during a hospital stay
Preop
Check BMI if <20 then is likely malnourished.
Establish history of recent weight loss.
Use Tools to evaluate nutritional status eg: MUST score (Do not use BMI alone)
Assess protein status (serum albumin, transferrin, prealbumin)
Beware specific nutritional deficiencies eg: Vit D
Identify malnutrition and patients at risk, but in general do not delay surgery
International guidelines recommend preop nutritional support for severe
malnutrition BMI<18.5
High protein oral supplements are most suitable for patients with wounds or
malignancy
Preop parental nutrition is associated with increased infectious complications
and mortality
Post op
The risk of post op malnutrition depends upon preop nutritional status,
complexity of surgery, and degree of post op hypermetabolism.
Consequences of malnutrition include:
Increased susceptibility to infection
Poor wound healing (10)
Increased risk decubitus ulcers
Bacterial overgrowth GIT
Immune system dysfunction
Resumption of oral nutrition within 24 hours of surgery is well tolerated and

safe, does not increase anastamotic dehiscence, or post op ileus, and has also
shown to be associated with
Reduced infectious complications
Improved wound healing
Resolution of ileus
Reduced LOS
Early enteral nutrition is therefore essential. Feed (orally) all unless there is
a contraindication, it’s a component of ERAS protocols
Post op TPN is not indicated unless bowel function is not anticipated to return
within 10 days
Y Ali Abdelhamid, M J Chapman & A M Deana. “Perioperative nutrition”.

Anaesthesia 2016
http://onlinelibrary.wiley.com/doi/10.1111/anae.13310/full
EXERCISE
Sedentary behaviour is associated with reduced aerobic fitness, progressive loss
of lean muscle mass, frailty and collectively the physiological changes
compromise the ability to withstand the physiological insult of major surgery.
Exercise is defined by the WHO. It is classified according to aerobic intensity

Recommendations by WHO and NICE determine weekly duration of exercise
required to prevent decreased aerobic capacity and loss of lean muscle mass.
Achieving these recommendations reduces all cause mortality by 30%.
Objective exercise testing is recommended as part of the assessment for

perioperative risk. Methods include (see next section for details)
 Subjective patient reporting (frequently overestimates physical
activity)
 Timed stair climbing
 6 minute walk test
 Incremental shuttle test
 Cardiopulmonary exercise testing
Preop exercise
In order to address both aerobic fitness and sarcopenia, the programme should
consist of both muscle strength and aerobic training.
Only 2 randomised controlled trials to date to show outcome benefit post op
Significant improvements can be seen in a 3 -4 week time frame.

High intensity training is superior to moderate, continuous training to achieve
short-term benefits.
However up to 40% individuals are non-responders and do not improve their
objectively measured aerobic capacity.
Risks of exercise are low even in high-risk populations.
How to change patient behavior

Use the teachable moment prior to surgery
Appropriate patient selection e.g.: undergoing major surgery, with current
sedentary lifestyle, and significant co morbidities
Patient education as to benefits, including patient leaflet
Sign post to local resources
Prescribed exercise /group interventions
www.aomrc.org.uk/publications/reports-guidance/exercise-the-miracle-cure
Durrand J, Hackett R, Yates D, Danjoux G. “Prehabilitation. Perioperative Medicine

Current Controversies”. Chapter 2 Springer Publications 2016;16-47
FUNCTIONAL EXERCISE TESTING
Functional capacity is the ability to increase and sustain tissue oxygen
delivery and consumption. Patients with diminished functional capacity
are at increased risk of adverse postoperative outcomes.
Patient History
Consider and define Metabolic Equivalents (Patients should be able to perform
>4 METs, which is equivalent to climbing at least one flight of stairs, if they are to
consider undertaking major surgery)
Studies show subjective reports of activity by patients do not correlate well with
objective measurements. Patients frequently overestimate activity levels.
Functional Walk Tests

Functional walk tests provide a simple alternative measurement of global
cardiorespiratory function. They include
6-minute walk test (6MWT)
Incremental shuttle walk test (ISWT)
Distance walked in both tests correlates well with peak VO2 and maximum work
capacity as measured by CPEX
Preoperative studies show that a 6MWT distance of less than 300 m is linked to a
poor prognosis following aortic valve replacement for aortic stenosis
A threshold distance of 350 m on ISWT predicts low mortality after
oesophagectomy
Cardiopulmonary Exercise Test

CPET provides a safe, reliable, repeatable, non-invasive, objective, individual
assessment of combined pulmonary, cardiac, and metabolic function.
It quantifies functional ability to respond to the increased metabolic demands of
major surgery generating a patient-specific measure of risk.
Anaerobic threshold (AT) marks the onset of anaerobic metabolism as measured
noninvasively by respiratory parameters. This measurement has been shown to
help identify those patients most at risk of postoperative death. We now use AT
to triage the patient to an appropriate postoperative care facility, in an attempt
to reduce postoperative mortality.
Older P, Hall A, “Cardiopulmonary Exercise Testing as a Screening Test for

Perioperative Management of Major Surgery in the Elderly”, Chest 1999: 116(2):
355-362
http://www.journal.publications.chestnet.org/article.aspx?articleid=1078092
2014 ACC/AHA: “Guidelines on perioperative cardiovascular evaluation and

management of patients undergoing non cardiac surgery”. J Am Coll Cardiol.
2014;64(22):e77-e137.
content.onlinejacc.org/article.aspx?articleid=1893784
BJA Education: “Preoperative cardiopulmonary exercise testing”

RISK STRATIFICATION
Postoperative outcome is a function of
 Patient, Anaesthetic and Surgical factors,
 Timing of surgery,
 Organisational processes,
 Standardisation of care and
 Multidisciplinary post op care.
Prolonged post op morbidity is thought to occur in 15% of UK surgical

population, and is associated with an increased risk of death for up to 3 years
post operatively. In addition post op morbidity and mortality has financial
implications for the NHS as complications are expensive. They have a devastating
impact upon the lives and social care required by patients and families.
NECPOD recommendations in 2011 were to develop a UK wide system to

allow easy and rapid identification of high risk patients, so they can be managed
appropriately.
The Royal College of Surgeons 2010 recommendations state any risk of mortality
> 5% must be admitted to HDU/ITU post op with active consultant input. Most
recent NELA data suggest overall mortality rate 11% for emergency major
surgery. For those >80yrs mortality rates for emergency surgery are 45%
overall
Risk prediction indices can assign individual patients to a category of risk for a
specified adverse outcome in a defined population, This will then assist to guide
the appropriate post operative care required and potentially improve outcomes.
There are a number of tools, all of which have limitations and can be compared
in terms of
 Performance (how well they identify post op outcomes),
 Generalisibility (across surgical populations),
 Utility (ease of use by clinical team), and
 Clinical effectiveness (provide clinically useful information).
Risk tools can also be divided depending upon whether they are a scoring
system, or a risk prediction model. There are 8 such tools in use to date:
1. ASA
Is familiar to all anaesthetists
Good interdisciplinary understanding
Simple easy to use
High score correlates to poor outcome
Subjective inter rater reliability is poor
No emphasis on either severity, or urgency of surgery.
2. Charlson Comorbidity Index
Designed for medical not surgical patients
Is the method used to adjust HES mortality data in the UK.
Both the type and number of co morbidities are taken into account.
Poor predictor of mortality in the surgical setting
3. Revised Cardiac Risk Index

