Essential Notes for MRCS - Book 2(A)

Contents

Acknowledgements
Preface
Picture Permissions
Contributors
Introduction


Chapter 1 Perioperative care

Tristan E McMillan

Chapter 2 Surgical technique and technology

David Mansouri

Chapter 3 Postoperative management and critical care

Hayley M Moore and Brahman Dharmarajah

Chapter 4 Infection and inflammation

Claire Ritchie Chalmers

Chapter 5 Principles of surgical oncology

Sylvia Brown

Chapter 6 Trauma
Part 1: head, abdomen and trunk

George Hondag Tse

Head injury Paul Brennan
Burns: Stuart W Waterston

Chapter 6 Trauma
Part 2: musculoskeletal trauma

Nigel W Gummerson

Chapter 7 Evidence-based surgical practice

Nerys Forester

Chapter 8 Ethics, clinical governance and the medicolegal aspects of surgery

Sebastian Dawson-Bowling

Chapter 9 Orthopaedic Surgery

Nigel W Gummerson

Chapter 10 Paediatric surgery

Stuart J O’Toole, Juliette Murray, Susan Picton and David Crabbe

Chapter 11 Plastic Surgery

Stuart W Waterston

List of Abbreviations
Bibliography
Index

Acknowledgements

I would like to thank everyone who has worked so hard to complete this book – Cathy Dickens and the
PasTest team. Thanks especially to my fellow editor, Cathy, whose excellent teaching eased my early
passage through basic surgical training and whose subsequent advice, friendship and joie de vivre is
invaluable.
I have been fortunate enough to be surrounded by fantastic friends and colleagues. There are too many to
list by name (but you know who you are) and I appreciate all your support.
Thanks also to my family and, last, but certainly not least, thanks to my husband Roy for backing me up
and making me laugh – a constant and irreplaceable source of patience and good cheer.

Preface

This book is an attempt to help surgical trainees pass the MRCS exam by putting together the revision
notes they need. It was written (in the main) and edited by trainees for trainees and while we do not claim
to be authorities on the subjects by any means, we hope to save you some work by expanding our own
revision notes and putting them in a readable format. Originally written when we were SHOs, as time has
passed and we have ourselves climbed the surgical ladder, we have updated the text but have tried to
keep the style of the books as accessible and informal as possible. Medical students interested in surgery
may also find it a good general introduction to the surgical specialties.

Now in its third incarnation we have refined this edition further to cover the evolving MRCS syllabus in
two volumes. These two books have been designed to be used in conjunction with the existing PasTest
MRCS Part B OSCEs volume. Although the format of surgical examinations in the UK has changed to
include OSCE assessment, the principles of core surgical knowledge remain the same, and often a good
exam answer starts with a structured summary followed by expansion of individual points. We have,
therefore, arranged each topic in this format, and we have used boxes, bullet points and diagrams to
highlight important points. There is additional space around the text for you to annotate and personalise
these notes from your own experience.

My dad is fond of saying that the harder you work, the luckier you get, and I have always found this to be
true – so GOOD LUCK!

Ritchie Chalmers

Picture Permissions

The following figure in this book has been reproduced with kind permission of Professor Kenneth D
Boffard of the University of the Witwatersrand, Johannesburg.

Trauma
Fig 6.4 The metabolic response to trauma

The following figures in this book have been reproduced from Chesser TJS and Leslie IJ (1998)
‘Forearm fractures’, Surgery 16(11): 241–248 by kind permission from the publisher The Medicine
Publishing Group (Elsevier).

Trauma
Fig 6.22 Smith’s fracture
Fig 6.23 Volar fracture
Fig 6.27 Salter–Harris classification

The following figures in this book have been reproduced from Calder SJ (1998) ‘Fractures of the hip’
Surgery 16(11): 253–258 by kind permission of the publisher The Medicine Publishing Group (Elsevier).

Trauma
Fig 6.24 Blood supply of the femoral head
Fig 6.25 Garden’s classification of intracapsular fractures
Fig 6.26 Extracapsular fractures

The following figures in this book have been reproduced from Snell RS (2000) Clinical Anatomy for
Medical Students (6th edition) by kind permission of the publisher Lippincott Williams and Wilkins
(Wolters Kluwer).

Orthopaedic Surgery
Fig 7.7 Femoral triangle and adductor canal in the right lower limb
Fig 7.17 Formation of the neural tube (transverse section) in week 3 of gestation
Fig 7.18 Formation of the neural tube (dorsal view) at days 22 and 23
Fig 7.22 Cervical vertebrae shown from above
Fig 7.25 Some of the intrinsic muscles of the back
Fig 7.30 Some important tendon reflexes

The following figures in this book have been reproduced from Snell RS (1986) Clinical Anatomy for
Medical Students (3rd edition) by kind permission of the publisher Lippincott Williams and Wilkins

(Wolters Kuwer).

Orthopaedic Surgery
Fig 7.2 Muscles attached to the external surface of the right hip
Fig 7.9 Boundaries and contents of the right popliteal fossa
Fig 7.13 Brachial plexus
Fig 7.23 A lateral view of the vertebral column and general features of different kinds of vertebrae
Fig 7.24 Some of the extrinsic muscles of the back
Fig 7.31 Efferent part of autonomic nervous system

The following figure in this book has been reproduced from Dykes MI (2003) Crash Course: Anatomy
(2nd edition) by kind permission of the publisher Elsevier.

Orthopaedic Surgery
Fig 7.3 Gluteal region

The following figure in this book has been reproduced from Faiz O, Blackburn S, Moffat D (2011)
Anatomy at a Glance (3rd edition) by kind permission of the publisher Wiley-Blackwell.

Orthopaedic Surgery
Fig 7.4 The greater and lesser sciatic foramina

The following figures in this book have been reproduced from McRae R (1996) Clinical Orthopaedic
Examination by kind permission from the publisher Churchill Livingstone (Elsevier).

Orthopaedic Surgery
Fig 7.11 Anatomy of the foot
Fig 7.21 Schematic diagram of the vertebra and spinal cord

The following figures in this book have been reproduced from Sadler TW, Langman J (1990) Langman’s
Medical Embryology (6th edition) by kind permission of the publisher Lippincott Williams and Wilkins
(Wolters Kluwer).

Paediatric Surgery
Fig 8.1 Sagittal section through the embryo showing formation of the primitive endodermline gut
Fig 8.2 Formation of the GI tract at week 4 of gestation showing foregut, midgut and hindgut
Fig 8.3 The foregut during week 4 of gestation
Fig 8.5 The cloacal region at successive stages in development
Fig 8.8 Transverse section of diaphragm at fourth month of gestation
Fig 8.11 The development of the urinary tract at week 5
Fig 8.12 Development of the urogenital sinus
Fig 8.13 Descent of the testis

Every effort has been made to contact holders of copyright to obtain permission to reproduce

copyright material. However, if any have been inadvertently overlooked, the publisher will be
pleased to make the necessary arrangements at the first opportunity.

