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

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

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

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

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

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)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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

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

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

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

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.

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

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