Validated and well-established tool for estimating post op MACE events
using 6 independent factors
No other post op morbidity considered.
4. Surgical Risk Scale

Simple and Quick method
Incorporates ASA, surgical NCEPOD urgency status, and BUPA
classification of surgical severity.
Moderate discrimination only
Only preop data required
Only validated by single centres in UK.
5. P-POSSUM
Risk prediction model using 18 variables
Widely validated in several countries and across different surgical
populations.
Moderate to high discrimination accuracy.
Recommended tool by NELA group.
Limitations include requirement for intra operative data therefore
requiring some preop estimation
6. NSQIP
Multivariable model (21 risk factors) used to predict morbidity and
mortality within 30 days post op
>1 million patients’ data used to construct model, and ongoing updates.
High discrimination accuracy for both morbidity and mortality
The ability to influence patient care and improve outcomes is promising.
Few limitations to performance.
Not validated outside NSQIP hospitals
7. SORT Tool
UK developed tool using snapshot data from 2011 NCEPOD audit
Requires 6 pre op variables and planned surgical procedure.
User friendly
Better discrimination than ASA
Prediction for mortality only, hence less applicable to low risk and
elective procedures
8. Nottingham Hip Fracture Score

Scoring system validated for the prediction of 30-day mortality after hip
fracture surgery
Seven independent predictors of mortality
Does not take account of acute illness
Moonesinghe SR et al. “Risk stratification tools for predicting morbidity and
mortality in adult patients undergoing major surgery: qualitative systematic
review”. Anesthesiology. 2013 Oct;119(4):959-81.
www.riskprediction.org.uk/index-pp.php
www.riskcalculator.facs.org/RiskCalculator/PatientInfo.jsp
ENHANCED RECOVERY
Enhanced recovery is a combination of elements of care for elective surgery that
aims to:
Optimise pre-operative preparation for surgery
Avoid iatrogenic problems such as postoperative ileus
Minimise the stress response to surgery
Speed recovery and return to normal function
Early recognition of abnormal recovery and intervention if necessary
Preop
Optimise patient health in community (correct anaemia, stop smoking, manage
HTN)
CPEX testing where appropriate
Initiation of appropriate care pathway and early discharge planning
Preop patient information eg: Joint School
Periop
Day of surgery admission
Patient optimisation:
VTE prophylaxis
No bowel prep
Carbohydrate loading
Reduced starvation times
Optimal intraop care:
Optimise fluid balance using goal directed fluid therapy
Pain control: regional anaesthesia, Minimally invasive surgery
Prophylactic anitemetic
Postop
Early oral fluid and food and stop IV fluid as early as possible
No post op NG tubes or drains
Planned early mobilisation
Avoid systemic opiates where possible
Early initiation of community care and support where needed: eg physio, stoma
nurse
Telephone follow up post discharge
Does Enhanced Recovery Work?

 170,000 fewer bed days since 2008/09
 Emergency readmission decreased
 Decreased length of stay
 Speeds up recovery
 Does not decrease mortality
Enhanced Recovery After Surgery Society (ERAS): List of all recommended
guidelines:
http://erassociety.org.loopiadns.com/guidelines/list-of-guidelines/
“Enhanced recovery: more than just reducing length of stay?”. Br. J. Anaesth.
(2012) 109 (5):671-674.
“Fast track surgery versus conventional recovery strategies for colorectal surgery”.
Cochrane Database Syst Rev. 2011 Feb 16;(2):CD007635. doi:
10.1002/14651858.CD007635.pub2.
http://www.rcoa.ac.uk/system/files/CSQ-ERP-Summ2012.pdf
www.frca.co.uk/Documents/204%20Enhanced%20recovery%20after%20surge
ry%20(ERAS).pdf
GOAL DIRECTED THERAPY
An important aspect of perioperative care is fluid management
Excessive fluid administration can harm patients significantly. Hypervolaemia
increases intravascular hydrostatic pressure, damaging endothelial glycocalyx,
increasing permeability and contributing to interstitial oedema. This is all
associated with increased morbidity, prolonged ileus, and delayed hospital
discharge.
Preop fluid management

Ensure patients present to surgery euvolaemic.
Intraop fluid management

Maintain normovolaemia using maintenance and small bolus replacement.
Maintenance fluid should not exceed 3ml/kg/hr
Evaporative losses during open abdominal surgery are only 0.5 – 1ml/kg/hr
Third space losses not supported by tracer studies therefore fluid are either
intravascular or interstitial.
Need for bolus must be accounted for.
Patients with haemodynamic instability must be adequately monitored to
determine whether they are volume depleted or not. As neither HR, BP, UO nor
CVP are reliable measures of volume status, GDFT has been developed to more
accurately determine volume status.
Proposed Benefits of GDFT

Reduced length of stay following major abdo/gynae/urology surgery
Reduced PONV
Reduced gut hypo-perfusion
Reduced GI complications (ileus, delayed feeding etc)
Minimally invasive CO monitoring for GDFT

1. Pulse Pressure and Systolic Pressure variation: variation >13% predict
fluid responsiveness.
2. Stroke volume variation - Oesophageal Dopper
3. Pulse Contour analysis PiCCO /LiDCO
Perioperative challenges
Pneumoperitoneum (laparoscopic surgery) and head down positions make GDFT
indices difficult to interpret.
Pulse pressure variation indices require constant intrathorcacic pressures and
TV above 7ml/kg for accurate interpretation.
GDFT is more effective when patients present hypovolaemic (ie emergency
patients) and less effective in the euvolaemic elective setting
Post op
Reduced Urine Output is a consequence of the normal neuroendocrine responses
to surgery and does not imply hypovolaemia.
Disconnect IV fluids and do not restart unless there is a clinical indication
Eat and drink as soon as able.
Oesophageal Doppler
Cardiac output can be estimated using Doppler ultrasound to determine the
flow of blood through the aorta
(Currently the recommended method of CO monitoring by NELA)
Oesophageal Doppler interpretation:

Stroke Volume/distance
Low: hypervolemia, increased afterload, failing LV
High: decreased afterload
Flow time corrected (FTc)
Low: hypovolaemia, increased afterload
High: decreased afterload
Peak Velocity
Low: cardiac failure, high afterload
Pulse Contour Analysis (PiCCO / LiDCO)
Continuous pulse contour analysis: Stroke Volume calculated from area under the
graph on arterial flow. CO = SV x HR
Intermittent calibration: PiCCO cold saline, LiDCO Lithium indicator dilution
“The place of goal-directed haemodynamic therapy in the 21st century”. BJA

