2. Introduction
• After surgery metabolic demands increases due to tissue destruction, blood loss, fluid shifts
from an average of 110ml/min/m2 at rest to 170ml/min/m2 in postoperative period
• Patients who are unable to meet their demands due to limited cardiorespiratory reserve are at risk of oxygen debt
• Occult hypovolemia resulting from fluid shift or blood loss ,lead to sphlanchnic vasoconstriction to compensate may
lead to gut ischemia
• So those with coronary artery and cerebrovascular disease are at high risk for myocardial ischemia or stroke
3. Who are the high risk patients ?
1.Surgery specific
2.Comorbidity related
3.others
4. Surgery specific estimates of risk
HIGH RISKS
> 5%
INTERMEDIATE RISK
1-5%
LOW RISK
<1%
Open aortic
Major vascular
Peripheral vascular
Urgent body cavity
Elective abdominal
Carotid endovascular aneurysm
Head and neck
Major neurosurgery
Arthroplasty
Elective pulmonary
Major urology
Breast
Dental
Thyroid
Ophthalmic
Gynaecological
Reconstructive
Minor orthopaedic
Minor urologic
7. Others
• Age – due to less physiological reserve
• Obesity
• Substance abuse
• Previous history of surgery
8. Factors contributing to the risk
• Previous cardiorespiratory illness
• Late stage vascular disease involving aorta
• Age>70 years with limited physiological reserve in one or more vital organs
• Extensive surgery for carcinoma
• Acute abdominal catastrophe with haemodynamic instability
• Acute massive blood loss > 8units
• Septicemia
• Positive blood culture or septic focus
• Respiratory failure pao2 <8kpa or fio2 >0.4 or mechanical ventilation > 48 hrs
• Acute renal failure { urea >20mmol or creatinine >260 mmol/l}
9. A PRACTICAL APPROACH TO THE CARE OF HIGH RISK PATIENTS
1.preoperative evaluation and care
a)preoperative assessment
b)preoperative preparation
2.intraoperative management
3.postoperative management
10. Preoperative assessment
HISTORY TAKING
Do not assume that history has been adequately covered previously
• Important points may have been overlooked in a busy OPD
• Standard history focuses on the patient’s hopes and expectations
Principles of history taking
• Listen: What is the problem? (Open questions)
• Clarify: What does the patient expect? (Closed questions)
• Narrow: Differential diagnosis (Focused questions)
• Fitness: Comorbidities (Fixed questions)
11. PAST MEDICAL HISTORY
Comorbidity related –
• cvs, rs, cns. Gut,git,endocrine disorders
Previous surgery
• Problems encountered
• Family history of problem with anaesthesia
Other
• Human immunodeficiency virus
• Malignancy
• Allergy
13. INVESTIGATIONS
CBC
• Major operations in elderly and in those with anemia
• Pathology with ongoing blood loss
Urea and electrolytes
• Major operation and >60 years old patient
• Cardiovascular, renal and endocrine disease
• Anticipated blood loss
• Medication : NSAID, diuretics, steroids
ECG
• Patients aged over 60 years
• Cardiovascular, renal and DM
β-Human chorionic gonadotrophin
• Pregnancy needs to be ruled out in all women of childbearing age.
