Perioperative Medicine 00 / 19 , all cards and bookmarks
Leaving recovery 01 / 19 Leave recovery on a scored check of activity, breathing, circulation, consciousness and saturation.
Modified Aldrete score (Miller): each item scores 2, 1 or 0 Leaving the first stage and going home Finding Decision Awake, airway‑protecting, air saturation, pain and nausea controlled → , open its explanation Bypass first stage; send straight to second‑stage care Phase 1 discharge → , open its explanation On the Aldrete score, not elapsed time Obstructive sleep apnoea, general anaesthesia, Aldrete met → , open its explanation Observe 60 more minutes Obstructive sleep apnoea, extra 60 minutes observed → , open its explanation Discharge once baseline room‑air saturation holds without respiratory events
After ambulatory surgery Report a problem with card 1: Leaving recovery
What the pneumoperitoneum and the tilt do 02 / 19 Pneumoperitoneum lowers functional residual capacity (FRC) and compliance and raises afterload; the tilt moves preload.
Change Effect CO2 pneumoperitoneum: lung mechanics and volumes → , open its explanation Compliance, FRC and vital capacity fall CO2 pneumoperitoneum: ventilation and airway → , open its explanation V/Q mismatch and peak airway pressure rise Insufflation: circulation → , open its explanation Systemic vascular resistance (SVR), mean arterial pressure (MAP) and arterial CO2 rise; cardiac output falls Insufflation: organ flow and pressures → , open its explanation Renal, portal, splanchnic flow fall; airway pressure, intracranial pressure (ICP) rise Head‑up tilt under anaesthesia → , open its explanation Preload and stroke volume fall, SVR rises; heart rate rises Steep head‑down tilt, euvolaemic → , open its explanation Leg resistance falls; output rise fades; steep tilt lowers it
Report a problem with card 2: What the pneumoperitoneum and the tilt do
Proceed, postpone or investigate 03 / 19 Postpone only for a finding that raises risk and can be improved before surgery.
American Society of Anesthesiologists (ASA) physical status classes (Miller) Before elective surgery Patient before elective surgery Decision Day‑of‑surgery hypertension → , open its explanation Possibly situational: address anxiety, recheck properly Rechecked blood pressure against 180/110 → , open its explanation Below: proceed; at or above: weigh delay individually Systolic under 180 and diastolic under 110 mmHg → , open its explanation Proceed; above, weigh optimisation against cost of delay Scoliosis correction, good exercise tolerance, normal lung tests → , open its explanation ECG and echocardiogram: ventricular function, pulmonary pressures Scoliosis correction, no lung tests yet → , open its explanation Pulmonary function tests first History and examination older than 30 days → , open its explanation Repeat it; valid only 30 days Update after admission, before surgery → , open its explanation Within 24 hours of admission (Miller: 48 hours) Previous stroke: what lowers the risk most → , open its explanation Defer elective surgery; waiting 6 months beats a short delay Previous stroke, existing antiplatelets → , open its explanation Continue them: standard care, not the risk‑lowering step Stroke the day before a booked operation → , open its explanation Defer; of usual offers, only 12 months clears the 9‑month plateau
Sources: AHA/ACC 2024 · §6.7
Report a problem with card 3: Proceed, postpone or investigate
Which tests 04 / 19 Order tests for what the history and examination find, never by routine.
Which test for which patient Patient Test Fit, asymptomatic, elective surgery → , open its explanation No routine tests; only if history, examination, procedure indicate Childbearing age, pregnancy not excluded → , open its explanation Consented pregnancy test before any anaesthetic Suspected obstructive sleep apnoea → , open its explanation Screen with the STOP‑Bang questionnaire Known obstructive sleep apnoea → , open its explanation Establish severity and positive airway pressure (PAP) settings, not screening
STOP-Bang questionnaire (Barash; risk bands Barash, Faust): one point per yes Item Scores a point when Snoring → , open its explanation Loud snoring Tiredness → , open its explanation Tired in the daytime Observed → , open its explanation Apnoea, choking or gasping seen during sleep Pressure → , open its explanation High blood pressure Body mass index (BMI) → , open its explanation Above 35 kg/m² Age → , open its explanation Over 50 years Neck → , open its explanation 40 cm either sex, or men 43 cm, women 41 Gender → , open its explanation Male Under 3 → , open its explanation Low risk 3–4 → , open its explanation Intermediate risk: the screen is positive (Miller calls 3 or more high) 5–8 → , open its explanation High risk: more severe sleep apnoea, more postoperative complications
Report a problem with card 4: Which tests
Fasting and antibiotic prophylaxis 06 / 19 Clear fluids to 2 hours; antibiotic within its window before incision, redosed when delayed.
Preventing nausea and vomiting 08 / 19 Count the Apfel risk factors; prophylaxis grows with the count.
