Preoperative Evaluation and Mx of Common Medical Conditions

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Preoperative Evaluation and Mx of Common Medical Conditions

25 Jul, 5:30 AM

[Music] at the outset i shall thank madiplux and as well as association of physician of gujarat and association of physician of ahmedabad on behalf of these two association i welcome all the delegates i am very happy that this talk is happening because for last two years we are planning to hold this and this is a very very unique and this is a very important topic of clinical relevance good morning everyone see we can have three types of approaches for any for that matter any medical problems we always have one is the evidence evidence-based medicine approach that means what is the scientific evidence as on today for that particular topic we are talking of pre-operative medications so pre-operative evaluations what is the evidence-based medicine second is what is the experience based medicine what your experiences suggested over and above evidence-based medicine and the third is expectation-based medicines expectation-based medicine is as a pre-operative or a barrier to management we are working in a very limited resources as you rightly said somebody is in the private nursing home with limited resources now we have to use all three of them see we are going to discuss as we discuss we i let you know that though we want to practice evidence based medicine every time at times we have to use experience as well as the expectation based medicine also so as we all will see but basically perioperative medical problem the physician role is mainly to identify whether the patient has any pre-existing comorbid conditions and whether there is unrecognized medical issues which might come off we know the time and again that every patient might have high blood pressure or diabetes or any such issues or we if we fail to forget in the recent times that whether patient had suffered from kovid it's very very important question that we would be asking to every patient who is undergoing pre-operative evaluation so we need to recognize the comorbid conditions risk factors respect there are certain risk factors age is a risk factor smoking is a risk factor so we need to enumerate the risk factors we have to find out the comorbid conditions and we have to optimize all these pre medical conditions whatever is the patient status whether it is diabetes or hypertension we have to optimize before we set let the page surgeon operate on it and we have to be a very important part of the pre-operative team that the surgical team surgeon obvious is the head and very importantly let me make it very clear as you rightly said as a physician we have no business to clarify somebody clear sorry somebody don't even if the surgeons insist that please clear or make the patient fit for surgery we cannot give the fitness part that is the anesthesiologist's job any studies will decide the type of surgery anesthesia right we can only say about the status of the cardiopulmonary system and the metabolic status so as a physician first thing i would say never ever right patient is cleared for surgery or patient is fit for surgery all that we can write is that the patient's cardiopulmonary status is satisfactory or is metabolic synthesis this factory or that requires control and these are the suggestions before we go ahead with the surgery so my first point is that physicians do not decide the fitness part fun it is the next physiologist's job when prerogative both and second part is we have to optimize the medical conditions because we know that many medical conditions if they are pre-existing and not under control they will decide the outcome negatively so that is our main job as a physician to make the patient as physically physiologically uh fit as possible that's it so the to the next question which is related to this only what is the role of a physician in uh perioperative management of a case undergoing any kind of surgery you have covered this i think this is interrelated questions so basically what we decide we can use certain parameters like suppose there is a standard asa american society of necessities classification right wherein the patient's patient conditions depending on the history and examinations would come to class one is a normal healthy person class two is a person having a minimum medical problems or control medical problems like hypertension like diabetes but control class three something problem is more medical problem is more critical something like coronary artery disease copd right and the class four is more critical than that that means the patient has either congestive heart failure or chronic kidney disease these are the patients who are likely to run into many problems so class four is something you are always on close and make the patient uh the surgeons and the anaesthetist that this is the person who is having class 4 status as as of now class 3 is a patient who has got then illness like copd like chronic disease like uncontrolled hypertension or diabetes they are class 3 class 4 is the one who has got a critical disease like congestive heart failure or chronic kidney diseases these are just names and examples right and class 5 is the one where the patient is more even it's very critical and not likely to survive beyond few hours or maybe patients is in the icu and new class is added as a asa class 6 where the patient is brain dead and is waiting for the organ donations so that is asa class 6 and in all these classes if the patient is taken for emergency you add the suffix e so maybe patient is taken a normal person is taken then class a e or patient is critically ill and class 5e something like this so asa classification is very very important as far as the making the surgeon and then is available inform about the patient's physical status i mean we can advise the patient also we can tell them this is the complication rate in these stages for example stage one and two complication rate is in the range of one of one to two percent and uh on one it increases three nine percent then fifteen percent then thirty five percent so that way we can explain the prognosis to the patient also so now to the next question what is the first thing you do when you get a referral from your uh your colleague for a pre-operative assessment or perioperative management right first and foremost thing we have to find out whether this is an emergency surgery plant surgery or a plant emergency what is plant emergency is that we know most most common with the people who believe in rituals or in the buhari and all so they create a plant emergency or the obstetricians very common janmastami or whether it's a rakshabandhan and they have a fixed time for this caesar and all so emergency surgery always carries lot of risk can be a very little time for optimizing the medical condition so it's very important but if it is a plant surgery i would say the pre-operative assessment should start the day patient and the surgeon decide to undergo surgery unfortunately we are called at the last minute i call them a point of knife preoperative evaluations that surgeon is almost about to put a knife and then we call us time and again we get the call that patient is planned at two o'clock please come and say we get the wallet around 12 o'clock that is not the way patients should be evaluated pre-operatively for a good outcome so plant surgeries it's a plant knee replacement or hernia surgery or whatever it is on plant surgery we should have optimum time to make the patient physiologically as fit as possible emergency surgery even if we get few hours right we can at least control their blood pressure their sugars so it's very important that we get enough time enough leg space to make the patient as fit as possible because we know that the outcome is definitely dependent on what is the patients it does at the time of incision it's very very important that we make the patient as optimized medically as possible so that's our job right anesthetist will do the job of selecting the anesthetic agents and the hypopens so to the next question uh according to you which are the most important risk factors which results in very operative complications right basically we are talking of the cardiac surgeon's number yeah see see there are risk factors related to the patient respect related the type of surgery and the risk factor related to the anesthesia duration so i would say one of the most important risk factor is the age anybody who is over the age of 70 definitely carries persons who are chronic smoker when we see chronic our standard definition is 20 packs cigarettes for 20 years so chronic smoker age more than 70 years and the pre-media pre-op morbid conditions whether it's a copd whether it's an uncontrolled hypertension or diabetes ischemic heart disease heart failure pulmonary hypertension severe stenotic cellular diseases like aortic stenosis or mitral stenosis or patients having restricted cardiomyopathy or patients having peripheral artery disease very few people realize that peripheral neural disease itself also carries a risk because the peripheral artery disease is equivalent of coronary artery disease because it reflects a generalized atheroscleroid process so i for one would always put the patience whenever i examine examine the patient's thoughts this bed is also and that's very very important particularly in the orthopedic surgeries when they operate on the neck fracture neck femur or the acetabulum if it's very important that we need to see the presence of peripheral artery so many times we'll find the problems of different thrombosis as well as the peripheral artery disease itself is a big risk factor for the perioperative cardiac