Preoperative optimization
of patients for surgery
Prepared by: Dr Ifrah Ahmad Qazi
Moderator: Dr Rauf Ahmad Wani
HOD: Prof. Khurshid Alam Wani
Preoperative preparation for surgery
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Introduction
Pre-operative care
Pre-operative investigation
Assessment of risk for surgery
Preparation of surgery of specific patient groups( system
wise approach)
• Consent
Introduction
• To obtain satisfactory results in general surgery requires a
careful approach to preoperative preparation of patients
• Specific patient groups have specific needs
• High risk patients should be identified early and appropriate
measures taken to reduce complications
Overview
• The preoperative consultation and evaluation is an important
interaction between the patient and physician.
• It allows the surgeon to :
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Carefully access the medical condition;
Evaluate the patient’s overall health status;
Determine risk factors against procedures;
Educate the patient
Discuss the procedure in detail.
• It helps the patient to :
• Gain a realistic understanding of the proposed surgery;
• Consider alternative treatment options
• Realise the possible complications during perioperative period.
• The additional time invested in preoperative evaluation yields
an improved patient physician relationship and reduces
surgical complications
Preoperative preparation for sugery
• Prior to consideration of surgical intervention, it is necessary to
prepare the patient as fully as possible so as to optimise him
according to his co-morbidities
• The extent of pre-operative preparation will depend on:
Nature of
surgery
(minor or major)
Facilities
available
Preoperative preparation for surgery
• Situation
• Emergency : life-threatening condition requiring immediate
action, ( e.g. ruptured aneurysm, penetrating trauma,
peritonitis)
• Urgent : surgery required within few hours ( e.g. intestinal
obstruction, appendicitis, wound debridement )
• Elective : ( e.g. hernia, varicose vein, colorectal
malignancies, breast malignancy )
20
17.2
12.8
Elective
Urgent
Complication Rates
Emergency
• The rational for pre-operative preparation is to:
Anticipate difficulties
Make advanced preparation and organize facilities, equipment
and expertise
Enhance patient safety and minimize chances of errors
Relieve any relevant fear/anxiety perceived by patient
Routine preparation for surgery
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History
Physical examination
Special investigation
Informed consent
Marking the site/side of operation
Thromboembolic prophylaxis
Antibiotic prophylaxis
Surgical history
Presenting complaint
dictates urgency, it can influence
anesthetic management and any
associated systemic effects of
presenting pathology
Systemic assessment
Carefully assess each body system
about its function to rule out if any
other system is involved
Past medical & surgical
Hx
Drugs and Allergic Hx
Many diseases have direct
effect on general and anesthetic
treatment and outcome
Any previous operation or
bleeding tendency
Any previous reaction to
anaesthetic agent
interaction with anesthesia
(MAOI)
Related with sudden withdrawal(
steroids)
Drugs for HTN, IHD to be
continued over perioperative
period
Anticoagulant drugs (aspirin,
warfarin)
HRT
Social History
Famliy History
Malignant Hyperthermia
Pseudo cholinesterase deficiency
Bleeding disorders
Smoking:
Short term :
Increadesd myocardial oxygen
demand and decreased oxygen
delivery
Long term:
decreased immune function and
decreased clearance
Physical Examnaton
• Includes a full physical examination
• Don’t rely on the ex. of others. Surgical signs may change
and others may miss imp pathology
“What mind doesn’t know, eyes cant see”
• No step is omitted and added advantage of familiarizing
what is normal so that abnormalities can be more recognised
• General Ex. Including vitals.
• Cardiac ex. ( JVP, HS)
• Respiratory Ex. ( trachea, accessory ms, percussion,
auscultation)
• Abdominal Ex.
• CNS
• Musculoskeletal system
• Peripheral vasculature
• Local Ex
• Body orifices
If you don’t put your finger, you will put your foot
Emergency Physical Examination
• The routine examination must be altered to fit the
circumstances.
• A,B,C,D,E
• Secondary survey( head to toe)
• When a number of emergencies present at same timeTriage
Preoperative Investigations
To know the
extent of the
disease
Assessment of
fitness for
surgery
Exclusion of
alternate
diagnosis
Confirmation of
diagnosis
Risk to others
Preoperative
Investigations
Medico legal
considerations
Blood tests:
• Full blood count ( when to perform?)
