MRCS PART A ESSENTIAL REVISION NOTES BOOK 1 - PasTest

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Preoperative management of coexisting diseaseAnticoagulants and fibrinolyticsConsider the risk of thrombosis (augmented bypostsurgical state itself) vs risk of haemorrhage.Warfarin Inhibits vitamin K-dependent coagulationfactors (II, VII, IX and X) as well as protein Cand its cofactor, protein S Illness and drug interactions may haveunpredictable effects on the level ofanticoagulation Anticoagulative effects can be reversedby vitamin K (10 mg IV; takes 24 h foradequate synthesis of inhibited factors) andfresh frozen plasma (15 ml/kg; immediatereplacement of missing factors) Stop 3–5 days before surgery and replacewith heparin; depends on indication foranticoagulation (eg metal heart valve is anabsolute indication, but atrial fibrillation[AF] is a relative one) INR should be
Perioperative CareCHAPTER 1Fibrinolytics Examples include streptokinase andalteplase Act by activating plasminogen to plasmin,which undertakes clot fibrinolysis Used in acute MI, extensive DVT and PE Contraindicated if the patient had undergonerecent surgery, trauma, recent haemorrhage,pancreatitis, aortic dissection, etcFor discussions of the management of immunosuppressionin the perioperative period seeTransplantation in Book 2. DVT prophylaxis inthe perioperative period is covered in Chapter 3,section 1.2, Surgical haematology.2.2 Preoperativemanagement ofcardiovascular diseaseIn a nutshell …Cardiac comorbidity increases surgicalmortality (includes ischaemic heartdisease, hypertension, valvular disease,arrhythmias and cardiac failure).Special care must be taken withpacemakers and implantabledefibrillators. In general it is necessary to: Avoid changes in heart rate (especiallytachycardia) Avoid changes in BP Avoid pain Avoid anaemia Avoid hypoxia (give supplementaloxygen)In addition, the details of preoperativeassessment before cardiac surgery iscovered in Book 2.The European Society of Cardiology haspublished guidelines (2009) to cover thepreoperative risk assessment and perioperativemanagement of patients with cardiovasculardisease. Patient-specific factors are moreimportant in determining risk than the type ofsurgery but, with regard to cardiac risk, surgicalinterventions can be divided into low-risk,intermediate-risk and high-risk groups: Low risk (cardiac event rate 1%): mostbreast, eye, dental, minor orthopaedics,minor urological and gynaecologicalprocedures Medium risk (cardiac event rate 1–5%):abdominal surgery, orthopaedic andneurological surgery, transplantationsurgery, minor vascular surgery andendovascular repair High risk (cardiac event rate >5%): majorvascular surgeryLaparoscopic surgery has a similar cardiac riskto open procedures because the raised intraabdominalpressure results in reduced venousreturn with decreased cardiac output anddecreased systemic vascular resistance, andshould therefore be risk assessed accordingly.The Lee Index is a predictor of individual cardiac riskand contains six independent clinical determinantsof major perioperative cardiac events: A history of ischaemic heart disease (IHD) A history of cerebrovascular disease Heart failure Type 1 diabetes mellitus Impaired renal function High-risk surgeryThe presence of each factor scores 1 point.Patients with an index of 0, 1, 2 and 3 pointscorrespond to an incidence of major cardiaccomplications of 0.4%, 0.9%, 7% and 11%respectively.20
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MRCS PART A ESSENTIAL REVISION NOTES BOOK 1 - PasTest

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