complications when we say periodic cardiac complications we are mainly generally the statistics say that the 30-day mortality for the myocardial ischemia or micro infarctions that is what is considered as one of the core standard for the cardiac complications relative to the surgery so another part as i said these are the patient related factors age medical conditions smoking then the surgery related complications any surgery which is done on the thoracic region or the upper abdominal region carries the high risk all the time right then nst is the duration the anaesthesia duration is more than three hours then also it carries a definite race so to me these are the main important factors which i would be keeping in mind when i check the patient for the pre-operative evaluation yeah no that that is related to surgery you see some of the surgical procedures are definitely carrying high risk as we already see thoracic and abdominal surgeries but even surgery like aortic on the outer aneurysms or on the peripheral vascular disease or the head and neck surgery they are definitely carrying a high risk and the major spinal surgery there's also carry high risk but most of the orthopedic surgeries most of the carotid endotrechtomy they fall in the intermediate risk and surgeries like cataract surgeries the prostate surgeries brace surgeries hysterectomy all endoscopies they all come in the low risk factories so that is related to this type of surgery now if the patient is more than 70 or medical problems obviously puts in the higher risk but this is as far as relation to the type of surgery that mentioned so basically my question would be what are the investigations you routinely ask for and what are the specific investigations you order and in which situation in the very beginning that we need to practice evidence base expectation base or the experience based this is where probably that comes in the applications there are few three issues right there is no universal recommendations for the all types of surgery all kinds of patients right it is not possible to generalize see there are two issues one issue is that in most of our patients they may not have any investigations earlier right most of them will say that's all right this is the first time illness that i am having it or i never had any test or something so we don't know about their metabolic profile so that is one issue second issue is that the overall most of the surgeries these days run into five figures right several thousands so whether we omit one investigation just because there is no evidence how far it is justified and the third is always the fear of medical approaches even though there is an evidence that if suppose a patient is undergoing a surgery we have young patients no medical problems and he is just 45 and he is undergoing cataract surgery or he is undergoing uh surgery where even if no investigation is required honestly i repeat no investigation is must for a patient who is healthy and but see would a patient that develops some complications would that will be acceptable to the court of law and when the patient is spending several thousand rupees for any minor surgery whether we should not go for certain investigations the good part is that most of the surgeons and most of the hospitals have tied up for the minimum pre-operative investigation so i would say if i would say that i would do at least complete blood count in all the patients even though except for really the anemia and that to severe enemy of less than 8 gram even the hemoglobin doesn't make a difference but we need to have the because we do not know how particularly the patients who are likely to undergo surgery where there are likely to be some blood loss so minimum investigation that i would ask for is complete blood count including the platelet counts then urine analysis is questionable because it's not required in most of the patients but patients or diabetic patients are likely to be catheterized i think it's worth going for and patients who are going to have implantations where presence of infection would make the difference so urine analysis but complete blood count platelet counts renal functions because we know that so many patients have asymptomatic rise in the creatinine so serum created in blood urea cpc complete blood count with platelet counts urine analysis electrolytes at least in the patients who are 50 plus or 55 plus i would go for shrimp sodium and sodium potassium so my list of investigation complete blood count platelet count urine random blood sugar right then serum created in blood urea scpt asymptomatic hepatic involvement is also one of the important things that we splash patients are going to get the nsaids or antibiotic patients are going to hypotension prolong so scpt serum created in serum potassium sodium are the basic medium of blood investigation i would be going through right so the question of x-ray chest yeah yeah question of exercise exercise is not required in most of the patients who do not have any background medical cardiopulmonary problems if the patient does not have history of copd or emphysema or asthma or cardiac problems and he's under the age of 60 chest x-rays not mandatory now echocardiogram very important investigations and most of the physician would insist for echocardiogram then there comes the assessment of functional status that means if the patient was ambulatory before the time of preoperative evaluations and if you can get the history that the patient has reasonable functional status what we mean by reasonable function status is if the patient can walk about four miles per hour for one hour person has been walking or patiently climb one flight of stairs one flight of stairs which will come to about four max max is the metabolic equivalence of the energy expenditure one metabolic equivalent comes to around 3.5 ml of oxygen consumption per minute per kg per minute in sitting position so that is the one map so format is something which is equivalent to a person can walk up flight one flight of stairs right or if the person can walk on the ground for at least one hour that means you don't need the echocardiogram because that means that the patient's functional strategy good enough to overcome the any surgical stress now problem is this is subjective this is subjective we rely on the patient's history so if the patient is as i said more than 60 or if the patient has some cardiac problems pre-existing cardiac problems or hypertension or diabetes i would definitely go for echocardiogram for the patients the surgery is intermediate to high risk surgery if the surgery is minor like cataract or prostate or breast surgery we may not go for the echocardiogram uh then your question was of specific investigations now that's again an opening of a huge controversial topics because see whether we should go for d diamond now these days patients who had suffered from covet infections recently right and already had high d diver i would definitely go for d diagonal but otherwise the dimer i would do it just for a negative predictive value for the patients who are bare hidden or patients who are going for operation for the hip or neck or patients who had some tenderness in the calf right then either i have a choice of going for a d dimer or i have choice for doppler studies in the limbs lower links doppler for or documenting any different tharmosis which could lead to pulmonary embolism so that's one then canadian cardiovascular society has come out in 2016 with the recommendations of doing pro-anti-bnp pro nt bnp in patients who are more than 65 years for any surgery or patients who are between 45 and 65 with risk factors or in a high to intermediate surgeries then they suggest that give go for pro and t bnp and if pro anti bnp is not available then one should go for the troponin test so proponent is we do offer a nowadays frequently in patients who are 60 plus or patients who had coronary artery disease or patients who are diabetics or patients with some echocardiographic abnormality or ecg abnormality it is better to go for proponentities because if the troponin is elevated definitely you have to be very watchful in the first three days post operatively because patients might be under the anesthesia or effect of medications and chest pain may not be one of the complaints and very high chance of getting the market infarctions in those period so troponin is another investigations that once you go for patients who are known diabetic patients right i would go for hb1s in all patients who are diabetic definitely we should go for hb1c and even if the patients had a random blood sugar of more than 140 150 it is worthwhile getting the hba1c because that will give idea about the previous metabolic status and definitely help us the as you stated that for simple surgeries like uh cataract surgeries and all we did not do any investigations but what i have seen is that the optimalists and even these surgeons who are doing simple surgeries have a knack of giving nsaids and all those antibiotics which can destabilize the compromising function also so that is why generally i prefer at least basic very basic tests of this nature because it is not for a patient to get jeopardized doing surgery but it is because of iatrogenic issues that may develop in these patients by wrong medication because if the creativity is high we can tell them that don't use these drugs even the same for dentists also i agree fully agree with him that is what i said to begin with that this is where we just don't go by the evidence-based medicine that no investor is required once the patient is going for surgery at least basically he should have cbc created in that is minimum that i would have learned blood sugar that i would definitely go for it and