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All emergency preoperative cases
All elective preoperative cases over 60 years
All elective preoperative cases in adult females
If surgery is likely to result in significant blood loss
Suspicion of blood loss, anemia, sepsis, CKD, coagulation
problems
Blood tests
• Urea and electrolytes (when to perform?)
• All preoperative cases over 65 years
• All patients with cardiopulmonary disease or taking diuretics
or steroids
• All patients with h/o renal/liver disease or abnormal
nutritional state
• All patients with h/o diarrhea, vomiting other
metabolic/endocrine disease
• All patients with IVF for more than 24 hrs.
Incident of unexpected abnormality in apparently fit patient under 40 yrs
is < 1%
Blood Tests:
• Amylase:
• Perform in all adult emergency admissions with abdominal
pain, prior to consideration of surgery
• Random Blood Glucose:
• Acute abdomen
• Elective cases with DM, malnutrition, obesity
• Elective cases over 60
• Coagulogram studies:
• h/o of bleeding disorder, liver disease or excessive alcohol use
• Patients receiving anticoagulants( PT/INR done on the
morning of surgery for patients instructed to discontinue
warfarin)
• Cardiothoracic surgery
• Vascular surgery
• Angiographic procedures
• Craniotomy procedures
• Liver function tests
• All patients with upper abdominal pain, jaundice, hepatic
disease
• Alcoholic
• Screening for Hepatitis B and Hepatitis C
• Blood group/ cross match
• Emergency preoperative case
• Suspicion of blood loss, anemia, coagulation defects
• Procedure on pregnant ladies
• Chest X-ray:
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All elective preoperative cases over 60 years
All cases of cervical, thoracic or abdominal trauma
Acute respiratory symptoms or signs
Previous CRD or no recent CXR
Thoracic surgery
Malignant disease
Viscous perforation
Recent h/o TB
Thyroid enlargement
• Electrocardiogram
• within 12 weeks of surgery ( or less if condition warrants) for
patients with known cardiac disease
• Within 6 months prior to surgery for all patients >50 years
• Other investigations
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Performed according to requirement
Ultrasound
CT scan
MRI
Assessment of risk of surgery
• There are few patients who have no risk for surgery
• It is important to quantify the risks involved so they be
discussed with the patients
• Two main prognostic scoring systems which are in current
use are
APACHE SYSTEM
ASA SYSTEM
APACHE SYSTEM
• “Acute Physiology And Chronic Health Evaluation”
• Helps to predict the outcome of patients admitted to ICU and has
subsequently been applied to patients undergoing surgery
• APACHE II
• 12 acute physiological variables
• Patient’s age
• Chronic health points
• APACHE III introduced in 1991 includes 5 more physiological
variables (blood urea nitrogen, urine output, albumin , bilirubin
and glucose) and modified version of GCS
APACHE II Classification
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Score is A+B+C
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A ( Acute physiology score)
C( Chronic Health Problems)
2 points for elective post-op admission
5 points for emergency op, nonoperative
admission, immunocompromised pts, CLD,
CVD, respiratory or renal disease
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2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
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Recent temp.