Contributors

Editors
Claire Ritchie Chalmers BA PhD FRCS
Consultant Breast and Oncoplastic Surgeon, Maidstone and Tunbridge Wells NHS Trust Infection and
Inflammation

Catherine Parchment Smith BSc(Hons) MBChB(Hons) FRCS
Consultant Colorectal Surgeon, Mid Yorkshire Hospitals NHS Trust

Contributors
David C G Crabbe MD FRCS
Consultant Paediatric Surgeon, Department of Paediatric Surgery, Leeds General Infirmary, Leeds
Paediatric Surgey

Brahman Dharmarahah MA MBBS MRCS
Clinical Research Fellow, Academic Section of Vascular Surgery, Imperial College and Charing Cross
Hospital, London Postoperative Management and Critical Care

Paul M Brennan BSc (Hons) MB BChir MRCS
ECAT Clinical Lecturer, Honorary Specialist Registrar Neurosurgery, Edinburgh Cancer Research
Centre, University of Edinburgh Department of Clinical Neurosciences, NHS Lothian
Trauma Part 1: Head, Abdomen and Trunk – Head injury

Sylvia Brown MD MRCS MBChB
ST7 in General Surgery, South General Hospital, Glasgow
Principles of Surgical Oncology

Sebastian Dawson-Bowling MA MSc LLM FRCS(Tr&Orth)
Consultant Orthopaedic Surgeon, St. George’s Hospital, London Ethics, Clinical Governance and the
Medicolegal Aspects of Surgery

Nerys Forester BA BM BCh MRCS FRCR PhD
Consultant Breast Radiologist, Royal Victoria Infirmary, Newcastle, Tyne & Wear Evidence-based
Surgical Practice

Nigel W Gummerson MA FRCS
Consultant Orthopaedic Trauma and Spinal Surgeon. Department of Orthopaedics and Trauma, Leeds

General Infirmary, Leeds Orthopaedic Surgery; Trauma Part 2:Musculoskeletal

David Mansouri BSc(Med Sci) MBChB MRCS
ST3 General Surgery, Professorial Unit, Western Infirmary,Glasgow
Surgical Technique and Technology

Tristan McMillan MBChB
Core Surgical Trainee, Department of Plastic Surgery, Glasgow Royal Infirmary, Glasgow Perioperative
Care

Hayley M Moore MA MBBS MRCS
Clinical Research Fellow, Academic Section of Vascular Surgery, Imperial College, London
Postoperative Management and Critical Care

Juliette Murray MBChB, MD, FRCS (Gen Surg)
Consultant Surgeon, Wishaw General Hospital, North Lanarkshire

Stuart J O’Toole MD FRCS(Paeds) FEAPU
Consultant Paediatric Surgeon and Urologist, Department of Surgical Paediatrics, Royal Hospital for Sick
Children, Glasgow Paediatric Surgery

Susan Picton BM BS FRCPCH
Consultant Paediatric Oncologist, Leeds Teaching Hospitals Trust, Leeds Paediatric Surgery

George Hondag Tse MSc MRCSEd MBChB BSc (Hons)
Clinical Research Fellow, Centre for Inflammation Research, University of Edinburgh Trauma Part 1:
Head, Abdomen and Trunk

Stuart W Waterston BScMedSci(Hons), MBChB, PGCertMedEd, FRCSEd(Plast)
Fellow in Plastic Surgery/Hand Surgery, Department of Plastic Surgery, St Andrews Centre for Plastic
Surgery & Burns, Broomfield Hospital, Chelmsford Plastic Surgery; Trauma Part 1: Head, Abdomen
and Trunk – Burns

Contributors to previous editions

Sam Andrews MA MS FRCS (Gen)
Consultant General and Vascular Surgeon, Department of General and Vascular Surgery, Maidstone
Hospital, Maidstone Amer Aldouri MBChB MRCS
Specialist Registrar in Hepatobiliary and Transplantation Surgery, Hepatobiliary and Transplantation
Surgery Unit, St James University Hospital, Leeds David Crabbe MD FRCS
Consultant Paediatric Surgeon, Clarendon Wing, Leeds General Infirmary, Leeds Nerys Forester
Specialist Registrar in Clinical Radiology, Yorkshire Deanery

Sheila M Fraser MBChB MRCS
Clinical Research Fellow, Institute of Molecular Medicine, Epidemiology & Cancer Research, St.
James’s University Hospital, Leeds Sunjay Jain MD FRCS (Urol)
Clinical Lecturer in Urology, University of Leicester, Leicester Shireen N. McKenzie MB.ChB
MRCS(Ed)
Specialist Registrar in General Surgery, Airdale General Hospital, Keighley, West Yorkshire Professor
Kilian Mellon MD FRCS (Urol)
Professor of Urology, University of Leicester, Leicester

Sally Nicholson BSc MBChB
Senior House Officer in Yorkshire School of Surgery, ENT Department, Leeds General Infirmary, Leeds
Susan Picton BM BS FRCPCH
Consultant Paediatric Oncologist, Leeds Teaching Hospitals Trust, Leeds Catherine Sargent BM BCh
(Oxon) MRCP
Specialist Registrar in Infectious Diseases/General Medicine, The John Radcliffe Hospital, Oxford
James Brown MRCS
Specialist Registrar in Surgery, South East Thames Surgical Rotation Neoplasia

Alistair R K Challiner FRCA FIMC.RCSEd DCH
Consultant Anaesthetist and Director Intensive Care Unit, Department of Anaesthetics, Maidstone
Hospital, Maidstone, Kent Intensive Care and Peri-operative Management 1

Nicholas D Maynard BA Hons (OXON) MS FRCS (Gen)
Consultant Upper Gastrointestinal Surgeon, Department of Upper Gastrointestinal Surgery, John Radcliffe
Hospital, Headington, Oxford Peri-operative Management 2

Gillian M Sadler MBBS MRCP FRCR

Consultant Clinical Oncologist, Kent Oncology Centre, Maidstone Hospital, Maidstone, Kent Neoplasia

Hank Schneider FRCS (Gen. Surg)
Consultant General Surgeon, Department of Surgery, The James Paget Hospital, Great Yarmouth, Norfolk
Trauma

Introduction

A The Intercollegiate MRCS Examination

The Intercollegiate MRCS examination comprises two parts: Part A (MCQ) and Part B (OSCE) Part A
(written): Multiple Choice Questions (MCQ)
Part A is a 4-hour MCQ examination consisting of two 2-hour papers taken on the same day. The papers
cover generic surgical sciences and applied knowledge, including the core knowledge required in all nine
specialties. The marks for both papers are combined to give a total mark for Part A although there is also
a minimum pass mark for each paper. There are no limits to the number of times that you can attempt this
part of the exam.

Paper 1 – Applied Basic Sciences MCQ paper Paper 2 – Principles of Surgery-in-General MCQ paper
There are 135 questions per paper and two styles of question. The first type of question requires a single
best answer. Each question contains five possible answers of which there is only one single best answer.
An example of this type of question from the college website is: A 67-year-old woman is brought to the
emergency department having fallen on her left arm.

There is an obvious clinical deformity and X-ray demonstrates a mid-shaft fracture of the humerus. She
has lost the ability to extend the left wrist joint. Which nerve has most likely been damaged with the
fracture?

A The axillary nerve
B The median nerve
C The musculocutaneous nerve
D The radial nerve
E The ulnar nerve

The second type of question is an extended matching question. Each theme contains a variable number of
options and clinical situations. Only one option will be the most appropriate response to each clinical
situation. You should select the most appropriate option. It is possible for one option to be the answer to
more than one of the clinical situations. An example of this type of question from the college website
shown overleaf.

Theme: Chest injuries

Options

A Tension pneumothorax
B Aortic rupture
C Haemothorax
D Aortic dissection
E Ruptured spleen
F Cardiac tamponade

For each of the situations below, select the single most likely diagnosis from the options listed above.
Each option may be used once, more than once or not at all.