Education. Sept 2015. 1-7
http://bjaed.oxfordjournals.org/content/early/2015/09/10/bjaed.mkv039
“Intraoperative goal directed hemodynamic therapy in noncardiac surgery: a

systematic review and meta-analysis.” Braz J Anesthesiol. 2016 Sep-Oct;66
(5):513-28
POST OP COMPLICATIONS
Introduction
Postoperative outcome is a function of
Patient, anaesthetic and surgical factors,
Timing of surgery,
Organisational processes,
Standardisation of care and
Multidisciplinary post op care.
Post-operative complications are an important cause of morbidity, mortality,
extended hospital stay and increased costs. Effectiveness of rescue in the event of
a complication is also known to be an important factor in survival, and in general
discriminates good from poorly performing hospitals.
Complications can be general or specific to the operation, and are not always
preventable
Issues
1. Prevention
2. Early identification and early rescue
NB: elevation of serum troponin following non-cardiac surgery is
the strongest predictor of 30-day mortality.
Scoring systems:
Postoperative Morbidity Score (POMS)
The POMS is an 18-item tool that addresses nine domains of morbidity relevant
to the post-surgical patient (pulmonary, infection, renal, gastrointestinal,
cardiovascular, neurological, wound complications, haematological and pain).
For each domain either presence or absence of morbidity is recorded on the basis
of precisely defined clinical criteria
In essence it is a Simple method to detect and quantify post op complications, the
design is suited to all surgery, Validated across a range of elective surgery and
POMs complications have been shown to correlate with ASA and P POSSUM
mortality scores
“The Use of a Postoperative Morbidity Survey to Evaluate Patients with Prolonged

Hospitalization After Routine, Moderate-Risk, Elective Surgery”. Anesth Analg.
1999 Aug;89(2):514-9
www.ucl.ac.uk/anaesthesia/StudentsandTrainees/Intro_to_postop_Complication
s
Clavien dindo
Widely used throughout surgery for grading adverse events which occur as a
result of surgical procedures
The therapy used to correct a specific complication is the basis of the Clavien-
Dindo Classification in order to rank a complication in an objective and
reproducible manner
“Classification of Surgical Complications: A New Proposal With Evaluation in a

Cohort of 6336 Patients and Results of a Survey”. Ann Surg. 2004 Aug; 240(2):
205–213.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1360123/
Oxford Hip and Knee Score

Patient Reported Outcome questionnaire developed to specifically assess the
patient's perspective of outcome following Hip and Knee surgery. It has
subsequently been validated for use in assessing other non-surgical therapies
applied to those suffering from issues with the knee.
OKS and OHS both consist of 12 questions covering pain and function and is
scored out of 48.
 Score of 0-19 suggests severe arthritis
 Score of 20-29 suggests moderate to severe arthritis
 Score of 30-39 suggests mild to mod arthritis
 Score of 40-48 suggests satisfactory joint function
http://www.orthopaedicscore.com/scorepages/oxford_knee_sc
ore.html
http://www.orthopaedicscore.com/scorepages/oxford_hip_score.html
CO-MORBIDITIES
Bariatric
Cancer
Elderly
Frailty
Jehovahs Witness
Lifestyle factors
Parkinsons Disease
Renal
Rheumatoid Arthritis
BARIATRIC
Major weight loss can lead to partial/complete resolution of a range of
conditions including, diabetes mellitus, ischaemic heart disease, and
hypertension.
The preoperative assessment is crucial in identifying potential risk factors that

might lead to perioperative adverse events.
The risk of perioperative pulmonary aspiration during subsequent procedures is

increased after bariatric surgery and dramatic weight loss,
Prolonged starving times are also required for patients with gastric bands in situ.
www.aagbi.org/sites/default/files/Obesity07.pdf
www.sobauk.co.uk/downloads/single-sheet-guideline
CANCER
Various perioperative factors are implicated in tumour growth, including
anaesthetic agents and analgesia.
Effects may be mediated via tumour cell signalling, the immune response or
neuroendocrine stress response effects.
Largely based on animal studies
Further evidence is awaited, until then the BJA consensus statement
acknowledges ‘insufficient evidence to support a change in clinical practice’.
Volatile agents
Conflicting studies, majority in vitro
Enhanced expression of tumourigenic markers: proliferation marker (eg: IGF-1
and isoflurane), angiogenic marker (eg: VEGF after isoflurane) as well as
proliferation and migration of cancer cells.
Nitrous oxide
No effect
Local anaesthetic agents

Some retrospective clinical studies show an association between use of RA and
reduced cancer metastasis. RA techniques both reduce the activation of the
stress response, and allow reduction in use of opioids and consequently less
immunosuppression
Other proposed mechanisms include a systemic anti-inflammatory action, or via
direct effects on proliferation (eg: inhibition of epidermal growth factor
receptor) and migration of cancer cells (eg: inhibition of protoncogene Src)
Amide LA may also directly demethylate DNA in breast cancer cells.
Overall however conflicting study results.
NSAIDS
Inhibition of cox 2 may lead to reduced resistance of cancer cell to apoptosis and
their reduced production of prostaglandins.
Current evidence suggests merit in using perioperative NSAIDS to lessen cancer
recurrence.
Opioids
Inhibit the function of NK cells, and stimulates cancer cell proliferation via
multiple angiogenesis and tumour cell signalling pathways.
Supplemental oxygen
Possible proangiogeneic effect on micro metastases
Dexamethasone
Does not affect overall rates of cancer cell survival.
Other in vitro studies suggest:
 Thiopentone reduces NK cell activity
 Ketamine reduces NK cell activity
 Pain increasing immunosuppression.
 Blood transfusion conflicting results suggesting liberal strategies may be
beneficial in early post op morbidity, but longer term there is an
association between transfusion and increased cancer recurrence.
 Fentanyl reduces NK cell activity, less than morphine.
 ACE inhibitors may increase breast cancer recurrence
 Epo - Surgically related  Handling of tumour / Increased local/systemic
growth factors after surgery / Peri-op immune suppression due to
surgery / Decrease in anti-angiogenesis factors from primary tumour
 β-blockers promote Anti-angiogenesis
 Statins also Anti-angiogenic & anti-inflammatory
 Tramadol improves NK cell action
“Effect of anaesthetic technique and other perioperative factors on cancer

recurrence”. British Journal of Anaesthesia 105 (2): 106–115 (2010)
http://www.bja.oxfordjournals.org/content/105/2/106.full.pdf
“Can anesthetic-analgesic technique during primary cancer surgery affect

recurrence or metastasis?” Canadian Journal of Anaesthesia, Volume
63, Issue 2, pp 184–192
http://link.springer.com/article/10.1007/s12630-015-0523-8
ELDERLY
Physiological changes occurring in the elderly need to be understood.
In sick elderly patients the normal age-related decline in physiological reserve, is

compounded by illness, cognitive decline, frailty and polypharmacy.
Compared with younger surgical patients, although the incidence of post op

complications is comparable, the elderly are at higher risk of post operative
mortality.
Elderly patients should be assumed to have the mental capacity to make

decisions about their treatment. Good communication is essential to this process.
(If they clearly lack that capacity, proxy information should be sought to
determine what treatment, if any, is in the patient’s best interests)
Anaesthetists must not ration surgical or critical care on the basis of age, but
must be involved in discussions about the utility of surgery and/or resuscitation.
MDT care (combined geriatrics, anaesthetics, surgeons) in this patient group

improves outcomes.
Preop
Optimise Polypharmacy
Undertake a Baseline cognitive score
Assess for frailty, mobilisation and need for physio/OT.
Assess help required for ADL
Nutritional assessment
Social circumstances.
Assess mental health
Assess falls and pressure ulcer risk
Ensure Hearing and Visual aids are available to patient at all times.
Prehabilitation to improve aerobic capacity and muscle mass
Discuss DNACPR and TEP in advance of surgery
Post op care
Early mobilisation
Optimise rehabilitation with physio and OT input prior to discharge
Postoperative delirium is common, but under diagnosed, in elderly surgical
patients. Treat any underlying cause. It increases complications and delays
rehabilitation.
Peri-operative pain is common, but underappreciated, in elderly surgical
patients, particularly if they are cognitively impaired
Administer opioid-sparing analgesia where possible.
Avoid sedatives
Intra op Care in the elderly
ALTERATIONS TO PHYSIOLOGY AND CLINICAL IMPLICATIONS FOR

