Perioperative Medicine ✅

🏥 Perioperative medicine is the medical care of patients before, during and after surgery. It aims to reduce complications, optimise long-term conditions, support shared decision-making and improve recovery.

📖 Overview

• Perioperative care starts when surgery is planned and continues through discharge and recovery.
• It applies to elective, urgent and emergency surgery.
• Key goals are risk assessment, optimisation, informed consent, complication prevention and early recognition of deterioration.
• It requires close working between surgeons, anaesthetists, physicians, nurses, pharmacists, therapists and primary care.

🎯 Core Aims

• Assess surgical, anaesthetic and medical risk.
• Optimise comorbidities before surgery where possible.
• Plan medication changes, VTE prophylaxis, fluids, nutrition and rehabilitation.
• Support shared decision-making, including alternatives and the option of no surgery.
• Detect and treat postoperative complications early.

⚠️ Patients at Higher Risk from Surgery

🛠️ Pre-optimisation Before Surgery

• Recent chest infection: elective surgery may need postponing after significant lower respiratory infection, especially with fever, productive cough, wheeze, antibiotics or ongoing symptoms. Many pathways use a practical 4–6 week delay, depending on severity, urgency and local policy.
• Smoking: smoking increases perioperative respiratory complications, wound infection, poor tissue oxygenation, cardiovascular events and delayed healing. Encourage stopping as early as possible before surgery.
• Exercise capacity: poor functional capacity increases perioperative risk. Ability to perform about 4 METs, such as climbing a flight of stairs or walking uphill, suggests better physiological reserve.
• Anaemia: check FBC before major surgery or expected blood loss. Investigate and treat iron deficiency, B12/folate deficiency, renal disease or inflammatory causes before elective surgery where possible.
• Diabetes: check recent HbA1c. A pragmatic target is HbA1c <69 mmol/mol or <8.5% where safely achievable.
• Prehabilitation: optimise exercise, nutrition, smoking, alcohol intake, mood and comorbidities to improve resilience before surgery.

📊 Perioperative Scoring Systems

🚦 CEPOD / NCEPOD Categories

👵 Frailty and Functional Reserve

• Frailty predicts poor surgical outcomes better than age alone.
• It increases risk of delirium, falls, prolonged admission, institutional care and mortality.
• Screen older or complex patients using a validated tool such as the Clinical Frailty Scale.
• Consider comprehensive geriatric assessment for frailty, multimorbidity, cognitive impairment or complex discharge needs.
• Discuss realistic outcomes, escalation plans, ceiling of care and postoperative rehabilitation early.

🩸 Anaemia and Transfusion

• Preoperative anaemia is associated with higher morbidity, transfusion requirement and poorer recovery.
• Use patient blood management: optimise haemoglobin, minimise blood loss and transfuse appropriately.
• In stable adults, consider red cell transfusion around Hb 70 g/L, aiming for 70–90 g/L.
• In acute coronary syndrome, a higher threshold may be used, commonly around Hb 80 g/L, aiming for 80–100 g/L.
• Thresholds must be individualised in active bleeding, symptoms, cardiac disease and local policy.

🍬 Diabetes

• Aim for safe glycaemic control while avoiding hypoglycaemia.
• Check HbA1c before elective surgery where diabetes is known or suspected.
• A pragmatic preoperative target is HbA1c <69 mmol/mol or <8.5% where safely achievable.
• Poor control increases infection risk, delayed wound healing, dehydration and metabolic complications.
• Plan perioperative adjustment of insulin, sulfonylureas, SGLT2 inhibitors, GLP-1 receptor agonists and metformin according to local guidance.
• Monitor capillary blood glucose perioperatively and treat hyperglycaemia or hypoglycaemia promptly.

💊 Medication Review

🫁 Respiratory Optimisation

• Assess smoking status, COPD, asthma, obstructive sleep apnoea and recent respiratory infection.
• Optimise inhalers and treat acute exacerbations before non-urgent surgery.
• Encourage smoking cessation as early as possible before surgery.
• Consider chest physiotherapy, breathing exercises and early mobilisation after surgery.

❤️ Cardiovascular Optimisation

• Identify unstable cardiac disease such as recent MI, unstable angina, decompensated heart failure or severe valve disease.
• Assess blood pressure, rhythm, symptoms, exercise tolerance and volume status.
• Poor functional capacity, active cardiac symptoms or major surgery may require senior anaesthetic/medical review.
• Postoperative myocardial injury may be silent, especially in older patients and people with diabetes.