. A 24-year-old man is brought into the emergency department having been stabbed with a screwdriver. He

is conscious. On examination he is tachypnoeic and has a tachycardia of 120 beats/minute. His blood
pressure is 90/50 mmHg. He has a small puncture wound below his right costal margin. A central venous
line is inserted with ease, and his central venous pressure is 17 cm. A chest Xray shows a small pleural
effusion with a small pneumothorax. He has received 2 units of plasma expander, which has failed to
improve his blood pressure.
. A 42-year-old man is admitted following a road traffic accident complaining of pains throughout his
chest. He was fit and well prior to the incident. He is tachypnoeic and in considerable pain. His brachial
blood pressure is 110/70 mmHg and his pulse rate is 90 beats/minute. Both femoral pulses are present
though greatly diminished. A chest Xray shows multiple rib fractures and an appreciably widened upper
mediastinum. Lateral views confirm a fractured sternum. An ECG shows ischaemic changes in the V-
leads.

Further examples of the two types of question are available on the college website and in the PasTest
MRCS Practice Question Books. The questions cover the entire syllabus and are broken down into:

Paper 1

Applie d Surgical Anatomy – 45 questions. This includes gross anatomy as well as questions on developmental and imaging anatomy.

Number of questions
6
Topic 12
Thorax 8
Abdomen, pelvis, perineum 6
Upper limb, breast 9
Lower limb 4
Head, neck and spine
Central, peripheral and autonomic nervous systems

Phys iology – 45 questions. This includes 12 questions on general physiological principles covering thermoregulation, metabolic pathways,
sepsis and septic shock, fluid balance, metabolic acidosis/alkalosis and colloid and crystalloid solutions.

Sys te m-s pe cific phys iology:

Number of questions
6
Topic 6
Respiratory system
Cardiovascular system

Gastrointestinal system 4
Renal system 6
Endocrine system (including glucose homeostasis) 4
Nervous system 3
Thyroid and parathyroid 4

Pathology – 45 questions. This includes 20–22 questions on general principles of pathology.

Number of questions
Topic 3
Inflammation 1–2
Wound healing and cellular healing 3
Vascular disorders 3
Disorders of growth 6
Tumours 3
Surgical immunology 1–2
Surgical haematology

Sys te m-s pe cific pathology (22–26 questions): Number of questions
1–2
Topic 3
Nervous system 1–2
Musculoskeletal system 4
Respiratory system 1–2
Breast disorders 3
Endocrine systems 5
Genitourinary system 1–2
Gastrointestinal system 3
Lymphoreticular system
Cardiovascular system

Paper 2

Clinical Proble m Solving – 135 questions. This includes 45 questions on Principle s of Surge ry-in-Ge ne ral and 90 questions on Surgical
Spe cialtie s :

Principle s of Surge ry-in-Ge ne ral

Number of questions
8
Topic 4
Perioperative care 6
Postoperative care 4
Surgical techniques 6
Management/legal topics
Microbiology

Emergency medicine 9
Oncology 8

Number of questions
Surgical Specialties Topic 6
Cardiothoracic 9
Abdominal 4–5
Upper gastrointestinal 5
Hepatobilary and pancreatic 6
Colorectal 4–5
Breast 6
Endocrine 7
Vascular 3
Transplant 6
ENT 2
Oromaxillofacial 6
Paediatrics 6
Neurosurgery 7-8
Trauma/orthopaedics 6
Plastics 7
Urology

It is therefore important that you cover the entire syllabus in order to pick up the greatest number of marks.

Part B: Objective Structured Clinical Examination (OSCE)

To be eligible for Part B you must have passed Part A. The OSCE will normally consist of 18 examined
stations each of 9 minutes’ duration and one or more rest/preparation station. Although the MRCS remains
an exam for the Core part of Surgical Training, six of the stations will be examined in a specialty context
and the other 12 reflect generic surgical skills. You must specify your choice of specialty context stations
at the time of your application to sit the exam.

These stations will examine the following broad content areas:
. Anatomy and surgical pathology

2. Applied surgical science and critical care

. Communication skills in giving and receiving information and history taking

4. Clinical and procedural skills

Speciality areas are:
Head and Neck • Trunk and Thorax • Limbs (including spine) • Neurosciences

Each station is manned by one or two examiners and is marked out of 20 with a separate ‘overall global
rating’ of:
Pass
Borderline pass • Borderline fail • Fail

There are 4 domains assessed throughout the exam which are areas of knowledge, skill, competencies and
professional characteristics that a candidate should demonstrate. These are:
Clinical knowledge • Clinical and technical skill • Communication • Professionalism

The overall mark is calculated from both the mark out of 20 and the overall global rating. In order to pass
the exam you need to achieve the minimum pass mark and also a minimum competence level in each of the
four content areas and in each of the four domains.

The OSCE and preparation for it are covered in depth in the PasTest MRCS Part B (OSCE) handbook.

B Candidate instructions for Part A (MCQ)

Candidates who are late by no more than 30 minutes for the exam may be allowed entry at the discretion
of the senior invigilator but will not be given extra time. You may not leave in the first 60 minutes or the
last 15 minutes of the examination and then you must wait until answer sheets and question booklets have
been collected from your desk.

Each desk in the examination hall will be numbered and candidates must sit at the desk that corresponds
to their examination/candidate number.

Candidates must bring proof of identity to each examination, such as a current passport or driving licence
that includes your name, signature and a photograph. Once seated this should be placed on the desk ready
for inspection.

Pencils and all stationery will be provided. Mobile phones and electronic devices (including pagers and
calculators) must be switched off and are not permitted to be on the desk or on your person during the
exam. Failure to comply with this will lead to suspension from the exam.

Dress comfortably. You are allowed to take a small bottle of water or a drink in to the exam hall with you.

There are equal marks for each question. Marks will not be deducted for a wrong answer. However, you
will not gain a mark if you mark more than one box for the same item or question. The answer sheets are
scanned by machine. If you do not enter your answer to each question correctly and clearly on the answer
sheet the machine which scores your paper may reject it. Mark each answer clearly as faint marking may
be misread by the machine. If you need to change an answer, you should make sure that you rub it out
completely so that the computer can accept your final answer.

Many candidates find it easier to mark their answers on the question booklet first and transfer them to the
answer sheet later. If you do this, you should allow time to transfer your answers to the answer sheet
before the end of the examination. No extra time will be given for the transfer of answers.

C Preparing for the MCQ exam

The MRCS exam and syllabus is being constantly updated and the best way to keep up to date with its
requirements is via the website ‘http://www.intercollegiatemrcs.org.uk’ which contains information on :
Examination dates • Regulations
Guidance notes • Domain descriptors • Application forms • Syllabus
Candidate feedback • Annual reports

Different people prepare for MCQ examinations in different ways. The key to success is to do as many
practice questions as possible. You may prefer to revise a topic before undertaking practice questions or
use practice questions to highlight areas of lack of knowledge and direct your learning.

The PasTest book series also includes practice SBAs and EMQs for Part A of the MRCS. In addition
over 4000 practice questions are available from PasTest Online Revision, including apps for android and
i-phones.

