PREOPERATIVE HEMATOLOGIC EVALUATION
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Several hematologic disorders may have an impact on the outcomes of surgery A detailed discussion of the preoperative management of patients with complicated hematologic disorders is beyond the scope of this section Three of the more common clinical situations faced by the medical consultant are the patient with preexisting anemia, the assessment of bleeding risk, and the perioperative management of oral anticoagulation The key issue in the anemic patient is to determine the need for preoperative diagnostic evaluation and the need for transfusion When feasible, the diagnostic evaluation of the patient with previously unrecognized anemia should be done prior to surgery because certain types of anemia (particularly sickle cell disease and immune hemolytic anemias) may have implications for perioperative management Anemia is common before major surgery, with a prevalence of 5 75% However, in a large study of patients who underwent ambulatory surgery, the prevalence of preoperative hemoglobin values below 9 g/dL was 16% Most data suggest that morbidity and mortality increase as the preoperative hemoglobin level decreases, although none of these data were corrected for the presence of preexisting diseases Hemoglobin levels below 7 or 8 g/dL appear to be associated with significantly more perioperative complications than higher levels In patients with ischemic heart disease and with Child-Turcotte-Pugh class B or C cirrhosis, a preoperative hemoglobin level below 10 g/dL has been associated with an increased perioperative mortality rate It is not known, however, whether preoperative transfusion reduces
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Preoperative Evaluation & Perioperative Management
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Table 3 6 Recommendations for perioperative anticoagulation management
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Annual Stroke Risk without Anticoagulation Low (< 8%) (eg, atrial fibrillation with fewer than 2 other stroke risk factors) Recommendation 1 Stop oral anticoagulation 4 5 days before surgery 2 Measure INR the day before surgery to confirm that it is < 16 3 Resume oral anticoagulation the night of surgery 4 No bridging 1 Stop oral anticoagulation 4 5 days before surgery 2 Measure INR the day before surgery to confirm that it is < 16 3 Begin therapeutic dose UH or LMWH 2 3 days after stopping oral anticoagulation, and discontinue it 12 24 hours before surgery 4 Resume oral anticoagulation the night of surgery 5 If procedure has a low risk of bleeding, consider therapeutic dose UH or LMWH beginning 24 hours after surgery and continuing until the INR is therapeutic
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High (> 8%) (eg, atrial fibrillation or mechanical heart valve with prior stroke, or recent [< 3 months] venous thrombosis)
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UH, unfractionated heparin; LMWH, low-molecular-weight heparin
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the risk for perioperative complications Determination of the need for preoperative transfusion in an individual patient must consider factors other than the absolute hemoglobin level, including the presence of cardiopulmonary disease, the type of surgery, and the likelihood of surgical blood loss Many patients have anemia postoperatively secondary to blood loss and hemodilution In a randomized trial of patients who underwent cardiac surgery, the use of enalapril postoperatively was associated with a significantly slower recovery in the hemoglobin level The medical consultant should be aware that enalapril, and perhaps all angiotensin-converting enzyme inhibitors, may slow the recovery from postoperative anemia The most important component of the bleeding risk assessment is a directed bleeding history (see Table 3 1) Patients who are reliable historians and who reveal no suggestion of abnormal bleeding on directed bleeding history and physical examination are at very low risk for having an occult bleeding disorder Laboratory tests of hemostatic parameters in these patients are generally not needed When the directed bleeding history is unreliable or incomplete or when abnormal bleeding is suggested, a formal evaluation of hemostasis should be done prior to surgery and should include measurement of the prothrombin time, the activated partial thromboplastin time, the platelet count, and the bleeding time The perioperative management of patients receiving long-term oral anticoagulation therapy is an increasingly common problem Firm evidence-based guidelines regarding which patients require perioperative bridging anticoagulation and the most effective way to bridge are lacking Intravenous unfractionated heparin and subcutaneous low-molecular-weight heparin in therapeutic doses reduce the risk of venous thromboembolism but have not been proven to reduce the risk of arterial thromboembolism Most experts recommend bridging therapy only in patients at high risk for thromboembolism Bridging anticoagulation involves the discontinuation of oral anticoagulation a few days before surgery and the use of intravenous or subcutaneous agents for a few days before and (sometimes) after surgery Most studies have shown that preoperative bridging is associated with an acceptably low
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postoperative bleeding rate (18 58%) Postoperative bridging is associated with fairly high bleeding rates (22% in one study) in patients undergoing procedures that are generally associated with higher bleeding risks (such as orthopedic surgery) but a relatively lower risk for minor surgery It is important to consider the patient's preferences when weighing the risks and consequences of a thromboembolic event versus major bleeding A practical approach to perioperative anticoagulation management is shown in Table 3 6
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Dunn A Perioperative management of oral anticoagulation: when and how to bridge J Thromb Thrombolysis 2006 Feb;21(1):85 9 [PMID: 16475048] O'Donnell M et al Perioperative management of oral anticoagulation Clinics Geriatr Med 2006 Feb;22(1):199 213 [PMID: 16377475] Olson RP et al The prevalence and significance of low preoperative hemoglobin in ASA 1 or 2 outpatient surgery candidates Anesth Analg 2005 Nov;101(5):1337 40 [PMID: 16243990] Ripamonti V et al Angiotensin converting enzyme inhibitors slow recovery from anemia following cardiac surgery Chest 2006 Jul;130(1):79 84 [PMID: 16840386] Shander A et al Prevalence and outcomes of anemia in surgery: a systematic review of the literature Am J Med 2004 Apr 5;116 Suppl 7A:58S 69S [PMID: 15050887]