as you rightly said that many of our patients even if clinically we may not suspect the hemoglobin of around six or seven rate because they are dark skinned people and surprising to our surprise the hemoglobin comes to seven grams or eight grams so there is something we can pick up and then we can find out the cause of an email later part of the post operative period if required so that's definitely i would go for the basic investigation even if though the evidence does not suggest the utility of that investigation as far as the outcome of surgery is concerned the patient is already as i said going to spend a large quantity and ecg see as a physician we include usage as a part of the examination itself so i would definitely offer an ecg to all patients who are 40 plus even though we do not charge for it but at least if we have ecg we have peace of mind and that becomes housed as the basic uh investigations and if something goes wrong in later part of the period variability period we know what was the basic ecg doubletine stress eco probably when we are talking we are mainly discussing about the non-cardiac surgeries right but as we said we have asked about the functional status we are not reliable if the patient is not reliable or if we are not in a position we have very strong suspicion of silent ischemia or underlying coronary disease or if the surgery is a major surgery definitely vitamin stress echo is very useful and because it doesn't require patients to undergo any something like treadmill right so definitely dobby dumb and stress eco has a role in a select patients where we have a strong suspicion of coronary disease and had the patient having critical diseases the surgery might complicate into many compost operating complications so definitely double damage stress eco will be useful here it's a pharmacological stress echo that dobitamine is injected and the heart rate is increased and we can inject dough vitamin gradually say starting with 10 microgram and then increases up to 40 microgram and then you see the heart rate and just like in treatments we have got a target heart rate so we try to achieve 80 85 percent of the target height rate of that perceptual person's age depending on the age and see the regional volvo abnormality while doing the echocardiogram because if there is a regional motion abnormality during that vitamin stress eco a that is the patient where probably we may need more investigations or a referral to cardiologists before subjecting that patient for surgery but i believe that you do critical care and do a lot of echoes so what are your inputs and the experience itself dr c actually the major thing is to assess the functional status and sometimes what happens is that you you got a vip patient and ecg show some key inversion or some changes so uh here you will not like to take this my surgeons also would not like to take this for dse in very specific situations and in dsc we have a set of patients where say at heart rate of 130 he starts getting engineering symptoms so the catalyst will give us a target of heart rate of 130 that using the perioperative period to keep the heart rate to below 130 so we start the patient on the medications which control the heart rate and we try to see a lot of these patients have been grazed when they don't they don't want to go for any angiography or anything of that salt before such if they just want to have the strategy completed and they have been explained the risk the concerns have been taken and then we try to treat the heart rate below the level at which the engine occurs and we generally get a bit away with it quite successfully so dsc basically to rule out a inducible viper infection uh michael is ischemia sorry and to know that at which level of heartache the patient will start because for minor surgeries and surgeries like hernia hydrocele we can get away with keeping the heart rate on the lower side even with a positive dhc but the cardiovascular target that you keep the heart rate below this level so that is one thing which is uh what do you do if you have some ecg novelties like teen present uh occurring in uh say anterior and relative least or so so what would be your approach to such cases patient is not having any symptoms right again as i said that whether the patient has any other pre-morbid conditions like the hypertension or percentage of murmur on oscillations and then definitely we'll go for echocardiogram definitely and these are the patients where if the patient is asymptomatic and there are subtle non-specific changes we just have to follow up in the very operating period and be on look out for any of the indicators that this could be an ischemia we may do properly test at that point of time and follow it up but i don't think we need to treat or postpone the surgery because of the minor ecg abnormalities so for minor ecg properties where functional state is okay no is this factor generally equal is sufficient that is also we also do so do you calculate risk do you have uh use any risk calculator for stratifying the risk before strategy yeah that is another question with the mobile applications available on the click right there are so many risk algorithms which are available but something which has to be handy and which is proven time tested one which is called the lease rcri or revised cardiac risk index i'll just try to see i have got the presentation some of this yeah so this is the revised cardiac risk in the index here there are six parameters one is the history of ischemic heart disease history of ischemic heart disease include patients who have markle infarction acute current syndrome angina but if the patient is had undergone angioplasty when you bypass but is asymptomatic he is not included in that isd then patient having heart failure patient who is diabetic on insulin patient who had a history of cellular vascular disease patients whose creatinine is more than two milligram percentage and the type of surgery like intrathoracic intraperitoneal or supraincinal vascular surgery these are the six parameters each parameter is given one score so this is very handy it's also there are four diseases right ischemic heart disease heart failure diabetes on insulin and cerebral vascular disease and one investigation creatinine and type of surgery like intrathoracic intra-peritoneal or supremum vascular surgery and originally was done only one single center and around thousand patients and there there is there was a zero score the complication rate was 0.4 but now after so many other patients uh centers have notified that and published that if the patient score is zero then the chances of complications if it is four it increases to six percent with one and with three or more it comes to fifteen percent is a very high uh risk so that's why it is very very important that at least we have some objective parameters to say to the surgeons and the anesthesiologists that these are the patients who are likely to risk or knowledge so rc error is one it is very easy all that we have to do is this and second one is a gupta period pre-operative cardiac risk assessment in dr gupta's risk assessment calculator is creating in asa class that we just discussed and pre-operative functional status of the patient that the patient is totally independent at the time of the evaluations partially dependent or totally dependent so then the operation sides all these are given in the tabulation forms and you just have to enter and you get the idea about the possible cardiac risk assessment and this is universally accepted as the preoperative risk calculators there may be many more but these two i thought are very handy they look quite simple actually and easy to execute yeah what are the common medical conditions you encounter more frequently in perioperative vision right as an adult practice that we are doing and most of the patients are of 50 plus or something we most often encounter is hypertension diabetes is chemical disease patients nowadays so many of our patients had already undergone angiography angioplasty or bypass then copd patients then patients who may be anemic patients who might be having some collagen disease in our under treatment or patients who might have suffered from or on anticoagulants so these are the common conditions that we come across and now covet also we keep have to keep in mind uh what is the approach for perioperative management of hypertension yeah yeah one of the most common condition is hypertension now we know that hypertension definitely carries the risk as if the hypertension is uncontrolled and many of times the operative anxiety pain all hassles and collecting all the formalities patient blood pressure might be elevated mildly so what is important is what is the stage of hypotension we know that hypertension is divided to mild moderate and severe if the severe hypertense is the one where the systolic blood pressure is more than 180 and diastolic is more than 110 right that is measured when the patient is otherwise quiet right so that's very very important that all we are hypertension patients we should not allow them to go ahead with the surgery but surgery should not be delayed in mild to moderate hypotension this is very important in a mild to moderate hypertension surgery is not required to be postponed yes there are anti-hypertensive medicines which we have got to be very careful in using in perioperative period the most common being is inhibitors and arvs ac inhibitors and arvs are known to cause intraoperative and post-operative hypotensions and we have seen even in practice they are so common and these days the saturns and ins inhibitors are so commonly used and you are asked to that is the reason that i said to begin with that at least we should have some time