PBM: Peri-op care

 

List:

·         Pre-op anaemia investigations

·         Pre-op anaemia treatment

·         Pre-op haemostasis tests

·         Pre-op anti-haemostatic cessation

·         Intra-op pro-haemostatics

·         Autologous blood transfusion

 

Pre-op anaemia investigation:

Haemoglobin

<130 men

<120 women

Mean cell volume

Small = IDA

Normal = chronic disease

Large = haematinics

Ferritin

<30 iron deficient

30-100 maybe iron deficient

Transferrin saturation

<20% iron deficient

Haematinics

B12, RBC, rolate

Haemopoiesis

Creat

LFT

TFT

Physician review

Blood loss

Gastroscopy + colonoscopy

 

Pre-op anaemia treatment:

Iron deficiency

IV iron 4/52 pre-op

Aim ferritin >100

Chronic disease

IV iron +/- Epo

Aim Hb 100-115

Haematinic deficiency

B12

Folate

 

Pre-op haemostasis tests:

Platelets

>50: likely ok for invasive procedure

(>100 if brain, eye, neuraxis)

INR

<2L likely ok for invasive procedure

(not if brain, eye, neuraxis)

 

Pre-op anti-haemostatic cessation:

Aspirin

Cardiac: withhold on day of surgery

Neuro and eye: consider ceasing pre-op 7-10 days (?)

Clopidogrel

Cardiac: cease ≥5/7 pre-op

If more important: maybe continue (DES 12/12, BMS 6/52, recent stroke)

If less important: cease 7-10 days pre-op

NSAIDs

Ortho: cease pre-op (time varies)

Warfarin

Continue if: scopes without intervention, cataract, minor dental

Reversal: see American College of Chest Physicians or Australasian Society of Thrombosis and Haemostasis

 

Intra-op pro-haemostatics:

TXA

Use if expecting significant loss

EACA

Use if expecting significant loss

Not available in Aus and NZ

Aprotinin

Removed from the market

Risk of renal failure and death

Desmopressin

Use if vWD type 1 or 2a (?)

Not for routine use

Risk of stroke and death

 

Autologous blood transfusion:

Autologous donation

Reduces risk of allogeneic transfusion

Increases risk of any blood transfusion

Routine use not recommended

Acute normovolaemic haemodilution

Use if a) health Hb b) expecting significant loss

Need a local protocol

Intra-op cell saver

Use if expecting significant loss intra-op (e.g. AAA)

Need a local protocol

Post-op cell saver

Use if expecting significant loss post-op (e.g. TKR)

Need a local protocol

 

Some don’ts:

Cardiac surgery

No routine FFP

No routine platelets

Liver disease

No routine FFP for ↑INR

Prophylactic F7a

Risk of thrombotic events

Epo

Not if PHx cancer (-> recurrence)

Not if active cancer (-> stroke, death)

Not a replacement for iron