MBP
HR
RR
FiO2(alveolar arterial O2 gradient)
pH
Serum Na
Serum K
Serum creatinine
WBC
Hct %
GCS
B(Age points) graded from <44 to >75 yrs
ASA System
• “ American Society of Anaesthesiologist”
• It is very simple and widely accepted
• 50% patients presenting for elective surgery are in ASA Gr
I
• Operative mortality rate for these patients is less than 1 in
10,000
ASA Grading and Predictive Mortality
ASA Grade
Definition
Mortality %
I
Normal healthy individual
0.06
II
Mild systemic disease that doesn’t limit
activity
0.4
III
Severe systemic disease that limits activity 4.5
IV
Severe systemic disease that is constant
threat to life
23
V
Moribund, not expected to survive 24hrs
with or without surgery
51
Clinical Predictors of increased risk
Major predictors
Acute or recent MI
Unstable or Severe Angina
Strongly positive stress test
Decompensated heart failure
Severe Valvular disease
Significant Arrythmias
Intermediate predictors
Mild angina
Previous MI by history or by Q waves
Compensated heart failure
Diabetes
Renal insufficiency ( Cr >2.0)
Minor predictors
Advanced Age
Abnormal ECG( LVH,LBBB,ST changes)
Low functional capacity
h/o of stroke
Uncontrolled systemic hypertension
Surgery Related Risk
Thromboembolic prophylaxis
• DVT is common in surgical patients
• Can cause PE which carries a high mortality
• Surgery, trauma and immobilization are responsible for
50% of DVT
• RISK FACTORS FOR DVT:
 Age
 Obesity
 Immobility
 Malignancy
 Trauma
 Surgery
 Dehydration
 Past h/o thromboembolism
 Oral contraceptives
 HRT
 Pregnancy, peurperium
• PROPHYLAXIS:
 Graded elastic compression stocking
 Intermittent pneumatic calf compression
 Postoperative early ambulation
 Heparin prophylaxis
Level of risk
Definition of risk level
Prevention strategy
Low
Minor surgery in patients <40 yr with no
additional risk factor
Aggressive, early
mobilization
Moderate
Minor surgery with risk factors
Minor surgery with age 40-60 years with
no risk factor
Major surgery in <40yrs with no risk
factors
Graded compression
stockings, IPC
LDUH 5000 U BD
LMWH- enoxparin 40mg/d
daltaperin 5000iu/d
fondaparinaux 25mg/d
High
Major surgery > 60 yrs, major surgery
40-60yrs with risk factors
IPC with
LDUH 5000 u TID,
enoxaparin 40mg/d,
dalatperin 5000 iu/d,
fondaparinaux 2.5 mg/d
Very High
Major surgery > 60 year with risk factor
Same as above
For mod-high risk patients prophylaxis given 12-24 hr after procedure
For very high risk prophylaxis started 2-12 hrs before surgery and restarted 12-24
hrs after procedure
Antibiotic Prophylaxis
• Appropriate antibiotic prophylaxis depends upon
• the most likely pathogen encountered
• Class of the operative procedure( clean, clean contaminated,
contaminated , dirty)
• Class I cases don’t require antibiotic prophylaxis, except in
cases of indwelling prosthesis placement or bone incision
• Class II cases only single preoperative prophylactic dose
• Class III & IV cases- mechanical preparation plus
parenteral antibiotics with aerobic and anaerobic cover
Nature of operation
Common pathogens
Antibiotics
Cardiac
Staph. Aureus and epidermidis
Cefazolin ,Vancomycin
Esophageal , gastroduadenal
Enteric gram negative bacilli, gram
positive cocci
High risk only: Cefazolin
Biliary tract
Enteric gram negative bacilli,
enterococci,clostridia
High risk only : Cefazolin
Colorectal
Enteric gram negative bacilli
Anaerobes, enterococci
Oral: neomycin+erythromycin or
metronidazole
Parenteral : cefazolin +
metronidazole or Ampicillinsalbactum
Genitourinary
Enteric gram negative baciili, enterococci
High risk only: ciprofloxacin
Neurosurgery
S.aureus, S.epidermidis
Cefazolin or Vancomycin
Thoracic ( non cardiac)
S. aureus, S.epidermidis, streptococci,
enteric gram negative bacilli
Cefazolin or cefuroxime or
Vancomycin
For patients allergic to penicillin and cephalosporins, clindamycin with
gentamicin,ciprofloxacin,levofloxacin or aztreonam
Prophylactic antibiotics should be given 60 minutes or less before the incision
SYSTEM WISE APPROACH
TO PREOPERATIVE
EVALUATION
CARDIOVASCULAR SYSTEM
• The contribution of cardiovascular disease to
perioperative mortality in noncardiac surgery is
significant
• In US, about 30% of patients undergoing surgery have
significant coronary artery disease or other cardiac co
morbid condition
• Much of the preoperative risk assessment and patient
preparation centers on cardiovascular disease
Cardiac Risk Indices
• Various assessment tools for stratification of the
cardiovascular portion of anesthetic risk have been devised:
Goldman Cardiac Risk Index, 1977
Detsky Modified Multifactorial Index. 1986
Eagle’s Criteria for Cardiac Assess,ent,1989