ANESTHESIA
Physiology Clinical Implications
CVS Decreased sympathetic Labile blood pressure 

response Susceptibility to
Decreased venous compliance hypotension 
Decrease in preload  Susceptibility to volume
Baroreceptor response overload
impaired Exaggerated decline in
Cardiac diastolic dysfunction cardiac function with
inadequate cardiac filling
Pulmonary Increased pulmonary arterial Increased A-a gradient  

pressures  
Decreased response to hypoxia Susceptibility to hypercarbia
and hypercarbia   and  hypoxemia  
Susceptibility to residual
anesthetic effects  
Decreased muscle mass and Increased work of breathing
lung elasticity    
Increased dead space
Decreased cough reflex and ventilation 
esophageal motility  
Aspiration risk  
Nervous Decreased neurotransmitters Increased risk of

System postoperative delirium and
cognitive dysfunction
Endocrine Impaired glucose tolerance Increased intra-op
System hyperglycemia
Hepatic/Re Altered drug metabolism  Decreased drug clearance 
nal System Decreased renal mass  Susceptible to acute kidney
Thermoreg Decreased muscle mass injury
ulation Decreased vascular reactivity Increased risk of
hypothermia
www.aagbi.org/sites/default/files/perioperative_care_of_the_elderly_2014.pdf
“Optimal perioperative management of the Geriatric Patient”. Best Practice

Guidelines 2016.
www.facs.org/~/media/files/quality%20programs/geriatric/acs%20nsqip%20
geriatric%202016%20guidelines.ashx
FRAILTY
Frailty is a syndrome, which involves dysregulation across many physiological
systems. A proinflammatory state, which has been shown to be associated with
sarcopenia, anaemia, relative deficiencies in anabolic hormones (androgens and
growth hormone), excess exposure to catabolic hormones (cortisol), insulin
resistance, compromised altered immune function, micronutrient deficiencies,
Vit D deficiency, autonomic dysfunction and oxidative stress.
It is characterised clinically by:

Slow walking speed
Weakness (grip strength)
Loss lean muscle mass and weight loss
Self reported exhaustion
Reduced activity
Frailty is recognized as an important risk factor for the development of

postoperative complications, associated with increased length of stay, increased
likelihood of post op discharge to nursing home, and increased post op mortality.
Scoring Systems for frailty include:

 Phenotype score (above)
 Edmonton Frailty Scale
More detailed research is required to document clearly interventions to improve

post operative outcomes
https://www.uptodate.com/contents/frailty - H598978312
JEHOVAH’S WITNESS
Wherever possible, consultant staff should be directly involved throughout the
care of Jehovah’s Witness patients.
In an emergency, an anaesthetist is obliged to care for a patient in accordance
with the patient’s wishes.
Properly executed Advance Directives must be respected and special Jehovah’s
Witness consent forms should be widely available for use as required.
All Jehovah’s Witnesses must be consulted individually, whenever possible, to
ascertain what treatments they will accept, and their acceptance or rejection of
treatments recorded and witnessed.
In the case of children, local procedures for application to the High Court for a
‘Specific Issue Order’ should be reviewed and available for reference.
A ‘Specific Issue Order’ or equivalent should only be applied for when it is felt to
be entirely necessary to save the child in an elective or semi-elective situation.
In a life-threatening emergency in a child unable to give competent consent all
life-saving treatment should be given, irrespective of the parents’ wishes.
https://www.aagbi.org/sites/default/files/Jehovah's%20Witnesses_0.pdf
LIFESTYLE – SMOKING / ALCOHOL

Airway complications on induction, particularly during facemask ventilation or
LMA insertion, are common, and the need for intubation should always be
anticipated. Pre-oxygenation should be routine.
Adequate anaesthesia should be administered for intubation to minimise the risk
of provoking bronchospasm.
Regional anaesthesia has advantages for patients with long term respiratory
complications of smoking. Underlying ischaemic heart disease and hypertension
should be identified, and anaesthesia administered to minimise the risk from
these factors.
Early mobilisation is important to improve lung function and sputum clearance.
Often patients manage this themselves to ensure access to a cigarette!
Anaesthetists must consider the acute and chronic effects of alcohol at all stages
of the patient pathway.
Alcohol withdrawal is a potentially life-threatening complication that must be
diagnosed and actively managed.
www.frca.co.uk/Documents/221%20Smoking%20and%20Anaesthesia.pdf
PARKINSONS DISEASE
Parkinson's disease (PD) is associated with additional perioperative morbidity
and mortality.
Abrupt withdrawal or omission of anti-parkinsonian medication can have
serious consequences. Make sure patients continue their medications at all times,
even when NBM. If patient is not swallowing or absorbing then discuss with
pharmacy to convert to NG administration or patches.
The transdermal dopamine agonist rotigotine is especially useful.
Many drugs used routinely in the perioperative period are contraindicated in

patients with PD.
Postoperative delirium is particularly common in PD, and is best managed by
non-pharmacological methods.
http://bjaed.oxfordjournals.org/content/early/2016/09/06/bjaed.mkw050?hw
oasp=authn%3A1479226275%3A4223523%3A1507133494%3A0%3A0%3Ax2
k9bRigzmjpeYSRGruq1w%3D%3D
RENAL GUIDELINES
AKI is a common problem in the perioperative period and an independent
contributor to morbidity and mortality.
AKI is defined using the RIFLE or AKIN criteria (see below)
Tubular injury results from a complex interaction between baseline pre-

disposition, haemodynamic disturbances, nephrotoxic insults and inflammatory
responses
Striking a careful balance between fluid under- and over-resuscitation,

maintaining adequate systemic arterial pressure and avoidance of nephrotoxins
are the cornerstones to preventing or halting the progression of kidney disease.
Creatinine is not a useful indicator for impending AKI.
Preop
Identify patients at risk for AKI using the ‘any stage’ AKI score, developed
in 2014, and validated. It is a 14 variable, online tool.
Assess and Modify (if possible) Risk factors for AKI
Preop work up Risk factors Non modifiable risk

