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for adolescents over 16 years, with considerable variation between countries and states/provinces. The clinician should be aware of the local practice.

• Incompetent patients: Consent should be obtained from the legally appointed guardian or the 'Person Responsible' as defined by the local Guardianship Board or equivalent.

• Religious and cultural issues: Restricted consent can be given by patients to allow certain treatments but not for others. A common example is Jehovah's Witnesses who may consent to surgery but not allow blood transfusion. The issues involved with the use of cell-savers and extra-corporeal bypass and specific blood products needs to be discussed in detail with Jehovah's Witnesses because there is some variation in attitudes to ensure there is no misunderstanding. In emergency situations where the patient's wishes are not clearly known, the patient must be treated according to Standard Protocols. In the case of children under 16 where blood transfusion is deemed necessary, application to the appropriate authority will be required if parental consent for transfusion is withheld.

Emergencies

In the emergency situation, estimation of physical status is compromised by the need to manage the presenting illness. A history may need to be taken from relatives during preopera-tive resuscitation and thorough physical examination may be difficult. Hospital records, if available, are invaluable to exclude systemic illness. Accurate estimation of fluid status is an essential part of successful preoperative management. Knowledge of the time course of the illness is important in guiding this process since previous fluid losses are particularly difficult to assess. Ongoing losses must be documented, bearing in mind that concealed losses are notoriously difficult to estimate. Serum electrolyte concentrations may significantly underestimate fluid losses in the presence of isotonic losses. Correction of problems such as fluid deficit and electrolyte imbalance can proceed while the patient is being prepared for emergency surgery. Preoperative resuscitation can nearly always be performed prior to surgery except in cases of life-threatening haemorrhage.

Increasing age increases perioperative risk because of progressive reduction in functional reserve of organ systems as well as increasing illnesses associated with increasing age. The commonest co-morbidities are arthritis, hypertension, diabetes and cardiac disease (Table 1.2).

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