The document discusses preoperative preparation and management of common high-risk surgical patients, outlining evaluation, correction of medical issues, prophylaxis needed, and specific considerations and protocols for patients with diabetes, deep vein thrombosis risk, use of anticoagulants, history of myocardial infarction, hypertension, COPD, steroid use, thyroid abnormalities, adrenal insufficiency, and pheochromocytoma. Precautions and protocols are provided to optimize patient health and safety prior to and following surgery.

1. Preoperative preparation for
High-Risk Surgical Patients
Dr. Nabarun Biswas
Registrar Surgery
MMCH

2. Pre-op Preparation in General
1. Evaluation of physical fitness
2. Correction of 
I. Anaemia (Hb% > 8gm/dl)
II. Dehydration
III. Nutrition
IV. Electrolytes
V. coagulopathy

3. Pre-op Preparation in General
3. Prophylaxis of
I. Antibiotics
II. DVT
III. tetanus
4. Diet :
I. Adult
a. Solid for 6 hr before surgery
b. Clear fluid for 2 hr before surgery
II. Infant & child
a. Solid/ formula/ cow milk 6 hr before surgery
b. Mothers milk 3 hrs
c. Clear fluid 2 hrs

4. Pre-op Preparation in General
5. Shaving & cleaning of operative site
6. Arrangement of blood transfusion/ frozen section biopsy/
imaging
7. Informed consent
8. Control of DM, HTN, Infection, COPD

5. Common High-Risk Patients
• DM
• DVT
• Anti-coagulant use
• MI
• HTN
• COPD
• Steroid
• Thyroid function abnormality
• Adrenal insufficiency
• Pheochromocytoma

6. Diabetes mellitus
• Aim: to maintain blood sugar 6-12 mmol/li
• Patient type:
–Controlled by diet
–Controlled by oral drugs
–Controlled by insulin
Short acting
Long acting  converted to short acting (starting dose of
short acting insulin is 0.2 – 0.4 unit/kg BW)

7. Diabetes mellitus
Sl Controlled
by
Minor surgery Major surgery
1 Diet Nonspecific If blood sugar > 12 mmol/li start GKI
regimen
2 Oral drug -Omit morning dose
-Strat when eating
normally
Omit Metformin 24 hrs before surgery
Omit glimepiride 48 hrs before
surgery
If blood sugar > 12 mmol/li start GKI
regimen
3 Insulin -Convert to short acting before surgery
-During surgery start GKI
-Continue till NPO
Per-operative

8. Diabetes mellitus
Post operative:
1. Patients on oral drugs
 Subcutaneous short acting for few days then oral drug
continue
2. Patients on insulin
 After omitting NPO short acting insulin for 3 days then
original regimen

9. GKI regimen
• Infusion 1:
– 500 ml 10% DA + 10 mmol KCL (100 ml/hr i.e., 25 d/m)
• Infusion 2:
– 50 ml NS + 50 unit short Acting insulin (taken in 50 cc syringe &
connected with insulin driver)
Blood sugar
mmol/li
Push driver / hr
<5 Off
5-7 1 ml/hr
7-10 2 ml/hr
10-20 3ml/hr
>20 4ml/hr
Sliding Scale

11. DVT prophylaxis
• Pre-operative
I. Weight reduction
II. Stop OCP 1 month before surgery
III. If any risk factor  manage accordingly
• Peri-operative
a. Mechanical
 Graduated compression stocking
 Intermittent pneumatic compression
 Electrical calf muscle stimulation

12. DVT prophylaxis
b. Pharmacological
 Low ml wt Heparin 40 mg/day, S/C for 5 days  started 12
hr before surgery & continued up to 5th POD
• Post operative:
– Early mobilization
– Calf muscle exercise
– Graduated stocking
– Adequate hydration

13. Stablished DVT
• Anticoagulant therapy
o Low mol wt Heparin S/C for 5-7 days + Oral Warfarin (10 mg in
day 1, 10 mg on day 2 & 5 mg on day 3  up to 3-6 months )
o PT & INR should be measured daily
o PT 1.5 to 2.5 times
o INR  2.5 to 3.5 times
• Thrombolysis: streptokinase  direct administration into
thrombus
• Stent grafting: IVC filter
• Surgery: thrombectomy with A-V fistula

14. Patients on Anticoagulants
Agent used
1. Oral anticoagulant: Warfarin
2. Injectable: Heparin
3. Antiplatelet: Aspirin, clopidogrel

15. Patients on Anticoagulants
A. Warfarin:
• Emergency operation:
I. Inj Vit K I/V
II. FFP
III. Factor 2, 7, 9, 10 (prothrombin complex) transfusion
• Elective operation:
I. Stopped 5 days before surgery
II. If INR < 1.5  L.M. Heparin S/C  stopped 2hr before
surgery
III. Post op heparin for 3 days  oral warfarin