factor
Check BMI Obesity BMI>35kg/m2 Age
Serum albumin <40g/dL Male
Dipstix urine Proteinuria if present COPD
Haemoglobin Preop anaemia, and volume of IHD, PVD, HTN, CVA
blood transfused
perioperatively
Assess for LV EF <55% Diabetes mellitus
dysfunction
Avoid and reduce Smoker
IV Contrast
Stop nephrotoxins NSAIDS, aminoglycoside CPB
antibiotics, some
immunosuppressants.
Continue statins Complexity of surgery
Minimise Preop dehydration Reduced eGFR and
starvation times proteinuria
Consider measuring biomarkers pre and post op, and the associated evolving
evidence including Cystatin C, Neutrophil Gelatinase-Associated Lipocalin
(NGAL), H/L/I type Fatty aid Bimdimg Protein (FABP), Troponin, Insulin like
growth factor Binding protein 7, and Tissue inhibitor of metalloproteinase
2(TIMP 2)
Periop
Optimisation of perioperative renal perfusion using GDFT is likely to be
beneficial to avoid renal hypoperfusion.
Renin angiotensin system inhibition, can reduce chronic decline in renal

function, especially in the presence of proteinuria. There is current controversy
whether to stop or continue RAS inhibitors in the perioperative period. RCT’s
underway. Currently do not cease RAS inhibitors preoperatively.
ANP – use of low dose ANP associated with improved outcomes in Cochrane
review 2009. High dose however associated with poorer outcomes, hypotension
and arrhythmias. Mechanism of action not fully understood.
N Acetyl Cysteine – summary of evidence published in 2010 concluded despite

early promising data, there is no overall benefit in outcome measures.
Frusemide treatment effective at reducing volume overload and the associated

morbidity, but this does not equate to improved renal function.
Do not use HES containing fluids.
No evidence to support sodium bicarbonate as a protective measure.
Post op
Early RRT is more beneficial as increased mortality seen when RRT is
commenced late.
Specialist nephrology follow up required post op , as this will improve long term
outcome for patients who have sustained an episode of AKI during/after surgery.
SCORING AKI:
Stage Serum creatinine Urine output
1 1.5 – 1.9 x baseline <0.5mg/kg/hr for 6 hours
or
>0.3mg/dl(>26.5 μmol/l)
increase in 48hrs
2 2.0 – 2.9 x baseline <0.5mg/kg/hr for 12 hours
3 3.0 x baseline <0.3mg/kg/hr for 24 hr or
or anuria for 12 hours.
increased serum creatinine
to >4.0mg/dl (>353μmol/l)
or
initiation of RRT.
“Perioperative acute kidney injury”. BJA Education.

http://bjaed.oxfordjournals.org/content/bjaed/early/2015/06/03/bjaceaccp.mku
030.full.pdf
Rheumatoid Arthritis
RA is a multisystem progressive disorder that significantly affects quality of life.
Early diagnosis and treatment with DMARDs is key in reducing long-term
morbidity.
Optimal care of patients with RA requires an integrated approach of
pharmacologic therapies such as NSAIDs, DMARDs, biological agents,
glucocorticoids, and immunomodulators as well as non-pharmacologic
techniques like physiotherapy, occupational therapy, patient education and
counselling.
www.frca.co.uk/Documents/266%20Rheumatoid%20Arthritis%20and%20Anaest
hesia%20-%20Part%201.pdf
Questions
RENAL QUESTIONS:
1. The normal adult kidneys:

a. Lie at the level of T12 to L2 within the peritoneum
b. Are approximately 9cm long
c. Have an outer cortex and an inner medulla
d. The left kidney has a longer renal artery
2. Regarding nephrons in the kidney:

a. Two distinct types are identifiable
b. All have their glomeruli in the medulla
c. The juxtaglomerular apparatus is part of the proximal tubule
d. The collecting ducts of all nephrons pass through the medulla
3. Renal blood flow:

a. Is equivalent to 400ml/min/100g of tissue
b. Is very high due to the kidneys high metabolic rate
c. Is less per unit weight that the brain
d. Is equally distributed between cortex and medulla
4. Glomerular filtration:
a. Occurs at a rate of 125ml/min
b. Is mainly controlled by the capillary endothelium
c. Results in a filtrate with the same osmolality as plasma
d. Favours filtration of negatively charged molecules
5. Regarding the re-absorptive processes in the proximal tubule of the

nephron: a. Diffusion requires external energy input to drive it
b. Active transport moves substances against their concentration gradient
c. Glucose reabsorption is an example of secondary active transport
d. Reabsorption all starts with the diffusion of Na+ from the lumen into proximal
tubule cells
6. In the proximal tubule:

a. There are multiple layers of cells to increase reabsorption
b. 50% of the glomerular filtrate volume is reabsorbed
c. Normally, all of the filtered glucose is reabsorbed
d. Bicarbonate is secreted
7. Regarding the loop of Henle and vasa recta:

a. All the loops of Henle are identical
b. The ascending limb is impermeable to water
c. The tubular fluid becomes hypotonic
d. The vasa recta remove solutes from the medulla
8. Regarding the collecting ducts:
a. All collecting ducts pass through the renal medulla
b. They receive 5 L/day of tubular fluid
c. They are naturally very permeable to water
d. ADH acting on the collecting ducts results in high volume, dilute urine
RENAL ANSWERS:
1. F, F, T, F
The kidneys are situated at the level of T12 – L3 but are retroperitoneal organs
measuring approximately 12cm from end to end. Each kidney has two clearly
distinguishable regions; the cortex and the medulla. The abdominal aorta is
slightly to the left of the midline while the IVC is slightly to the right; therefore
the left kidney has a slightly shorter renal artery but longer renal vein.
2. T, F, F, T
There are two different types of nephrons; cortical and juxtamedullary.
Regardless of the type of nephrons, all of the glomeruli are within the cortex of
the kidney. The juxtaglomerular apparatus is situated after the loop of Henle, i.e.
in the distal tubule. All of the collecting ducts pass through the medulla and drain
the urine that is produced into the calyces.
3. T, F, F, F
Renal blood flow is around 400ml/100g/min, which higher than either coronary
or cerebral blood flow. This blood flow is unevenly distributed with the vast
majority supplying the cortex. The high flow rate and preferential distribution to
the cortex is necessary to drive glomerular filtration, rather than to meet
metabolic demands.
4. F, T, T, F
In health the glomerular filtration rate is 125ml/min. The main barrier to
glomerular filtration is the glomerular basement membrane. This is made from
connective tissue, which is negatively charged and so tends to oppose the
filtration of negatively charged molecules e.g. plasma proteins. Small molecules
such as electrolytes, urea and glucose are freely filtered so that the ultrafiltrate
produced by the glomerulus has the same osmolality as plasma.
5. F,T,T,F
Diffusion does not require any external energy. Active transport does require
energy to move solute against their concentration gradient. Glucose reabsorption
is an example of secondary active transport. All reabsorption starts with the
action of the Na+ /K+ ATPases acting to lower intracellular Na+ concentration.
6. F,F,T,F
There is a single layer of epeithelial cells lining the nephron lumen. 70% of the
glomerular filtrate volume, but 100% of the glucose is reabsorbed in the
proximal tubule. Bicarbonate is reabsorbed in the proximal tubule.
7. F,T,T,F
There are two types of loop of Henle; long and short. The ascending limb of all
the loops of Henle is impermeable to water. By the end of the loop of Henle the
tubular fluid is hypotonic. The purpose of the vasa recta is to deliver nutrients to
the medulla without removing the solutes that have accumulated there.
8. T,F,F,F
All collecting ducts pass through the renal medulla to drain into the renal pelvis.
Collectively they receive 23L of tubular fluid per day. In their natural state they
are impermeable to water. They become permeable to water due to the action of
ADH. This allows most of the water to be reabsorbed resulting in a low volume,
concentrated urine.
RA QUESTIONS:
1. Regarding rheumatoid arthritis (RA):