at least a day or two before optimizing the patient's condition if the patient is on uh any of the certains or on these inhibitors definitely we should defer the surgery for 24 hours because time in again improperly hypotension has been a big problem and that in both general anesthesia as well as final anesthesia more since final anesthesia so better that we withhold this inhibitors and arvs if the patient is controlled with beta blockers and clonidine it should not be stopped because if we stop abruptly there are chances of rebound taking card and remove hypertensions so no surgeries to be postponed for mild moderate hypertensions severe hypertension it is better that we control the blood pressure and then only go for the surgery and the important part is that if the patient's blood pressure goes up in a perioperative period the cause may be something like uncontrolled pain patient might have fluid overload patient might have electrolyte disturbances patient me may be anxious patient is in icu because in rice psychosis patient has no sleep previous night or patients had a distended bladder or uncomfortable weight so all these problems could be attributing to the patients increasing the blood pressure and the data says that 30 percent of the rising post operative blood pressure resolve by itself what is more important and that i want to stress to all of our viewers that better avoid hypotension because hypotension is one of the most important risk factors for acute kidney injury in the perioperative period so make sure that don't allow the blood pressure to fall right below at least hundred and ten systolic or the seventy nashville is very very important that we maintain the blood pressure and the moment the patient is allowed to take the fluid and the oral intake we may resume the patient's anti-medicines but we have seen in experience that most of them at least as far as their ac inhibitors arvs are concerned they may need two or three days to start the medicines that blood pressure doesn't come up to an level that we need to start the medicines anesthesiologists quite often use nitroglycerin patch for the perioperative severe hypertensions so that can be used but we have to be very careful and obviously these patients are going to remain under the continuous monitoring ecg and blood pressure monitoring so that's about hypertension i may ask you a question yes in your opinion if the patient is having suppose severe hypertension yeah what will be the drug of choice during this period management see as i said rightly whether we need to go for an emergency surgery see if patient need an emergency surgery we have to optimize by starting the nitroglycerin drip right we can start with the nitroglycerin drip and for few hours and and see the patient's blood pressure under control and surgery is imminent we have to go for it right but otherwise in emergencies should not be started like that right beta blockers are only required in short acting ultra sorting beta photovocals as well may be used by the ancestors at the time of inductions when there is a severe surge in the blood pressure expected otherwise beta blockers is not a favored drug as far as controlling the blood pressure in emergency is concerned you can start with if required the nitroglycerins if we have got time see there are hypertension is emergency and urgency emergency is something when we have got the target organ damage is already there right facing this angina patient is failure but if the just patient has to be taken for surgery it comes in urgency and we have got at least few hours and we should not precipitously fall bring down the blood pressure it's very very important because that is more complications likely i will be happy if the blood pressure can be dirt down by 10 percent right in next two to three hours rather than going for the 120 or 130 systolic or 90 diastole it's not required right if you can bring down the blood pressure to mild to moderate levels that should be good enough otherwise blocker will be the drug of choice if you have time on your hand yes agreed yes uh there are two three questions one is that we we know all that asymmetries here is to be stopped in the perioperative period but does it apply to very minor surgeries like cataract and those surgery sort of daycare such as one thing no you can think of if the patient needs to undergo under general analysis their spinal is here then only this applied number one second if the patient is on a rb or as inhibitors because of the heart failure then we don't have to stop that's very important that because then we are likely to precipitate the heart failure part so the clear-cut guidelines suggest that if the patient is on this drug for the indication of heart failure we don't have to stop we have to be very careful about blood pressure monitoring that's it the second thing is i have seen the tendency that patient comes with accelerated habitation the uh physician starts amlodipine as an antihypertension now i have not been is a very slowly acting it will take a couple of weeks to achieve its maximum effects so if at all uh calcium channel workers are to be used which are the ones which you prefer so we are very happy with the cellular dipping dot not it's a very great anti-high plus medicines but it's very good and it is a long half-life so we don't have to give very frequently so my preference we can use our nephew pin also for only thing is we don't use the short right thing in the philippine we have to use the preparations but again as i said if your time otherwise i would definitely go for cylindrical uh now the similar situation occurs when the patient is diabetic so what are the very operative management studies in the patient of diabetes and tell us about stress hyperglycemia about unknown patient who did not have diagnosed diabetic patient who had diagnosed diabetic all those situations which occur in patients of diabetes detected or freshly ejected or known diabetic during uh perfect period in hospital i think management of diabetes in a peripheral material is probably more than one hour two hour session discussing itself but to give few sentences i would say that surgery is a neuroendocrine stress and no matter what surgery it's a stress and that is going to produce insulin resistance even if it is temporary and hyperglycemia we have release of glucagon we have release of stress hormones epinephrine we have release of steroids so all these all and as again there is only one insulin that is counteracting hyperglycemia and diabetes is a known risk factors for the perioperative infections cardiovascular morbidity mortality it's very important if the patient is the known patient of diabetes then we must try to ascertain whether the patient is any of the microvascular complications or target organ damage like whether the patient is nephropathy very important whether the patient is coronary disease and especially i am interested in the autonomic neuropathy because resting tachycardia orthostatic hypotensions they are very common in patients who are diabetes and undergoing surgery and the effect of anesthetic agent on the status of diabetes if they have autonomic neuropathy so very important that we at least evaluate the patients well in advance for plant surgeries that nephropathy coronary disease autonomic neuropathy and hba1c is must right what is the degree of hp1c to be maintained while there is controversies i could see some of the questions in the comments section also that whether nine persons see there are two things one is the long diabetes metabolic status and one on day of the surgery first we must try to maintain the sugar in the range of 110 to 200 broad range if we say better that we have the optimum control of the diabetes as far as the hb1c is concerned we stopped all anti-diabetic drugs on the previous day evening and especially sclt-2 and metformin at least three to four days in advance on the day of bitter we plant the surgeries in the morning and we start with the glucose infusion and the insulin infusions in the two parallel arms and accordingly we cube you yourself are also diabetes doctors uh one thing which is generally i try to avoid is the sliding scale basically because it is fine as far as the patient is nbm but as soon as the patient starts taking orally i have seen a lot of doctors continuing with the sliding scale which may be detrimental i basically as soon as the patient starts taking only i will shift him on five times a day point of clear blood sugar readings or six times a day and split my spin according to their sugars uh giving pre-parental improved mental correction to disease and daily treating those so i am basically a little against sliding scale which i feel is not an appropriate way to manage diabetes in career operating settings unless the patient is nvm and second thing is i am all for analog specifically because a lot of patients cannot wait for half an hour after giving a regular incidence or some of them you eject and they declare after half an hour they're they're not going to eat because they're not feeling like it they're free nausea and all so that complicates the situation pretty much and pretty much comfortable with analogs as far as the management of diabetes in my hospitalized patients is concerned and third thing is that if all the sugars peep and post injuries are keeping on the higher side i will be very fast on initiating basal insulins like glycine 2g or receiver so these are the three things basically which i focus on while managing perioperative missions i would like to take these patients off as you literally just met for men and even sulfurase for that matter if it is a major surgery and would like to manage purely on uh insulin basal cranial maybe [Music] so that is