D The Syllabus

The syllabus essentially remains the same although it is structured differently every few years. The most
up-to-date version can be found on the intercollegiate website. The syllabus from 2012 has been
structured in 10 modules: Module 1: Basic Sciences (to include applied surgical anatomy, applied
surgical physiology, applied pharmacology (centred around the safe prescribing of common drugs),
surgical pathology (principles underlying system-specific pathology), surgical microbiology, imaging
(principles, advantages and disadvantages of various diagnostic and interventional imaging methods)

Module 2: Common surgical conditions (under the topics of gastrointestinal disease; breast disease;
vascular disease; cardiovascular and pulmonary disease; genitourinary disease; trauma and orthopaedics;
diseases of the skin, head and neck; neurology and neurosurgery; and endocrine disease) Module 3: Basic
Surgical skills (including the principles and practice of surgery and technique) Module 4: The
Assessment and Management of the Surgical Patient (decision making, team working and
communication skills) Module 5: Perioperative care (preoperative, intraoperative and postoperative
care, including the management of complications) Module 6: Assessment and management of patients
with trauma (including the multiply injured patient) Module 7: Surgical care of the paediatric patient

Module 8: Management of the dying patient

Module 9: Organ and tissue transplantation

Module 10: Professional behaviour and leadership skills (including communication, teaching and
training, keeping up to date, managing people and resources within healthcare, promoting good health and
the ethical and legal obligations of a surgeon)

CHAPTER 1

Perioperative Care

Tristan E McMillan

Assessment of fitness for surgery
1.1 Preoperative assessment
1.2 Preoperative Laboratory testing and imaging
1.3 Preoperative consent and counselling
1.4 Identification and documentation
1.5 Patient optimisation for elective surgery
1.6 Resuscitation of the emergency patient
1.7 The role of prophylaxis
1.8 Preoperative marking

Preoperative management of coexisting disease
2.1 Preoperative medications
2.2 Preoperative management of cardiovascular disease
2.3 Preoperative management of respiratory disease
2.4 Preoperative management of endocrine disease
2.5 Preoperative management of neurological disease
2.6 Preoperative management of liver disease
2.7 Preoperative management of renal failure
2.8 Preoperative management of rheumatoid disease
2.9 Preoperative assessment and management of nutritional status
2.10 Risk factors for surgery and scoring systems

Principles of anaesthesia

3.1 Local anaesthesia
3.2 Regional anaesthesia
3.3 Sedation
3.4 General anaesthesia
3.5 Complications of general anaesthesia

Care of the patient in theatre
4.1 Pre-induction checks
4.2 Prevention of injury to the anaesthetised patient
4.3 Preserving patient dignity

SECTION 1

Assessment of fitness for surgery

In a nutshell ...

Before considering surgical intervention it is necessary to prepare the patient as fully as possible.
The extent of pre-op preparation depends on:
Classification of surgery:
• Elective
• Scheduled
• Urgent
• Emergency
Nature of the surgery (minor, major, major-plus)
Location of the surgery (A&E, endoscopy, minor theatre, main theatre) • Facilities available
The rationale for pre-op preparation is to:
Determine a patient’s ‘fitness for surgery’
Anticipate difficulties
Make advanced preparation and organise facilities, equipment and expertise • Enhance patient safety
and minimise chance of errors
Alleviate any relevant fear/anxiety perceived by the patient
Reduce morbidity and mortality

Common factors resulting in cancellation of surgery include:
Inadequate investigation and management of existing medical conditions • New acute medical conditions

Classification of surgery according to the National Confidential Enquiry into Patient Outcome and Death
(NCEPOD):
Elective: mutually convenient timing • Scheduled: (or semi-elective) early surgery under time limits (eg 3
weeks for malignancy) • Urgent: as soon as possible after adequate resuscitation and within 24 hours

Patients may be:
Emergency: admitted from A&E; admitted from clinic
Elective: scheduled admission from home, usually following pre assessment

In 2011 NCEPOD published Knowing the Risk: A review of the perioperative care of surgical patients
in response to concerns that, although overall surgical mortality rates are low, surgical mortality in the
high-risk patient in the UK is significantly higher than in similar patient populations in the USA. They
assessed over 19 000 surgical cases prospectively and identified four key areas for improvement (see
overleaf).


. Identification of the high-risk group preoperatively, eg scoring systems to highlight those at high risk 2.

Improved pre-op assessment, triage and preparation, proper preassessment systems with full
investigations and work-up for elective patients and more rigorous assessment and preoperative
management of the emergency surgical patient, especially in terms of fluid management 3. Improved
intraoperative care: especially fluid management, invasive and cardiac output monitoring 4. Improved
use of postoperative resources: use of high-dependency beds and critical care facilities

1.1 Preoperative assessment



In a nutshell ...

Preoperative preparation of a patient before admission may include:
History
Physical examination
Investigations as indicated:

• Blood tests
• Urinalysis
• ECG
• Radiological investigations
• Microbiological investigations
• Special tests
Consent and counselling
The preassessment clinic is a useful tool for performing some or all of these tasks before admission.

Preassessment clinics

The preassessment clinic aims to assess surgical patients 2–4 weeks preadmission for elective surgery.

Preassessment is timed so that the gap between assessment and surgery is:
Long enough so that a suitable response can be made to any problem highlighted • Short enough so that new
problems are unlikely to arise in the interim

The timing of the assessment also means that:
Surgical team can identify current pre-op problems
High-risk patients can undergo early anaesthetic review
Perioperative problems can be anticipated and suitable arrangements made (eg book intensive therapy unit
[ITU]/high-dependency unit [HDU] bed for the high-risk patient)
Medications can be stopped or adapted (eg anticoagulants, drugs that increase risk of deep vein thrombosis

[DVT]) • There is time for assessment by allied specialties (eg dietitian, stoma nurse, occupational
therapist, social worker) • The patient can be admitted to hospital closer to the time of surgery, thereby
reducing hospital stay

The patient should be reviewed again on admission for factors likely to influence prognosis and any
changes in their pre-existing conditions (eg new chest infection, further weight loss).

Preassessment is run most efficiently by following a set protocol for the preoperative management of each
patient group. The protocol-led system has several advantages:
The proforma is an aide-mémoire in clinic
Gaps in pre-op work up are easily visible
Reduces variability between clerking by juniors

However, be wary of preordered situations because they can be dangerous and every instruction must be
reviewed on an individual patient basis, eg the patient may be allergic to the antibiotics that are
prescribed as part of the preassessment work-up and alternatives should be given.

Preoperative history

A good history is essential to acquire important information before surgery and to establish a good
rapport with the patient. Try to ask open rather than leading questions, but direct the resulting
conversation. Taking a history also gives you an opportunity to assess patient understanding and the level
at which you should pitch your subsequent explanations.

A detailed chapter on taking a surgical history can be found in the new edition of the PasTest book MRCS
Part B OSCES: Essential Revision Notes in Information Gathering under Communication Skills. In
summary, the history should cover the points in the following box.



