Pre-operative assessment and optimisation — structured oral station (12 minutes)

Opening prompt — "Walk me through your pre-operative assessment of this patient."

Model response, in this order: ^[1][4][8]

• "I would structure this as a risk-stratification exercise — assign the ASA Physical Status, score the Lee RCRI, calculate the ARISCAT, and complete the Caprini. Then I would tailor the optimisation plan to the four pillars and the day-of-surgery preparation."
• "Her ASA is class 3 — severe systemic disease without current incapacity. The Lee RCRI is 1 point for ischaemic heart disease; her creatinine 144 micromol per litre is below the 177 micromol per litre threshold; she is not on insulin — the history states metformin alone, so diabetic component is 0. Total RCRI 1, approximate cardiac risk around 1 percent. Functional capacity is a METs modifier — I would ask about stairs."
• "Her ARISCAT score: age 60 — 3 points; pre-operative anaemia Hb 96 g per litre — 11 points; smoker. Total 14 points — low risk, but the anaemia is the modifiable signal."
• "Caprini: age 60, BMI 33, prior DVT, planned major surgery — easily score 5 or more, so extended prophylaxis for 28 to 35 days after surgery."

Examiner is listening for: structure, the named scores, and the immediate identification of the modifiable risks. ^[1][2]

Probe 1 — "Her Hb is 96 g per litre and ferritin is 24. What do you do?"

• "Iron deficiency. The Ferraro consensus and the 2017 international consensus on perioperative anaemia define iron deficiency as ferritin under 30 microgram per litre, or ferritin under 100 microgram per litre with transferrin saturation below 20 percent. She qualifies on both counts."
• "I would offer 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."
• "I would not give oral iron — she has at least 3 to 4 weeks to surgery, but oral iron is often poorly tolerated, and the IV route brings iron stores up faster and reliably. Transfusion is reserved for Hb under 70 to 80 g per litre or symptomatic patients."^[4]

Probe 2 — "She has had a previous DVT. What changes about the VTE plan?"

• "Caprini 5 or more — extended prophylaxis for 28 to 35 days with LMWH. Enoxaparin 40 mg subcutaneously daily is a typical Australian dose, adjusted for renal function and weight."
• "Bridging: she is not on anticoagulation currently, so no bridging is needed. If she is on warfarin — and she is not — it would be stopped 5 days preoperatively with LMWH bridging when INR is subtherapeutic, and resumed 24 to 48 hours postoperatively when haemostasis is secure."
• "Mechanical prophylaxis with intermittent pneumatic compression and anti-embolism stockings from induction until discharge, in addition to pharmacologic prophylaxis."^[8]

Probe 3 — "She smokes 12 cigarettes a day. What do you say to her?"

• "I would offer structured brief counselling combined with nicotine replacement therapy. The Thomsen 2009 Cochrane review and subsequent trials show that cessation of 4 weeks or more reduces postoperative complications by approximately 50 percent."
• "Even 24 hours of abstinence reduces carboxyhaemoglobin and improves oxygen delivery. The pre-admission clinic is the teachable moment — I would refer her to the quitline, provide written information, and arrange follow-up."
• "I would not ask her to quit alone; behavioural support combined with pharmacotherapy is the intervention that works."^[6]

Probe 4 — "What are the three phases of the WHO Surgical Safety Checklist, and who leads each?"

• "Sign In — before induction of anaesthesia, led by the anaesthetist. Confirm 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, imaging."
• "Sign Out — before the patient leaves theatre, led by the nurse. Confirm procedure recorded, instrument and swab count, specimen labelling, equipment issues, recovery concerns."^[3]

Probe 5 — "What is the fasting instruction for the day of surgery?"

• "The 2-4-6 rule per ANZCA PG07: clear fluids 2 hours, breast milk 4 hours, formula or light meal 6 hours. Carbohydrate loading with 12.5 percent maltodextrin drink 800 mL the night before and 400 mL 2 to 3 hours before surgery is part of ERAS."^[8]

Probe 6 — "She is on metformin. What about her diabetes management on the day of surgery?"

• "HbA1c is not given — I would check it. If above 8.5 to 9 percent, defer surgery if non-urgent. If 7 to 8.5 percent, proceed with caution."
• "On the day of surgery: hold metformin; continue basal insulin at 80 percent of usual dose; stop SGLT2 inhibitors 3 days prior; aim for morning glucose under 10 mmol per litre. The POISE-2 trial and the 2014 ACC/AHA guideline support omitting aspirin without a coronary stent; I would not start a beta-blocker on the day of surgery."^[7]

Probe 7 — "She is anxious about the surgery and asks whether it is safe. How do you respond?"

This is a scored domain, not a courtesy. Demonstrate it out loud. ^[8]

• Move to her eye level, use her name, and be plain: "There are several things we can do between now and surgery to make this safer. We can build your iron with an infusion today, help you stop smoking, and start a walking and breathing program. We will plan your diabetes, your blood-thinning injections, and your recovery together."
• Be honest without forecasting: "No surgery is risk-free, but the team has a written plan to reduce each risk, and we will walk it through with you."
• Plain language, avoid jargon, invite questions, and commit to a follow-up visit.