what i do basically you know in my questions hospital setup is good i agree fully agree with you nobody likes actually this sliding scale because that is not physiological but the problem is that when you are working outside i mean small nursing home they are not ready to i mean they don't have stuff to cover that so then it becomes a issue obviously this fast acting insulin should be used analogs and obviously this uh iv variable rate insulin infusion is the best and obviously as as early as possible i will also try to shift them basal bonus one of the uh delegates ask for if the patient is pregnant and already in labor troll however which we can continue to happen definitely levitating is very safe and we have got overall as well as injectable laboratories available and we routinely use even for hypertensive emergency in the setting of angioplasty capg or patients on antibiotic drugs what instructions would you give your patients surgeons and anesthesiologists for such a class of patients so it's very very important that we have time we have time if we do not have time for a plant surgery there is not an issue but an emergency surgery it's really the nightmare for the orthopedic surgeons or the other surgeons right it's very important that we keep in mind that if the patient has acute coronary syndrome and a fracture it's a real nightmare because there are very high risk of medical infarction death and we need if the surgery is inevitable we have got to take all precautions and the help of the cardiologist also patients should be operated only the super speciality or multi specialty hospital where the icu facility backup is available it's very very important if patient is non-emergent non-cardiac surgery and patient is on dual anti-platelet drugs right that we must stop clopidogrel at least five days prior to surgery lopidogram at least five days prior to surgery because clopidogress is a very long half-life and patience bleed even surgery which looks simple like the knee replacements plant surgery and you'll be surprised to know that there is a significant amount of bloodlust in the knee surgeries and at least in the orthopedic surgeons with whom i work they resist the two replacements at a time otherwise there are so many centers where both the knees are replaced on the same day severe blood loss you've seen they require the blood transmission so often and now if they are on lopido girls and drugs like school program it's a nightmare so it's better that clopidogrel should be stopped at least five days before the surgery if the patient is on rasu grill it is much longer time long acting so seven days before the surgery trigger low is something where you can have only three days of period required to be stopped the drugs right experience should be continued but it's better that we stop at least three days if there is not imminent danger of the thrombosis right we have to trade off between the thrombosis and hemorrhage if the patient had a very recent procedures undergone recent procedures aspirin may be continued till the last day that's fine if one drug has to be country it has to be aspirin but if we can stop aspirin because the patient had bypass before a long time or patient has angioplasty and before six months then at least we can stop both the antiplatelet drugs in the patients who had a recent marker infarction or ptca with stenting especially the drug and leading standing in less than three months then stopping the drugs is inviting the instant thrombosis so where we have just to stop the dual antiplatelet drugs but we should have a bridging with the gb2a3 antibodies uh drugs antiplatelet drugs like tyrophebon or inhibited and products better that we take the help of the cardiologists and the controls the cardiologists in such patients and whenever we use drugs like tear of even or weight we have to have also heparin along with it right if surgery is a plant surgery like as i repeatedly telling the plant surgery if the patient has undergone angioplasty with a des drug elating stand postponed the surgery for six months something which is plant cataract surgery knee replacement surgeries also shoulder replacement surgeries there are also surgeries where definitely cosmetic surgeries should be deferred for at least six months if it is a drug a living standard if it is must we can do it in the three months period of time but with the due precautions and resuming that these drugs in the parable period so is important once the hemostatis is achieved then only we should try to achieve and we start with their spin first and then tica growler is a good drug to start with right because it has got a reversible antiplatelet effect but we can go back to the original patients once the hemorrhage is achieved maybe after the second or third day of the post-operative period provided there are no drains or drains are removed or there is no bleeding if the patient says undergoing spinal anesthesia it's very very important or the epidural is there we make sure that the patient's effect of dual anticipated drugs are gone otherwise the anesthesiologist will have a hard time and there may be spinal hematoma and the patients we may have pain long pain for a long time so it's very important even in the regional anaesthesia that we make sure that the effect of the dual antibody drugs are taken off before we allow the patients to undergo surgery the patient is having pacemaker which is quite common in the euro surgical patient and they ask me whether we can use cautery or not your thoughts see depend definitely when the patient has pacemaker the pacemaker vendor or the cardiologist has to be contacted fast and the surgeon has to be informed about the patient has a pacemaker and the space maker has to be temporarily set off or disconnected if they are using the electrocautery and the cotton should be used for minimum time and again the pacemaker setting has to be done so most of the time the persons who has given the pacemakers that person the technician is always kept in the operation theater all the time actually what i was they do provided services they do provide the services of the settings i have searched that i have found it bipolar you can use but only thing is that both poles should be as far away from the leads as possible as far as the leads from possible and unipolar is stick no and it should be used away but the upper part you cannot use lower parts surgery you can use that is what i heard actually i was not very sure so i asked you now coming to the next i mean next type of patient like a patient who are having uh lung disease like copd asthma and now of course lot of people are obstructively apnea and interstitial lung disease of course is a separate subject it's very difficult to manage those patients so how you will instruct a surgeon or anaesthetist to take care of this patient or what will be your advice in these patients copd assistance amongst all the medical problems the one which i am always afraid is the pulmonary problems especially if they are not controlled right so all hormonal disease definitely are one of the highest post-operative complications and the mortality also in all these are especially if the patient has to undergo general anesthesia because it becomes extremely difficult to control the patient's lung functions and especially patients who are more than 60 years patients who have copd patients who are smokers patients have obstructed sleep apnea we said patients having heart failure or pulmonary hypertensions it's very very important and the surgery like thoracic or upper abdominal surgeries or headache surgery it's definitely a very very tricky situations and you've got to be on toes the anesthesiologist and the critical care space analysis has to be involved in the perioperative management and we need to get the consent due informed consent to the patients and the relatives about the very high chance of post-operative complications and if the patient is a known patient of copd or asthma then their bronchodilator therapy has to be optimized well in advance this should be instructed about the physiotherapy use of incentive spirometry and these are the conditions patients whom we definitely get the pulmonary functions echocardiogram harmonologists and cardiologists reference in advance and get their inputs for the better outcome of the perioperative management and this is one situations where as far as possible we should avoid general anesthesia regarding the smoking people have the impression that if you stop smoking on the previous day it definitely changes no in fact we have seen so many patients who come out with severe rebound tachycardia and hypertension knowledge they are made to stop smoking the previous night the real effect of smoking season comes only if it is done at least one month before the surgery that is where the need for all plant surgeries the patients educations and we must try to make the patient understand that because the smoking there are high chance of post energetic complications arrhythmias the increased need for anesthetic agents and there is a very good two acronyms that i would suggest to remember one is called stop acronym it's a questionnaire only four simple questions whether the patient is snoring patient has tiredness during the day patient has observed apnea or patient having high blood pressure if any of the two are present then the predictive value of obstructive sleep apnea is more than 78 percent and if any of these obstacles sleep neptune is patient the chances of post-operative complications are simply doubled up so you are on toes for these patients as you said absolutely sleep apnea right and similarly we must make the patient understand about another economist called i cough that we how to prescribe