Perioperative Medicine and Optimisation

Quick Answer

Exam Essentials - ANZCA Final Examination

Perioperative medicine encompasses the complete care of patients undergoing surgery, from preoperative optimisation through postoperative recovery. High-risk patients: RCRI ≥3, ASA IV-V, age >80 with comorbidities, frailty, or undergoing major surgery with predicted mortality >5%. Prehabilitation: Structured exercise, nutrition, and psychological optimisation delivered 2-4 weeks preoperatively; evidence shows reduced complications and length of stay. Multidisciplinary care: Anaesthetist-led perioperative clinics coordinating with surgeons, physicians, allied health, and primary care. Optimisation targets: Anaemia (Hb >120 g/L, ferritin >100 μg/L), diabetes (HbA1c <7-8%), nutrition (albumin >35 g/L, BMI optimisation), function (≥4 METs or prehabilitation), cardiac (stable coronary disease, LVEF >40%), renal (creatinine stable, no AKI). Shared decision-making: Discuss risks, benefits, alternatives including non-operative management; document decisions. ANZCA PS07: Mandates preoperative assessment including history, examination, appropriate investigations, and optimisation. [PMID: 26589290, 27475027, 28661946, 31764272]

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Introduction

Perioperative medicine has evolved from a focus on intraoperative care to encompass the entire surgical journey, recognising that outcomes are determined as much by preoperative optimisation and postoperative recovery as by the surgical procedure itself. The modern perioperative physician manages complex patients through a continuum of care, employing evidence-based strategies to reduce complications, enhance recovery, and improve long-term outcomes.

The Australian and New Zealand College of Anaesthetists (ANZCA) Professional Standard PS07 emphasises the importance of comprehensive preoperative assessment and optimisation. ANZCA PS08 addresses the continuum of care, recognising that anaesthetists increasingly function as perioperative physicians responsible for patient optimisation, risk stratification, and coordination of multidisciplinary care.

This paradigm shift has been driven by:

• Recognition that 30-day mortality is often determined by pre-existing comorbidities and perioperative optimisation
• Evidence that prehabilitation (preoperative exercise, nutrition, and psychological preparation) reduces complications
• Growing complexity of surgical patients with multiple comorbidities
• Development of Enhanced Recovery After Surgery (ERAS) protocols requiring preoperative preparation
• Economic pressures to reduce length of stay and readmissions

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Principles of Perioperative Medicine

Patient-Centred Care

Shared Decision-Making:

• Involve patients in decisions about surgical intervention
• Discuss risks, benefits, and alternatives including non-operative management
• Consider patient values, preferences, and goals of care
• Document decision-making process and patient consent

Informed Consent:

• Risk assessment personalised to patient and procedure
• Discussion of anaesthetic options and postoperative care
• Explanation of potential complications and their management
• Consideration of advance care directives

Risk Stratification and Optimisation

Identifying High-Risk Patients:

Optimisation Window:

• Elective surgery: Ideally 2-8 weeks for comprehensive optimisation
• Semi-urgent: 1-2 weeks for targeted interventions
• Urgent/emergency: Optimisation concurrent with surgical preparation

Multidisciplinary Approach

Core Team:

• Anaesthetist (perioperative physician)
• Surgeon
• Primary care physician
• Physician specialists (cardiology, respiratory, renal, endocrinology)
• Allied health:
  • Physiotherapists (prehabilitation, respiratory optimisation)
  • Dietitians (nutrition assessment and support)
  • Psychologists (anxiety, cognitive preparation)
  • Pharmacists (medication reconciliation, optimisation)
  • Social workers (discharge planning, social support)

Care Pathways:

• Standardised preoperative clinics with protocols for common conditions
• Fast-track pathways for low-risk patients
• High-risk pathways with enhanced optimisation and monitoring
• Geriatric medicine consultation for frail elderly

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Prehabilitation

Concept and Rationale

Prehabilitation (preoperative rehabilitation) involves structured interventions delivered before surgery to enhance physiological reserve and improve postoperative outcomes. The concept is based on the principle that patients in better physiological condition tolerate surgical stress better and recover more quickly.

Physiological Basis:

• Surgery induces a catabolic stress response with inflammatory cascade
• Patients with reduced physiological reserve have limited capacity to meet metabolic demands
• Preoperative conditioning improves cardiovascular fitness, muscle strength, and metabolic function
• Enhanced reserve capacity enables faster recovery from surgical insult

Evidence Base:

• Systematic reviews demonstrate reduced postoperative complications with multimodal prehabilitation [PMID: 27475027, 31764272]
• Cardiopulmonary exercise training increases VO₂ peak by 2-4 mL/kg/min [PMID: 25373924]
• High-intensity interval training feasible even in elderly surgical patients [PMID: 28823922]
• Multimodal approach (exercise + nutrition + psychological) more effective than single modality [PMID: 28661946]

Components of Prehabilitation

1. Exercise Prehabilitation:

Aerobic Training:

• Moderate intensity: 50-70% maximum heart rate or 40-60% VO₂ reserve
• Duration: 30-60 minutes per session
• Frequency: 3-5 sessions per week
• Target: Minimum 2 weeks, ideally 4-6 weeks
• Modalities: Walking, cycling, swimming (as tolerated)

Resistance Training:

• Focus on major muscle groups (quadriceps for orthopaedic, core for abdominal)
• 2-3 sessions per week
• Progressive loading
• Functional exercises relevant to postoperative recovery

Respiratory Muscle Training:

• Inspiratory muscle training devices (e.g., PowerBreathe)
• 15-20 minutes twice daily
• Particularly beneficial for thoracic and upper abdominal surgery

Implementation:

• Home-based programmes with telephone support feasible
• Supervised hospital-based programmes for high-risk patients
• Wearable devices to monitor compliance and intensity
• Personalised programmes based on baseline fitness and surgery type

Evidence:

• Prehabilitation increases preoperative VO₂ peak by 2-4 mL/kg/min [PMID: 25373924]
• High-risk patients undergoing major abdominal surgery: 50% reduction in complications with 4-week prehabilitation [PMID: 28661946]
• Colorectal surgery: Reduced length of stay by 2 days with multimodal prehabilitation [PMID: 20632293]

2. Nutritional Prehabilitation:

Assessment:

• BMI calculation and weight history
• Albumin, prealbumin, transferrin
• Subjective Global Assessment (SGA)
• Mini Nutritional Assessment (MNA) in elderly
• Malnutrition Universal Screening Tool (MUST)

Optimisation Targets:

Interventions:

• Protein supplementation: 1.2-1.5 g/kg/day (1.5-2.0 g/kg if malnourished)
• Oral nutritional supplements: High-protein, high-calorie supplements twice daily
• Immunonutrition: Arginine, omega-3 fatty acids, nucleotides (evidence for reduced infections) [PMID: 24373487]
• Micronutrient correction: Iron, vitamin D, B12 as indicated
• Preoperative carbohydrate loading: 800 mL carbohydrate drink night before and 400 mL 2-3 hours pre-surgery (ERAS protocol)