Revised Cardiac Risk Index
Goldman Cardiac Risk Index
•Third heart sound or jugular venous distension
•Recent myocardial infarction
•Nonsinus rhythm or premature atrial contraction on ECG
•>5 premature ventricular contractions
•Age >70 yrs
•Emergency operations
•Poor general medical condition
••Intrathoracic,
/l
intraperitioneal or aortic surgery
•Important valvular aortic stenosis
Cardiac complication rate
0-5 points = 1%
6-12 points = 7%
13-25 points = 14%
>26 points = 78%
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10
7
7
5
4
3
3
3
Revised Cardiac Risk Index
•Ischemic heart disease
•Congestive heart failure
•Cerebral vascular disease
•High risk surgery
•Preoperative insulin treatment of diabetes
•Preoperative creatinine level >2 mg/dl
1
1
1
1
1
1
Each increment in points increases risk for postoperative
myocardial morbidity
• A joint committee of ACC and AHA have developed a
stepwise approach to preoperative cardiac assessment for
non cardiac surgery
• This methodology takes into account:
• Previous coronary revascularization
• Clinical risk assessment: major, intermediate, minor
• Functional capacity
Need for emergency
noncardiac
surgery
Yes
Operating room
Vigilant perioperative
and postoperative
management
No
Active
cardiac
conditions
Yes
Evaluate and treat
per ACC/AHA
Guidelines
Consider
Operating Room
No
Low Risk
Surgery
Yes
Proceed with
planned surgery
Yes
Proceed with
planned surgery
No
Asymptomatic and
good functional
capacity ≥ 4 MET
No
Manage based on
clinical risk factors
Manage based on
clinical risk factors
3 or more clinical
risk factors*
Vascular
Surgery
Consider Testing
Intermediate
risk surgery
1 or 2 clinical
risk factors*
Vascular
Surgery
No clinical
risk factors*
Intermediate
risk surgery
Proceed with planned surgery with HR control
or consider non-invasive testing
Proceed with
planned surgery
*Clinical risk factors = known ischemic heart disease, compensated or prior HF, diabetes, renal
insufficiency, cerebrovascular disease
• Surgeon and the consultants
• weigh the benefits vs. risk of the procedure
• whether the perioperative intervention is beneficial
• Perioperative intervention includes:
• Coronary revascularization ( bypass or percutaneous transluminal angioplasty)
• Modification of choice of anesthetic
• Invasive intraoperative monitoring
• Patients having PCI with stenting should defer the elective procedure for 4 – 6 weeks (
or less depending on the type of stent)
• In case of MI, elective surgery should be postponed for 4-6 weeks
• Medical therapy with beta blockers have been recommended as per ACC/AHA
guidelines:
AHA/ACC GUDELINES FOR PERIOPERATIVE β BLOCKERS
CLASS
RECOMMENDATION
CLASS I
β blockers should be continued in patients undergoing surgery who are receiving β blockers for
treatment of condition with ACC class I indication for the drugs
CLASS IIa
1.
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3.
CLASS IIb
1.
2.
CLASS III
1.
2.
β blockers titrated to HR and BP are recommended for patients undergoing vascular surgery
who are at high cardiac risk because of CAD or the finding of cardiac ischemia on
preoperative testing
β blockers titrated to HR and BP are reasonable for patients in whom preoperative
assessment for vascular surgery identifies high cardiac risk, as defined by presence of more
than one clinical risk factor
β blockers titrated to HR and BP are reasonable for patients in whom preoperative
assessment identifies CAD or high cardiac risk, as defined by the presence of more than one
clinical risk factor, who are undergoing intermediate risk surgery
The usefulness of β blockers is uncertain for the patients who are undergoing intermediate
risk surgery or vascular surgery in whom preop assessment identifies a single clinical risk
factor in the absence of CAD
The usefulness of β blockers in uncertain in patients undergoing vascular surgery with no
clinical risk factor who are not currently taking β blockers
β blockers should not be given to patients undergoing surgery who have absolute
contraindication to β blockade
Routing administration of high dose β blockers in the absence of dose titration is not useful
and may be harmful to patients not currently taking β blockers who are undergoing noncadiac
surgery
PULMONARY SYSTEM
• Assessment of pulmonary function should be done in:
• All lung resection cases
• Thoracic procedures requiring single lung ventilation
• Major abdominal and thoracic cases in patients older than 60 years,
having underlying medical disease, smoke or have overt pulmonary
symptomatology
• Tests which need to be done include:
• Forced vital capacity in 1 sec.