incentive spirometry and make the patient use well in advance then patients should know how to do coughing and deep breathing and oral care is equally important and education is equally important and patients should be made ambulatory as early as possible and try to keep the patient's head and elevated because these are the patients who are likely to get the aspirations microaspirations and the post-operative complications so it's very important that we optimize the pulmonary functions and still be prepared for the worst outcomes or the complicated outcomes in all patients who have the problems hemoglobin is nine what should i do so what will be your advice see anemia per se is very well tolerated as far as the surgery is concerned the outcome of the surgery really doesn't make much difference as long as the hemoglobin is more than eight grams the american national blood banks have uh recommended a hemoglobin cutoff of 8 gram for the patients undergoing orthopedic and cardiac surgery but again you have to take the individual call patients who are having the as i said patients already on the dual antiplatelet drugs or patient is a known patient of acid peptic disease or patient head piles or patients who keep getting the blood losses frequently or the type of surgeries that somebody has to go for the major surgery on the vascular bed or the abdominal aneurysm surgeries then i think 80 gram hemoglobin would not be acceptable that at least i would go for the minimum 10 grams of hemoglobin but for most of the surgeries when we don't expect the blood loss 8 grams would be fine what is important is that if the patient has hemoglobin of 8 gram or 7 gram or even 9 gram it is better that if you have got the time to try to find out the cause of anemia cause of anemia because if the patient is a cause something like the blood loss is going on or if the patient has hemolysis right that is something that definitely will go uh will create more problems and the simple investigations of reticulocyte count if we can send a reticulocyte count in patients with anemia at least we can pick up patients who is having some blood loss or patients having the hemolysis right because these two conditions reticulocyte count would always be elevated so it's very important that we find out especially something like sql if the patient is undiagnosed sickle cell anemia he is likely to go into a sickle crisis in a post-operative period so type of enemy also matters not only the degree of anya but otherwise by and large the hemoglobin of 8 gram is recommended by the major bodies as far as the orthopedic or cardiac surgeon is concerned but individual centers they try to keep the hemoglobin more if the blood loss is expected to be on the higher side and if the patient has a good hemoglobin well in advance and is going for a surgery where blood was expected there is a provision of autologous blood uh transmissions this the blood patient's own blood is being collected tapped in advance and the same blood can be injected uh very operatively now the little cutoff for as is given in these slides lately cutoffs for the platelet transfusions are differ from the different types of the procedures that person might want to undergo if the patient is undergoing neurosurgery or head injury it's better that we keep platelet count more than one leg and the anything less we need to give the blood platelet transmissions for epidural catheter transition or removal minimum 50 to 80 000 platelets are required to be there the patients undergoing the lumbar puncture or surgery or vaginal delivery fifty thousands then patients having fever and coil but these days we see patients with dengue right that they have got the coagulopathy and then if they need some emergency surgery they have any secretomy or something at least the blood transfusion should be given if the electrics are less than 20 percent and patients who are going to require multiple blood transplants in a polytrauma or a severe blood loss right it is better that we keep the level threshold of 75 because there is chances of dilutional thrombocytopenia with multiple blood transmission so this is about the anemia and the platelets so coming to the next set of patient patient is supposed on asteroid maybe it is continuously on destroyed or often known so what will be your advice yeah that's a very important questions there are two parts involved in it one is the whether the patient is on a continuous steroids or patient has been on steroid in the past we are afraid of two three things in the when the patient is the problem of steroid comes if the patient is on steroid and that one higher dose suppose somebody is on more than 10 milligram prednisolon or equivalent dosages then the chances of post-operative complications are known right plus patients who are on steroid for a long time their upon chances of the easy bruising then wound healing is a problem and the concurrent other problems but if the patient had history of steroids in the past it is said if the patient has received 7.5 milligram of redness alone or equivalent for three weeks in the past one year right if the patient had received seven point five milligram of red insulin or equivalent for three consecutive weeks in the past one year we anticipate adrenal cortical insufficiency in that patients and we should be giving the stress those of in the form of hydrocortisone 100 milligram time of surgery and maybe another two to three dosages depending on the requirement so that's very important but patients who are suppose already on steroids right we try to make sure that the patient steroid dose can be cut down to less than 10 milligram or patient can be seizure to alternate day because they fare much better as far as the adrenal insufficient concern patients who are on less than five milligram or alternate distributes uh we are not afraid about the adrenal insufficiency chances of infections and the other problems in distributes are always there and we have to be very careful for that and long-term maintenance corticosteroids uh have to be continued if it is required because otherwise the patients might flare up of their original problems if the patient is of slv and if you stop the steroids spacing might flare up and that itself will bring about other problems so we have to balance between the minimum use of steroids and the steroid related complications in the form of stopping the steroid producing insufficiency steroids leading to post-operative complications so coming to the next set of patient who has got altered renal function test so what will you do i think next to pulmonary problems the renal functions are another one which we have got to take it very seriously very vigorously and we should try to find out right the underlying cause of chronic whether it's an acute renal impairment or a chronic kidney disease we should never judge by a single reading of creatinine right we must try to get the egfr and if it is possible to get the patient's previous creatinine report is going to be very useful little doubling of the creatinine or just increasing the creatinine by 0.5 milligram over a few days itself spills doom for the patient so renal functions impairment is another important negative predictor as far as the good outcome of the surgery is concerned so very important we must try to maintain and if required we should get the sonography of the abdomen to find out whether there is any the underlying cause for the chronic kidney disease and very importantly we must try to maintain the volume in the blood pressure in all patients with altered creatinine right uh as i said creatinine varies from person to persons by in the muscle mass so it is better that we include egfr for the assessing the renal functions and patients who are on drugs like syndicators and diuretics must be stopped definitely patients or ac inhibitors the airbase diabetics must be stopped in advance and monitoring of the serum potential is very important we need to get the urea and create into so whether there is an element of pre-renal azotemia then it's better that we give fluids and we will bring up the patient's volume status also and if the patient has persistent hyperkalemia or if the patient is edematous in spite of the good optimum diet therapy it is worthwhile involving nephrologists and getting the pre-operative dialysis one or two setting for a better outcome because these are the difficult situations and it is not possible to manage uh without the help of the nephrologist or dialysis and we must obviously by all means avoid the non-steroidal and implement drugs and the nephrotoxic antibiotics so next set of patients who are having altered liver function yeah generally the liver functions abnormality the significant liver function abnormality are going to come in the way of the surgery are not very common but common right to the common belief it is very important to make sure that if the patient has acute viral hepatitis or acute alcoholic hepatitis and if it's a plant surgery it must be withheld it must be thrilled because they are going to have complications so delay the surgery if there is an acute viral or alcoholic hepatitis if the incidental abnormality of seo to your recipient is in the range of the upper limit of the normal or up to two times i think it's not going to come in the way as long as we get the other two important functions that is the pro thumb in time the pro thumb time is in the normal range uh all is well and we can go ahead with the surgery only the anesthesiologist has to be informed about this so that the choice of anaesthetic agents has to be according to the liver important functions and if the patient is a known patient of chronic liver disease or cirrhosis it is better that we categorize them by these