Peri-operative assessment and ASA grading

🟢 Lite — Quick Review (1h–1d)

Rapid summary for last-minute revision before your Saudi GP Board exam.

Topic 1 is the introductory surgical block in the Saudi GP Board blueprint (~3% weight) that frames peri-operative assessment, wound classification, haemostasis, asepsis, and surgical ethics. Candidates need safe gatekeeping decisions, not operative skill.

Scope: 3% of the SCFHS GP Board exam; tested as short clinical vignettes (single-best MCQ).
Peri-operative ABCDE + ASA I–VI risk stratification drive referral urgency.
Wound classes — clean, clean-contaminated, contaminated, dirty-infected — set SSI risk and antibiotic prophylaxis.
Wound healing = haemostasis → inflammation (0–3 d) → proliferation (3–21 d) → remodelling (weeks–years).
Asepsis: sterilisation kills spores; disinfection does not.
Informed consent must be taken by the operating surgeon or a delegated qualified clinician.

High-yield trap: confusing sterilisation with disinfection — a classic single-line MCQ distractor.

🟡 Standard — Regular Study (2d–2mo)

Standard content for students with a few days to months.

Peri-operative assessment and ASA grading

The GP’s surgical role begins with structured risk stratification, not the operation. The ABCDE primary survey (Airway with Mallampati view, Breathing, Circulation, Disability/neurology, Exposure) flags the unstable patient for urgent escalation. Stable patients are then graded using the American Society of Anaesthesiologists (ASA) Physical Status classification:

ASA	Descriptor	Example	GP action
I	Healthy	Uncomplicated hernia	Routine referral
II	Mild systemic disease	Controlled hypertension	Optimise, then refer
III	Severe systemic disease	Stable angina	Pre-op clinic review
IV	Severe, constant threat	Recent MI	Defer elective surgery
V/V–VI	Moribund / brain-dead	—	Emergency only

Wound classification and SSI risk

The National Research Council (NRC) wound class is the most-tested surgical basic in the GP exam because it dictates prophylaxis and counselling.

Class	Definition	Typical SSI rate	Prophylaxis
Clean	Uninfected GI/respiratory tract not entered	<5%	Single-dose cefazolin if implant
Clean-contaminated	Controlled entry into GI or respiratory tract	5–15%	Cefazolin 30 min pre-incision
Contaminated	Open, fresh accidental wounds or major breaks in sterility	>15%	Therapeutic antibiotic course
Dirty-infected	Old traumatic wounds, perforated viscus, pus	~30–40%	Full therapeutic course

Misclassifying a clean-contaminated case as clean is the commonest trap — always read the operative findings, not the skin.

Wound healing and haemostasis

Healing proceeds in four overlapping phases: haemostasis (platelet plug + fibrin clot, minutes), inflammation (neutrophils 0–24 h, then macrophages up to day 3), proliferation (fibroblasts, angiogenesis, epithelialisation, days 3–21), and remodelling (collagen cross-linking, type III → type I, weeks to >1 year). The clotting cascade — intrinsic (PTT), extrinsic (PT/INR), common pathway — provides secondary haemostasis after the platelet primary plug.

🔴 Extended — Deep Study (3mo+)

Comprehensive coverage for students on a longer study timeline.

Asepsis, sutures, and incisions

Sterilisation (autoclave at 121 °C × 15 min, EtO gas, plasma H₂O₂) destroys all microbial life including spores; disinfection (70% alcohol, chlorhexidine, iodophors) eliminates vegetative organisms but not spores, so it suits intact skin but not instruments. A correct surgical scrub is 5-minute chlorhexidine or povidone-iodine, from fingertips to elbows, with a sterile brush — fingertips first, never returning to a cleaned area.

Suture choice is frequently tested:

Property	Absorbable (e.g., polyglactin 910)	Non-absorbable (e.g., nylon, polypropylene)
Tensile loss	60–90 days	Indefinite
Use	Peritoneum, mucosa, subcutaneous	Skin, vascular, tendon
Removal	Not required	D 7–14 (skin)

Common incisions map to specific pathologies: midline laparotomy (rapid trauma access), Kocher (subcostal, gallbladder/biliary), McBurney / Lanz (appendicitis), Pfannenstiel (Caesarean, gynaecology), Rockey-Davis (transverse McBurney variant).

Informed consent requires capacity, disclosure of risks/benefits/alternatives, voluntariness, and — crucially — the operating surgeon (or explicitly delegated qualified clinician) must obtain it. Disclosure of adverse events is mandatory under SCFHS professionalism standards; the GP who first learns of a complication must document and escalate, not conceal.

Operative urgency categories — elective (planned, e.g., hernia), urgent (within 24 h, e.g., obstructing colon cancer), emergency (immediate, e.g., ruptured AAA) — drive theatre prioritisation and patient counselling.

Common mistakes

Confusing the Saudi GP Board (family practice) with the Saudi Board of General Surgery — different SCFHS tracks.
Underestimating a 3% topic; integrated vignettes carry the principles forward.
Quoting remodelling in days rather than months-to-years.
Forgetting that consent taken by a medical student alone is invalid.

Practice prompts

A 62-year-old ASA III diabetic has an elective open cholecystectomy. Using NRC wound class and ASA, what is your predicted SSI risk and pre-op counselling?
A nurse asks whether chlorhexidine skin prep gives “sterile” instruments. Explain sterilisation versus disinfection and the appropriate instrument processing.

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Peri-operative assessment and ASA grading