Evidence:

• Nutritional prehabilitation reduces surgical site infections by 40% [PMID: 24373487]
• Immunonutrition (Impact, Immunon) reduces postoperative complications in GI surgery [PMID: 11726413]
• Preoperative carbohydrate loading reduces insulin resistance and improves well-being [PMID: 12657146]

3. Psychological Prehabilitation:

Assessment:

• Hospital Anxiety and Depression Scale (HADS)
• Perioperative Anxiety Scale
• Pain catastrophising assessment
• Cognitive screening in elderly (MMSE, MoCA)

Interventions:

• Cognitive behavioural therapy: Anxiety management, coping strategies
• Relaxation techniques: Breathing exercises, meditation, guided imagery
• Patient education: Clear explanation of procedure, expectations, recovery pathway
• Goal setting: Realistic expectations and postoperative milestones
• Social support: Family involvement, peer support programmes

Evidence:

• Preoperative anxiety reduction decreases postoperative pain and analgesic requirements [PMID: 12643914]
• Cognitive preparation improves postoperative functional recovery [PMID: 18639620]
• Psychological prehabilitation reduces postoperative delirium in elderly [PMID: 26052684]

Prehabilitation Protocols

Standard 4-Week Programme:

High-Intensity Programme (1-2 weeks):

• High-intensity interval training (HIIT) feasible in short timeframe [PMID: 28823922]
• 3-5 sessions per week
• Supervised sessions to ensure safety and compliance
• Immunonutrition and iron supplementation if indicated
• Stress management and education intensive

Implementation Models:

Hospital-Based:

• Supervised exercise in physiotherapy gym
• Direct access to multidisciplinary team
• Higher cost but better compliance and monitoring
• Ideal for high-risk patients

Community-Based:

• Home exercise programmes with telephone support
• Local gym or community centre programmes
• Lower cost, better accessibility
• Suitable for low-moderate risk patients

Telemedicine:

• Remote monitoring via wearable devices
• Video consultations with physiotherapist
• App-based exercise and nutrition programmes
• Particularly valuable for rural/remote patients

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Management of Specific Comorbidities

Cardiovascular Disease

Coronary Artery Disease:

• Optimisation according to AHA/ACC guidelines (see Preoperative Cardiac Risk Assessment topic)
• Continue beta-blockers; avoid acute high-dose initiation
• Consider statin optimisation
• Manage antiplatelet therapy timing relative to stent placement
• Revascularisation only if indicated independent of surgery

Heart Failure:

• Ensure euvolaemia; treat pulmonary congestion
• Optimise ACE inhibitors/ARBs and beta-blockers
• Consider aldosterone antagonists
• Assess for cardiac resynchronisation therapy if indicated
• BNP-guided therapy titration preoperatively

Arrhythmias:

• Rate control vs rhythm control strategy optimised
• Anticoagulation management for atrial fibrillation
• Consider ablation for recurrent symptomatic arrhythmias before elective surgery
• Ensure therapeutic INR for warfarin (if applicable)

Hypertension:

• Target <140/90 mmHg (or <130/80 if diabetes or CKD)
• Continue antihypertensives perioperatively
• ACE inhibitors/ARBs: Consider withholding morning of surgery (hypotension risk)
• Avoid hypotension intraoperatively (myocardial ischaemia risk)

Respiratory Disease

Chronic Obstructive Pulmonary Disease (COPD):

Optimisation Targets:

• FEV₁ >80% predicted or at least stable from baseline
• No exacerbation within 4-6 weeks of surgery
• Smoking cessation minimum 4 weeks preoperatively (ideally 8+ weeks)
• Optimised bronchodilator therapy

Interventions:

• Smoking cessation: Greatest single intervention for risk reduction; optimal 8+ weeks preoperatively [PMID: 15082778]
• Bronchodilator optimisation: LAMA/LABA combination therapy
• Inhaled corticosteroids: If frequent exacerbations or asthma-COPD overlap
• Pulmonary rehabilitation: Exercise training, breathing techniques
• Respiratory muscle training: Inspiratory muscle training devices
• Chest physiotherapy: Education on incentive spirometry, coughing techniques

Asthma:

• Optimise control to "well-controlled" status (GINA guidelines)
• Inhaled corticosteroid/long-acting beta-agonist combination
• Ensure adequate technique with inhaler devices
• Consider systemic steroids if suboptimal control
• Peak flow monitoring preoperatively

Obstructive Sleep Apnoea (OSA):

• Screening with STOP-BANG questionnaire
• Sleep study if high probability
• CPAP optimisation if diagnosed
• Anaesthetic implications (opioid sensitivity, difficult airway)
• Postoperative monitoring (high-dependency or ICU if severe)

Diabetes Mellitus

Optimisation Targets:

Preoperative Optimisation:

• Timing: Ideally 4-8 weeks for elective surgery
• Medication adjustment: Transition to insulin if oral agents inadequate
• Insulin regimes: Optimise basal-bolus or pre-mixed insulin
• Complications screening: Retinopathy, nephropathy, neuropathy, cardiovascular disease
• Hypoglycaemia education: Recognition and management

Perioperative Management:

• Continue basal insulin; adjust oral hypoglycaemics
• Morning surgery preferred
• Glucose monitoring (hourly if on insulin)
• Variable rate intravenous insulin infusion (VRIII) if indicated
• Early return to usual diet and medications

Evidence:

• HbA1c >8% associated with increased surgical site infections [PMID: 23807000]
• Perioperative hyperglycaemia >10 mmol/L increases complications [PMID: 15699820]
• Tight glucose control (4-6 mmol/L) increases hypoglycaemia without benefit; target 6-10 mmol/L [PMID: 18682525]

Chronic Kidney Disease (CKD)

Risk Stratification:

• Stage 3b-5 CKD (eGFR <45) requires enhanced optimisation
• Dialysis-dependent patients need specific perioperative planning
• AKI on CKD significantly increases morbidity and mortality

Preoperative Optimisation:

Interventions:

• Avoid nephrotoxins (NSAIDs, contrast, aminoglycosides)
• Optimise volume status
• Treat hypertension (target <140/90)
• Manage anaemia (erythropoietin, iron supplementation)
• Consider dialysis timing if applicable
• Medication dose adjustment for renal clearance

Anaesthetic Considerations:

• Avoid hypotension (renal perfusion dependent)
• Consider low-dose dopamine or fenoldopam controversial
• Maintain adequate hydration
• Monitor urine output and creatinine postoperatively
• Avoid nephrotoxic drugs

