Introduction

INTRODUCTION

The stress of major surgery can lead to increased oxygen demand by up to 40%. Inflammatory changes due to cytokine release, endocrine responses, hypercoagulability and redistribution of fluid between compartments may last several postoperative days. The purpose of careful preoperative planning is to minimise the unwanted e ff ects of these physiological changes. Systematic history taking, examination and investigation at the preoperative clinic should include not only an assessment of functional reserve but also the form ulation of advice on optimisation, to best cope with the anticipated operative stress. Primary care physician records and hospital notes are useful sources of baseline information. Ideally a multidisciplinary team approach, including the primary care physician, specialist nurses, physiotherapist, dietician and perioperative physician, is utilised. This allows optimisation of chronic conditions, facilitates weight reduction and smoking cessation, and allows coordination of prehabilitation and postoperative rehabili- tation needs. The anaesthetist and surgeon must plan the safest anaesthetic technique and operation for the patient. A simple questionnaire can identify risk factors for patients undergoing surgery that will require specific tests or optimisation. Patients with severe comorbidities or undergoing high-risk surgery should be r eferred to specialists to quantify and reduce perioperative risks. The risks of surgery and Summary box 21.1 Preoperative plan for the best patient outcomes /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF anaesthesia and the e ff ects of comorbid conditions should be discussed so that the patient can make an informed decision. Patients should be given advice on preoperative fasting times, adjustments to regular medication and specific premedication at the preoperative visit. To enable the list to run smoothly on the day , key personnel involved in the list (surgeon, anaesthetist and senior theatre sta ff ) should be involved in planning the list order. The National Patient Safety Agency’s adaptation of the World Health Organization’s checklist recommends a ‘team brief ’ before the start of each list, which is also a valuable opportunity to share information with the theatre team and improve the safety of anaesthesia and surgery .

Gather and record all relevant information Optimise patient condition Choose surgery that offers minimal risk and maximum bene /f_i t Informed consent of the patient (see Chapter 14 ) Anticipate and plan for adverse events Adequate hydration, nutrition and exercise are advised Importance of critical care in management • Emergency cases • To be able to organise preoperative care and the operating list