Fitness for Surgery

Elements of the Pre-Anaesthetic Evaluation

  • Determines whether a patient is fit for anaesthesia.

  • Ensures optimal perioperative outcomes and reduces complications.

  • Involves assessing patient’s physiological reserve and predicting surgical risk.

Preoperative Testing and Optimisation

  • Testing must change management; otherwise, it’s unnecessary.

  • Non-invasive interventions like optimising comorbidities (e.g., anaemia correction, fluid balance).

  • Cardiology/anaesthesia referrals for complex cases.

ACTIVE Mnemonic for Preoperative Risk Assessment

  • A – Assess METs and functional status.

  • C – Cardiac history: Recent MI, heart failure, arrhythmias.

  • T – Testing: Does additional testing alter management?

  • I – Infection or inflammation: Active conditions requiring optimisation.

  • V – Ventilation: Pulmonary disease, CO2 retention, wheezing.

  • E – Extra considerations: Diabetes, renal disease, anaemia.

Special Considerations in Rural vs. Tertiary Settings

  • Limited resources in rural areas:

    • Must balance urgency of surgery vs. stabilisation and transfer.

    • Importance of knowing local surgical capabilities.

  • Tertiary hospitals:

    • More specialised care available (e.g., cardiac catheterisation, ICU support).

Surgical coordination and consideration

Communicating with the Surgical Team

  • Essential to coordinate management strategies with the surgeon.

  • Discussions on operative approach based on patient condition.

  • Example: Lap vs. open surgery considerations based on stability.

Risk Stratification: Classifying Surgeries

  • Emergency: Immediate intervention (e.g., bleeding from trauma).

  • Urgent: Needs surgery within 24-48 hours (e.g., hip fracture repair).

  • Time-sensitive: Within 2 weeks (e.g., cancer resection).

  • Elective: Can be delayed (e.g., hernia repair).

Low-Risk vs. High-Risk Surgeries

  • Low-risk:

    • Cataract surgery, minor dermatological procedures.

    • Minimal cardiovascular impact, safe under local anaesthesia.

  • High-risk:

    • Major abdominal, vascular, or thoracic surgeries.

    • Require detailed preoperative workup and risk stratification.

Patient Assessment tools

Metabolic Equivalents (METs) and Functional Capacity

  • METs assess a patient’s ability to tolerate surgery.

  • Duke Activity Status Index (DASI) helps determine MET levels.

  • DASI Overview:

    • A questionnaire assessing a patient’s ability to perform daily activities.

    • Scores correlate with METs, allowing stratification of surgical risk.

    • Can be used as an alternative to formal exercise testing.

    • DASY Components:

      • Dressing and grooming,

      • Ambulation,

      • Stair climbing,

      • Yard work or other activities

  • Key thresholds:

    • 1 MET – Basic survival at rest.

    • 4 METs – Walking 5.6 km/h or climbing stairs.

    • 10 METs – Running a short distance, highly functional.

  • Patients with <4 METs have increased perioperative risk.

Evaluating Cardiopulmonary Reserve

  • High-risk surgeries (thoracic, liver resection, high-risk TURP) require specialised testing.

  • Cardiopulmonary exercise testing (CPET) and stress tests provide deeper insights.

  • Lack of stairs in rural settings – ask function-based questions (e.g., farming activities).

Specific Patient Conditions and Red Flags

Murmurs and Aortic Stenosis

  • Red flags:

    • Severe AS: Postpone elective surgery, seek echocardiogram.

    • Symptomatic AS: High mortality risk.

    • Mild/moderate AS with good exercise tolerance – may proceed.

ECG Abnormalities & Active Cardiac Conditions

  • Triphasicular block + syncope: Needs pacemaker before surgery.

  • Recent myocardial infarction (MI): Consider deferring non-urgent cases.

  • Low METs and high cardiac risk: Refer for further evaluation.

Pulmonary Considerations

  • Active wheezing/Asthma/COPD exacerbation:

    • Postpone elective surgery.

    • Optimise with bronchodilators, steroids, and antibiotics.

  • Well-controlled moderate asthma/COPD:

    • Low risk; proceed with surgery.

    • Consider spinal anaesthesia if feasible.

Diabetes, Hypertension, and Anaemia Optimisation

  • Diabetes: Optimise blood glucose.

  • Hypertension: Control BP within acceptable ranges.

  • Anaemia:

    • Consider IV iron or transfusion preoperatively.

    • Hb optimisation before elective cases.

Decision to Proceed

Decision Algorithm for Proceeding with Surgery

  1. Is the surgery an emergency?

    • If yes → Proceed with best available resuscitation.

  2. Is there an active cardiac condition?

    • If yes → Postpone elective, optimise, or refer.

  3. Is the surgery low-risk?

    • If yes → Proceed without further testing.

  4. Are METs >4?

    • If yes → Proceed.

    • If no → Consider stress test or optimisation.

Key Mnemonic: ‘Every Anaesthetist Loves Morning Coffee’

  • E – Emergency or elective?

  • A – Active cardiac conditions?

  • L – Low-risk procedure?

  • M – METs assessment.

  • C – Cardiology referral/testing if needed.

Perioperative Anaesthetic Management Strategies

  • Intraoperative monitoring: Arterial lines, cardiac output monitoring.

  • Blood management: Minimise blood loss, transfuse when necessary.

  • Analgesia: Multimodal approach (regional + systemic analgesia).

Handling Cancellations and Ethical Considerations

  • When to cancel a case:

    • Unoptimised high-risk patients for elective procedures.

    • Active infection or decompensated medical conditions.

  • How to handle cancellations:

    • Communicate effectively with the patient.

    • Involve referring physicians for further optimisation.

    • Document reasons for cancellation and plan for reassessment.

  • Diabetes: Optimise blood glucose.

  • Hypertension: Control BP within acceptable ranges.

  • Anaemia:

    • Consider IV iron or transfusion preoperatively.

    • Hb optimisation before elective cases.

Decision to Proceed

Decision Algorithm for Proceeding with Surgery

  1. Is the surgery an emergency?

    • If yes → Proceed with best available resuscitation.

  2. Is there an active cardiac condition?

    • If yes → Postpone elective, optimise, or refer.

  3. Is the surgery low-risk?

    • If yes → Proceed without further testing.

  4. Are METs >4?

    • If yes → Proceed.

    • If no → Consider stress test or optimisation.

Key Mnemonic: ‘Every Anaesthetist Loves Morning Coffee’

  • E – Emergency or elective?

  • A – Active cardiac conditions?

  • L – Low-risk procedure?

  • M – METs assessment.

  • C – Cardiology referral/testing if needed.

Perioperative Anaesthetic Management Strategies

  • Intraoperative monitoring: Arterial lines, cardiac output monitoring.

  • Blood management: Minimise blood loss, transfuse when necessary.

  • Analgesia: Multimodal approach (regional + systemic analgesia).

Special Considerations in Rural vs. Tertiary Settings

  • Limited resources in rural areas:

    • Must balance urgency of surgery vs. stabilisation and transfer.

    • Importance of knowing local surgical capabilities.

  • Tertiary hospitals:

    • More specialised care available (e.g., cardiac catheterisation, ICU support).

Handling Cancellations and Ethical Considerations

  • When to cancel a case:

    • Unoptimised high-risk patients for elective procedures.

    • Active infection or decompensated medical conditions.

  • How to handle cancellations:

    • Communicate effectively with the patient.

    • Involve referring physicians for further optimisation.

    • Document reasons for cancellation and plan for reassessment.

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