course like the child poop classifications or the newer one is the male score the model for the institutional disease it's very important and again very handy just like the rcri that we talked over the gupta it's available in these smart forms and all that you have to enter are the certain values for childhood we need to add the societies presence of societies or comma or the levels of bilirubin scp bilirubin serum proteins and the prothomine time versus the control patients called automated time and for whales called what we need is an age creatinine and also the bilirubin and probably there is one build ns core where the sodium is added so these are very very important calculators or the risk and stratification tools which will definitely decide whether the patients should undergo and whether he carries the low risk or a high risk and patients with a very high score of say build score of more than 15 it is better we don't go for it there is no point in optimizing by just giving the vitamin k for two or three days and then allow the patients if the patient has acute hepatic in cells like viral hepatitis are called hepatitis it is better than the liver functions return to normal then only subject into the surgery if a patient has corrosion vascular disease or is on d how mars you manage this patient yeah that's uh again we now see so many patients who are undergoing especially the orthopedic surgeries the knee represent all because of their or deformity corrections and the incidental all whether it is appendicitis or diverticulitis or perforation any of these surgeries or the head injuries it's very very important to make again just like steroids you have to be very sure about the status of the patient as far as their collagen underlying collagen this is concerned is the patient is stable or patient has acute flare that's very important and first thing all patients with collagen diseases they have increased chance of very operative infections as long as their orthotic surgeries are concerned these have been proved an innumerable study so they carry a very high risk of periprosthetic complications uh joint replacement surgeries and if the patient is on tmrds this is modifying anti-romantic drugs whether it's a methotrexate or lepromite or hcqs or cellulose of iron uh they can be continued without interruptions because on one side we are worried about the immunosuppressants and the other side we are worried about the flares but immunosuppression is not a big issue as long as the non-biological dmrd's are concerned but for biological dmrs that's a real threat real problems and there are guidelines we suggest that the depending on what biologic the patient is on we should have the delay of the surgery right if the patient is on something like weekly international that is anti-tnf right then it is better that we wait for at least one week if the patient was victimized the patient has taken monday uh the last dose then it's right that you do it on the next monday only this surgery so allow one week if the patient is on drugs which are one month apart right like at aluminum web and it's at two weeks at eleven it's two weeks so for wait for two weeks and on the third week only allow the surgery right so likewise that is what is called the withheld close to the one losing cycle if the cycle is every two weeks three weeks depending on that the next week only the patient should be allowed to undergo surgery for a plant surgery because biologics definitely carry a very high risk of post-operative infections if the patient is on drugs these days we use so many tyrosine kinase inhibitors or tinibs right which is very tiny or all the drugs then it is better that you wait for at least one week so for all these jack two inhibitors one week for other biologics depending on their how frequently they are being given depending on drugs like rituximab we give once in six months and they say if it's a plant surgery definitely if it can be avoided for six months avoid six months or it took similar so these are the recommendations by the uh guidelines that look at the dmard the patient is taking or the biologics that the patient is taking and but for the routine methotrexate at all you don't have to wait for them steroids if the patient is on as i said also earlier if the patient is on dose of 10 milligram or less probably we are better off because that means the disease is under control and the chances of post-operative infections are much less but anybody who is on steroids prednisone of 10 milligram or more the documented infection rate is much higher so you have to be very careful about so a patient is has come for surgery [Music] up in the last couple of days definitely we can stop for at least one or two cycles definitely how how will you proceed for surgery in a thyroid patient first question second question is if the patient is diagnosed first time with the hygienism so how long will you wait for a surgery if the surgery is little urgent thyroid patients with the thyroid disease are definitely carrying some complications especially if it is a hypothyroidism then the post-operative hypotensions delayed recovery from the anesthesia and the infections are very common and the hypertension blood pressure fluctuations for thyroid toxicosis and the fear of getting into thyroid stomach is one of the most important and the arrhythmias and the again blood pressure fluctuation so if the patient has a severe thyroid disorder or first time diagnose it is better that the surgery is different if the thyroid functions are visibly controlled but a minor elevations right you say 80 definitely i would not allow them to go for surgery because we expect the problems and it's usually uh you need one and a half to two six to eight weeks to con bring it to the optimum levels we can do it right but if the tsa is supposed eight or nine i i don't think we should wait for the uh defer the surgery if it is required because then it's not going we don't expect them to have any problems because of the mild uh uh hypothyroidism uncorrected hypothyroidism hydraulics is again we have got to control it and then only allow the patients to undergo surgery if what is your prescription for antibiotics for pre-operative surgical prophylaxis therefore your step curriculum is negative and entropy these are the guidelines by the uh all the idsa and all these uh or body so sephazoline still remains the number one drug of choice right or say ferroxine if we feel that in our setup in the operation thetas it's also not only always gram positive per gram negative also calm all these cephalins are not available many times so either sephorazole in two grams or safer exam 1.5 gram or if the patient has a sensitivity of cephalosporins or penicillins maybe clindamycins uh otherwise amping salvation three grams or when a suspicion of mrsa or patient who had had infections in the recent past or decent hospitalization or multiple surgeries in the recent time and now we may suspect an mrs then vancomycins all these injectable forms should be given at least minimum 30 minutes before the time of incision it's very very important that we complete the infusion before 30 minutes now except for vancomycin all other can be given in half an hour but for vancomycin we need one hour so maybe the one vancomycin infusion should be started one and half hours before the stipulated incision time or surgery time unfortunately many times the orders are given that the before the patient is shifted from the uh war to the operation theta the antibiotics are given that is not the right way that doesn't cover cover the patients as far as the pre-surgical profile access is concerned and as we say profile axis it should be less than 24 hours most often it is the one dose that is enough if the surgery time is more than six hours maybe we give another dose after six hours and bypass is the only surgery where we give profile axis the same dose it is for every six hours up to 48 hours so this is about the surgical profile axis and even i see some of the dental surgeons also in this crowd even for the dental procedures we use because they are the most common organisms in the overall cavity step two was very dance right and so the same antibiotics either cephazolina cepheroxine or clindamycin or uh ambicillin sulbactem would suffice single dose is enough in most of the conditions so what is your practice about the dvd processes yeah or in some syllabuses see dvt earlier we used to think that the different thrombosis or pulmonary embolism is not very common in indian patients but now we see again again so many patients right who end up with the post-operative complications and so i would better say that dvd prophylaxis definitely has a role especially in patients who are elderly patients patients who are the conditions like hypertension or diabetes or persons who are immobile or patients or elderly patients or major surgeries patients who are going to be in the bed for a long time deal by mouth for a long time orthopedic surgeries where they are also not going to be able to immediately so what is important is we know that thromboembolisms require three important things the blood the type of blood the blood flow and the blood vessel wall so if based on this any of these situations or predisposing conditions a patient is a known patient of cancers or on cancer therapy or patient had a history of ventricular means venous thromboembolisms or a patient is a known person of inflammatory bowel disease or a female patient some oc pills or patients having history of smoking patient pregnant or polycythemia they are all hypercoagulable states and likely to increase the chance of different thrombosis patients on antiphospholipid is a known patient of antiphospholipids and also are