This audit exists to evaluate the incidence and management of uncontrolled and untreated hypertension at pre-assessment among an adult population prior to major orthopaedic surgery. It exists as part of a series of articles presented in this journal. The author will outline the aims and objectives of the audit and discuss its design. This will be followed by the access and sampling method and the data collection method. Thereafter, the audit standards, ethical considerations and audit findings will be discussed. Next, a change model will be outlined with discussion as to how this may be used to implement and develop changes in practice. Recommendations for practice will follow with a conclusion and reflection.

Hypertension is the most common avoidable medical indication for postponing anaesthesia and surgery and although care guidelines exist for the medical patient with hypertension, there are no accepted guidelines for pre-operative evaluation and perioperative care of patients with hypertension who undergo non-cardiac surgery. Therefore management of hypertensive surgical patients remains unclear, whether blood pressure (BP) level or BP-related target organ damage at the time of surgery predicts perioperative cardiovascular complications in patients undergoing major surgery, and thus whether deferring surgery in order to improve BP control will lead to a reduction in perioperative cardiac risk. The literature review critically evaluates the current literature on the topics of hypertension and the surgical patient, white coat hypertension and hypertension and obesity. The literature review supports the uncertainty of patient's management prior to non-cardiac elective surgery as there are no published national guidelines as a direct association between pre-operative hypertension and the perioperative cardiac complications are unclear. Although there appears to be a general agreement that patients with mild-to-moderate hypertension can proceed with surgery because such hypertension poses little additional risk of perioperative cardiovascular complications. Severe hypertension and the presence of hypertension-induced end organ damage should be postponed until better BP control is obtained.

Background: Postoperative hypothermia is stressful and elevates blood pressure and heart rate. This study evaluated the effects of warming IV fluids on the perioperative hemodynamic situation.

Methods: Perioperative hemodynamic parameters were measured in 60 patients undergoing orthopaedic surgery. Patients were divided into two groups according to the temperature of intraoperative IV fluids.

Results: Core and skin temperature of the two groups decreased during surgery but reduced more in the hypothermic group (p < 0.005). Postoperative mean arterial blood pressure increased more in the hypothermic group versus normothermic group (p < 0.005). Shivering was observed in 21 of 30 hypothermic and 11 of 30 normothermic group (p < 0.005) and recovery time was lower in normothermic group (36 ± 5 vs. 26 ± 3 min, p < 0.005).

Conclusion: Warming of intraoperative IV fluids reduces perioperative changes in hemodynamic parameters.

A non-invasive ultrasound imaging technique (BladderScan) was used prospectively in an attempt to reduce the need for catheterization of the urinary bladder and the incidence of urinary tract infections after orthopaedic surgery. Over a 4-month period, in which 1920 patients were included, catheterization was performed if there was no spontaneous diuresis by 8 h after surgery. A total of 31% of these patients were catheterized, and 18 patients developed urinary tract infections. In a subsequent 4-month period, there were 2196 patients, catheterization was performed only if the bladder volume was more than 800 mL 8 h after surgery. The rate of catheterization decreased to 16%, and five patients developed urinary tract infections. In our patients, measuring bladder volume reduced the need for a urinary catheter and the likelihood of urinary infection.

Patients expected to need at least three units of blood for their elective cardiovascular or orthopaedic surgery, were allocated randomly to receive intravenous (i.v.) Epoetin alfa 600 IU kg−1 (n = 27), 300 IU kg−1 (n = 30) or placebo (n = 23), on days 1, 4 and 7. Provided haemoglobin ≥ 11 g dL−1, one unit of blood was collected on days 1, 4, 7, 11 and 14. Iron supplementation was given throughout the study. Surgery was scheduled between days 18 and 21. Significantly more patients treated with Epoetin alfa (100% for 600 IU kg −1 ; 97% for 300 IU kg−1) were able to donate ≥ 4 units of blood compared with placebo (78%) (P = 0.011 and P = 0.032). No significant differences were seen in total patient exposure to homologous blood (7.4%, 3.3% and 17.4%, respectively). Mean red cell volume donated (P = 0.005 for 600 IU kg−1 ; P = 0.158 for 300 IU kg−1 both vs. placebo) and production (P < 0.001 and P = 0.012, respectively) were dose related. Twenty-four patients became iron deficient. No differences in the incidence of adverse events were seen between the groups.