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
• 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 :

• 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
Facilities
surgery
available
(minor or major)
 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 Emergency

Complication Rates
• 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

• 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
Many diseases have direct
effect on general and anesthetic
treatment and outcome
Any previous operation or
bleeding tendency
Any previous reaction to
anaesthetic agent
Drugs and Allergic Hx
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
Smoking:
Famliy History
Short term :
Increadesd myocardial oxygen
Malignant Hyperthermia demand and decreased oxygen
Pseudo cholinesterase deficiency delivery
Bleeding disorders 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 time-
Triage
Preoperative Investigations
To know the Assessment of
extent of the fitness for
disease surgery

Exclusion of
alternate Risk to others
diagnosis

Confirmation of Preoperative Medico legal

diagnosis Investigations considerations
Blood tests:

• Full blood count ( when to perform?)

• 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:

• 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

• 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
• Score is A+B+C

• 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
1. Recent temp.
2. MBP
3. HR
4. RR
5. FiO2(alveolar arterial O2 gradient)
6. pH
7. Serum Na
8. Serum K
9. Serum creatinine
10. WBC
11. Hct %
12. 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 0.4

activity
III Severe systemic disease that limits activity 4.5

IV Severe systemic disease that is constant 23

threat to life
V Moribund, not expected to survive 24hrs 51
with or without surgery
Clinical Predictors of increased risk
Major predictors
Intermediate predictors
Acute or recent MI
Mild angina
Unstable or Severe Angina
Previous MI by history or by Q waves
Strongly positive stress test
Compensated heart failure
Decompensated heart failure
Diabetes
Severe Valvular disease
Renal insufficiency ( Cr >2.0)
Significant Arrythmias

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 Aggressive, early
additional risk factor mobilization
Moderate Minor surgery with risk factors Graded compression
Minor surgery with age 40-60 years with stockings, IPC
no risk factor LDUH 5000 U BD
Major surgery in <40yrs with no risk LMWH- enoxparin 40mg/d
factors daltaperin 5000iu/d
fondaparinaux 25mg/d
High Major surgery > 60 yrs, major surgery IPC with
40-60yrs with risk factors 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 High risk only: Cefazolin
positive cocci
Biliary tract Enteric gram negative bacilli, High risk only : Cefazolin
enterococci,clostridia
Colorectal Enteric gram negative bacilli Oral: neomycin+erythromycin or
Anaerobes, enterococci metronidazole
Parenteral : cefazolin +
metronidazole or Ampicillin-
salbactum

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, Cefazolin or cefuroxime or

enteric gram negative bacilli 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 11
•Recent myocardial infarction 10
•Nonsinus rhythm or premature atrial contraction on ECG 7
•>5 premature ventricular contractions 7
•Age >70 yrs 5
•Emergency operations 4
•Poor general medical condition 3
••Intrathoracic,
/l intraperitioneal or aortic surgery 3
•Important valvular aortic stenosis 3

Cardiac complication rate

0-5 points = 1%
6-12 points = 7%
13-25 points = 14%
>26 points = 78%
Revised Cardiac Risk Index

•Ischemic heart disease 1

•Congestive heart failure 1
•Cerebral vascular disease 1
•High risk surgery 1
•Preoperative insulin treatment of diabetes 1
•Preoperative creatinine level >2 mg/dl 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 Yes Vigilant perioperative
noncardiac Operating room and postoperative
surgery management

No

Active Yes Evaluate and treat

Consider
cardiac per ACC/AHA
Operating Room
conditions Guidelines

No

Low Risk Yes Proceed with

Surgery planned surgery

No

Asymptomatic and Yes Proceed with

good functional
planned surgery
capacity ≥ 4 MET

No Manage based on
clinical risk factors
 Manage based on
clinical risk factors

3 or more clinical 1 or 2 clinical No clinical

risk factors* risk factors* risk factors*

Vascular Intermediate Vascular Intermediate

Surgery risk surgery Surgery risk surgery

Proceed with planned surgery with HR control Proceed with

Consider Testing
or consider non-invasive testing 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. 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
2. 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
3. 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

CLASS IIb 1. 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
2. The usefulness of β blockers in uncertain in patients undergoing vascular surgery with no
clinical risk factor who are not currently taking β blockers
CLASS III 1. β blockers should not be given to patients undergoing surgery who have absolute
contraindication to β blockade
2. 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 :
• 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
• 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:

• 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

• 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:
 Increased UTIs
 Impaired mucosal barriers
 Increased pulmonary infections
 Impaired phagocytosis
 Impaired elimination of certain viruses
PREOPERATIVE OPTIMISATION
• 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 1 2 3
Encephalopathy None Stage I or II Stage III or IV

Ascitis Absent Slight Moderate

( controlled despite diuretic
with diuretics) 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 Mortality : 10%
• Class B :- 7-9 points Mortality : 31%
• Class C :- 10-15points Mortality : 76%
Approach to patient with liver disease
Patient with liver
disease facing Obstructive
Acute hepatitis jaundice
surgery

Chronic
hepatitis

Postpone elective 1. Perioperative fluid Mx to

surgery prevent renal dysfunction
2. No dopamine or
mannitol
Surgery safe 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 Encephalopathy
Target PT- no more than 2 sec above 1. Treat with lactulose
normal 2. Prevent by treating
1. Vit K- 10 mg SQ ppt. condition like GI
2. FFP if no improvement Vit K bleed, uremia,
3. Cryoprecipitate as needed alkalosis

Ascites
1. Fluid restriction
2. Diuretics- furosemide or
spironolactone
3. Paracentesis –
diagnostic/therapeutic with
administration of albumin
 Endocrine System
• Diabetes mellitus:
• History and examination:
• To assess adequacy of glycemic control
• To access evidence of diabetic complication

• Investigation :
• 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 140-
180 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 Perioperative
Chronic Management
Anticoagulation
Prosthetic heart High risk Strongly recommend
valves Recent (<1 mo) stroke or TIA bridging
Any mitral valve
Caged ball or tilting disc aortic valve
Moderate risk- Bileaflet aortic valve with two or more risk Consider bridging
factors for stroke
Low risk- bileaflet aortic valve with fewer than two risk Bridging optional
factors for stoke
Chronic atrial High risk Strongly recommend
fibrillation Recent stroke or TIA bridging
Rheumatic mitral valve disease
Moderate risk- chronic atrial fibrillation with 2 or more risk Consider bridging
factors for stroke
Low risk- chronic atrial fibrillation with < 2 risk factors Bridging optional

Venous High risk Strongly recommend

thromboembolism Recent(< 3 wk) VTE bridging
Active (< 6 mo or palliative) cancer
Antiphospholipid antibody
Major comorbid disease( cardiac/pulmonary)
Moderate risk Consider bridging
VTE in last 6 mo
VTE with interruption of anticoagulant
Low risk- none of above 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 :
• 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:

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