Apfel score for postoperative nausea and vomiting (PONV), consensus guideline and Miller Risk factor Points Female sex → , open its explanation 1 Non‑smoker → , open its explanation 1 Prior PONV or motion sickness → , open its explanation 1 Postoperative opioids → , open its explanation 1, only when stated Apfel score 0, 1, 2 → , open its explanation 10%, 20%, 40% risk Apfel score 3, 4 → , open its explanation 60%, 80% risk
Weight of the risk factors High-risk plan Report a problem with card 8: Preventing nausea and vomiting
Laparoscopy on the monitors 09 / 19 Read the monitors against the pneumoperitoneum: name the cause before treating.
Fluid responsiveness on the monitor 10 / 19 A high pleth variability index (PVI) predicts a fluid response; a low one points elsewhere.
Laparoscopy goes wrong 12 / 19 Find the true cause first; release pneumoperitoneum when it threatens circulation, oxygenation or heart rhythm.
Event during laparoscopy Event during laparoscopy Action Subcutaneous emphysema with hypercarbia alone → , open its explanation Hyperventilate; desufflate only if inadequate Emphysema plus hypotension, hypoxia or high airway pressure → , open its explanation Tension capnothorax: desufflate now, support circulation, decompress if severe Hypotension despite fluid and pressor, failing heart → , open its explanation Reduce or release pneumoperitoneum, not more pressor or fluid Desaturation soon after head‑down tilt → , open its explanation Suspect endobronchial tube; auscultate both sides, withdraw tube Bradycardia or asystole as insufflation begins → , open its explanation Deflate; prevent with slow insufflation, lower pressure, glycopyrrolate
The mechanism behind each event Report a problem with card 12: Laparoscopy goes wrong
Temperature 13 / 19 Core temperature falls first by redistribution; heat then leaves mainly by radiation and convection.
How heat is lost Phases of core cooling Mild hypothermia: prevention and harm Postoperative shivering Report a problem with card 13: Temperature
Nausea in recovery 14 / 19 Rescue with a different class from the prophylaxis; match the drug to the patient.
After surgery: the common problems 15 / 19 After surgery, name the commonest cause or fix: each problem has its own risk set.
Delirium Delirium Detail Baseline risk factors → , open its explanation Over 65, cognitive impairment, hearing or visual loss, ASA III+ Further risk factors → , open its explanation Low albumin, dehydration, sleep deprivation, immobilisation Prevention in frail elderly → , open its explanation Titrate to processed EEG, avoid burst suppression; depth over technique Daily drinker: agitation, tachycardia 24+ hours abstinent → , open its explanation Alcohol withdrawal: small titrated benzodiazepine doses first‑line
Low oxygen and low urine output Urinary retention: risk factors Report a problem with card 15: After surgery: the common problems
Clots, cement and hip fracture 16 / 19 Major surgery carries clot risk, orthopaedic surgery adds cement, and age drives death after hip fracture.
Venous thromboembolism: the risk Venous thromboembolism: prevention Bone cement implantation syndrome Named operations: the leading hazard Report a problem with card 16: Clots, cement and hip fracture
Pulmonary risk and outcome 17 / 19 Smoking, lung disease and the operation site predict pulmonary complications; analgesia changes outcome.
Laparoscopy: the gas and cardiopulmonary disease 18 / 19 Absorbed carbon dioxide must be breathed off; sick hearts and lungs bear it worst.
Traps Check these before you finish 1 card · about 1 min 19 Traps
Traps 19 / 19 The tempting choice is the familiar one; the books often name another.
Tempting Right call Obturator nerve injury after lithotomy → , open its explanation Common peroneal (fibular): commonest motor injury; obturator, one all‑neuropathy count Cancelling for day‑of‑surgery hypertension → , open its explanation Address anxiety, recheck; proceed below 180/110, else weigh delay Repeat ondansetron after failed prophylaxis → , open its explanation New‑class rescue; same‑class repeat within 6 hours adds nothing CO2 embolism for asystole at insufflation → , open its explanation Vagal reflex from peritoneal stretch: deflate the abdomen Radiation and conduction as main heat loss → , open its explanation Radiation and convection; conduction and evaporation contribute little Evaporation as insufflation heat loss → , open its explanation Convection: cold, dry gas carries heat from peritoneal contents Worse V/Q mismatch in COPD pneumoperitoneum → , open its explanation Absorbed CO2 load the diseased lungs cannot clear Extra delay: pulp‑free apple juice two hours ago → , open its explanation Clear fluid; two‑hour interval met, proceed Central retinal artery compression after prone spine surgery → , open its explanation Posterior ischaemic optic neuropathy, unless the globe was pressed
Report a problem with card 19: Traps
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Sheet 06 · Perioperative Medicine 19 / 19
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