🧪 Preoperative Tests

• Tests should be targeted to the patient, operation and comorbidities — not performed routinely for everyone.
• Consider FBC, U&E, LFTs, coagulation screen, ECG, HbA1c, group and save, pregnancy test or chest imaging where clinically indicated.
• Testing should answer a clinical question or change management.

🦵 VTE Prophylaxis

• Assess both VTE risk and bleeding risk for hospitalised surgical patients.
• Use early mobilisation, hydration and mechanical prophylaxis where appropriate.
• Pharmacological prophylaxis is commonly with low molecular weight heparin unless contraindicated.
• Duration depends on procedure type, mobility, bleeding risk and local protocol.
• Reassess VTE and bleeding risk if the clinical situation changes.

🦠 Infection Prevention

• Use surgical antimicrobial prophylaxis only when indicated and at the correct time before incision.
• Optimise glucose control, skin preparation, temperature management and wound care.
• Remove urinary catheters and invasive lines as soon as clinically appropriate.
• Recognise sepsis early in the postoperative period.

💧 Fluids and AKI Prevention

• Patients are vulnerable to dehydration, bleeding, hypotension and nephrotoxic drug exposure.
• Monitor fluid balance, blood pressure, urine output, creatinine and electrolytes.
• Avoid both under-resuscitation and fluid overload.
• Review nephrotoxic drugs such as NSAIDs, ACE inhibitors, ARBs, diuretics and contrast exposure in high-risk patients.

😵 Delirium Prevention

• Older patients and those with dementia, frailty, infection, pain or polypharmacy are at higher risk.
• Prevent delirium by treating pain, avoiding constipation and urinary retention, supporting sleep, hydration, glasses, hearing aids and orientation.
• Avoid unnecessary sedatives and anticholinergic medicines.
• New confusion after surgery should trigger assessment for infection, hypoxia, pain, urinary retention, constipation, metabolic disturbance and drug effects.

🤢 Postoperative Nausea and Vomiting: PONV

• PONV can delay eating, drinking, mobilisation and discharge.
• It may cause dehydration, electrolyte disturbance, distress, wound pain and rarely wound complications.
• Risk is increased by patient factors, anaesthetic technique, opioid use and some types of surgery.

📊 Apfel Risk Score for PONV

• Higher Apfel score means higher PONV risk.
• Use multimodal prevention in higher-risk patients: adequate hydration, opioid-sparing analgesia and prophylactic antiemetics.
• Common antiemetics include ondansetron, dexamethasone, cyclizine, prochlorperazine or droperidol depending on patient factors and local policy.

🛌 Postoperative Care

• Monitor observations, pain, sedation, wound status, fluid balance, oxygen requirement and urine output.
• Escalate early if there is hypotension, tachycardia, hypoxia, oliguria, fever, bleeding or worsening confusion.
• Encourage early mobilisation, nutrition, bowel care and respiratory exercises.
• Plan discharge early, including medications, VTE prophylaxis, wound care, follow-up and safety-netting.

🚨 Important Postoperative Complications

🗣️ Shared Decision-Making

• Discuss expected benefits, risks, alternatives and the option of no surgery.
• Explain likely recovery time, complications and impact on independence.
• For high-risk patients, discuss critical care, escalation plans, resuscitation status and treatment ceilings where appropriate.
• Document the discussion clearly.

⚠️ Red Flags After Surgery

• Persistent hypotension or tachycardia.
• New oxygen requirement or respiratory distress.
• Chest pain, collapse or suspected PE.
• Reduced urine output or rising creatinine.
• New confusion, drowsiness or agitation.
• Severe pain out of proportion to findings.
• Fever, rigors, wound discharge or signs of sepsis.
• Unexpected bleeding or rapidly falling haemoglobin.

🧠 Exam Pearls

• Perioperative medicine is not just “fitness for surgery”; it is whole-pathway risk reduction.
• Frailty often predicts poor surgical outcomes better than age alone.
• About 4 METs of exercise capacity suggests better physiological reserve.
• HbA1c <69 mmol/mol is a useful pragmatic target before elective surgery where safely achievable.
• Postoperative confusion is delirium until proven otherwise — look for reversible causes.
• Preoperative anaemia should be investigated and treated before major elective surgery where possible.
• Use ASA, POSSUM/P-POSSUM, Clinical Frailty Scale and Apfel score to structure risk assessment.
• CEPOD categories help describe urgency: immediate, urgent, expedited and elective.

✅ Key message: Perioperative medicine improves surgical outcomes by identifying risk early, optimising comorbidities, preventing complications and supporting safe recovery.