The perioperative journey

What “perioperative” means (the whole pathway)

• Perioperative care covers: preoperative assessment → anaesthesia and surgery → recovery → postoperative care and handover.
• Your priorities throughout: patient safety, good communication, physiological stability, pain and nausea control, and clear documentation.
• Think in phases: assess risk, optimise where possible, plan the anaesthetic, deliver safely, recover safely, and hand over clearly.

Preoperative assessment (before the day if possible)

• Confirm: patient identity, procedure, side/site, consent status, allergies, and relevant past anaesthetic issues (e.g., difficult airway, awareness, severe PONV).
• History focus: cardiorespiratory symptoms (chest pain, breathlessness, exercise tolerance), reflux/aspiration risk, diabetes control, OSA symptoms, pregnancy status where relevant, and functional status/frailty.
• Medication check: anticoagulants/antiplatelets, antihypertensives, diabetes meds (especially insulin/SGLT2 inhibitors), steroids, opioids, recreational drugs.
• Examination: airway assessment (mouth opening, neck movement, dentition), baseline observations, heart/lung exam if indicated.
• Investigations: only if they will change management (e.g., Hb for major surgery/anaemia risk, ECG for significant cardiac disease or major surgery, renal function if relevant).
• Risk discussion: explain anaesthetic plan, common side effects, and material risks tailored to the patient; document clearly.

Optimisation and planning (making the day safer)

• Optimise what you can: treat anaemia, control asthma/COPD, manage hypertension, address infection, plan perioperative diabetes management, consider prehab for major surgery.
• Fasting: follow local policy; typical approach is 6 hours for solids and 2 hours for clear fluids (unless specific concerns).
• Aspiration risk: consider rapid sequence induction (RSI) if high risk (e.g., full stomach, bowel obstruction, severe reflux with symptoms, pregnancy, emergency surgery).
• Analgesia plan: simple ladder (paracetamol ± NSAID if safe, local/regionals, opioids as needed); plan for chronic opioid users (expect higher requirements).
• PONV plan: assess risk (female, non-smoker, history of PONV/motion sickness, opioids) and give multimodal prophylaxis.
• Equipment/people: if anticipated difficulty (airway, vascular access), escalate early and ensure appropriate kit and help are available.

On the day: before anaesthesia (theatre checks and preparation)

• Team brief and WHO checks: sign-in (before anaesthesia), time-out (before incision), sign-out (before leaving theatre). Speak up if anything is unclear.
• Machine and drugs: complete anaesthetic machine check, suction working, oxygen available, capnography ready, emergency drugs accessible.
• Monitoring (minimum): ECG, non-invasive BP, pulse oximetry, capnography for any airway device/ventilation, temperature for longer cases; consider invasive monitoring for high-risk cases.
• IV access: ensure reliable cannula; plan for difficult access (ultrasound, senior help). Label lines and syringes clearly.
• Positioning and pressure care: protect eyes, nerves, and pressure points; check straps and padding before draping.
• Antibiotics and VTE prevention: give antibiotics on time (per local guidance); ensure VTE plan (mechanical ± pharmacological) is considered.

Induction of anaesthesia (common first-time scenarios)

• Pre-oxygenation: aim for good denitrogenation (tight mask seal, calm coaching) to increase safe apnoea time.
• Induction sequence: check monitors on, IV working, give induction agent, manage airway, confirm ventilation with capnography.
• Airway basics: start with simple steps (head position, jaw thrust, oral/nasal airway, two-person mask ventilation) before escalating.
• Supraglottic airway (SGA): common for routine cases; confirm placement with chest movement and capnography; secure well.
• Intubation: plan A/B/C; confirm tube position with continuous capnography; secure tube; set ventilator appropriately.
• RSI: used to reduce aspiration risk; ensure skilled help, suction ready, clear plan for failed intubation, and do not persist with repeated traumatic attempts.

Maintenance (keeping the patient stable)

• Keep checking: oxygenation, ventilation, circulation, depth of anaesthesia, temperature, urine output (if indicated), and blood loss.
• Fluids: give what the patient needs (replace losses, maintain perfusion); avoid both under-resuscitation and fluid overload; reassess frequently.
• Hypotension: common after induction; treat with fluids if appropriate, vasopressors, and adjust anaesthetic depth; look for bleeding or anaphylaxis if severe.
• Analgesia: give early enough to work before wake-up; consider local infiltration or regional blocks where appropriate.
• Temperature: active warming reduces complications; monitor and warm early, especially in long cases.

Emergence and extubation (finishing safely)

• Plan the wake-up: ensure analgesia and antiemetics are in place, neuromuscular blockade is reversed appropriately, and the patient is warm and stable.
• Extubation readiness: adequate breathing, oxygenation, protective airway reflexes, haemodynamic stability, and no unresolved airway concerns.
• Common issues: coughing/laryngospasm, airway obstruction, agitation, pain, PONV; treat early and call for help if not rapidly improving.
• Post-extubation: give oxygen as needed, monitor closely, and ensure clear instructions for recovery staff.

Recovery (PACU): what good looks like

• Handover: structured and complete (patient, procedure, anaesthetic, airway, analgesia, antiemetics, fluids/blood loss, complications, ongoing concerns).
• Monitor: airway patency, respiratory rate, oxygen saturation, pain score, nausea, BP/HR, temperature, bleeding/drains, and level of consciousness.
• Common PACU problems: airway obstruction (especially OSA), hypoventilation from opioids, hypotension, shivering, pain, PONV, delirium.
• Discharge criteria: stable observations, pain and nausea controlled, acceptable oxygenation, appropriate level of consciousness, and clear plan for ward care.

Postoperative care and ward handover

• Analgesia: prescribe clearly (regular non-opioids if safe, PRN opioids, consider PCA/epidural/regional follow-up). Include bowel regimen if opioids likely.
• PONV: continue antiemetics if needed; consider hydration and opioid-sparing strategies.
• Respiratory care: encourage deep breathing, early mobilisation, and appropriate oxygen; consider CPAP for known OSA if used at home.
• Escalation: ensure clear instructions for what to do if pain uncontrolled, hypotension, bleeding, low urine output, or respiratory depression.

Communication, documentation, and professionalism

• Introduce yourself, confirm patient understanding, and check concerns (fear, pain, previous bad experiences).
• Document: assessment, ASA grade (overall physical status), plan, consent discussion, airway management, complications, and postoperative instructions.
• Escalate early: if you feel out of depth, call a senior; early help prevents harm.
• Human factors: use checklists, avoid distractions at critical moments, and encourage a culture where anyone can speak up.