a. It only affects bones and connective tissue
b. It mainly affects the axial skeleton
c. It is associated with the HLA-DR4 subtype
d. Over 95% of rheumatoid patients are positive for rheumatoid factor
e. Environmental factors may play a role in it’s aetiopathogenesis
2. The following features are seen in patients with RA:

a. Dry eyes
b. Obstructive lung disease
c. Anaemia
d. Weight gain
e. Increased susceptibility to infections
3. The drugs that can be used to treat the symptoms of RA are:

a. Paracetamol
b. Infliximab
c. Indomethacin
d. Prednisolone
e. Ciclosporin
4. A patient with long standing rheumatoid arthritis (RA) presents with

hoarseness of voice. What are the anaesthetic implications of this? Choose
the single best answer.
a. This history is not significant
b. Hoarseness might worsen after endotracheal intubation-the patient should be
warned about this
c. The patient may be difficult to intubate as the vocal cords may be swollen
d. The patient probably has cricoarytenoid involvement, which combined with
airway oedema post intubation can cause complete airway obstruction in the
post operative period.
2. Regarding anaesthesia for patients with RA (true/false):
a. Spinal and epidural anaesthesia should be used where possible
b. Regional nerve blocks are contraindicated
c. Awake fibreoptic intubation (AFOI) may be needed in cases of severe atlanto-
axial subluxation
d. An LMA can be used for airway management to limit neck manipulation
e. Cervical spine involement in RA is always accompanied by symptoms
3. Regarding atlanto axial involvement in RA (true/false):

a. The most common type of atlanto-axial subluxation (AAS) is posterior AAS
b. Subluxation exists when the distance between the atlas and the odontoid peg
exceeds 4 mm in patients older than 44 and 3 mm in younger patients
c. Flexion of the neck is more harmful than extension
d. AAS can be diagnosed only by a CT scan
e. Severe AAS may necessitate an awake tracheostomy for airway management
RA ANSWERS:
1 F,F,T,F,T
RA is a multisystem disorder and is not limited to the bones and connective
tissue. Axial skeleton involvement does occur, but more commonly affected
joints include the wrists, fingers, neck, shoulders, elbows, hips, knees, ankles and
feet. Approximately 70% of cases are associated with the HLA-DR4 subtype, and
only 80% of patients are seropositive for rheumatoid factor. Environmental
factors may also play a role, including as yet, unidentified viral or bacterial
agents.
2 T,F,T,F,T
Long standing RA patients can develop Sjogrens syndrome with dry eyes and
mouth. RA causes restrictive (not obstructive) lung disease due to pulmunory
fibrosis and costochondral arthritis limiting chest wall movement. Anaemia is
common; anaemia of chronic disease (normochromic) and anaemia due to
gastric bleeding secondary to drugs (microcytic). RA is associated with
rheumatoid cachexia, and weight gain is rare. RA patients have an increased
susceptibility to infections as a result of the immunosupressive effects of the
drugs used to manage their disease.
3 T,F,T,T,F
The drugs that are useful to treat symptoms of RA are paracetamol, NSAIDs and
corticosteroids. The others modify the disease process, prevent exacerbations
and long term disability, but do not treat symptoms.
4D
Hoarse voice in a patient with longstanding RA, should lead to suspicion of
cricoarytenoid arthritis, which is variable in frequency and often unrecognised.
Other symptoms include stridor, a sense of pharyngeal fullness when speaking
and swallowing or dyspnoea. Pre operative nasoendoscopy may aid in diagnosis.
If cricoarytenoid involvement is suspected, avoid endotracheal int inubation in
favour of supraglottic airway devices. If intubation is essential, use the smallest
internal diameter tracheal tube possible. Problems occur post extubation, when
the oedema combined with an already narrow airway can cause complete
obstruction. Consider the use of an airway exchange catheter at extubation, and
observe patient in a high dependency area for some time post extubation. In
severe cases, a preoperative tracheostomy may be required.
5 T,F,T,T,F
Regional anaesthesia in the form of neuraxial blocks or peripheral nerve blocks
should always be considered as it avoids airway manipulation, provides good
postoperative pain relief and reduces polypharmacy. However, regional and
neuraxial blocks may be technically difficult due to spinal arthritis and loss of
anatomical landmarks from contractures or deformities. LMAs and other
supraglottic airway devices should be used where possible as they require
minimal neck manipulation for insertion and cause lesser trauma and
subsequent laryngeal oedema compared with a tracheal tube. AFOI is the
technique of choice in patients with an expected difficult airway or known
cervical spine instability needing intubation. Cervical spine involvement is not
always symptomatic.
6 F,T,T,F,T
The most common type of AAS is anterior AAS, occurring in 80% cases. Anterior
AAS is worsened by flexion. Subluxation exists when the distance between the
atlas and the odontoid peg exceeds 4 mm in patients older than 44 and 3 mm in
younger patients; this can be diagnosed by plain radiography of the neck. Severe
cervical spine instability may necessitate an AFOI or a tracheostomy under local
anaesthesia for safe management of the airway.
JEHOVAH’S WITNESS QUESTIONS:
1 blood transfusion may lawfully be administered to:

a. An adult Jehovah's Witness undergoing elective surgery if the anaesthetist
feels it would be in the patient's best interests.
b. An adult patient in an emergency whose Jehovah's Witness status is uncertain.
c. An unconscious adult patient who is carrying an advance directive indicating
his Jehovah's Witness status and refusing transfusion of blood products.
d. A child of Jehovah's Witness parents for whom a specific issue order has been
obtained.
e. A child of Jehovah's Witness parents in an emergency.
2. The following may reduce intraoperative blood transfusion

requirements:
a. High starting packed cell volume.
b. High percentage of hypochromatic red cells.
c. High central venous pressure.
d. High thoracic epidural.
e. High-dose recombinant factor VIIa.
3. Desirable characteristics of a blood substitute include:

a. Long shelf-life.
b. Binding of nitric oxide.
c. High oxygen affinity.
d. Maintenance of buffering capacity.
e. Maintains blood viscosity at 4 cP.
ELDERLY QUESTIONS:
1. Expected adverse drug effects in a geriatric population receiving a high