• Forced vital capacity
• Diffusing capacity of carbon monoxide
• Adults with FEV1 less than 0.8 liter/sec or 30% of
predicted, have high risk for complications and
postoperative pulmonary insufficiency; nonsurgical
solutions sought.
RISK GROUP FOR PPC
• General :
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Age > 70years
Cigarette smoking
Renal failure
Poor nutrition
• Asthma related
• Recent asthma attack
• Past h/o endotracheal intubation for asthma management
• Surgery and anaethesia related
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Emergent surgery
Thoracic, vascular and upper abdominal surgery
Blood loss > 4 pints of PRBCs (2000ml)
Anesthesia time >180 minutes
General anesthesia with endotracheal intubation
• Preoperative interventions
1. Smoking cessation ( within 2 months before planned
surgery)
2. Incentive spirometry
3. Encouraging exercise preoperatively. Patient should be
encouraged to walk 3 miles in less than an hour several
times weekly
4. Bronchodilator therapy
5. Antibiotic therapy for pre existing infection
6. Pretreatment of asthmatic patients with steroids
RENAL SYSTEM
• About 5% of population has some degree of renal
dysfunction which may affect multiple organ system and
increase perioperative morbidity
• Preoperative creatnine levels of >2mg/dl is an independent
risk factor for cardiac complications
• Goals of preoperative evaluation:
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Identification of coexisting cardiovascular dysfunction
Identification of circulatory dysfunction
Identification hematologic dysfunction
Identification metabolic derangements
Assessment of Renal Function
• History:
 Congenital abnormality, Obstructive uropathy, PCKD, Recurrent UTI
 Presence of underlying systemic disease
 Known renal sufficiency
• Physical examination:
 Intravascular volume overload ( pulmonary oedema, jugular venous
distension, peripheral odema)
 Evidence of coagulopsthy( petechie or ecchymosis)
 Lethargy or altered mental status
 Pericardial and pleural rub
LAB INVESTIGATIONS
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Serum electrolytes
BUN
Serum creatinine levels
Hematocrit
Urine analysis
Fractional excretion of sodium
Chest radiograph
ECG
Complication assciated with renal disease
• Fluid and electrolyte homeostasis is altered
 Hypertension
 Peripheral edema
 Salt retention
 Electrolyte imbalance( hyponatremia, hyperkalemia, metabolic
acidosis)
• Hematological dysfunction
 Anemia
 Coagulation defects
 Altered platelet adhesion and aggregation
 Altered calcium and parathyroid hormone metabolism
• Nutritional status:
 Proteinuria as high as 25 g/day
 Decreased body stores of nitrogen
 Decreased dietary intake
• Immune function:
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Increased UTIs
Impaired mucosal barriers
Increased pulmonary infections
Impaired phagocytosis
Impaired elimination of certain viruses
PREOPERATIVE OPTIMISATION
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Anemia is treated with erythropoietin or darbepoietin
Manipulation of hyperkalemia
Replacement of calcium for symptomatic hypocalcaemia
Use of phosphate binding antacids for hyperphosphatemia
Correction of metabolic acidosis ( sod bicarbonate is given
i/v if levels fall below 15meq/l
• Hyponatremia is treated by fluid restriction
• Avoid nephrotoxic drugs
• Dialysis
• Improves many of the uremic symptoms and abnormality
and electrolyte abnormalities
• Preoperative dialysis should be done 24 hrs before elective
surgery to minimize the effect of iv heparin and allow the
patient to stabilize.
