Perioperative care for MRCS Part A

What the paper tends to test

• Questions typically describe a postoperative patient with a fever, breathlessness, confusion or a falling urine output and ask for the most likely cause given the day after surgery, or the most appropriate first investigation.
• Expect the ASA grade, cardiopulmonary exercise testing and the common risk scores — P-POSSUM, the NELA risk calculator, the revised cardiac risk index — as the language of preoperative assessment.
• Intraoperative questions test diathermy — monopolar against bipolar, the return electrode, pacemakers and alcohol-based skin preparation — and tourniquet pressures and times.
• Fluid and nutrition questions use the NICE CG174 maintenance figures, the indications for enteral and parenteral nutrition, and the refeeding syndrome.
• Transfusion questions ask about the thresholds for red cells, platelets and plasma, the recognition of a transfusion reaction, and the management of major haemorrhage.
• VTE questions test risk assessment, mechanical and pharmacological prophylaxis and its duration, and the management of a confirmed DVT or pulmonary embolism.
• Metabolic and endocrine lines ask how to manage insulin and oral hypoglycaemics on the day of surgery, steroid cover, and the thyrotoxic or phaeochromocytoma patient before an operation.

Classic traps and discriminators

• A fever in the first 24–48 hours after surgery is usually the inflammatory response to the operation or atelectasis; from day 3 think of the urinary tract and the surgical site, from day 5 an anastomotic leak, a collection or pneumonia, and from day 7 wound infection and venous thromboembolism — but a persistent tachycardia after bowel surgery is a leak until proved otherwise.
• Refeeding syndrome follows the reintroduction of carbohydrate after prolonged starvation: insulin drives phosphate, potassium and magnesium into cells, so a falling phosphate is the marker. Patients at risk are fed slowly, given thiamine before feeding, and have their electrolytes replaced and monitored daily (NICE CG32).
• Restrictive transfusion is the standard (NICE NG24): red cells at a haemoglobin of 70 g/L, or 80 g/L in acute coronary syndrome, one unit at a time outside major haemorrhage; platelets are not given for a low count alone unless it is below 10 × 10⁹/L or a procedure is planned.
• The WHO Surgical Safety Checklist has three parts — sign in before induction, time out before the skin incision and sign out before the patient leaves theatre — and the operating site is marked by the operating surgeon or a delegate, with the patient awake and involved, before the anaesthetic room.
• Patients on long-term steroids (about 5 mg of prednisolone a day or more) risk an adrenal crisis under the stress of surgery and need hydrocortisone at induction and for the first 24–48 hours, scaled to the size of the operation; hypotension that does not respond to fluids after surgery is adrenal insufficiency until proved otherwise.
• Monopolar diathermy needs a return electrode over a well-perfused muscle mass away from bony prominences and metal implants; bipolar current passes only between the tips of the forceps and is used near nerves, on digits and in patients with pacemakers. Alcohol-based skin preparation must be dry and pooling avoided before diathermy is used.

Free revision notes

Perioperative care questions, answered