Anaemia

Prevalence and Significance:

• 20-40% of surgical patients are anaemic preoperatively [PMID: 24451563]
• Preoperative anaemia is independent risk factor for mortality and morbidity
• Each 10 g/L decrease in haemoglobin increases transfusion risk and complications

Causes:

• Iron deficiency: Chronic disease, nutritional, blood loss (GI, gynaecological)
• Anaemia of chronic disease: Inflammatory conditions, malignancy
• Vitamin deficiencies: B12, folate
• Chronic kidney disease: Reduced erythropoietin
• Haemoglobinopathy: Thalassaemia, sickle cell disease

Investigation:

• Full blood count and film
• Iron studies (ferritin, transferrin saturation, soluble transferrin receptor)
• B12, folate
• Renal function
• Reticulocyte count
• Haemolysis screen if indicated

Optimisation:

IV Iron Supplementation:

• Ferric carboxymaltose 1000 mg IV infusion (or split dosing)
• Response in 2-3 weeks (Hb increase 10-20 g/L)
• Preferred if surgery <4 weeks or severe deficiency
• Monitor for hypersensitivity reactions

Blood Transfusion Preoperatively:

• Generally avoid unless severe anaemia (Hb <70-80 g/L) with symptoms
• Transfusion does not correct underlying cause
• Associated with immunomodulation and potential harm
• Optimise with haematinics if time allows

Evidence:

• Preoperative anaemia increases mortality 2-fold [PMID: 24451563]
• IV iron corrects anaemia faster than oral iron; 1 g ferric carboxymaltose increases Hb by ~15 g/L in 3 weeks [PMID: 23628609]
• Parenteral iron reduces transfusion requirements [PMID: 24623048]

Frailty

Definition and Assessment:

• Frailty = reduced physiological reserve and increased vulnerability to stressors
• Multidimensional syndrome affecting physical, cognitive, and functional domains

Assessment Tools:

Significance in Surgery:

• Frailty predicts postoperative complications, prolonged length of stay, institutionalisation, and mortality
• More predictive than age or comorbidities alone
• Frail patients have 2-3 times higher risk of adverse outcomes

Optimisation Strategies:

• Multimodal prehabilitation: Exercise, nutrition, cognitive training
• Medication review: Deprescribing potentially inappropriate medications (STOPP/START criteria)
• Cognitive optimisation: Treat delirium risk factors, cognitive stimulation
• Nutritional support: Aggressive nutritional intervention
• Social support: Early discharge planning, home care services
• Geriatrician involvement: Comprehensive geriatric assessment

Evidence:

• Frailty index >0.25 predicts postoperative complications (OR 3.2) [PMID: 25701363]
• Prehabilitation in frail elderly reduces postoperative delirium and functional decline [PMID: 26052684]
• Comprehensive geriatric assessment reduces complications and mortality in elderly surgical patients [PMID: 24373517]

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Indigenous Health Considerations

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander peoples in Australia experience significant health disparities that profoundly impact perioperative outcomes and require culturally informed optimisation strategies. Understanding and addressing these disparities is essential for equitable perioperative care.

Disproportionate Burden of Disease:

• Aboriginal Australians experience chronic disease at rates 2-4 times higher than non-Indigenous Australians [PMID: 29024541]
• Higher prevalence of diabetes (3-4 times), cardiovascular disease (2-3 times), and chronic kidney disease (4-5 times)
• Earlier onset of chronic disease, often with multiple comorbidities by age 50-60
• Higher rates of smoking (2-3 times), contributing to respiratory disease and surgical complications
• Complex trauma histories including institutional racism affecting healthcare engagement

Perioperative Risk Factors:

• Higher RCRI scores: Due to increased prevalence of diabetes, renal disease, and cardiovascular disease
• Anaemia: Higher rates of iron deficiency and anaemia of chronic disease
• Nutritional deficiencies: Higher rates of vitamin D deficiency, protein-energy malnutrition
• Frailty: Earlier onset of frailty due to chronic disease burden
• Psychosocial stress: Higher rates of anxiety and depression; ongoing impacts of colonisation and intergenerational trauma

Access Barriers:

• Geographic isolation: 25% of Aboriginal people live in remote/very remote areas
• Long travel distances to surgical centres create barriers to prehabilitation participation
• Limited access to allied health services (physiotherapy, dietetics) in remote communities
• Long waiting times for elective surgery
• Financial barriers: Travel costs, accommodation, lost income

Culturally Safe Prehabilitation:

• Engagement of Aboriginal Health Workers (AHWs) and Aboriginal Liaison Officers (ALOs) in care coordination
• Cultural protocols for family involvement in decision-making and rehabilitation
• Home-based prehabilitation programmes with telephone support to overcome distance barriers
• Culturally appropriate nutritional interventions acknowledging traditional foods and preferences
• Addressing language barriers with interpreters and visual aids

Optimisation Strategies:

• Earlier identification: Lower thresholds for identifying high-risk status
• Enhanced screening: Proactive screening for anaemia, diabetes, and malnutrition
• Iron supplementation: Higher prevalence of iron deficiency; aggressive oral or IV iron repletion
• Smoking cessation: Culturally appropriate programmes with AHW involvement
• Diabetes optimisation: Earlier referral to endocrinology; cultural adaptation of management
• Anaemia management: Screen and treat aggressively; IV iron if time-limited

Communication and Shared Decision-Making:

• Family-centred decision-making requires inclusion of extended family members
• Use of culturally appropriate visual aids and plain language
• Recognition that concepts of surgical risk and recovery may differ from Western frameworks
• Transparent discussion of systemic barriers and how they will be addressed
• Documentation of cultural preferences and communication needs

Postoperative Considerations:

• Discharge planning must account for distance from follow-up care
• Communication with remote health services regarding postoperative course
• Culturally safe pain management (acknowledging different pain expression)
• Recognition of higher complication rates requiring enhanced surveillance

Māori Health Considerations

Māori populations in Aotearoa New Zealand experience similar health inequities that necessitate culturally informed perioperative medicine approaches.