14. Chest xray
• Cardiac failure and smokers
• COPD and Acute respiratory symptoms
Blood glucose and HbA1c
• DM or family history
• Obese or poor nutrition
• Steroid use
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
15. Coagulation 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
16. Additional investigations
Echocardiogaraphy
• Have newly occurring dyspnoea of unknown origin
• Have known heart disorder with symptoms of detoriation
• Have cardiomyopathy
• Have undergone preoperative chemotherapy with epirubicin
Arterial blood gas analysis
Carotid doppler
• had experienced TIA or stroke within 3 months that occurred without proper follow up or medical
assessment or diagnosis
Pulmonary function tests
• Elderly patients
• Previous history of thoracotomies or major surgeries near diaphragm
• Known case of restrictive or obstructive lung disorders
• Prolonged surgery
17. Identification ofhighriskpatientsandassessment oflevelofrisk
There are number of scoring systems have been developed for identification of high risk patients, most
widely used are
1.ASA GRADING
it does not account age and nature of surgery and it is operator dfependent
It is simple and related to operative mortality
18. 2. METABOLIC EQUIVALENT
To assess overall functional fitness
1 met ~ oxygen consumption of adult at rest (3.5ml/kg/min)
If a person able to perform > 4 met then
he / she is considered as suitable candidate for surgery
22. 5.CPET(cardiopulmonary exercise testing)
It used to detect oxygen consumption and co2 production
When subject’s delivery of oxygen to tissues becomes inadequate then anaerobic metabolism begins
.
AT= oxygen consumption ml/kg/min above which anaerobic metabolism occurs
Vo2 = peak oxygen consumption (measured)
AT CUTOFF OF 11, VO2 15ml/kg/min indicates high risk of postoperative morbidity and mortality
If CPET is not available six minute walk test or incremental shuttle walk test can be used to assess the
functional capacity of the patient.
23. Preoperative preperation
• Informed patient consent and motivation
• Interdisciplinary risk assessment
• Optimising physical condition and medication
a)nutritional assessment and intervention
b)review of medications and administration of antibiotics
24. Nutritional assessment and intervention
• Malnutrition increases risk of major morbidity
• Obesity has increased risk for cardiovascular events , DVT,PE
ASSESSMENT
• A - Anthropometry{ BMI}
• B – Biochemical {albumin,transferrin}
• C - Clinical
• D - Dietary history
BMI - <18.5KG
Sr.Albumin-<3g
Wt loss 10-15 % in 6months
Has poor outcome
25. Calorie requirement:
ABW (ADJUSTED BODY WEIGHT)
= IBW (IDEAL BODY WEIGHT) + 0.4 (ACTUAL WEIGHT – IBW)
IBW For men =50kg +2.3 kg for each inch over 5’ in height
IBW for women =45.5 kg +2.3 kg for each inch over 5’in height
Normal calorie requirement : 25 kcal/kg/day
Protein requirement:
Minimal daily requirement is 0.8gm /kg/day
Severely ill patients : 2 gm/kg/day
Nutritional risk assesement (15.19x sr albumin g/dl+41.7x present wt/usual weight).
• NRI < 83% indicates increased mortality
26. Preoperative fluid therapy
1.Correction of hypovolemia 2.Correction of anemia 3.correction of other
disorders
Causes:vomiting,bloodloss. In elective surgery
Third space losses 1.fluid overload
Ex. Acute intestinal obstruction, should be corrected 2.electrolyte disturbances
48- 72 hrs prior
Acute pancreatitis
Mild dehydration-4%bw deficit as 2,3,dpg restoration
takes 48 hrs
Mod dehydration-6-8% bw
packed cell better for
Severe dehydration -10%bw correction
0.9%ns,RL,colloid, wholeblood
Monitor achieving urine output
>30 – 5oml/hr suggests correction
27. Perioperative intervention includes:
• Coronary revascularization ( bypass or percutaneous transluminal angioplasty)
• Modification of choice of anesthetic
• Invasive intraoperative monitoring
• Pts with pacemakers- should turn off to uninhibited mode,bipolar cautery to be used
• Pts with defribillator – turned off during surgery
• Patients with recent angioplasty stenting should defer the elective procedure for 4 – 6 weeks
• 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:
Cardiovascular system optimization
28. • Smoking cessation ( within 2 months before planned surgery)
• Incentive spirometry
• Encouraging exercise preoperatively.
