Pre-operative assessment and optimisation — structured SAQ (15 marks)

(a) Lee Revised Cardiac Risk Index — calculation and risk (3 marks)

One mark for naming the six components, one mark for correctly identifying which components this patient has, one mark for the risk estimate. ^[1]

• The six RCRI components (one point each): high-risk surgery, ischaemic heart disease, heart failure, cerebrovascular disease, insulin-treated diabetes, and pre-operative creatinine above 177 micromol per litre.
• This patient's score: ischaemic heart disease (previous MI) — 1 point; cerebrovascular disease (previous stroke) — 1 point; insulin-treated diabetes — 1 point; creatinine 158 micromol per litre — below the 177 micromol per litre threshold — 0 points. Total score 3.
• Approximate risk of major cardiac complication: score 3 corresponds to approximately 11 percent risk of major cardiac complication (death, MI, pulmonary oedema, complete heart block, ventricular arrhythmia). Class 0 — 0.4 percent; class 1 — 1.0 percent; class 2 — 2.4 percent; class 3 and above — 5.4 to 11 percent.
• Functional capacity matters: she reports she cannot climb two flights of stairs — METs below 4 — which is itself a cardiac risk marker and supports further assessment.

(b) ARISCAT score — calculation and threshold (4 marks)

One mark per variable identified, one mark for the threshold. ^[2]

• Age 50 to 80 — 3 points.
• Pre-operative SpO2 96 percent or lower — 8 points (the case describes a current smoker with airway risk; assume measured SpO2 by this point).
• Pre-operative anaemia Hb under 100 g per litre — 11 points (her Hb is 96 g per litre).
• Upper abdominal or thoracic surgery — 15 points (laparotomy for hysterectomy is lower abdominal, but the gynaecological reference places it in the moderate-risk category; award 0 points if judged correctly).

Other variables are 0 in this case: no respiratory infection in the last month (0); surgery duration not prespecified; not emergency surgery (0). Score 3 + 8 + 11 = 22 points (or 3 + 8 + 11 + 15 = 37 if the procedure is classed as upper abdominal — examiner discretion). ^[2]

• ARISCAT risk categories: low risk under 26 points; intermediate 26 to 44 points; high risk 45 or above (out of 123 maximum). The threshold for high risk is 45 points. ^[2]

(c) The four pillars of optimisation (5 marks)

One mark per pillar with at least one named intervention, dose, and timing. Bonus mark for cross-pillar integration. ^[4][5][8][9]

• Anaemia. Hb 96 g per litre with ferritin 22 microgram per litre is iron deficiency. Give intravenous iron isomaltoside or ferric carboxymaltose 1000 mg as a single infusion at the pre-admission visit; reticulocytosis in 7 to 10 days, Hb response in 4 to 6 weeks. Oral iron is poorly tolerated and 3 weeks is too short for full response. Recheck Hb on the day of surgery; aim for 100 g per litre or above; transfusion is reserved for Hb under 70 to 80 g per litre or symptomatic patients.
• Diabetes. HbA1c is not given but the patient is on metformin and insulin — assume poor control. Check HbA1c; if above 8.5 to 9 percent, defer surgery if non-urgent and refer to endocrinology. If 7 to 8.5 percent, proceed with caution, hold metformin on the day of surgery, continue basal insulin at 80 percent of usual dose, and stop SGLT2 inhibitors 3 days prior. Aim for morning glucose under 10 mmol per litre on day of surgery.
• Smoking. Brief structured counselling combined with nicotine replacement therapy (or varenicline if NRT failed previously). Cessation of 4 weeks or more reduces postoperative complications by approximately 50 percent; even 24 hours reduces carboxyhaemoglobin. The pre-admission clinic is the teachable moment — book a quitline referral and provide written information.
• Functional capacity. She cannot climb two flights of stairs — METs below 4. Refer to physiotherapy for a supervised prehabilitation programme of aerobic exercise, resistance training, and inspiratory muscle training, ideally 4 to 6 weeks before surgery. Combine with nutrition optimisation (protein 1.2 g per kg per day) and psychological preparation. In addition, given that RCRI score 3 places her at high cardiac risk, refer to cardiology for consideration of stress testing and risk stratification.

(d) Fasting and the WHO Surgical Safety Checklist (3 marks)

One mark for the 2-4-6 fasting rule with an example, one mark for the three phases of the WHO checklist, one mark for the timing of each phase. ^[3][5]

• Fasting — the 2-4-6 rule per ANZCA PG07: clear fluids 2 hours, breast milk 4 hours, formula or light meal 6 hours. Pre-operative carbohydrate loading (12.5 percent maltodextrin drink, 800 mL the night before and 400 mL 2 to 3 hours before surgery) is part of ERAS.
• WHO Surgical Safety Checklist — three phases:
  • Sign In — before induction of anaesthesia, led by the anaesthetist; identity, site, procedure, consent, site marked, anaesthetic safety, pulse oximeter, allergy, airway, aspiration risk, blood-loss risk.
  • Time Out — before skin incision, led by the surgeon; team introduces themselves by name and role, confirm patient, procedure, site, antibiotic prophylaxis given, imaging displayed.
  • Sign Out — before the patient leaves theatre, led by the nurse; procedure recorded, instrument and swab count, specimen labelling, equipment issues, recovery concerns, key recovery plans.