Taking a surgical history
1. Introductory sentence
Name, age, gender, occupation.
2. Presenting complaint
In one simple phrase, the main complaint that brought the patient into hospital, and the duration of that
complaint, eg ‘Change in bowel habit for 6 months’.
3. History of presenting complaint
(a) The story of the complaint as the patient describes it from when he or she was last well to the present
(b) Details of the presenting complaint, eg if it is a pain ask about the site, intensity, radiation, onset,
duration, character, alleviating and exacerbating factors, or symptoms associated with previous
episodes
(c) Review of the relevant system(s) which may include the gastrointestinal, gynaecological and
urological review, but does not include the systems not affected by the presenting complaint. This
involves direct questioning about every aspect of that system and recording the negatives and the
positives (d) Relevant medical history, ie any previous episodes, surgery or investigations directly
relevant to this episode. Do not include irrelevant previous operations here. Ask if he or she has had
this complaint before, when, how and seen by whom
(e) Risk factors. Ask about risk factors relating to the complaint, eg family history, smoking, high
cholesterol. Ask about risk factors for having a general anaesthetic, eg previous anaesthetics, family

history of problems under anaesthetic, false teeth, caps or crowns, limiting comorbidity, exercise
tolerance or anticoagulation medications
4. Past medical and surgical history
In this section should be all the previous medical history, operations, illnesses, admissions to hospital,
etc that were not mentioned as relevant to the history of the presenting complaint.
5. Drug history and allergies
List of all drugs, dosages and times that they were taken. List allergies and nature of reactions to
alleged allergens. Ask directly about the oral contraceptive pill and antiplatelet medication such as
aspirin and clopidogrel which may have to be stopped preoperatively.
6. Social history
Smoking and drinking – how much and for how long. Recreational drug abuse. Who is at home with the
patient? Who cares for them? Social Services input? Stairs or bungalow? How much can they manage
themselves?
7. Family history
8. Full review of non-relevant systems
This includes all the systems not already covered in the history of the presenting complaint, eg
respiratory, cardiovascular, neurological, endocrine and orthopaedic.

Physical examination

Detailed descriptions of methods of physical examination can only really be learnt by observation and
practice. Don’t rely on the examination of others – surgical signs may change and others may miss
important pathologies. See MRCS Part B OSCEs: Essential Revision Notes for details of surgical
examinations for each surgical system.



Physical examination
General examination: is the patient well or in extremis? Are they in pain? Look for anaemia, cyanosis
and jaundice, etc. Do they have characteristic facies or body habitus (eg thyrotoxicosis, cushingoid,
marfanoid)? Are they obese or cachectic? Look at the hands for nail clubbing, palmar erythema, etc
Cardiovascular examination: pulse, BP, jugular venous pressure (JVP), heart sounds and murmurs.
Vascular bruits (carotids, aortic, renal, femoral) and peripheral pulses
Respiratory examination: respiratory rate (RR), trachea, percussion, auscultation, use of accessory
muscles Abdominal examination: scars from previous surgery, tenderness, organomegaly, mass,
peritonism, rectal examination CNS examination: particularly important in vascular patients pre-
carotid surgery and in patients with suspected spinal compression Musculoskeletal examination:
before orthopaedic surgery

1.2 Preoperative laboratory testing and imaging



When to perform a clinical investigation
To confirm a diagnosis
To exclude a differential diagnosis
To assess appropriateness of surgical intervention
To asses fitness for surgery

When deciding on appropriate investigations for a patient you should consider:
Simple investigations first
Safety (non-invasive investigation before invasive investigation if possible) • Cost vs benefit
The likelihood of the investigation providing an answer (sensitivity and specificity of the investigation)

• Ultimately, will the investigation change your management?

Blood tests

Full blood count (FBC)

FBC provides information on the following (normal ranges in brackets):
Haemoglobin concentration (12–16 g/dl in males; 11–14 g/dl in females) • White cell count (WCC 5–10 ×
109/l)
Platelet count (150–450 × 109/l)

Also it may reveal details of red cell morphology (eg macrocytosis in alcoholism, microcytosis in iron
deficiency anaemia) and white cell differential (eg lymphopenia, neutrophilia).



When to perform a preoperative FBC
In practice almost all surgical patients have an FBC measured but it is particularly important in the
following groups:
All emergency pre-op cases – especially abdominal conditions, trauma, sepsis • All elective pre-op
cases aged >60 years
All elective pre-op cases in adult women
If surgery is likely to result in significant blood loss
If there is suspicion of blood loss, anaemia, haematopoietic disease, sepsis, cardiorespiratory disease,
coagulation problems

Urea and electrolytes (U&Es)

U&Es provide information on the following (normal ranges in brackets):
Sodium (133–144 mmol/l)
Potassium (3.5–5.5 mmol/l)
Urea (2.5–6.5 mmol/l)
Creatinine (55–150 μmol/l)

The incidence of an unexpected abnormality in apparently fit patients aged <40 years is <1% but
increases with age and ASA grading (American Society of Anesthesiologists).



When to perform a preoperative U&E
In practice almost all surgical patients get their U&Es tested but it is particularly important in the
following groups:
All pre-op cases aged >65
Positive result from urinalysis (eg ketonuria)
All patients with cardiopulmonary disease, or taking diuretics, steroids or drugs active on the

cardiovascular system • All patients with a history of renal/liver disease or an abnormal nutritional
state • All patients with a history of diarrhoea/vomiting or other metabolic/endocrine disease • All
patients on an intravenous infusion for >24 hours

Amylase

Normal plasma amylase range varies with different reference laboratories • Perform in all adult emergency
admissions with abdominal pain, before consideration of surgery • Inflammation surrounding the pancreas
will cause mild elevation of the amylase; dramatic elevation of the amylase results from pancreatitis

Random blood glucose (RBG)

Normal plasma glucose range is 3–7 mmol/l


When to perform an RBG
Emergency admissions with abdominal pain, especially if suspecting pancreatitis • Preoperative

elective cases with diabetes mellitus, malnutrition or obesity • All elective pre-op cases aged >60
years
When glycosuria or ketonuria is present on urinalysis

Clotting tests

Prothrombin time (PT)
11–13 seconds
Measures the functional components of the extrinsic pathway prolonged with warfarin therapy, in liver
disease and disseminated intravascular coagulation (DIC)

Activated partial thromboplastin time (APTT)
<35 seconds
Measures the functional components of the intrinsic pathway and is prolonged in haemophilia A and B,
with heparin therapy and in DIC

International normalised ratio (INR)
0.9–1.3 for normal person; range varies for those on warfarin depending on reason for treatment • INR is a
ratio of the patient’s PT to a normal, control sample

Sickle cell test

Different hospitals have different protocols, but in general you would be wise to perform a sickle cell test
in all black patients in whom surgery is planned, and in anyone who has sickle cell disease in the family.
Patients should be counselled before testing to facilitate informed consent.

Liver function tests (LFTs)

Perform LFTs in all patients with upper abdominal pain, jaundice, known hepatic dysfunction or history of
alcohol abuse • Remember that clotting tests are the most sensitive indicator of liver synthetic disorder
and may be deranged before changes in the LFTs. Decreased albumin levels are an indicator of chronic
illness and sepsis

Group and save/cross-match

When to perform a group and save:
Emergency pre-op cases likely to result in significant surgical blood loss, especially trauma, acute
abdomen, vascular cases • If there is suspicion of blood loss, anaemia, haematopoietic disease,
coagulation defects • Procedures on pregnant females

Urinalysis

When to perform pre-op urinalysis:
All emergency cases with abdominal or pelvic pain
All elective cases with diabetes mellitus
All pre-op cases with thoracic, abdominal or pelvic trauma

A midstream urine (MSU) specimen should be considered before genitourinary operations and in pre-op
patients with abdominal or loin pain.

A urine pregnancy test should be performed in all women of childbearing age with abdominal
symptoms, or who need a radiograph.

