This document provides guidance on perioperative assessment for a patient undergoing hernia repair surgery who has diabetes and is on warfarin. It outlines steps to evaluate the patient, including taking a history and physical, performing diagnostic testing, and considering specific medical factors like diabetes, anticoagulation, and cardiovascular status. Evaluation ensures the patient's medical status is optimized and surgery is appropriate. It also provides recommendations for managing the patient's diabetes and anticoagulation in the perioperative period.

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Perioperative assessment
SARAH Al-Ghanim
ORL-HNS Resident ( R1)

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The goals of perioperative assessment
1
• Identify the patient’s medical problems
2
• Determine if further information is needed to
characterize the patient’s medical status
3
• Establish if the patient’s condition is medically optimized
4
• Confirm the appropriateness of the planned procdure.

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Scenario
Dr.Hessa ( GS- R1 ) has been called form ward
8 for an elective admission under the care of
Dr.Alsalman :
A 50 year old non insulin dependant diabetic is
planned for a right inguinal hernia repair. He is
on warfarine for past hx of DVT.
Outline the steps needed to assess and
prepare this man for the planned surgery

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Perioperative Evaluation & Management
General
Evaluation
Specific
Consideration

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General Evaluation of the
Surgical Patient

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General Evaluation of the Surgical
Patient
History & physical
Examination
Routine
Diagnostic testing
Preoperative
medications

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 Preexisting medical conditions
 Prior operation
 Operative complication
 Medication allergy
 Use of tobacco , alcohol , or drugs
History & physical
Examination

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Routine Diagnostic
testing
CBC
Serum electrolytes , Cr, BUN
Coag. profile
Biochemical & profiles
(e.g. liver enzyme )
Pregnancy test
CXR
ECG
Type & screen
Urine analysis

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 In general patients should continue their medications in the
immediate perioperative period.
 Exceptions to this rule include;
 diabetic medications
Anticoagulants
Antiplatelet
Preoperative
medications

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Specific Consideration
In preoperative management

11. Cerebrovascular
Cardiovascular
Pulmonary
Renal
Infectious
Diabetes mellitus
Adrenal insufficiency
Anticoagulation

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Cerebrovascular
disease
 Risk factors:
Previous CVA, age, hypertension, CAD, DM, tobacco use
 Special consideration :
The Asymptomatic carotid bruit ?
Recent transient ischemic attack?
Elective surgery for patient with recent CVA ?

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The Asymptomatic carotid bruit ?
 In 14% of surgical patients older than 55 years
 50% of bruits reflect hemodynamically significant disease.
 No increased in risk of stroke has been demonstrated during no
cardiac surgery
Cerebrovascular
disease

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Recent transient ischemic attacks
 Patients with Recent transient ischemic attack (TIAs)are at
increased risk for perioperative stroke
 They should have perioperative neurological evaluation ;
 Patients with symptomatic carotid artery stenosis should have
an endarterectomy or carotid stenting before elective surgery
Cerebrovascular
disease

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Elective surgery for patient with
recent CVA ?
 Elective surgery for patient with recent CVA should be delayed
for :
A Minimum of 2 weeks
Ideally for 6 weeks
Cerebrovascular
disease

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Cardiovascular
 Cardiovascular disease is one of the leading cause of death
after non cardiac surgery .
 Patients who experience a myocardial infarction after non
cardiac surgery have a hospital mortality rate of 15% to 25%.
 Risk factors :
 The patient’s age , unstable angina , Recent MI , Untreated
CHF, DM, valvular heart disease, Arrhythmia, peripheral
vascular disease , type of procedure , functional impairment .

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Perioperative Testing :
1
• ECG
2
• Non invasive testing
• Exercise stress testing , Dipyridamole thallium,
Dobutamine stress echo
3
• Invasive testing
• angiography
• Definitive tx ( CBAG – angioplasty )

18. • Turned to the uninhibited mode before surgery.
• Bipolar cautery should be used
• Monopole if necessary the pad should be placed
away from the heart
Patients with Pacemaker
• The device should turned off during surgery
Internal defibrillators
• Delay noncardiac surgery at least 6 weeks
Recent angiography or stenting

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Pulmonary disease
Risk factors :
 Chronic obstructive pulmonary disease (COPD), smoking ,
advanced age , obesity , type of surgery, acute respiratory
infections, functional status .
Diagnostic evaluation :
 CXR  acute symptoms related to pulmonary disease
 ABG hx of lung disease
 preoperative pulmonary function testing ?

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Preoperative prophylaxis &
management
Pulmonary toilet: incentive spirometry
Antibiotics:
elective procedure should be postponed,
if emergent surgery ;IV antibiotics
Cessation of smoking
Bronchodilators

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 Risk factors:
Additional underlying medical disease , metabolic & physiologic
derangements of CRI , type of operative procedure.
 Management :
 Timing of dialysis  within 24 hr of the planned procedure
 Intravascular volume status hypovolemia & volume overload
are both poorly tolerated
Renal

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 Assessment of risk :
 Procedure specific risk factors :
type of operation , the degree of wound contamination ,& duration
& urgency of the operation
 Patient specific risk factors:
Age , DM, obesity , immunosuppression, malnutrition
,preexisting infection, & other chronic illness.
Infectious

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Prophylaxis
 1- non antimicrobial strategies:
 Strict sterile technique ,maintain normal body
temperature & normal blood glucose , hyper
oxygenation
 2- surgical wound infection: AB prophylaxis
 3-Preop skin antisepsis
 4- respiratory infections
 5- genitourinary infections

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Diet
controlled
Can maintain
safely without
food or glucose
infusion
Oral
hypoglycemic
agent
Stop medications Sliding scale
On insulin Sliding scale
Insulin pumps
should be
inactivated in the
morning of
surgery
Diabetes mellitus

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Preoperative stress dose steroid are indicated for patients undergoing major
surgery who have :
 Chronic steroid replacement or
 Immunosuppressive steroid therapy within the preceding year.
Dosage Recommendations :
A regimen of hydrocortisone sodium succinate 100 mg IV;
 on the evening before major surgery
 At the beginning of surgery,
 & every every 8 hours on the day of surgery.
 Patients who undergoing minor surgery or diagnostic procedures usually do
not required stress dose steroid
Adrenal insufficiency

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Preoperative anticoagulation :
 It is safe to perform surgery when INR below 1,5
 Patient who is INR = 2-3  require withholding of medication
for 4 days before surgery
 If the INR value is greater than 3  withholding the medication
for a longer period
 The INR should be measured the day before surgery
Anticoagulation

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Post operative anticoagulation :
High risk of thromboembolism :
 Resume warfarin + bridged with therapeutically dosed SC LW
heparin or IV UFH
Moderate risk :
 warfarin + bridged with therapeutically or prophylactic dosed
SC LW heparin or IV UFH
Low risk :
no need to be bridged
Anticoagulation

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Reference

29. THANK
you