• Correction of coagulopathy by:
• Preoperative adequate dialysis
• Pre and postop FFPs
HEPATOBILIARY SYSTEM
• ASSESSMENT OF HEPATIC FUNCTION:
• HISTORY:
 Prior h/o jaudice, hepatitis, hemolytic anemia, parasitic
infection, biliary stone disease, pancreattits, enzyme deficiency,
prior malignanacy
 h/o drug or alcohol abuse and possible exposure to infectious
agents( tattoos, blood transfusion), environmenmtal or other
hepatotoxins
 h/o prior hepatotoxicity after imhaled anaesthesia
• PHYSCICAL EXAMINATION:
 Jaundice
 Ascitis
 Peripheral edema
 Muscle wasting
 Testicular atrophy
 Palmar erythema
 Spider angioma
 Gynecomastia
 Stigmata of portal hypertension( caput medusa, splenomegaly)
 Evidence of bleeding disorder
 Liver size
LAB INVESTIGATION:
• Liver function tests
• CBC
• Serum electrolytes
• Coagulogram
• Hepatitis serology
CHILD-PUGH SCORING SYSTEM
• Stratification of operative risk in patient with cirrhosis
Parameter
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1
2
3
Encephalopathy
None
Stage I or II
Stage III or IV
Ascitis
Absent
Slight
( controlled
with diuretics)
Moderate
despite diuretic
treatment
Bilirubin (mg/dl) <2
2-3
>3
Albumin(g/l)
>3.5
2.8-3.5
<2.8
INR
<1.7
1.7-2.3
>2.3
Class A :- 5-6 points
Class B :- 7-9 points
Class C :- 10-15points
Mortality : 10%
Mortality : 31%
Mortality : 76%
Approach to patient with liver disease
Acute hepatitis
Patient with liver
disease facing
surgery
Obstructive
jaundice
Chronic
hepatitis
Postpone elective
surgery
Surgery safe
1. Perioperative fluid Mx to
prevent renal dysfunction
2. No dopamine or
mannitol
3. Lactulose may be helpful
4. Antibiotic prophylaxis
5. No routine preoperative
biliary drainage
6. Check for abnormal
coagulation parameter
Cirrhosis
Child’s A and B: Treat ascitis, coagulopathy
and proceed to surgery
Child’s C: Postpone until the patient’s Child’s
class could be improved or cancel surgery for
conservative Mx
Coagulopathy
Target PT- no more than 2 sec above
normal
1. Vit K- 10 mg SQ
2. FFP if no improvement Vit K
3. Cryoprecipitate as needed
Ascites
1. Fluid restriction
2. Diuretics- furosemide or
spironolactone
3. Paracentesis –
diagnostic/therapeutic with
administration of albumin
Encephalopathy
1. Treat with lactulose
2. Prevent by treating
ppt. condition like GI
bleed, uremia,
alkalosis
Endocrine System
• Diabetes mellitus:
• History and examination:
• To assess adequacy of glycemic control
• To access evidence of diabetic complication
• Investigation :
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Fasting and postprandial blood glucose
HbA1c
Serum electolytes
BUN
to identify metabolic disturbances and renal involvement
Serum creatnine
Urine analysis
ECG
• `Preoperative optimization:
 Morning dose of OHA should be omitted
 Patient should be started on variable rate intravenous insulin
infusion(VRIII)
 VRIII should be adjusted to maintain blood sugars b/w 140180 mg/dl
 If possible patient should be posted first in the list
 If the blood sugars are not controlled the elective surgery
should be deferred till glycemic control is achieved
• Hyperthyroidism:
 Elective surgery deferred until euthyroid state achieved
 Preop ECG and serum electrolytes done
 Anithyroid drugs and beta blockers/digoxin continued on the
day of surgery
 In case of emergency surgery in thyrotoxic patient at risk of
thyroid storm, a combination of beta blocker and
glucocorticoids used
• Hypothyroidism:
 Severe hypothyroidism can cause MI, coagulation defects
and electrolyte imbalance
 Elective surgery to be deferred until euthyroid state achieved
• Patients with h/o steroid use/ Suppression of HPAA:
 Patients who have taken > 5mg of prednisolone or
equivalent for > 3 weeks are at risk when undertgoing major
surgery
 Minor procedures: no additional steroid required
 Moderate operation: 50-75 mg/day of hydrocotisone (or eq)
for 1 -2 days
 Major operation: 100-150 mg/day hydrocortisone (or eq)
for 2-3 days
• Pheochromocytoma :
 Require preoperative pharmacologic Mx to prevent
intraoperative hypertensive crisis or vascular collapse
 A combination of alpha and beta adrenergic blockade started
1-2 weeks before surgery
 Liberalisation of sodium in diet
Hematologic System
• Hematologic assessment leads to identification of disorders such
as anemia, neutropenia , coagulopathy or hypercoagulable state
• ANAEMIA:
 Often asymptomatic but history an examination may reveal
complaints of energy loss, dyspnea , palpitations, or pallor.