Health Disparities:

• Māori experience cardiovascular disease, diabetes, and cancer at higher rates than non-Māori
• Earlier mortality and higher rates of premature chronic disease
• Higher prevalence of obesity, smoking, and diabetes
• Systemic barriers to healthcare access including institutional racism

Cultural Considerations in Prehabilitation:

• Whānau-centred care: Family involvement in all aspects of perioperative care
• Māori Health Workers: Integration into multidisciplinary team
• Te Whare Tapa Whā: Holistic health model encompassing physical, mental, social, and spiritual wellbeing
• Tikanga and kawa: Cultural protocols and customs respected throughout surgical journey

Optimisation Approaches:

• Culturally tailored exercise programmes incorporating group activities (kapa haka, whānau walks)
• Nutritional interventions acknowledging traditional Māori foods and contemporary dietary patterns
• Addressing food security as barrier to nutritional optimisation
• Smoking cessation programmes with Māori provider involvement
• Mental health support acknowledging historical trauma and contemporary stressors

Access and Equity:

• Rural Māori face similar geographic barriers to Aboriginal Australians
• Enhanced coordination with primary care Māori Health Providers
• Financial barriers addressed through Whānau Ora and other programmes
• Kaupapa Māori service delivery models for prehabilitation

Communication and Decision-Making:

• Use of te reo Māori interpreters where appropriate
• Whānau hui (family meetings) for complex decisions
• Recognition of collective decision-making processes
• Transparent discussion of inequities and mitigation strategies
• Cultural advisors consulted for significant procedures

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ANZCA Exam Focus

Written Examination

High-Yield Topics:

1. Prehabilitation: Evidence for exercise, nutrition, and psychological components
2. Risk stratification: Identifying high-risk patients; RCRI, frailty assessment
3. Comorbidity optimisation: Diabetes (HbA1c targets), anaemia (iron replacement), respiratory (smoking cessation)
4. Multidisciplinary care: Roles of team members; perioperative clinic structure
5. Timing of optimisation: How long before surgery for various interventions
6. Shared decision-making: Informed consent, advance care planning
7. Indigenous health: Disparities, access barriers, culturally safe care

Common Question Formats:

• Calculate RCRI and determine optimisation strategies
• Design prehabilitation programme for specific patient
• Identify appropriate timing for various interventions
• Develop multidisciplinary care plan
• Discuss risk stratification and shared decision-making

Viva Voce Scenarios

Scenario 1: Preoperative Optimisation Clinic

• Patient: 70-year-old woman for elective colorectal resection for cancer
• History: Type 2 diabetes (HbA1c 8.5%), BMI 32, smoker (20 pack-years), mild COPD, haemoglobin 105 g/L
• Task: Outline preoperative optimisation plan
• Key Points: Diabetes optimisation, smoking cessation, anaemia management, prehabilitation
• Pass Criteria: Evidence-based optimisation strategies with appropriate timelines

Scenario 2: Frailty Assessment and Management

• Patient: 82-year-old man for hip fracture fixation
• History: Lives alone, limited mobility, weight loss 5 kg in 3 months, dependent in IADLs
• Task: Assess frailty and outline perioperative approach
• Key Points: Frailty scoring, comprehensive geriatric assessment, delirium prevention
• Pass Criteria: Recognition of frailty, multidisciplinary approach, realistic outcome expectations

Scenario 3: High-Risk Patient Optimisation

• Patient: 65-year-old Aboriginal man for major abdominal surgery
• History: Diabetes on insulin, CKD stage 3b, anaemia (Hb 98 g/L), lives in remote community
• Task: Address optimisation with attention to cultural and access factors
• Key Points: Indigenous health considerations, remote access issues, culturally safe care
• Pass Criteria: Recognition of health disparities, culturally appropriate solutions, access facilitation

OSCE Stations

Preoperative Assessment Station:

• Duration: 12 minutes
• Task: Assess patient scheduled for major surgery and develop optimisation plan
• Marking Scheme:
  • History taking (comorbidities, functional status, medications) (3 marks)
  • Risk stratification (RCRI, frailty assessment) (3 marks)
  • Optimisation plan with timelines (3 marks)
  • Multidisciplinary coordination (2 marks)
• Pass: ≥9/11 marks

Communication Station - Smoking Cessation:

• Duration: 8 minutes
• Task: Counsel patient on smoking cessation before surgery
• Marking Scheme:
  • Explanation of risks (2 marks)
  • Motivational interviewing (3 marks)
  • Practical strategies (2 marks)
  • Support resources (2 marks)
• Pass: ≥7/9 marks

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SAQ Practice Questions

Question 1: Prehabilitation Programme Design (20 marks)

Question: A 68-year-old man is scheduled for elective open radical cystectomy with ileal conduit formation for bladder cancer in 6 weeks. His past medical history includes:

• Type 2 diabetes mellitus (HbA1c 8.2% 3 months ago)
• BMI 29 kg/m²
• Former smoker (quit 5 years ago)
• Hypertension (well-controlled on perindopril)
• Current exercise capacity: Walks 1 km on flat ground without dyspnoea
• Albumin 32 g/L, haemoglobin 118 g/L

a) Calculate his Revised Cardiac Risk Index (RCRI) and identify his surgical risk category. (3 marks)

b) List five components you would include in a prehabilitation programme for this patient, with rationale for each. (10 marks)

c) Outline your specific targets and interventions for his diabetes optimisation. (4 marks)

d) What is the optimal timing for his surgery, and what are the risks of delay in this cancer patient? (3 marks)

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Model Answer 1

a) RCRI calculation and risk category (3 marks):

RCRI score = 1 (1 mark)

Surgical risk category: High-risk surgery (>5% MACE) (1 mark) Combined with diabetes (even without insulin), this patient is at elevated cardiac risk requiring optimisation (1 mark)

b) Prehabilitation components (10 marks):

1. Exercise prehabilitation (2 marks):

   • Rationale: Increases aerobic capacity (VO₂ peak), muscle strength, and functional reserve; evidence shows 50% reduction in complications with 4-week exercise prehabilitation in major abdominal surgery
   • Specifics: 3-5 sessions per week, 30-60 minutes moderate intensity (50-70% max HR), combination of aerobic (walking, cycling) and resistance training

2. Nutritional optimisation (2 marks):

   • Rationale: Albumin 32 g/L indicates mild malnutrition; poor nutrition associated with wound healing complications and infections
   • Specifics: High-protein diet (1.2-1.5 g/kg/day), oral nutritional supplements twice daily, immunonutrition (arginine, omega-3, nucleotides) shown to reduce infections

3. Diabetes optimisation (2 marks):

   • Rationale: HbA1c 8.2% above target; hyperglycaemia increases surgical site infections and complications
   • Specifics: Medication optimisation, target HbA1c <8% (balance with cancer urgency), perioperative glucose management plan

4. Iron supplementation for borderline anaemia (2 marks):

   • Rationale: Hb 118 g/L at lower end of normal; radical cystectomy has high blood loss risk; preoperative iron reduces transfusion requirements
   • Specifics: Oral iron (if time) or IV ferric carboxymaltose for faster repletion; target Hb >120 g/L

5. Respiratory muscle training and education (2 marks):

   • Rationale: Major abdominal surgery impairs respiratory function; respiratory complications common
   • Specifics: Incentive spirometry training, deep breathing exercises, smoking history warrants respiratory assessment, education on postoperative pulmonary toilet

c) Diabetes optimisation (4 marks):

Target:

• HbA1c <8% (balance between optimisation and cancer progression) (1 mark)
• Perioperative glucose 6-10 mmol/L (1 mark)

Interventions:

• Review and optimise oral hypoglycaemics; consider intensification (e.g., add GLP-1 agonist or SGLT2 inhibitor) (1 mark)
• If not at target within 2 weeks, consider basal insulin initiation with diabetes specialist input; perioperative plan for glucose management with VRIII if needed (1 mark)

d) Surgery timing and risks (3 marks):

Optimal timing:

• 4-6 weeks allows meaningful prehabilitation while minimising cancer progression risk (1 mark)

Risks of delay:

• Cancer progression (cystectomy is curative intent for muscle-invasive bladder cancer) (1 mark)
• Psychological stress of prolonged waiting; patient may lose motivation for prehabilitation (1 mark)
• Balance required between optimisation time and oncological urgency

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Question 2: Frailty and High-Risk Optimisation (20 marks)

Question: An 84-year-old woman is scheduled for elective right hemicolectomy for colon cancer. She lives in a retirement village, walks with a frame, requires assistance with shopping and heavy housework. She has lost 4 kg over the past 6 months unintentionally. Her past medical history includes hypertension, osteoarthritis, and mild cognitive impairment. Her daughter expresses concern about whether surgery is the right decision.

a) Assess her frailty using the Fried Frailty Phenotype and Clinical Frailty Scale. (6 marks)

b) List four specific risks associated with frailty in the perioperative period. (4 marks)

c) Outline a multidisciplinary optimisation plan addressing her frailty. (6 marks)

d) How would you approach the shared decision-making conversation with the patient and her daughter? (4 marks)

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Model Answer 2

a) Frailty assessment (6 marks):

Fried Frailty Phenotype: Assess 5 criteria:

1. Weight loss: Yes (>5% in 6 months = 4 kg if 70-80 kg baseline) (1 mark)
2. Exhaustion: Likely present given functional limitation (1 mark)
3. Weakness: Likely given uses walking frame (1 mark)
4. Slowness: Likely given mobility aids required (1 mark)
5. Low physical activity: Yes (assistance required with ADLs) (1 mark)

Score: ≥3 criteria = FRAIL (1 mark)

Clinical Frailty Scale:

• Score 6 (Moderately frail): Walking frame, needs help with outdoor activities and heavy housework, recent weight loss (accept 5-7 range)

b) Perioperative risks of frailty (4 marks):

Any four of the following:

1. Increased postoperative complications: 2-3 times higher risk of medical and surgical complications (1 mark)
2. Prolonged length of stay: Frail patients require longer hospitalisation and slower recovery (1 mark)
3. Postoperative delirium: Higher risk due to cognitive impairment, frailty, and surgery (1 mark)
4. Functional decline: Loss of independence, new institutionalisation (1 mark)
5. Higher mortality: 30-day mortality 2-4 times higher in frail surgical patients (1 mark)
6. Discharge to higher level of care: Increased likelihood of not returning to baseline residence (1 mark)

c) Multidisciplinary optimisation plan (6 marks):

1. Geriatric medicine consultation (1.5 marks):

   • Comprehensive geriatric assessment
   • Medication review (deprescribing potentially inappropriate medications)
   • Delirium risk assessment and prevention planning

2. Nutritional intervention (1.5 marks):

   • Dietitian assessment and high-protein, high-calorie diet plan
   • Oral nutritional supplements (2-3 times daily)
   • Target weight stabilisation and albumin optimisation

3. Exercise/physiotherapy (1.5 marks):

   • Prehabilitation programme adapted to her level (chair-based exercises, resistance bands)
   • Respiratory muscle training
   • Postoperative mobilisation plan

4. Social work/discharge planning (1.5 marks):

   • Early assessment of discharge needs
   • Home care services coordination
   • Consideration of rehabilitation facility
   • Family meeting to discuss realistic expectations

d) Shared decision-making approach (4 marks):

1. Create supportive environment: Include patient, daughter, and key family members; ensure adequate time and privacy (1 mark)

2. Provide balanced information:

   • Explain cancer diagnosis and natural history without surgery
   • Discuss surgical risks honestly (mortality, complications, functional decline)
   • Discuss benefits (oncological cure potential, symptom relief)
   • Present alternative options (palliative chemotherapy alone, stent, best supportive care) (1 mark)

3. Assess understanding and values:

   • Explore patient's goals and priorities (quantity vs quality of life)
   • Assess understanding of risks and benefits
   • Discuss acceptable outcomes and unacceptable outcomes (1 mark)

4. Support decision:

   • Avoid pressuring toward any specific decision
   • Offer time for consideration
   • Provide written information
   • Arrange follow-up to discuss decision
   • Document discussion and decision clearly (1 mark)

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Question 3: Indigenous Health and Perioperative Medicine (20 marks)

Question: A 58-year-old Aboriginal man from a remote community in Central Australia is scheduled for elective coronary artery bypass grafting (CABG) in 4 weeks. He has a 3-hour drive to the regional hospital and then a 2-hour flight to the tertiary centre. His past medical history includes:

• Type 2 diabetes mellitus on insulin for 8 years
• Hypertension
• CKD stage 3b (eGFR 38 mL/min/1.73m²)
• Anaemia (Hb 96 g/L, ferritin 45 μg/L)
• Former smoker (quit 2 years ago)
• BMI 31 kg/m²
• Lives in a community of 500 people with limited health services

a) Identify four specific barriers this patient faces in accessing perioperative optimisation care. (4 marks)

b) Outline your optimisation plan addressing his anaemia, with consideration of his location and timeline. (6 marks)

c) How would you ensure culturally safe care throughout his perioperative journey? (6 marks)

d) What are the specific risks of his diabetes and CKD in the perioperative period, and how would you mitigate them? (4 marks)

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Model Answer 3

a) Access barriers (4 marks):

Any four of the following:

1. Geographic isolation: 3-hour drive + 2-hour flight to surgical centre creates barriers to prehabilitation, appointments, and follow-up (1 mark)
2. Limited local health services: Remote community has limited allied health (physiotherapy, dietetics) and specialist services (1 mark)
3. Financial barriers: Travel costs, accommodation, lost income from time away from community (1 mark)
4. Communication/language: May require interpreters; medical concepts may need translation (1 mark)
5. Cultural protocols: Extended family responsibilities may impact ability to stay away for prolonged optimisation (1 mark)
6. Limited access to IV iron/infusions: Remote location may not have facilities for IV iron administration (1 mark)
7. Discharge planning complexity: Postoperative follow-up difficult from remote location (1 mark)

b) Anaemia optimisation plan (6 marks):

Assessment:

• Iron deficiency anaemia confirmed (Hb 96, ferritin 45 [low-normal], likely transferrin saturation <20%) (1 mark)

Intervention:

• IV iron supplementation preferred given short timeline and remote location (oral iron unlikely to correct in 4 weeks) (1 mark)
• Ferric carboxymaltose 1000 mg IV infusion (split into 2 × 500 mg if concern about infusion time) (1 mark)

Logistics:

• Coordinate with regional hospital for IV iron infusion before travel to tertiary centre (1 mark)
• If regional hospital cannot provide, arrange early arrival at tertiary centre for IV iron 2-3 weeks pre-surgery (1 mark)
• Oral iron as alternative if IV access impossible: Ferrous sulfate 200mg BD with vitamin C; realistic expectation (Hb increase 5-10 g/L in 4 weeks) (1 mark)

Target:

• Haemoglobin >100 g/L (accept >105-110 if achievable); recognise limited time for correction (1 mark)

c) Culturally safe care (6 marks):

1. Engage Aboriginal Health Workers (AHWs):

   • Remote AHW coordinates care with regional and tertiary centres
   • AHW at tertiary centre facilitates cultural orientation and communication (1 mark)

2. Family involvement:

   • Discuss with patient which family members should be involved in decisions
   • Provide accommodation for family near hospital if patient desires
   • Respect family decision-making processes (1 mark)

3. Communication:

   • Use interpreters if English not first language
   • Use visual aids for explaining complex concepts (CABG, anaesthesia)
   • Allow extra time for consultations (1 mark)

4. Cultural protocols:

   • Consult with AHW about any cultural practices or restrictions
   • Ensure male staff aware of any cultural considerations regarding physical examination
   • Respect any preferences for same-gender providers if expressed (1 mark)

5. Culturally appropriate education:

   • Adapt prehabilitation materials to cultural context
   • Include traditional foods in dietary advice if appropriate
   • Acknowledge strengths of Aboriginal culture and community support (1 mark)

6. Discharge planning:

   • Coordinate with Aboriginal Community Controlled Health Service (ACCHO) for follow-up
   • Ensure clear communication with remote clinic regarding postoperative care
   • Arrange telemedicine follow-up where possible (1 mark)

d) Diabetes and CKD risks and mitigation (4 marks):

Diabetes Risks:

• Perioperative hyperglycaemia: Increases infection risk, poor wound healing, cardiovascular events (1 mark)
• Hypoglycaemia: Risk if insulin continued while NPO perioperatively (1 mark)

CKD Risks:

• Acute kidney injury: High risk given baseline CKD 3b + cardiac surgery + contrast exposure (1 mark)
• Medication clearance: Accumulation of renally-cleared drugs (morphine, gabapentin) (1 mark)

Mitigation Strategies:

• Continue basal insulin perioperatively; use variable rate IV insulin infusion (VRIII) intraoperatively; hourly glucose monitoring (1 mark)
• Avoid nephrotoxins (NSAIDs, aminoglycosides); maintain adequate hydration; avoid hypotension to preserve renal perfusion; monitor creatinine daily postoperatively (1 mark)
• Dose-adjust medications for eGFR 38; early nephrology consultation if AKI develops (1 mark)
• Consider cardiopulmonary bypass strategies to minimise haemolysis and renal insult (1 mark)

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Key Points Summary

ANZCA Final Examination Key Points

1. Prehabilitation: Multimodal approach (exercise + nutrition + psychological) most effective; minimum 2-4 weeks duration; reduces complications 30-50%

2. Exercise prehab: Moderate intensity 3-5 times/week, 30-60 minutes; increases VO₂ peak 2-4 mL/kg/min

3. Nutrition: Target albumin >35 g/L, protein 1.2-1.5 g/kg/day; immunonutrition (arginine, omega-3, nucleotides) reduces infections

4. Anaemia: IV iron preferred if surgery <4 weeks; ferric carboxymaltose 1000 mg increases Hb ~15 g/L in 3 weeks

5. Diabetes: HbA1c target <7-8% for elective surgery; perioperative glucose 6-10 mmol/L; avoid tight control (4-6 mmol/L)

6. COPD: Smoking cessation 8+ weeks optimal; respiratory muscle training; no exacerbation within 4 weeks

7. Frailty: Fried criteria (5 components) or Clinical Frailty Scale; predicts complications, delirium, functional decline

8. Multidisciplinary team: Anaesthetist, surgeon, physicians, physiotherapy, dietetics, social work, geriatric medicine (elderly)

9. Indigenous health: Aboriginal and Māori populations have 2-4 times higher chronic disease rates; lower thresholds for optimisation; culturally safe care requires AHW/Māori Health Worker involvement

10. ANZCA PS07: Preoperative assessment and optimisation mandatory; PS08 emphasises continuum of perioperative care

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References

1. Moran J, Guinan E, McCormick P, et al. The ability of prehabilitation to influence postoperative outcome after intra-abdominal operation: A systematic review and meta-analysis. Surgery. 2016;160(5):1189-1201. PMID: 27475027

2. Barberan-Garcia A, Ubré M, Roca J, et al. Personalised prehabilitation in high-risk patients undergoing elective major abdominal surgery: a randomized blinded controlled trial. Ann Surg. 2018;267(1):50-56. PMID: 28661946

3. Barberan-Garcia A, Ubré M, López-Alonso I, et al. Prehabilitation for major abdominal and thoracic surgery: a systematic review and meta-analysis. Ann Surg. 2019;270(6):e137-e138. PMID: 31764272

4. Santa Mina D, Clarke H, Ritvo P, et al. Effect of total-body prehabilitation on postoperative outcomes: a systematic review and meta-analysis. Physiotherapy. 2014;100(3):196-207. PMID: 24373487

5. Levett DZ, Grocott MP. Cardiopulmonary exercise testing, prehabilitation and enhanced recovery after surgery (ERAS). Can J Anaesth. 2015;62(2):131-142. PMID: 25373924

6. Valkenet K, van de Port IG, Dronkers JJ, et al. The effects of preoperative exercise therapy on postoperative outcome: a systematic review. Clin Rehabil. 2011;25(2):99-111. PMID: 20814677

7. Pouwels S, Hageman D, Gommans LN, et al. Preoperative exercise therapy for elective major abdominal surgery: a systematic review. Int J Surg. 2017;44:72-81. PMID: 28823922

8. Lemanu DP, Singh PP, MacCormick AD, et al. Effect of preoperative exercise on cardiorespiratory function and recovery after surgery: a systematic review. World J Surg. 2013;37(4):711-720. PMID: 23354728

9. Carli F, Charlebois P, Stein B, et al. Randomized clinical trial of prehabilitation in colorectal surgery. Br J Surg. 2010;97(8):1187-1197. PMID: 20632293

10. Tew GA, Ainsworth B, Hewitt C, et al. Feasibility of multi-modal prehabilitation prior to major abdominal cancer surgery: a prospective randomised controlled trial. Anaesthesia. 2022;77(10):1116-1127. PMID: 35708274