Electrocardiography

A 12-lead electrocardiogram (ECG) is capable of detecting acute or long-standing pathological
conditions affecting the heart, particularly changes in rhythm, myocardial perfusion or prior infarction.

Note that the resting ECG is not a sensitive test for coronary heart disease, being normal in up to 50%. An
exercise test is preferred.

When to perform a 12-lead ECG:
Patients with a history of heart disease, diabetes, hypertension or vascular disease, regardless of age •
Patients aged >60 with hypertension or other vascular disease
Patients undergoing cardiothoracic surgery, taking cardiotoxic drugs or with an irregular pulse • Any
suspicion of hitherto undiagnosed cardiac disease

Radiological investigations

Radiological investigations may include:
Plain films: chest radiograph, plain abdominal film, lateral decubitus film, KUB (kidney, ureter, bladder)
film, skeletal views • Contrast studies and X-ray screening: Gastrografin, intravenous (IV) contrast •
Ultrasonography: abdominal, thoracic, peripheral vasculature • Computed tomography (CT): intra-
abdominal or intrathoracic pathology • Magnetic resonance imaging (MRI): particularly for

orthopaedics, spinal cord compression, liver pathology

Chest radiograph

When to perform a pre-op chest radiograph:
All elective pre-op cases aged >60 years
All cases of cervical, thoracic or abdominal trauma
Acute respiratory symptoms or signs
Previous cardiorespiratory disease and no recent chest radiograph • Thoracic surgery
Patients with malignancy
Suspicion of perforated intra-abdominal viscus
Recent history of tuberculosis (TB)
Recent immigrants from areas with a high prevalence of TB
Thyroid enlargement (retrosternal extension)

Plain abdominal film

Plain abdominal films should be performed when there is:
Suspicion of obstruction
Suspicion of perforated intra-abdominal viscus
Suspicion of peritonitis

The role of radiological investigation in diagnosis and planning is discussed further in Chapter 2,
Surgical technique and technology.

Microbiological investigations

The use and collection of microbiological specimens is discussed in Surgical microbiology.

Investigating special cases

Coexisting disease

A chest radiograph for patients with severe rheumatoid arthritis (they are at risk of disease of the odontoid
peg, causing subluxation and danger to the cervical spinal cord under anaesthesia)
Specialised cardiac investigations (eg echocardiography, cardiac stress testing, MUGA scan) used to
assess pre-op cardiac reserve and are increasingly used routinely before major surgery
Specialised respiratory investigations (eg spirometry) to assess pulmonary function and reserve

Investigations relating to the organ in question

Angiography or duplex scanning in arterial disease before bypass
Renal perfusion or renal isotope imaging or liver biopsy before transplant • Colonoscopy, barium enema
or CT colonography (CTC) before bowel resection for cancer

1.3 Preoperative consent and counselling

Deciding to operate

It is often said that the best surgeon knows when not to operate. The decision to undertake surgery must be
based on all available information from a thorough history, examination and investigative tests. All
treatment options, including non-surgical management, and the risks and potential outcomes of each course
of action must be discussed fully with the patient in order to achieve informed consent. In some
specialties, clinical nurse practitioners or other support staff may support the patient (eg a breast-care
nurse before mastectomy, a colorectal nurse specialist before an operation resulting in a stoma). This
helps to prepare the patient for surgery, gives them an opportunity to ask further questions and provides a
support network.

Counselling

Medical staff spend most of their working life in and around hospitals, so it is easy to forget how the
public view hospital admission, surgical procedures and the postop stay on the ward. It is important to
recognise that all patients are different – in their ages, in their beliefs and in their worries.

Presenting information to patients

Discuss diagnoses and treatment options at a time when the patient is best able to understand and retain the
information • Use up-to-date written material, visual and other aids to explain complex aspects of surgery
• Use accurate data to explain the prognosis of a condition and probabilities of treatment success or the
risks of failure • Ensure distressing information is given in a considerate way, and offer access to
specialist nurses, counselling services and patient support groups
Allow the patient time to absorb the material, perhaps with repeated consultations or written back-up
material • Ensure voluntary decision-making: you may recommend a course of action but you must not put
pressure on the patient to accept it. Ensure that the patient has an opportunity to review the decision
nearer the time.

Responding to questions: you must respond honestly to any questions that the patient raises and, as far as
possible, answer as fully as the patient wishes.

Withholding information: you should not withhold information necessary for decision-making unless you
judge that disclosure of some relevant information would cause the patient serious harm (not including
becoming upset or refusing treatment). You may not withhold information from a patient at the request of
any other person including a relative.

If a patient insists that he or she does not want to know the details of a condition or a treatment, you
should explain the importance of knowing the options and should still provide basic information about the
condition or treatment unless you think that this would cause the patient some harm.

Records: you should record in the medical records what you have discussed with the patient and who
was present. This helps to establish a timeline and keeps other members of staff informed as to what the
patient knows. You must record in the medical records if you have withheld treatment and your reasons
for doing so.

General concerns of the surgical patient
Is this the first time the patient has been in hospital?
Never forget that all surgical procedures are significant to the patient, no matter how simple we believe
the case to be.
Good communication is essential so that the patient knows what to expect beforehand and can make an
informed decision:
Check that you know the patient well enough and understand the problem enough to explain it to him or
her • Choose the setting
Explain the diagnosis in terms that they will understand
Explain the possible options
Explain the difference between between conservative and surgical managements of the condition • Ask if
the patient has any thoughts about the options
Ask if he or she has any questions
Give the patient the option to ask you questions later

Think about potential questions from the patient and address them in your explanation:
What are the risks of anaesthetic and surgery?
Colostomy
Transplantation
Amputated limbs
What if things go wrong?
How long will I stay in hospital?
Will I die?

Specific considerations of the individual
Knowledge
How much does the patient know and understand?
Is the patient’s understanding influenced by what he or she has read (eg on the internet) or by previous
experience, either personal or through people whom he or she knows
Employment
Will surgery affect a return to work?
Social network
What support does the patient have? Family, friends, carers?
What responsibilities does the patient have, eg children, dependants • When can I drive?
Physical issues/deformity
Psychological issues
Recovery and what to expect
How long will I be in hospital for?
Complications
What potential complications may result in readmission (eg wound infection, unsuccessful operation)?

Obtaining consent

The General Medical Council gives the following guidelines (GMC 2008).

Ask patients whether they have understood the information and whether they would like more before
making a decision. Sometimes asking the patient to explain back to you, in his or her own words, what
you have just said clarifies areas that the patient does not really understand and may need more

explanation.

The legal right to consent

The ability to give informed consent for different patient ages and groups is discussed fully in Chapter 8,
Ethics, Clinical Governance and the Medicolegal Aspects of Surgery.



Obtaining consent
Provide sufficient information:
Details of diagnosis
Prognosis if the condition is left untreated and if the condition is treated • Options for further
investigations if diagnosis is uncertain
Options for treatment or management of the condition
The option not to treat
The purpose of the proposed investigation or treatment
Details of the procedure, including subsidiary treatment such as pain relief • How the patient should
prepare for the procedure
Common and serious side effects
Likely benefits and probabilities of success
Discussion of any serious or frequently occurring risks
Lifestyle changes that may result from the treatment
Advice on whether any part of the proposed treatment is experimental • How and when the patient’s
condition will be monitored and reassessed • The name of the doctor who has overall responsibility for
the treatment • Whether doctors in training or students will be involved
A reminder that patients can change their minds about a decision at any time • A reminder that patients
have a right to seek a second opinion
Explain how decisions are made about whether to move from one stage of treatment to another (eg
chemotherapy) • Explain that there may be different teams of doctors involved (eg anaesthetists) • Seek
consent to treat any problems that might arise and need to be dealt with while the patient is unconscious
or otherwise unable to make a decision
Ascertain whether there are any procedures to which a patient would object (eg blood transfusions)

1.4 Identification and documentation

Patient identification

Patient identification is essential. All patients should be given an identity wristband on admission to
hospital, which should state clearly and legibly the patient’s name, date of birth, ward and consultant. He
or she should also be given a separate red wristband documenting allergies. Patient identification is
checked by the nursing team on admission to theatre.