• Bronchodilator therapy
• Antibiotic therapy for pre existing infection
• Pretreatment of asthmatic patients with steroids
Respiratory system optimization
29. • Anemia is treated with erythropoietin or darbepoietin
• Management 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
• Preoperative dialysis should be done 24 hrs before elective surgery
Renal disorder optimization
30. • 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
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 undergoing
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
Endocrine disorder optimization
31. Pheochromocytoma :
• Require preoperative pharmacologic Management 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
32. • Patients with diet-controlled diabetes require no special preoperative treatment
• Morning dose of OHA should be omitted
• Patient should be started on variable rate intravenous insulin infusion
• Insulin infusion should be adjusted to maintain blood sugars b/w 140 to 180 mg/dl
• If possible patient should be posted till glycemic first in the list
• Long-acting insulin should be avoided the night before major surgery •
• If the blood sugars are not controlled the elective surgery should be deferred until control is achieved
Diabetes mellitus optimization
33. Prophylaxis of Venous Thromboembolism
• Aspirin is not supported as a single agent for thromboprophylaxis.
• Low-dose unfractionated heparin <5000 units subcutaneous bid),
• low-molecular weight heparin (e.g., enoxaparin 30 mg bid or 40 mg qid) or a pentasaccharide
(fondaparinux 2.5 mg qid) for patients at moderate risk,
• unfractionated heparin (5000 units subcutaneous tds) for patients at high risk.
• Graduated compression stockings and pneumatic compression device e useful supplements to
anticoagulant therapy
34. Medication to STOP
• NSAIDS - discontinued before surgery 5-7 days.
• Clopidogrel – stopped 7 days prior to surgery
• Hypoglycaemics
• Oral contraceptive pill (OCP) or Hormone Replacement Therapy (HRT) – stopped 4 weeks before surgery
• Warfarin – usually stopped 5 days prior to surgery
For those on LMWH last dose should be given 20 -24 hours prior to surgery and restarted approx. 12-24 hours
postoperatively.
35. Prophylactic antibiotics
SSI occurs at or near surgical incision within 30 days of the procedure
• Prophylactic antibiotics should be initiated within 1h before surgical incision or two hours if the patient is
receiving vancomycin or fluoroquinolones
• Patients should receive appropriate for their specific procedure
• discontinued 24 hours of surgery completion
36.
37. Intraoperative management
•Atraumatic surgical technique
•Combined general and epidural analgesia
•Optimised airway management and ventilation
•Blood glucose control
•Optimised fluid management
•Maintanenece of normothermia
38. Rl is most common fluid used as it more physiologically similar to body fluid
0.9%NS is used in case of hypovolemic shock as large volume has to be replaced
5% dextrose used as intial fluid replacement to replace insensible losses – rapid
replacement – osmotic diuresis
DM- 5% dextrose+6 units insulin ( or ½ of morning dose) followed by using sliding scale
mechanism
HTN-5% dextrose given (if needed RL in optimum amount)
CHF/RF/Cirrohosis- RL is contraindicated, 0.9%ns avoided, 5 % dextrose given in least
possible amount
Intraoperative fluid management
39. Postoperative management
Modern fast track programmes
6 Major elements
• 1. Modern opiod sparing analgesia
• 2. Early mobilisation and prevention of VTE
• 3. Extended lung expansion exercises
• 4. Early removal of tubes,catheter and drains
• 5. Early oral nutrition
• 6. Early detection of complications
40. postoperative complications
Complications related to:
• 1) Wound
• 2) Thermal regulation
• 3) GI
• 4) DVT and Pulmonary Embolism
• 5) Infections and fever
• 6) Pulmonary
• 7) Renal
• 8) Cardiovascular
• 9) Neurological
• 10)Complications of Diabetes
45. RESPIRATORY SYSTEM
predisposing risk factors for pulmonary complications
1. Upper respiratory tract infection: cough, dyspnea
2. Age >60 years
3. COPD
4. American Society of Anesthesiologists Class 2
5. Functionally dependent
6. Congestive cardiac failure
7. Serum albumin <3.5 g/dl
8.FEV1 < 2l
9.pco2 > 45 mmHg
10. PO2 <50 mmHg
46. Risk Modification to Reduce Perioperative Pulmonary Complications
Preoperatively
• Cessation of smoking
• Training in proper breathing (incentive spirometry)
• Inhalation bronchodilator therapy
• Control of infection and secretion,
• when indicated -Weight reduction, when appropriate
Intraoperatively
• Limited duration of anaesthesia
• Select shorter acting neuromuscular blocking drugs when indicated
• Prevention of aspiration -Maintenance of optimal broncho dilation
47. Postoperatively
Continuation of preoperative measures, with particular attention to
inspiratory spirometry
mobilization of secretions
early ambulation
encouragement of coughing
selective use of a nasogastric tube
adequate pain control without excessive narcotic agents
51. Endocrine disorders
Diabetes mellitus
Many patients with diabetes mellitus have significant symptomatic or asymptomatic CAD and may have
silent myocardial ischemia due to autonomic dysfunction.