dose of a selective serotonin reuptake inhibitor for depression would
include all of the following EXCEPT
A. hyponatraemia caused by inappropriate secretion of ADH
B. impairment of platelet aggregation caused by depletion of 5HT (serotonin)
stores
C. withdrawal symptoms characterised by anxiety, agitation and increased
sweating
D. sedation, dry mouth, orthostatic hypotension and cardiac conduction defects
E. gastro-intestinal effects (nausea, vomiting, diarrhoea
2. You are seeing a 68yo man in the pre-anaesthetic clinic before his right
total knee replacement. He weighs 70kg and apart from his osteoarthritis
is fit and well. You discuss with him the options of a general anaesthetic
with multi-modality analgesia and enoxaparin postoperatively as well as
the option of an epidural for both the anaesthetic and post operative pain
management. What is incorrect regarding the epidural?
A. It will shorten his hospital stay and accelerate his rehabilitation –give him
better pain relief particularly for the CPM machine
B. It will give him better pain relief
C. It will reduce his risk of myocardial ischaemia
D. There will be little difference in his risk of thromboembolism
E. If he has no sedation, his risk of post-operative delirium and cognitive
impairment will be reduced
3. The absorption of fluid in to the circulation during TURP is not related

to:
A. prostate size
B. height of the irrigation fluid bag
C. duration of surgery
D. surgical technique
E. type of irrigation fluid
4. Which one of the following is not CORRECT regarding spinal anaesthetic

technique In patients undergoing TURP?
A. early detection of TURP syndrome is better
B. reduced incidence of cardiac overload
C. less blood loss
D. less post-op hypertension
E. less mortality than GA
5. 78 years old,severe carotid artery stenosis,surgeon is doing awake

CEA(CAROTID ENDARTERECTOMY). Patient becomes confused & combative
after carotid is clamped and opened. What is the most appropriate
treatment
a) tell surgeon to release clamp
b) tell surgeon to place shunt
c) induce GA
d) give IV midazolam
e) give IV Haloperidol
6. Which one of the following drug not associated with post-op delirium in
elderly patient?
A. Digoxin
B. thiazides
C. Midazolam
D. amitryptyline
E. Glycopyrrolate
7. 70 year old man with small cell lung ca, post-op lobectomy, in Recovery
room, desaturating. Shoulder abduction and hip flexion weakness, weak
but sustained handgrip. 8mg cisatracurium given 90 minutes earlier,
reversed with 2.5mg neostigmine and 1.2mg atropine. What is the most
likely diagnosis?
A. Eaton-Lambert syndrome
B. Myasthenia Gravis
C. Steroid myopathy
D. Brachial plexus injury
E. Guillaine -Barre syndrome
8. Which of the following is CORRECT regarding renal function in elderly

patient
A. loss of function of renal glomeruli in medulla correlates well with
impaired renal function
B. renal blood flow is maintained due to autoregulation.
C. creatinine clearance is relatively unchanged.
D. creatinine value progressively increased.
E. serum creatinine is a poor predictor of renal function
9. Which ONE of the following is not true regarding pharmacokinetics in an

elderly patient
A. volume of distribution is increased for lipid soluble drugs
B. volume of distribution is decreased for water soluble drug
C. low cardiac output results in slow onset for inhalational agents
D. low cardiac output results in slow onset of IV induction
E. fewer acetyl choline receptors in NMJ
10. Increased left ventricular end diastolic pressure (LVEDP) in elderly

leads to all EXCEPT:
A. reduces early diastolic filling of the ventricle.
B. increases the importance of atrial contraction on late ventricular filling.
C. Atrial hypertrophy develops to the increased impedance (LVEDP)
D. LVEDV is decreased in stress
E. Coronary artery vascular resistance increases in the elderly because of the
increased LVEDP and ventricular hypertrophy
ELDERLY ANSWERS:
1. D
Sedation, dry mouth, orthostatic hypotension and cardiac conduction defects –
WRONG, these are all anticholinergic symptoms, which are side effects of TCA\
2. E
If he has no sedation, his risk of post-operative delirium and cognitive
impairment will be reduced – it has not been shown anywhere in the literature
that regional anaesthesia decreases the risk of both post-op delirium and post-op
cognitive decline.
3. E
A. Large prostatic glands have rich venous networks that promote intravascular
absorption of irrigation solution
B. The hydrostatic pressure of the irrigation solution is an important
determinant, depends primarily on the height of the irrigation solution pole.
When the height of the pole exceeds 60cm, the absorption of irrigation solution
is greatly enhanced
C. fluid absorption increases with the extent of the resection as the exposure is
prolonged
D. performing TURP with a low fluid pressure, below the critical pressure for IV
absorption, would limit the risk. This can be achieved by applying a suprapubic
evacuation instrument … or a special channel in a resectoscope .
E. Irrigating fluids have unique pathophysiological properties, but it does not
influence the rate of absorption
4. E
Mortality is same for both spinal & GA but there are advantages with spinal
anaesthesia such as
1. Monitoring the patient mentation allows us to detect sings of TURP in Spinal
anaesthesia
2. Peripheral vasodilation reduces venous return(>60% blood volume in venous
capacitance vessels),reduces pulmonary oedema ,subsequently the water is
being excreted by kidney,if it's working
3. Reduces blood loss due to drop in pressure
4. Post-op analgesia reduces sympathetic stimulation caused by pain
5. B
a) tell surgeon to release clamp – releasing the clamp is only indicated if the
altered mental state is noticed after clamping but prior to opening of the artery
b) tell surgeon to place shunt – If neurological deficit develops, tell the surgeon
who will place a shunt. Recovery should be rapid once the shunt is in place – if it
is not, convert to GA
c) induce GA – converting to GA is only indicated if there are legitimate concerns
that the patient will not remain still during shunt placement .
it only takes a vascular surgeon a few minutes to place a shunt,
d) give midazolam –this arguably makes confusion and combativeness worse
If the patient had an intraoperative BP lower than pre-op, a reasonable thing to