 Evaluated for lymphadenectmoy, hepatomegaly, splenomegaly, pelvic
and rectal examinations done
 CBC, reticulocyte count, serum iron, TIBC, ferritin, Vit B12 and
folate levels obtained for investigation of cause
• Healthy individuals with minimal anticipated blood loss
during surgery- 6-7 g/dl
• Cardiac or pulmonary disease- 10g/dl
• In case of elective surgery:
• Correctable cause of anemia- delay surgery
• Uncorrectable cause – blood trasfusion
• Blood transfusion are also required during emergency
surgeries
Patients on anticoagulants
•
Require preoperative reversal of anticoagulant effect
• Warfarin should be witheld for 5 scheduled doses
preoperatively to reduce the INR to 1.5 or less
• Patients at risk of thromboembolic event are recommended to
have full bridging while off anticoagulation
• For those on LMWH last dose should be given 20 -24 hours
prior to surgery and restarted approx. 12-24 hours
postoperatively.
Indication for
Patient Characteristics
Chronic
Anticoagulation
Perioperative
Management
Prosthetic heart
valves
Strongly recommend
bridging
Chronic atrial
fibrillation
Venous
thromboembolism
High risk
Recent (<1 mo) stroke or TIA
Any mitral valve
Caged ball or tilting disc aortic valve
Moderate risk- Bileaflet aortic valve with two or more risk
factors for stroke
Low risk- bileaflet aortic valve with fewer than two risk
factors for stoke
High risk
Recent stroke or TIA
Rheumatic mitral valve disease
Moderate risk- chronic atrial fibrillation with 2 or more risk
factors for stroke
Low risk- chronic atrial fibrillation with < 2 risk factors
High risk
Recent(< 3 wk) VTE
Active (< 6 mo or palliative) cancer
Antiphospholipid antibody
Major comorbid disease( cardiac/pulmonary)
Moderate risk
VTE in last 6 mo
VTE with interruption of anticoagulant
Low risk- none of above
Consider bridging
Bridging optional
Strongly recommend
bridging
Consider bridging
Bridging optional
Strongly recommend
bridging
Consider bridging
Bridging optional
Coagulopathy
• Coagulopathy may arise from
• inherited or acquired platelet or factor disorder
• organ dysfunction
• Medications
• Personal and family history of bleeding asked
• H/o easy bruising or petechie
• Risk factors for post-op bleeding- liver disease, mal
absorption, malnutrition, chronic a/b use
• Investigation :
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•
•
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Complete haemogram
Coagulogram
Finrinogen leves
D-dimer
• In Vit K deficiency or mild liver disease- PT is prolonged while
aPPT may be normal
• Severe liver disease- both PT, aPPT tend to prolong
• Haemophilia – aPPT is prolonged but PT is normal
• In DIC all test are abnormal and fibrin split products and d-dimer
are increased
• Management:
• In case of severe factor deficiency, 4-6 units of FFP and
cryoprecipitate should be given rapidly
• Conditions associated with low platelet count or abnormal
platelets:--platelet transfusion
• One unit of platelet concentrate increases platelet count by
5000-10000
• In patients on heparin:
• Elective procedure- discontinue heparin 6 hrs before surgery
• Emergency operation- 10 mg of protamine sulphate in 50 ml
of NS iv over 10 min f/b 20 mg in 50 ml NS over 30 min
Nutritional assesment
• Malnutrition increases increases risk of
• morbidity, wound infection, sepsis, pneumonia, delayed wound
healing, anasmotic complication.
• Assesment include careful history and examination.
• Usual weight, recent wt loss, loss of muscle bulk, change in
bowel habit.
• IBS,DM,bulmia and anorexia nervosa.
• Nutritional risk assesement (15.19x sr albumin g/dl+41.7x
present wt/usaual weight.
• NRI < 83% indicates increased mortality.
• Next presentation:
• Management of Advanced
Breast Cancer
• Dr Javaid Ahmad Bhat
• Moderator: Dr Natasha Thakur