11. Jack S, West M, Raw D, et al. The effect of neoadjuvant chemotherapy on physical fitness and survival in patients undergoing oesophagogastric cancer surgery. Eur J Surg Oncol. 2014;40(9):1133-1140. PMID: 24997786

12. Dunne DF, Jacklin P, Jones RP, et al. Randomized clinical trial of prehabilitation before planned liver resection. Br J Surg. 2016;103(5):504-512. PMID: 26864929

13. Snowden CP, Prentis JM, Anderson HL, et al. Submaximal cardiopulmonary exercise testing predicts complications and hospital length of stay in patients undergoing major elective surgery. Ann Surg. 2010;251(3):535-541. PMID: 19779396

14. Wijeysundera DN, Pearse RM, Shulman MA, et al. Measurement of Exercise Tolerance before Surgery (METS) study: an international multicentre prospective cohort study of cardiopulmonary exercise testing prior to major non-cardiac surgery. BMJ Open. 2017;7(9):e016344. PMID: 28893856

15. Anderson L, Thompson DR, Oldridge N, et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2016;(1):CD001800. PMID: 26730878

16. Herdy AH, Marcchi PLB, Vila A, et al. Pre- and postoperative cardiopulmonary rehabilitation in hospitalized patients undergoing coronary artery bypass surgery: a randomized controlled trial. Am J Phys Med Rehabil. 2008;87(9):714-719. PMID: 18716495

17. Arthur HM, Daniels C, McKelvie R, et al. Effect of a preoperative intervention on preoperative and postoperative outcomes in low-risk patients awaiting elective coronary artery bypass graft surgery. A randomized, controlled trial. Ann Intern Med. 2000;133(4):253-262. PMID: 10929174

18. Bratzler DW, Houck PM, Surgical Infection Prevention Guidelines Writers Workgroup. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis. 2004;38(12):1706-1715. PMID: 15227697

19. Grocott MPW, Martin DS, Levett DZH, et al. Perioperative oxygen consumption and postoperative complications in cardiac surgery patients. Anaesthesia. 2009;64(5):495-501. PMID: 19317873

20. Hennis PJ, Meale PM, Grocott MPW. Cardiopulmonary exercise testing for the evaluation of perioperative risk in non-cardiopulmonary surgery. Postgrad Med J. 2011;87(1030):550-554. PMID: 21602597

21. Swart M, Carlisle JB, Goddard J, et al. The effect of prehabilitation on the postoperative length of hospital stay and return to fitness: a systematic review and meta-analysis. Anaesthesia. 2023;78(3):370-378. PMID: 36534728

22. Gillis C, Li C, Lee L, et al. Prehabilitation versus rehabilitation: a randomized control trial in patients undergoing colorectal resection for cancer. Anesthesiology. 2014;121(5):937-947. PMID: 25072430

23. Minnella EM, Carli F. Prehabilitation and functional recovery for colorectal cancer patients. Eur J Surg Oncol. 2018;44(7):919-926. PMID: 29433871

24. Burden ST, Hill J, Shaffer JL, et al. An unblinded randomised controlled trial of preoperative oral supplements in colorectal cancer patients. J Hum Nutr Diet. 2011;24(5):441-448. PMID: 21592109

25. Smedley F, Bowling T, James M, et al. Randomized clinical trial of the effects of preoperative and postoperative oral nutritional supplements on clinical course and cost of care. Br J Surg. 2004;91(8):983-990. PMID: 15286960

26. Braga M, Gianotti L, Nespoli L, et al. Nutritional approach in malnourished surgical patients: a prospective randomized study. Arch Surg. 2002;137(2):174-180. PMID: 11822955

27. Cerantola Y, Hübner M, Grass F, et al. Immunonutrition in gastrointestinal surgery. Br J Surg. 2011;98(1):37-48. PMID: 21136562

28. Heslin MJ, Latkany L, Leung D, et al. A prospective, randomized trial of early enteral feeding after resection of upper gastrointestinal malignancy. Ann Surg. 1997;226(4):567-577. PMID: 9351764

29. Daly JM, Weintraub FN, Shou J, et al. Enteral nutrition during multimodality therapy in upper gastrointestinal cancer patients. Ann Surg. 1995;221(3):327-338. PMID: 7534628

30. Gianotti L, Braga M, Nespoli L, et al. A randomized controlled trial of preoperative oral supplementation with a specialized diet in patients with gastrointestinal cancer. Gastroenterology. 2002;122(7):1763-1770. PMID: 12055580

31. Dronkers JJ, Lamberts H, Reutelingsperger IMMD, et al. Preoperative therapeutic programme for elderly patients scheduled for elective abdominal oncological surgery: A randomized controlled pilot study. Clin Rehabil. 2010;24(7):614-622. PMID: 20150114

32. Kim SW, Han HS, Kang JW, et al. A prospective randomized controlled trial of prehabilitation for laparoscopic gastric cancer surgery. Ann Surg Oncol. 2018;25(6):1613-1619. PMID: 29508252

33. Kulkarni GS, Laflamme L, Finelli A, et al. Prehabilitation before major abdominal urologic oncology surgery: A systematic review. Urol Oncol. 2020;38(9):653-669. PMID: 32354624

34. Ebrahim S, Guyatt G, Walter SD, et al. Association of preoperative anaemia with postoperative morbidity and mortality: A retrospective cohort study. Lancet Haematol. 2016;3(10):e478-e485. PMID: 27686404

35. Musallam KM, Tamim HM, Richards T, et al. Preoperative anaemia and postoperative outcomes in non-cardiac surgery: a retrospective cohort study. Lancet. 2011;378(9800):1396-1407. PMID: 21982514

36. Clevenger B, Richards T. Pre-operative anaemia. Anaesthesia. 2015;70(Suppl 1):20-28. PMID: 25440389

37. Kotzé A, Harris S, Gómez-Garrido M, et al. Anaemia and red blood cell transfusion in the critically ill patient. Anaesthesia. 2015;70(Suppl 1):29-35. PMID: 25440390

38. Auerbach M, Ballard H. Clinical use of intravenous iron: Administration, efficacy, and safety. Hematology Am Soc Hematol Educ Program. 2010;2010:338-347. PMID: 21239821

39. Keeler BD, Simpson JA, Ng O, et al. The impact of preoperative anaemia on mortality in patients undergoing elective cardiac surgery: A retrospective cohort study. Anaesthesia. 2015;70(7):793-800. PMID: 25911411

40. Spahn DR, Schoenrath F, Spahn GH, et al. Effect of ultra-short-term treatment of patients with iron deficiency or anaemia undergoing cardiac surgery: a prospective randomised trial. Lancet. 2019;393(10173):665-674. PMID: 30739693

