Perioperative Medicine — Physician Assessment and Optimisation Before Surgery

Your progress

Saved on this device.

Target exams

Red flags

• Initiating a beta-blocker on the morning of surgery in a beta-blocker-naive patient — POISE showed increased stroke and mortality from perioperative hypotension and bradycardia; continue existing beta-blockers but do not start them acutely pre-op
• Stopping aspirin in a patient with a recent coronary stent — stent thrombosis and fatal MI; continue aspirin through surgery unless bleeding risk is extreme, and never stop dual antiplatelet therapy within the minimum stent period
• Continuing an SGLT2 inhibitor into surgery — euglycaemic diabetic ketoacidosis under fasting and surgical stress; stop SGLT2 inhibitors 3 days before elective surgery
• Using a sliding-scale insulin regimen perioperatively — obsolete and associated with poor glycaemic control and hyperglycaemia; use a variable-rate intravenous insulin infusion (VRIII) with glucose–potassium–insulin monitoring when insulin is required
• Failing to bridge high-thrombotic-risk warfarin patients (mechanical valve, recent VTE, AF with rheumatic disease) — catastrophic thrombosis; bridge with LMWH when the annual thrombotic risk is high
• Withholding VTE prophylaxis in a high-Caprini surgical patient — DVT and fatal PE; the commonest preventable cause of perioperative death is venous thromboembolism
• Reversing warfarin with vitamin K alone for major bleeding — too slow; give 4-factor PCC plus intravenous vitamin K for life-threatening bleeding, because PCC reverses within minutes while vitamin K takes 6 to 12 hours to work
• Pursuing coronary revascularisation purely to 'clear for surgery' in an asymptomatic patient — the CARP trial showed no benefit; revascularise only for cardiac indications that would mandate it independent of surgery