do would be to give vasopressors to increase the BP.
the onset of altered mental state during awake CEA (under regional block) :
1.About half occur within minutes of clamping the carotid:
This signifies inadequate perfusion of the ipsilateral cerebral hemisphere from
the contralateral carotid (via the circle of Willis)
Treatment is to release the clamp and perform a shunt
2.About half occur 20-30 minutes after clamping the carotid (i.e. when the
carotid artery has been opened):
caused by relative hypotension which reduces collateral blood flow
Treatment is to improve cerebral perfusion and therefore oxygenation.
6. E
Al of them have got anticholinergic effects except Midazolam. anticholenergic
effects worsens delirium and dementia. glycopyrollate is anticholenergic but
doesn't cross BBB. Midazolam causes paradoxical excitation in elderly patients.
1.Delirium - Clinical features: Alteration of consciousness, Visual hallucinations,
delusional thoughts. Anxiety and distress. predisposing factors: UTI or chest
infection, alcohol withdrawal. drugs with anticholinergic actions are implicated
in delirium.
2.Dementia - Organic brain lesion, irreversible, failure of cholinergic
transmission, patients are very sensitive to anticholinergic drugs, delirium may
occur in the patients with dementia.
3.Parkinson's disease - deficiency of dopaminergic neurons in extrpyramidal
system
4.Postoperative cognitive decline - long term, possibly permanent, disabling
deterioration in cognitive function following surgery.
7. A
Eaton-lambert syndrome Is a autoimmune disorder, in which antibodies are
formed against presynaptic voltage-gated calcium channels, in the
neuromuscular junction. It is associated with Small cell carcinoma of lung, affects
males more than females, manifests as proximal limb weakness, and shows a
poor response to anticholinestserases.
8. E
Renal mass in renal cortex is reduced by 30 % at the age of 80, glomeruli are in
cortex . Renal blood flow is reduced by 10% per decade(maintain renal
perfusion, normovolemia). Progressive reduction of creatinine clearance-watch
our drugs eliminated through kidney (pancuronium 75%,rocuronium 25%)
Creatinine value is normal or low normal due to less muscle mass, not a good
predictor for kidney function in renal patients.
9. C
N Ach receptors reduced in NMJ and muscle mass is reduced.
Muscle mass progressively decreases in elderly people, and body fat increases
Total body water is decreased so:
1. The volume of distribution for water soluble drugs is decreased, which leads to
greater plasma concentrations. Lower doses of drugs are needed.
2. Volume of distribution for lipid soluble drugs is increased, and plasma
concentrations may be reduced. Elimination time is prolonged.
3. Duration of action is also affected by decline in hepatic function, reduction in
GFR and so clearance.
Distribution and elimination are also affected by altered protein binding. Level of
Albumin decreases with age (binds acidic drugs e.g., barbiturates,
benzodiazepines, opioid agonists).
Alpha1 - acid glycoprotein increases (which binds basic drugs e.g, local
anaesthetics).
MAC of inhalational agents is reduced by 4% per decade of age, after 40 years.
Onset of action is faster if cardiac output is depressed and is delayed if there is
significant ventilation/perfusion abnormality.
IV induction is slowed with low cardiac output.
10. D
1.The arterial system less compliant due to a loss in elastic tissue -increases after
load and BP
The venous system also less compliant, with a reduction in the strength of
smooth muscle contraction
2.The ventricle hypertrophies due to age & increased afterload.
3.Ventricular hypertrophy reduces ventricular compliance and increases LVEDP
and reduces early diastolic filling of the ventricle.
4.In the elderly due to vagal predominance , heart rate falls during exercise,
LVEDV increases (by 20–30%) but amount of blood ejected from left ventricle is
not proportionately increased,(refer starlings curve)
PARKINSON’S QUESTIONS:
1. During anaesthesia, a patient with Parkinson’s disease on levodopa

should not receive:
A. enflurane
B. fentanyl
C. morphine
D. droperidol
E. nitrous oxide
2. Extrapyramidal effects can be seen following the administration of:
A. chlorpropamide
B. terfenadine
C. metoclopramide
D. domperidone
E. perphenazine
3. Recognised causes of abnormal movements of the hands include:

A. respiratory failure
B. renal failure
C. chronic alcoholism
D. liver failure
E. depigmentation of substantia nigra
4. Oral drugs which can be used in the treatment of Parkinson’s disease as

first line agents are:
A. entacapone
B. Levodopa
C. Selegiline
D. Apomorphine
E. pethidine
5. Recognised features of Parkinson’s disease are:

A. rigidity
B. dry mouth
C. orthostatic hypotension
D. dysphagia
E. restrictive ventilatory defect
6. During anaesthesia, a patient with Parkinson’s disease on levodopa

should not receive:
a) enflurane
b) fentanyl
c) morphine
d) droperidol
e) nitrous oxide
PARKINSON’S ANSWERS:
1. F,F,F,T,F
2. F,F,T,T,T
3. T,F,T,T,T
4. F,T,T,F,F
Levodopa and selegiline can be used orally as single agents to treat Parkinson’s
disease. Entacapone is used in conjunction with levodopa- DDI. Pethidine should
not be used in patients on MAO type B inhibitors.
5. T,F,T,T,T
Rigidity is a feature of PD. PD results in excess saliva/ sialorrhoea. Orthostatic
hypotension can be due to PD itself, or due to the effects of dopaminergic or
anticholinergic agents used in PD. Respiratory muscle rigidity may result in a
restrictive ventilatory defect.
6. F,F,F,T,F

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Table of Contents

POA history taking

Additional Intermediate guidelines

Examples of typical co morbidities

Irregular heart rhythm

Cardiac training (as needed)

Geriatric training (as needed)

Investigations if not seen previously

Obstetric POA clinic for intermediate trainees

Compulsory Activity No. Assessment

Recommended Core topics to be covered

Recommended Activity No. Assessment

Recommended Intermediate topics to be covered

NICE guidelines on pre-operative investigations

No evidence in routine pre-op assessment or for stable cardiac disease

Future developments include:

The latest ACC/AHA guidelines recommend against coronary revascularisation

Indication for coronary angiogram includes:

2016 AAGBI Guideline: The measurement of adult blood pressure and

2014 ACC/AHA Guideline: Perioperative Cardiovascular Evaluation and

“Atrial Fibrillation: Management” - NICE

ICD function must be switched off during surgery

Identify PPM dependency:

MHRA 2006: “Guidelines for the perioperative management of patients with

1. INDICATION FOR PULMONARY FUNCTION TESTS

Routine use of PFT is not recommended in non-thoracic surgery, but it may

If GA, then artificial ventilation can be challenging due to:

3. INDENTIFICATION OF PULMONARY HTN

High-risk patients include:

Indication for Sliding scale (VRII)

Management of intra-operative Hyper-glycaemia:

Management of intra-operative Hypo-glycaemia:

Document causative agent if known

AMT Questions are as follows:

Alzheimers society has useful information.

See O DRIVE for Bucks Healthcare Guideline – “Anaemia investigation and

BCSH: “British Committee for Standards in Haematology Guidelines on the

European Society of Cardiology: “Guidelines in non-cardiac surgery”

2014 ACC/AHA: “Guideline on Perioperative cardiovascular evaluation”.

“Perioperative management of antiplatelet therapy”. BJA (2013) 111, i3-i17

Indication for Warfarin Therapy

DAY -5 DAY -4 DAY -3 DAY -2 DAY -1

DAY +1 +2 +3 POST PROCEDURE

For intermediate risk of perioperative thrombosis

Other high-risk groups for screening (local policy) include:

It is also important to understand the difference between preop suppression and

NICE CG74: “Surgical site infections: prevention and treatment”

Resumption of oral nutrition within 24 hours of surgery is well tolerated and

Y Ali Abdelhamid, M J Chapman & A M Deana. “Perioperative nutrition”.

Exercise is defined by the WHO. It is classified according to aerobic intensity

Objective exercise testing is recommended as part of the assessment for

Significant improvements can be seen in a 3 -4 week time frame.

How to change patient behavior

Durrand J, Hackett R, Yates D, Danjoux G. “Prehabilitation. Perioperative Medicine

Functional Walk Tests

Cardiopulmonary Exercise Test

Older P, Hall A, “Cardiopulmonary Exercise Testing as a Screening Test for

2014 ACC/AHA: “Guidelines on perioperative cardiovascular evaluation and

CVS Decreased sympathetic Labile blood pressure 

Pulmonary Increased pulmonary arterial Increased A-a gradient  