Preoperative optimization of patients for surgery

Prepared by: Dr Ifrah Ahmad QaziModerator: 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:

Situation

Nature of surgery (minor or

major)

Facilities availableLocation of

surgery

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 )

Complication RatesElective Urgent Emergency

12.8

17.2

20

• 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 historySystemic 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 Hxinteraction with anesthesia

(MAOI)Related with sudden withdrawal( steroids)

Drugs for HTN, IHD to be continued over perioperative

periodAnticoagulant drugs (aspirin,

warfarin)HRT

Famliy History

Malignant HyperthermiaPseudo cholinesterase

deficiencyBleeding disorders

Social HistorySmoking:

Short term : Increadesd myocardial oxygen demand and decreased oxygen

deliveryLong 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

Preoperative Investigations

Confirmation of diagnosis

Exclusion of alternate diagnosis

To know the extent of the

disease

Assessment of fitness for surgery

Risk to others

Medico legal 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 disease1. Recent temp.2. MBP3. HR4. RR5. FiO2(alveolar arterial O2 gradient)6. pH7. Serum Na8. Serum K9. Serum creatinine10. WBC11. 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 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 predictorsAcute or recent MI

Unstable or Severe AnginaStrongly positive stress test

Decompensated heart failureSevere Valvular diseaseSignificant Arrythmias

Intermediate predictorsMild angina

Previous MI by history or by Q wavesCompensated heart failure

DiabetesRenal insufficiency ( Cr >2.0)

Minor predictorsAdvanced Age

Abnormal ECG( LVH,LBBB,ST changes)

Low functional capacity h/o of stroke

Uncontrolled systemic hypertension

Surgery Related Risk

High Risk Surgery (>5%)•Emergent major surgery•Aortic and other major vascular•Peripheral Vascular•Anticipated prolonged or associated with large fluid shift and/or blood loss

Intermediate Risk( <5%)

•Carotid endaterectomy•Endovascular AAA repair•Head and neck•Intraperitoneal and intrathoracic•Orthopedic•Prostate

Low Risk(<1%)

•Endoscopic procedures•Superficial procedures•Cataract surgery•Breast surgery

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 factorsMinor surgery with age 40-60 years with no risk factorMajor surgery in <40yrs with no risk factors

Graded compression stockings, IPCLDUH 5000 U BDLMWH- enoxparin 40mg/d daltaperin 5000iu/d fondaparinaux 25mg/d

High Major surgery > 60 yrs, major surgery 40-60yrs with risk factors

IPC withLDUH 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 procedureFor 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 bacilliAnaerobes, enterococci

Oral: neomycin+erythromycin or metronidazoleParenteral : 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, enteric gram negative bacilli

Cefazolin or cefuroxime or Vancomycin

Prophylactic antibiotics should be given 60 minutes or less before the incision

For patients allergic to penicillin and cephalosporins, clindamycin with gentamicin,ciprofloxacin,levofloxacin or aztreonam

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, 1977Detsky Modified Multifactorial Index. 1986Eagle’s Criteria for Cardiac Assess,ent,1989

Revised Cardiac Risk Index

Goldman Cardiac Risk Index

• /l

•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, intraperitioneal or aortic surgery 3•Important valvular aortic stenosis 3

Cardiac complication rate0-5 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 emergencynoncardiac

surgeryOperating room

Evaluate and treatper ACC/AHA

Guidelines

Vigilant perioperative and postoperative

management

Consider Operating Room

Low RiskSurgery

Active cardiac

conditions

No

Yes

Yes

No

Proceed withplanned surgery

Asymptomatic andgood functional

capacity ≥ 4 MET

Yes

Proceed withplanned surgery

No

Yes

Manage based onclinical risk factors

No

Manage based onclinical risk factors

3 or more clinical risk factors*

1 or 2 clinical risk factors*

No clinical risk factors*

Vascular Surgery

Intermediate risk surgery

Vascular Surgery

Intermediate risk surgery

Proceed withplanned surgery

Proceed with planned surgery with HR controlor consider non-invasive testingConsider Testing

*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 RECOMMENDATIONCLASS 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 spirometry3. Encouraging exercise preoperatively. Patient should be

encouraged to walk 3 miles in less than an hour several times weekly

4. Bronchodilator therapy5. Antibiotic therapy for pre existing infection6. 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 UTIPresence of underlying systemic diseaseKnown renal sufficiency

• Physical examination: Intravascular volume overload ( pulmonary oedema, jugular venous

distension, peripheral odema)Evidence of coagulopsthy( petechie or ecchymosis)Lethargy or altered mental statusPericardial 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

• Class A :- 5-6 points Mortality : 10%• Class B :- 7-9 points Mortality : 31%• Class C :- 10-15points Mortality : 76%

Parameter 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

Approach to patient with liver disease

Acute hepatitis

Patient with liver disease facing

surgeryObstructive

jaundice

Postpone elective surgery

Chronic hepatitis

Surgery safe

1. Perioperative fluid Mx to prevent renal dysfunction

2. No dopamine or mannitol3. Lactulose may be helpful

4. Antibiotic prophylaxis5. No routine preoperative

biliary drainage6. Check for abnormal

coagulation parameter

CirrhosisChild’s A and B: Treat ascitis, coagulopathy

and proceed to surgeryChild’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 SQ2. FFP if no improvement Vit K3. Cryoprecipitate as needed

Encephalopathy 1. Treat with lactulose2. Prevent by treating

ppt. condition like GI bleed, uremia,

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 Chronic Anticoagulation

Patient Characteristics Perioperative Management

Prosthetic heart valves

High risk Recent (<1 mo) stroke or TIA

Any mitral valveCaged 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

Strongly recommend bridging

Consider bridging

Bridging optional

Chronic atrial fibrillation

High riskRecent stroke or TIA

Rheumatic mitral valve diseaseModerate risk- chronic atrial fibrillation with 2 or more risk factors for strokeLow risk- chronic atrial fibrillation with < 2 risk factors

Strongly recommend bridging

Consider bridging

Bridging optional

Venous thromboembolism

High riskRecent(< 3 wk) VTE

Active (< 6 mo or palliative) cancerAntiphospholipid antibody

Major comorbid disease( cardiac/pulmonary)Moderate risk

VTE in last 6 moVTE with interruption of anticoagulant

Low risk- none of above

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 :• 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.

Thank you

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