• Evidence supports intensive perioperative glycemic control to achieve near-normal glucose levels (90–110
mg/dL using insulin infusion.
• This practice must be balanced against the risk of hypoglycemic complication
• Oral hypoglycemic agonists should be held on the morning of operation.
• Perioperative hyperglycemia should be treated with intravenous infusion of short-acting insulin or
subcutaneous sliding-scale insulin.
• Patients who are diet-controlled may proceed to surgery with close postoperative monitoring.
52. Long question
1. Perioperative fluid replacement
2. Discuss the Perioperative management of a patient having dibates
Meletus as co morbidity
3. Discuss the PeriOperative management of a pertinent on
thromboprophylaxis{( post CABG) STATUS} Requiring emergency
eploiratory laparotormy
53. MCQ
1))Young male presented with dyspnea,bleeding and petechial
hemorrhage in the chest after two days following fracture shaft
of the femur right side stop most likely the cause is:
a) air embolism
b) fat emboilism
c) pulmonary thromboembolism
d) amniotic embolisim
2) Reactionary hemorrhage occurs:
a) after 24 hours
b) after 48 hours
c) within 24 hours
d) after 7 days
3) Secondary hemorrhage is due to
a) Slipped ligature
b) Occurs 7 to 16 days after surgery
c) Due to disconnection of blood transfusuion line
d) None of the above
4) Post-dural puncture headache is typically:
a. A result of leakage of blood into the epidural space
b. Worse when lying down than in sitting position
c. Bifrontal or occipital
d. Seen within 4 hours of dural puncture
5)Air embolism in neural surgery maximum in which position?
a. Sitting b. Supine
c. Trendelenberg d. Left lateral
e. Right lateral
6)Most common coagulopathy noted in surgical
patients is:
a. Thrombocytopenia
b. Afibrinogenemia
c. Fibrinolysis
d. Factor VIII deficiency
54. MCQ
7)Presence of trifluroacetic acid (TFA) in urine
indicates that volatile anesthetic agent used was:
a. Halothane
b. b. Methoxyflurane
c. Trichloroethylene
d. None of the above
8)A patient undergoing surgery suddenly develops
hypotension. The monitor shows that the end tidal
CO2 has decreased abruptly by 155 mm Hg. What
is the probable diagnosis?
a. Hypothermia
b. Pulmonary embolism
c. Massive fluid deficit
d. Myocardial depression due to anesthetic agent
9)A patient developed respiratory distress and
hypoxemia after central venous catheterization
through internal jugular vein, reason for this is:
a. Pneumothorax
b. b. Hypovolemia
c. Septicemia
d. Cardiac tamponade
10)In the immediate post operative period, the
common cause of respiratory insufficiency could be
because of the following except:
a. Residual effect of muscle relaxant
b. Overdose of narcotic analgesic
c. Mild hypovolemia
d. Myocardial infarction
