an overview of preoperative optmisation

1. Preoperative optimization
of patients for surgery
Prepared by: Dr Ifrah Ahmad Qazi
Moderator: Dr Rauf Ahmad Wani
HOD: Prof. Khurshid Alam Wani

2. 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

3. 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

4. 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.

5. • 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

6. 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:

7. Nature of
surgery
(minor or major)
Facilities
available

8. 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 )

9. Complication Rates
12.8
17.2
20
Elective Urgent Emergency

10. • 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

11. Routine preparation for surgery
• History
• Physical examination
• Special investigation
• Informed consent
• Marking the site/side of operation
• Thromboembolic prophylaxis
• Antibiotic prophylaxis

12. 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

13. 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

14. Famliy History
Malignant Hyperthermia
Pseudo cholinesterase deficiency
Bleeding disorders
Social History
Smoking:
Short term :
Increadesd myocardial oxygen
demand and decreased oxygen
delivery
Long term:
decreased immune function and
decreased clearance

15. 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

16. • 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

17. 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

18. 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

19. 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

20. 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%

21. 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

22. • 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

23. • 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

24. • 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

25. • 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. Surgery Related Risk

33. 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

34. • RISK FACTORS FOR DVT:
 Age
 Obesity
 Immobility
 Malignancy
 Trauma
 Surgery
 Dehydration
 Past h/o thromboembolism
 Oral contraceptives
 HRT
 Pregnancy, peurperium

35. • PROPHYLAXIS:
 Graded elastic compression stocking
 Intermittent pneumatic calf compression
 Postoperative early ambulation
 Heparin prophylaxis

36. 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

37. 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

38. 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 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

39. SYSTEM WISE APPROACH
TO PREOPERATIVE
EVALUATION

40. 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

41. 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

42. 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 rate
0-5 points = 1%
6-12 points = 7%
13-25 points = 14%
>26 points = 78%

43. 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

44. • 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

45. Need for emergency
noncardiac
surgery
Operating room
Evaluate and treat
per ACC/AHA
Guidelines
Vigilant perioperative
and postoperative
management
Consider
Operating Room
Low Risk
Surgery
Active
cardiac
conditions
No
Yes
Yes
No
Proceed with
planned surgery
Asymptomatic and
good functional
capacity ≥ 4 MET
Yes
Proceed with
planned surgery
No
Yes
Manage based on
clinical risk factors
No

46. Manage based on
clinical 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 with
planned surgery
Proceed with planned surgery with HR control
or consider non-invasive testing
Consider Testing
*Clinical risk factors = known ischemic heart disease, compensated or prior HF, diabetes, renal
insufficiency, cerebrovascular disease

47. • 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:

48. 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

49. 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

50. • 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.

51. 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

52. • 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

53. 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

54. 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

55. LAB INVESTIGATIONS
• Serum electrolytes
• BUN
• Serum creatinine levels
• Hematocrit
• Urine analysis
• Fractional excretion of sodium
• Chest radiograph
• ECG

56. 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

57. • 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

58. 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

59. • 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

60. 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

61. • 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

62. LAB INVESTIGATION:
• Liver function tests
• CBC
• Serum electrolytes
• Coagulogram
• Hepatitis serology

63. 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

64. Approach to patient with liver disease
Acute hepatitis
Patient with liver
disease facing
surgery
Obstructive
jaundice
Postpone elective
surgery
Chronic
hepatitis
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

65. 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
Encephalopathy
1. Treat with lactulose
2. 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

66. 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

67. • `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

68. • 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

69. • 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

70. • 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

71. 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

72. • 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

73. 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.

74. Indication for
Chronic
Anticoagulation
Patient Characteristics Perioperative
Management
Prosthetic heart
valves
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
Strongly recommend
bridging
Consider bridging
Bridging optional
Chronic atrial
fibrillation
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
Strongly recommend
bridging
Consider bridging
Bridging optional
Venous
thromboembolism
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
Strongly recommend
bridging
Consider bridging
Bridging optional

75. 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

76. • 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

77. • 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

78. • 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

79. 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.

81. •Next presentation:
•Management of Advanced
Breast Cancer
• Dr Javaid Ahmad Bhat
• Moderator: Dr Natasha Thakur