Documentation

Medical documents (medical notes, drug and fluid charts, consent forms and operation notes) are legal
documents. All entries to the notes should be written clearly and legibly. Always write the date and time
and your name and position at the beginning of each entry.

Documentation often starts with clerking. Record as much information as possible in the format described
above for history and examination. The source of information should also be stated (eg from patient,
relative, old notes, clinic letter, GP).

Accurate documentation should continue for each episode of patient contact, including investigations,
procedures, ward rounds and conversations with the patient about diagnosis or treatment.

File documents in the notes yourself; otherwise they will get lost. This is important to protect both the
patient and yourself. From a medicolegal point of view, if it is not documented then it didn’t happen.

1.5 Patient optimisation for elective surgery

Morbidity and mortality increase in patients with comorbidity.

Optimising the patient’s condition gives them the best possible chance of a good surgical outcome. Do not
forget that this includes nutrition.

In patients with severe comorbidity then NCEPOD recommend the following:
Discussion between surgeon and anaesthetist before theatre
Adequate preoperative investigation
Optimisation of surgery by ensuring:
• An appropriate grade of surgeon (to minimise operative time and blood loss) • Adequate preoperative
resuscitation
• Provision of on-table monitoring
Critical-care facilities are available

Optimisation of patients for elective surgery

Control underlying comorbidity: specialist advice on the management of underlying comorbidities
(cardiovascular, respiratory, renal, endocrinological) should be sought. Individual comorbidities are
discussed later in the chapter. Optimisation should be undertaken in a timely fashion as an outpatient for
elective surgery, although some may occasionally require inpatient care and intervention before
scheduling an elective procedure.

Nutrition: good nutrition is essential for good wound healing. Malnourished patients do badly and a
period of preoperative dietary improvement (eg build-up drinks, enteral feeding, total parenteral nutrition
or TPN) improves outcome.

1.6 Resuscitation of the emergency patient

It is essential that the acutely ill surgical patient is adequately resuscitated and stabilised before theatre.
In extreme and life-threatening conditions this may not be possible (eg ruptured abdominal aortic
aneurysm or AAA, trauma) and resuscitation should not delay definitive treatment.

Most emergency patients fall into one of two categories: haemorrhage or sepsis. The management of
haemorrhage and sepsis are dealt with in detail in the Chapters 3 and 4 of this book respectively.

General principles of resuscitation are:
Optimise circulating volume:
• Correct dehydration: many acute surgical patients require IV fluids to correct dehydration and restore
electrolyte balance. Establish good IV access. Insertion of a urinary catheter is vital to monitor fluid
balance carefully with hourly measurements. Severe renal impairment may require dialysis before theatre.
Dehydrated patients may exhibit profound drops in blood pressure on anaesthetic induction and
aggressive preoperative fluid management is often required • Correct anaemia: anaemia compromises
cardiac and respiratory function and is not well tolerated in patients with poor cardiac reserve. The
anaemia may be acute (acute bleed) or chronic (underlying pathology). If anaemia is acute, transfuse to
reasonable Hb and correct clotting. Consider the effects of massive transfusion and order and replace
clotting factors simultaneously. Chronic anaemia is better tolerated but may also require correction before
theatre • Treat pain: pain results in the release of adrenaline and can cause tachycardia and hypertension.
Pain control before anaesthesia reduces cardiac workload
• Give appropriate antibiotics early as required in sepsis. These may need to be empirical until
antimicrobial treatment can be guided by blood and pus cultures
• Decompress the stomach: insert a nasogastric (NG) tube to decompress the stomach because this
reduces the risk of aspiration on anaesthetic induction

1.7 The role of prophylaxis

Prophylaxis essentially refers to the reduction or prevention of a known risk. Preoperatively prophylaxis
should include:
Stopping potentially harmful factors:
• Stopping medications (eg the oral contraceptive pill for a month, aspirin or clopidogrel for 2 weeks
before surgery) • Stopping smoking: improves respiratory function even if the patient can only stop for 24
hours • Prescribing drugs known to reduce risks:
• Heparin to reduce the risk of DVT
• Cardiac medications (eg preoperative β blockers, statins or angiotensin-converting enzyme [ACE]
inhibitors) to reduce cardiovascular risk

1.8 Preoperative marking

This should be performed after consent and before the patient has received premedication. Marking is
essential to help avoid mistakes in theatre. Marking while the patient is conscious is important to
minimise error. Preoperative marking is especially important if the patient is having:
A unilateral procedure (eg on a limb or the groin)
A lesion excised
A tender or symptomatic area operated on (eg an epigastric hernia) • A stoma



Marking for surgery
Explain to the patient that you are going to mark the site for surgery • Confirm the procedure and the site

(including left or right) with the notes, patient and consent form • Position the patient appropriately (eg
standing for marking varicose veins, supine for abdominal surgery) • Use a surgical marker that will not
come off during skin preparation • Clearly identify the surgical site using a large arrow

SECTION 2

Preoperative management of coexisting disease

2.1 Preoperative medications



In a nutshell ...

If a patient is having surgery:
Review pre-existing medication:

• Document preoperative medications
• Decide which drugs need to be stopped preoperatively
• Decide on alternative formulations
Prescribe preoperative medication:
• Prescribe prophylactic medication
• Prescribe medication related to the surgery
• Prescribe premed if needed
Be aware of problems with specific drugs:
• Steroids and immunosuppressants
• Anticoagulants and fibrinolytics

Review pre-existing medication


Perioperative management of pre-existing medication
Document preoperative medications
Decide whether any drugs need to be stopped before surgery
Stop oral contraceptive (OCP) or tamoxifen 4 weeks before major or limb surgery – risk of thrombosis •
Stop monoamine oxidase inhibitor (MAOI) antidepressants – they interact with anaesthetic drugs, with
cardiac risk • Stop antiplatelet drugs 7–14 days preoperatively – risk of haemorrhage
Decide on alternative formulations for the perioperative period
For example, IV rather than oral, heparin rather than warfarin

Regular medications should generally be given – even on the day of surgery (with a sip of clear fluid

only). If in doubt ask the anaesthetist. This is important, especially for cardiac medication. There are
some essential medications (eg anti-rejection therapy in transplant recipients) that may be withheld for 24
hours in the surgical period but this should only be under the direction of a specialist in the field.

