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E very year, more than 3 500 000 patients require a general anaesthetic. When undergoing a general anaesthetic comorbidities can increase a patient's risk of peri-operative morbidity and mortality, and thus, it is sometimes necessary to delay planned procedures in order to address this problem. When referring patients for consideration of surgery, GPs have a fundamental role in optimisation of many chronic conditions in order to reduce perioperative mortality and avoid delays. Furthermore, with the increase of day surgery procedures and prompt discharge, GPs are regularly reviewing patients post-operatively and have to advise on the management of common side effects and complications. This article will discuss the management of chronic conditions and comorbidities prior to surgical referral, as well as common complications of general anaesthesia that GPs may encounter. The GP curriculum and anaesthetics Core statement 1: Being a general practitioner states that GPs should be able to:. Refer appropriately to other professionals by predicting sources of delay and taking steps to avoid these where appropriate. Maintain a positive attitude to improving the health of patients living with chronic conditions. Recognise the additional impact of multi-morbidity on the therapeutic options available to the patient Clinical module 3.03: Care of acutely ill people states that GPs should be able to:. Inform patients and offer appropriate explanations for any new symptoms, signs or changes in an existing condition. Use timely review of acutely ill patients in order to monitor their condition and determine changes to your initial management plans. Know when it is safe and appropriate to manage a patient in the community and when the patient needs to be referred to hospital for assessment or admission Chronic conditions Hypertension Hypertension is the second-most-common condition associated with post-operative morbidity (Daley et al., 1997). Recent guidelines have recommended that patients should have recorded blood pressures below 160/100 mmHg in primary care in the 12 months prior to referral for elective surgery (Hartle et al., 2016). This should be documented in the referral letter. Patients can be referred if they remain hypertensive despite optimal treatment, and if patients decline treatment the letter should document that an informed discussion has taken place. Managing hypertension pre-operatively must take into consideration the risk of anaesthesia, versus the delay for the patient. There has been no evidence to show any benefit for delaying surgery in hypertension with a blood pressure less than 180/110 mmHg. In contrast, patients with stage 3 hypertension (greater than 180/110 mmHg) are more likely to develop peri-operative complications, such as myocardial ischaemia and infarction (Howell et al., 2004). It is appreciated

Epidural analgesia is the gold standard for labour analgesia. Dural puncture epidural analgesia is a modification of the conventional technique, where the dura is intentionally perforated with a spinal needle but no intrathecal medication is given. This article reviews the evidence for and against the clinical use of dural puncture epidural.