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Role of critical care and outreach services Reports from the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) show that the majority of postoperative deaths in the UK occur more than 5 days after surgery . Admission to a critical care unit...

Valvular heart disease While anaesthetic management is altered to achieve haemo dynamic stability in moderate valvular diseases, patients with severe aortic and mitral stenosis may benefit from valvuloplasty before elective non-cardiac surgery . Appropriate ref...

ARRANGING AN ELECTIVE THEATRE LIST The date, place and time of operation should be matched with the availability of appropriately skilled personnel. Appropriate equipment and instruments should be made available. The operating list should be distributed as e...

ASSESSMENT OF RISK Despite more comorbid patients presenting for surgery , the perioperative mortality has decreased significantly over the last half century , especially in resource-rich countries. In a published systematic review in The Lancet by Bainbridge ...

Airway assessment The di ffi culty encountered when performing airway manoeu - vres, i.e. hand ventilation, intubation and front of neck access, can be predicted to some extent by simple examination. Failure to assess and plan airway management can have fatal co...

COMMON PREOPERATIVE PROBLEMS AND MANAGEMENT Specific medical problems encountered during preoperative assessment should be corrected to the best possible level. Many patients with severe disease will need to be referred to special - ists; the referral letter s...

CONSENT Consent is a key part of preoperative care. The process of consent has evolved over the years and, in the UK, is deter - mined by relevant Acts of Parliament, legal judgement and in detail in Chapter 14 .

Cardiopulmonary exercise testing CPET is the gold standard measurement of a patient’s fitness. The oxygen consumption (VO ) and carbon dioxide produc 2 tion (VCO ) of the patient are measured while they undergo 2 a 10-minute period of incrementally demanding ...

Cardiovascular disease Perioperative cardiovascular complications are frequent. Patients who can climb a flight of stairs without getting short - of breath, having chest pain or needing to stop are likely to tolerate a wide range of surgeries with an accepta...

Cerebral vascular disease Patients who have su ff ered a cerebrovascular accident have been shown to have a higher rate of MACE postoperatively . This is highest in the first 3 months after a stroke. The urgency of surgery needs to be discussed with the surgeo...

Choosing the right operation for the high-risk patient There are situations in which the selection of one surgical technique over another may be significantly influenced by patient risk factors. Some procedures are not primarily high risk but may become so in u...

Drug-eluting coronary stents (DES) Primary percutaneous intervention is the treatment of choice for acute coronary syndromes, and many patients receive stents and are on dual antiplatelet therapy for 12 months. If surgery is absolutely necessary within the pe...

Dysrhythmias In patients with atrial fibrillation (AF), β -blockers, digoxin or calcium channel blockers should be continued in order to control rate. New AF or atrial flutter should be investigated and treated. These patients should be considered for cardiovers...

EMERGENCY SURGERY In emergency surgery the principles of preoperative assessment should be the same as in elective surgery , except that the opportunity to optimise the condition of the patient is limited by time constraints. The urgency of surgery should b...

Endocrine and metabolic disorders Malnutrition Body mass index (BMI) is weight in kilograms divided by height in metres squared. A BMI of less than 18.5 indicates nutritional impairment and a BMI below 15 is associated with Thomas Addison , 1795–1860, physici...

Examination Patients should be treated with respect and dignity , receive a clear explanation of the examination undertaken and be kept as comfortable as possible. A chaperone should be present, especially for intimate examinations. This should be part of a ...

FURTHER READING Bainbridge D, Martin J, Arango M, Cheng D; for the Evidence-based Peri-operative Clinical Outcomes Research (EPiCOR) Group. Perioperative and anaesthetic-related mortality in developed and developing countries: a systematic review and meta-anal...

Factors contributing to risk Risk is a complex interaction of multiple factors that can be classified into patient and surgical factors. Patient factors are listed in Table 21.6 . The elderly , although not independently at higher risk, not only have more card...