MRCS PART A ESSENTIAL REVISION NOTES BOOK 1 - PasTest

SECTION 1Assessment of fitness for surgeryCHAPTER 1In a nutshell …Before considering surgical intervention itis necessary to prepare the patient as fullyas possible.The extent of pre-op preparationdepends 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, maintheatre) Facilities availableThe rationale for pre-op preparation is to: Determine a patient’s ‘fitness forsurgery’Anticipate difficultiesMake advanced preparation andorganise facilities, equipment andexpertiseEnhance patient safety and minimisechance of errorsAlleviate any relevant fear/anxietyperceived by the patientReduce morbidity and mortalityCommon factors resulting in cancellation ofsurgery include: Inadequate investigation and managementof existing medical conditions New acute medical conditionsClassification of surgery according to theNational Confidential Enquiry into PatientOutcome and Death (NCEPOD): Elective: mutually convenient timing Scheduled: (or semi-elective) earlysurgery under time limits (eg 3 weeks formalignancy) Urgent: as soon as possible after adequateresuscitation and within 24 hoursPatients may be: Emergency: admitted from A&E; admittedfrom clinic Elective: scheduled admission from home,usually following pre assessmentIn 2011 NCEPOD published Knowing the Risk: Areview of the perioperative care of surgical patientsin response to concerns that, although overallsurgical mortality rates are low, surgical mortalityin the high-risk patient in the UK is significantlyhigher than in similar patient populations in theUSA. They assessed over 19 000 surgical casesprospectively and identified four key areas forimprovement (see overleaf).3