16. Patients on Anticoagulants
B. Heparin:
 Emergency operation:
I. Neutralized by Protamine sulphate
II. PT in maintained within 1.5 to 2.5
 Elective operation:
I. Stopped 4-6 hrs before surgery
C. Antiplatelet:
I. Aspirin: stopped 7 days before surgery
II. Clopidogrel: stopped 10 days before surgery
NB: if coagulation risk is high Aspirin may be continued

17. Patients with MI
A. Preoperative
I. Postpone surgery if recent MI within 6 months
II. If angina β blocker + GTN
B. Per operative
I. Anaesthetist must avoid any condition that increase myocardial O2
demand: tachycardia, HTN, hypotension
II. Avoid Atropine (causes tachycardia)
III. Use halothane
C. Postoperative
I. Adequate analgesia
II. Regular ABG
III. Cardiac monitoring

18. Patients with HTN
A. Preoperative
 Anti HTN drugs (diuretics, β blocker, Ca ch blocker, ACE
inhibitor)
 Anti HTN drugs taken up to morning dose
B. Per operative
 Propranolol may be used to control HTN
C. Post operative
 Adequate analgesia
 Regular ABG
 Cardiac monitoring

19. Patients with COPD
A. Preoperative
I. Stop smoking 4-6 weeks before surgery
II. Bronchodilator  continue
III. Steroid  continue
B. Per operative
I. Additional dose of steroid
II. Monitoring of O2 saturation
III. Inj hydrocortisone @ induction

20. Patients with COPD
C. Post operative
I. Clearance of airway
II. O2 inhalation by O2 mask
III. Nebulization
IV. Inj hydrocortisone 6 hrly for 3 days  tapper
V. Chest physiotherapy
VI. Early ambulation
VII.Adequate analgesia

21. Steroid user
Preparation for surgery:
1. Short procedure e.g. Endoscopy  single dose injectable
2. Minor surgery  single dose preoperative + another dose 12
hrs later
3. Major surgery 
• Elective  stop 2 months before with tapering dose
• Emergency  inj Hydrocortison I/V @ induction then 6 hrly
for 3 days

22. Steroid user
Additional management:
1. Control of DM
2. Control of infection
3. Control of HTN
4. Exercise & physiotherapy

23. Hypothyroidism
For elective surgery
Aim: to achieve euthyroid state 
–Levothyroxine 25 μgm /day
–Gradually increase up to 150 – 200 μgm /day
For emergency surgery
– Levothyroxine 500 μgm I/V or Orally
N.B: before administration of Levothyroxine check if the patient is suffering
from Addison’s disease or Coronary Artery disease.

24. Hyperthyroidism
Aim: to achieve euthyroid state 
A. For elective surgery:
1. Carbimazole:
 30-40 mg /day for 8-12 weeks {10 mg TDS}
 When patient becomes euthyroid reduce the dose 15 mg / day
 Last dose give evening before surgery
2. Lugols Iodin:
 Started 10-14 days before surgery
 5 drops TDS with milk
 Or, potassium iodide tablet 60 mg TDS

25. Hyperthyroidism
B. For rapid control: {A+B}
1. Tab. Propranolol
 40 mg TDS
 Continue up to 7th POD or,
2. Tab. Nindolol
 80 mg TDS

26. Management of Thyroid Storm
CF:
Dehydration
Hyperthermia
Restlessness
Shock
Cardiac failure

27. Management of Thyroid Storm
A. General Mx:
 I/V fluid
 Cooling by ice pack
 Sedation
 Diuretics if cardiac failure
 Digoxin Fibrilation
 hydrocortison
B. Specific Mx:
 carbimazole 10-20 mg QDS
 Lugols Iodin 10 drops TDS
 Propranolol  40 mg QDS

28. Pheochromocytoma
Preparation of patient:
1. α Blocker: Phenoxy Benzamine
 20-40 mg /day
 Gradually increase 10 mg /day  up to patient complains about postural
hypotension or dose reached 100-160 mg /day.
2. β Blocker: Propranolol
 After blocking α receptor, β Blocker started
 40 mg TDS
3. Preoperative extra fluid overload to be done to prevent
hypovolemia after removing the tumor.

29. Pheochromocytoma
Precaution:
1. CV line for invasive monitoring
2. IV α Blocker
3. IV β Blocker
4. IV peripheral vasodilator
5. Tumor handled gently
6. Vein ligated first

30. Pheochromocytoma
Post operative:
First 24 hrs should be in ICU
Monitoring of hypoglycaemia
Monitoring of hypotension