hypercoagulable states then venous disease because of the heart failure or immobility or the old age and varicose veins these are all the venous stages which again increase the chance of venous thrombosis and patient who had a recent surgery or patient who had severe infections and in this we also include there is some covered infections i think we have got to go for the dvd profile axis i would go for dvd profile axis at least for a period of a post operative period of about one to two weeks and follow up the patients and patients suppose the orthopedic surgeons whom we uh involved in pests right particularly patients who to undergo the heap or acetabulum or the neck surgeries will definitely go for the d dimer as well as the venus doppler studies in advance and will definitely start the dvd profile axis if not pre-operatively immediately after post-operative period we can start with the low molecular tapering or unfraction our our newer oral antivirus they are all very good very safe and they should be started at least once the hemostasis is achieved or six hours after the operations we should put them on the dvd profile axis we sensored a very high risk we may even start 24 hours before uh the procedures and at least make sure that the low molecular tapering is stopped before 12 hours and the hippie really stopped six hours before the operations [Music] uh so a lot of patients especially elderly patients who undergo surgery lined up with the delivery or post of psychosis and very difficult to manage especially [Music] so how do you manage such patients i think that's very very important issue and it is multi-factorial even in one paper particular patient also there can be more than one factor operating any change in the functional behavior we have got to find out the cause whether it's an as simple as the distended bladder or a pain or uncomfortable bed or icu psychosis or electrolyte disturbances or hypoxia hypoglycemia it could be any of this very important that we try to find out the cause of the altered behavior right it could be as i said uncontrolled pain abnormal electrolytes hypoxia hypoglycemia infections fecal impactions also that could be the patients are not used to pass by stool in the bed and all these things and the drugs any of the drugs can cause psychosis in the post-operative particularly when you are giving drugs which can produce something like serotonin syndrome it's very important that most of our patients receive some analgesics in the form of tramadol and antimatic routinely like undone central and maybe that on top of it here is a drug like linus only so we are sure to get serotonin syndrome so these things we have to keep in mind as a possibility that if the patient is agitated and if you don't find any of the cause which could be related to his conditions or maybe there is no acute blood loss or something i would definitely keep in mind and especially in patients with the heap surgeries right the acute delirium definitely carries a very high risk post-operative complication so you are on toes for this and if we find out the correctable cause we should go for it if patient is unmanageable conventionally we have been using the haloperidol injectable forms but orally if we have to give it we can use polyzepine or respiratory but very importantly correct the preceding factors then hyponatrium is one of the very important factor we have seen that patients and next day or third only the patients behave abnormally and we get the sodium of 115 or 120 something like that [Music] uh i did not miss bleeding risk he is generally not there unless the patient is a see first thing is very important the history we have to ask the patients about the history of any previous bleeding spontaneous building or at the time of surgery there was the laurent bleeding or any of the blood reports which indicate any of the abnormality like thrombocytopenia or we need to get the patient's pta ptt they are very important investigations to look for and whether there is any family history of breeding also is important if there are no such histories then i don't think that we should be running the test for the bleeding tendency because i don't think it's going to be a cost effective but we need to basic what we need is a platelet counts and pt and aptt gone out of time when we go for reading time floating time they are very crude test it's better that we do pta pdt platelets and cbc and that would suffice to pick up and significant [Music] head toward neurosurgery and we waited for five days uh we got all these tests uh normal and vision was operated and he started losing now before taking for second surgery uh we basically got the btct done and it was pretty long so basically what i feel is that in patients who are on like a spring fabric if you have to undergo some surgeries like neurosurgery then this ptpt platelet would not function and unfortunately there are no proper tests available to assess the painted function so here there is some role of vtcp altered function test and alternate renal function test they can also cause bleeding right that's true but one is that if the patient is undergoing intra-abdominal surgery definitely gram negative coverage is need to be done agree fully ah then if the patient is undergoing uh for c overreal surgery definitely as such all patients who are having cancers or on cancer chemotherapy definitely needed dvt prophylaxis and we would go for it if then if the patient is already on anticoagulants right this there's so many questions are on antigone that it's better that we get this course called char s2 scores then that each letter stands for an abnormality and everything is one score c for chf h for h hypertension a for age more than 75 d for diabetes and if the patient is stroke or tiaa is two points so if the chart score charts s to score is between 0 and 4 and patient is already in anticoagulant then we can safely stop the oral anticoagulants right five days before if we use vitamin k intervals like warfarin that we stop five days before and get the patients inr the patients who are on anticoagulant the reasonable iron before allowing the surgery is 1.6 so if the surgery if the patient's iron is less than 1.6 we can go for the surgery if the charge score is between 0 and 4 but if the scar is between 5 and six that means the chances of patients having the problems are more then it is better that we stop warfarin but two days after stopping the warfarin we start the epa or low molecular heparin and we continue to measure the inr and as uh earlier also i said that we stopped the lower reverend before 24 hours and the if you are using hipaa infusion for at least six hours so it's very important and these are the subsets of patients like patients who have chronic atrial fibrillation patients who undergo prosthetic surgery or patient who had a past history of venous thrombose embolisms they are the ones who are going to be all anticoagulants and that is where we need to go for evaluate them before allowing for the surgery with the charts for charts as to score the patient who has recovered from kobe 19 he had a severe coverage disease and say around three to four four months back now he has come for an active surgery what will be your approach uh i think that's very very important and now we do get many reports coming up with the what is the status of covet first and foremost thing we have to have detail history about what was his covet illness whether it was mild moderate severe whether he was hospitalized with their undergone the he had went on ventilator what was his day dimer whether he received anti dvd profile axis or whether he received the nt oral anti-governments and all but the largest study is over running over the multiple countries right had a report in october 2020 over one like 40 000 patients study in which more than 3100 patients had kov at the time of undergoing the surgery and what they come out the important outcome was that if surgery was delayed by at least seven weeks if a plant surgery was delayed by seven weeks the chances of complications with the patient who did not have covet are same but less than that definitely there is a graded risk of more nearer to the covet infections and the time of surgery so that is one uh study i could pick up from this review of literature so better if it's a before surgery surgery which is planned differ by at least seven weeks to minimize the chance of ovid related outcome but kovi definitely is a very unpredictable disease and we know it's a kind of thrombo inflammations and definitely i'll go for dvd prophylaxis in all patients who is undergoing surgery after covering infections and we have to also make sure that whether he is vaccinated or not vaccinated so would you like to do any additional investigations in these pressures like definitely that kovid patients have we see that they have the long covet in the form of the some interstitial lung disease or the breathlessness issues or even myocardial involvement so i definitely go for echocardiogram cardiologist concurrence as well as the pulmonologist concurrence and maybe if he had the earlier hr ct i would also repeat the hrct thorax also before making them for a major search

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A physician has an important role to play in most surgical procedures. By optimizing patient's pre-existing medical condition, peri and post operative complications can be significantly reduced. Let's brush up on some concepts like what all investigations to be done, any calculator to be used to stratify risk, which patients are at high risk and Mx of some common medical conditions like hypertension, diabetes, thyroid disorders, anemia and more such.

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