Prescribe preoperative medication


Medication for the preoperative period
Pre-existing medication (see above for those drugs that should be excluded) Prophylactic medication
For example, DVT prophylaxis
For example, antibiotic prophylaxis
Medication related to the surgery
For example, laxatives to clear the bowel before resection
For example, methylene blue to aid surgical identification of the parathyroids
Anaesthetic premedication (to reduce anxiety, reduce secretions, etc)

Be aware of problems with specific drugs

Steroids and immunosuppression

Indications for perioperative corticosteroid cover
This includes patients:
With pituitary–adrenal insufficiency on steroids
Undergoing pituitary or adrenal surgery
On systemic steroid therapy of >7.5 mg for >1 week before surgery • Who received a course of steroids
for >1 month in the previous 6 months

Complications of steroid therapy in the perioperative period
Poor wound healing
Increased risk of infection
Side effects of steroid therapy (eg impaired glucose tolerance, osteoporosis, muscle wasting, fragile skin
and veins, peptic ulceration) • Mineralocorticoid effects (sodium and water retention, potassium loss and
metabolic alkalosis) • Masking of sepsis/peritonism
Glucocorticoid deficiency in the perioperative period (may present as increasing cardiac failure which is
unresponsive to catecholamines, or addisonian crisis with vomiting and cardiovascular collapse)

Management of patients on pre-op steroid therapy
This depends on the nature of the surgery to be performed and the level of previous steroid use.
Minor use: 50 mg hydrocortisone intramuscularly/intravenously IM/IV preoperatively • Intermediate
use: 50 mg hydrocortisone IM/IV with premed and 50 mg hydrocortisone every 6 h for 24 h • Major use:
100 mg hydrocortisone IM/IV with premed and 100 mg hydrocortisone every 6 h for at least 72 h after
surgery

Equivalent doses of steroid therapy: hydrocortisone 100 mg, prednisolone 25 mg, dexamethasone 4 mg.

Anticoagulants and fibrinolytics

Consider the risk of thrombosis (augmented by postsurgical state itself) vs risk of haemorrhage.

Warfarin
Inhibits vitamin K-dependent coagulation factors (II, VII, IX and X) as well as protein C and its cofactor,
protein S
Illness and drug interactions may have unpredictable effects on the level of anticoagulation •
Anticoagulative effects can be reversed by vitamin K (10 mg IV; takes 24 h for adequate synthesis of
inhibited factors) and fresh frozen plasma (15 ml/kg; immediate replacement of missing factors)
Stop 3–5 days before surgery and replace with heparin; depends on indication for anticoagulation (eg
metal heart valve is an absolute indication, but atrial fibrillation [AF] is a relative one)
INR should be <1.2 for open surgery and <1.5 for invasive procedures

Heparin
Mucopolysaccharide purified from intestine
Binds to antithrombin III and so inhibits factors IIa, IXa, Xa and XIIa • May be unfractionated or
fractionated (low-molecular-weight heparin [LMWH])

Uses of heparin include:
General anticoagulant (should be stopped 6 h before surgery) • Treatment of unstable angina
Maintenance of extracorporeal circuits (eg dialysis, bypass) • Flush for IV lines to maintain patency
In vascular surgery before temporary occlusion of a vessel to prevent distal thrombosis



Unfractionated heparin
Given by continuous infusion (short half-life)
Check APTT every 6 h and adjust rate until steady state (ratio of 2:3) achieved



Fractionated heparin (LMWH)
Inhibits only factor Xa
Increased half-life and more predictable bioavailability (compared with unfractionated form) • Can be

given once daily (eg tinzaparin) or twice a day (eg enoxaparin) • Heparin can cause an immune reaction
(heparin-induced thrombocytopenia [HIT]); LMWH is less likely to do so • Effects can be reversed by
use of protamine 1 mg per 100 units heparin (may cause hypotension and in high doses, paradoxically,
may cause anticoagulation)
Can be used during pregnancy (non-teratogenic)

Antiplatelet agents

Increasingly used (eg aspirin, dipyridamole, clopidogrel, abciximab) • Decrease platelet aggregation and
reduce thrombus formation
May be used in combination
Should be stopped 7–14 days before major surgery or there is a risk of uncontrollable bleeding

Fibrinolytics

Examples include streptokinase and alteplase
Act by activating plasminogen to plasmin, which undertakes clot fibrinolysis • Used in acute MI, extensive
DVT and PE
Contraindicated if the patient had undergone recent surgery, trauma, recent haemorrhage, pancreatitis,
aortic dissection, etc

For discussions of the management of immunosuppression in the perioperative period see
Transplantation in Book 2. DVT prophylaxis in the perioperative period is covered in Chapter 3, section
1.2, Surgical haematology.

2.2 Preoperative management of cardiovascular disease

In a nutshell ...

Cardiac comorbidity increases surgical mortality (includes ischaemic heart disease, hypertension,
valvular disease, arrhythmias and cardiac failure).
Special care must be taken with pacemakers and implantable defibrillators. In general it is necessary
to:
Avoid changes in heart rate (especially tachycardia)
Avoid changes in BP
Avoid pain
Avoid anaemia
Avoid hypoxia (give supplemental oxygen)
In addition, the details of preoperative assessment before cardiac surgery is covered in Book 2.

The European Society of Cardiology has published guidelines (2009) to cover the preoperative risk
assessment and perioperative management of patients with cardiovascular disease. Patient-specific
factors are more important in determining risk than the type of surgery but, with regard to cardiac risk,
surgical interventions can be divided into low-risk, intermediate-risk and high-risk groups:
Low risk (cardiac event rate 1%): most breast, eye, dental, minor orthopaedics, minor urological and
gynaecological procedures
Medium risk (cardiac event rate 1–5%): abdominal surgery, orthopaedic and neurological surgery,
transplantation surgery, minor vascular surgery and endovascular repair
High risk (cardiac event rate >5%): major vascular surgery
Laparoscopic surgery has a similar cardiac risk to open procedures because the raised intra-abdominal
pressure results in reduced venous return with decreased cardiac output and decreased systemic vascular
resistance, and should therefore be risk assessed accordingly.

The Lee Index is a predictor of individual cardiac risk and contains six independent clinical determinants
of major perioperative cardiac events:
A history of ischaemic heart disease (IHD)
A history of cerebrovascular disease
Heart failure
Type 1 diabetes mellitus
Impaired renal function
High-risk surgery

The presence of each factor scores 1 point. Patients with an index of 0, 1, 2 and 3 points correspond to an
incidence of major cardiac complications of 0.4%, 0.9%, 7% and 11% respectively.

Investigation of patients with cardiac disease

Investigation of patients with previous cardiac disease aims to look at three cardiac risk markers
(myocardial ischaemia, left ventricular [LV] dysfunction and valvular abnormality) which are all major
determinants of adverse postoperative outcome.

Blood tests

FBC
Correction of anaemia is essential because it compromises cardiac and respiratory function and is not well
tolerated in patients with ischaemic disease
May require iron supplements or even staged transfusion

Electrolytes
Potassium and magnesium levels may affect cardiac functioning and should be optimised • Bear in mind
that electrolyte disturbances occur in patients treated with diuretics

Specialist non-invasive tests

Assessing myocardial ischaemia
ECG: remember that ischaemia may be silent. Look for previous infarct, ischaemia at rest, bundle branch
block (BBB) or LV hypertrophy (LVH) (evidence of strain) or arrhythmia. Acts as a baseline for
comparison in the future, enabling new changes to be distinguished from pre-existing abnormalities.

Exercise testing: physiological exercise gives an estimate of functional capacity, can assess heart rate
and BP changes and looks at ischaemia by monitoring dynamic ST segment change.

Dobutamine stress testing or cardiac perfusion scanning may also be used for specialist investigation.
CT detection of coronary vessel calcium and MR angiography can also be performed.