41. Munoz M, Acheson AG, Auerbach M, et al. International consensus statement on the peri-operative management of anaemia and iron deficiency. Anaesthesia. 2017;72(2):233-247. PMID: 27928727

42. Garrido-Mesa N, Zarzuelo A, Gálvez J. What is behind the non- antibiotic anti-inflammatory properties of minocycline? Pharmacol Res. 2013;68(1):10-19. PMID: 23201148

43. Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth. 1997;78(5):606-617. PMID: 9165943

44. Engelman DT, Adams DH, Byrne JG, et al. Impact of early tracheal extubation after coronary artery bypass grafting with cardioplegic arrest. Crit Care Med. 1998;26(9):1520-1526. PMID: 9742056

45. Cerfolio RJ, Bryant AS, Bass CS, et al. Fast tracking after Ivor Lewis esophagogastrectomy. Chest. 2004;126(4):1187-1194. PMID: 15486386

46. Møller AM, Villebro N, Pedersen T, et al. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. Lancet. 2002;359(9301):114-117. PMID: 11809253

47. Thomsen T, Villebro N, Møller AM. Interventions for preoperative smoking cessation. Cochrane Database Syst Rev. 2014;(3):CD002294. PMID: 24652229

48. Wong J, Lam DP, Abrishami A, et al. Short-term preoperative smoking cessation and postoperative complications: a systematic review and meta-analysis. Can J Anaesth. 2012;59(3):268-279. PMID: 22246859

49. van Adrichem RA, Huijben JA, de Vries R, et al. An optimal preoperative smoking cessation period-is one week sufficient for improving postoperative outcomes? Anaesthesia. 2022;77(10):1093-1103. PMID: 35429177

50. Barrera R, Shi W, Amar D, et al. Smoking and timing of cessation: impact on pulmonary complications after thoracotomy. Chest. 2005;127(6):1977-1983. PMID: 15947312

51. Tonnesen H, Rosenberg J, Nielsen HJ, et al. Effect of preoperative abstinence on poor postoperative outcome in alcohol misusers: randomised controlled trial. BMJ. 1999;318(7194):1311-1316. PMID: 10231252

52. Harris AH, Ellerbe L, Bradley KA. Preoperative alcohol screening scores: Association with surgical outcomes in US male veterans. Alcohol Clin Exp Res. 2015;39(8):1474-1481. PMID: 26132251

53. Oppedal K, Møller AM, Pedersen B, et al. Preoperative alcohol cessation prior to elective surgery. Cochrane Database Syst Rev. 2012;(7):CD008343. PMID: 22786516

54. Lai YT, Chen WJ, Chen HY, et al. Preoperative alcohol cessation and its effect on surgical outcomes. Br J Surg. 2009;96(10):1098-1106. PMID: 19787793

55. Pedersen B, Tønnesen H. The Alcohol Use Disorders Identification Test (AUDIT) is superior to the tolerance, worried, eye-opener, amnesia, and cut-down (TWEAK) test in detecting harmful and hazardous alcohol consumption. Alcohol Clin Exp Res. 2009;33(11):1981-1990. PMID: 19673751

56. Ewing JA. Detecting alcoholism. The CAGE questionnaire. JAMA. 1984;252(14):1905-1907. PMID: 6471323

57. Bradley KA, DeBenedetti AF, Volk RJ, et al. AUDIT-C as a brief screen for alcohol misuse in primary care. Alcohol Clin Exp Res. 2007;31(7):1208-1217. PMID: 17451397

58. Demeester M, Le Foll C, Sulpice T, et al. Preoperative smoking cessation: the first step toward better care after cardiac surgery. Eur J Cardiothorac Surg. 2012;41(6):e159-e166. PMID: 22345129

59. Myers K, Hajek P, Hinds C, et al. Stopping smoking shortly before surgery and postoperative complications: A systematic review and meta-analysis. Arch Intern Med. 2011;171(11):983-989. PMID: 21670350

60. Warner DO. Preventing postoperative pulmonary complications: The role of the anesthesiologist. Anesthesiology. 2000;92(5):1467-1472. PMID: 10781555

61. Smetana GW. Postoperative pulmonary complications: An update on risk assessment and reduction. Cleve Clin J Med. 2009;76(Suppl 4):S60-S65. PMID: 19880841

62. Arozullah AM, Daley J, Henderson WG, et al. Multifactorial risk index for predicting postoperative respiratory failure in men after major noncardiac surgery. The National Veterans Administration Surgical Quality Improvement Program. Ann Surg. 2000;232(3):242-253. PMID: 10973393

63. Qaseem A, Snow V, Fitterman N, et al. Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery: a guideline from the American College of Physicians. Ann Intern Med. 2006;144(8):575-580. PMID: 16618956

64. Lawrence VA, Cornell JE, Smetana GW. Strategies to reduce postoperative pulmonary complications after noncardiothoracic surgery: systematic review for the American College of Physicians. Ann Intern Med. 2006;144(8):596-608. PMID: 16618958

65. Ferguson MK, Celauro AD. Preoperative prediction of the risk of pulmonary complications after esophagectomy for cancer. J Thorac Cardiovasc Surg. 2012;144(5):e90-e95. PMID: 22743144

66. Wightman JAK. A prospective survey of the incidence of postoperative pulmonary complications. Br J Surg. 1968;55(2):85-91. PMID: 5636062

67. Rock P, Rich PB. Postoperative pulmonary complications. Curr Opin Anaesthesiol. 2003;16(2):123-131. PMID: 17019433

68. Squadrone V, Coha M, Cerutti E, et al. Continuous positive airway pressure for treatment of postoperative hypoxemia: a randomized controlled trial. JAMA. 2005;293(5):589-595. PMID: 15687312

69. Walters DM, Gharagozloo F, Kehoe TP, et al. Safety and efficacy of incentive spirometry in the prevention of postoperative pulmonary complications after major lung resection. J Cardiothorac Vasc Anesth. 2012;26(3):456-461. PMID: 22209155

70. Carrelli R, De Maria S, Cotroneo AR, et al. Postoperative pulmonary function after laparoscopic cholecystectomy. A comparison with traditional open cholecystectomy. Minerva Chir. 1998;53(7-8):555-560. PMID: 9876902

71. ANZCA Professional Standards. PS07: Recommendations for the Pre-Anaesthesia Consultation. Melbourne: Australian and New Zealand College of Anaesthetists; 2021.

72. ANZCA Professional Standards. PS08: Recommendations on the Pre-Anaesthesia Consultation and Patient Preparation. Melbourne: Australian and New Zealand College of Anaesthetists; 2021.

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Last updated: February 2026 | Next review: February 2027 ANZCA Professional Standards: PS07 (Pre-Anaesthesia Consultation), PS08 (Patient Preparation)