Heme Assessment Flashcards
What should be your preoperative considerations for a patient with Sickle Cell Disease?
Disease versus Trait
- TRAIT: don’t go into crisis→ no anesthesia considerations
- Disease: thinking about all those ischemic areas that may be damaged
High risk predictors of perioperative vasooclusion complication
- Infection
- Advanced Age
- Recent hospitalizations
- (4). Level of dehydration
Preoperative assessment should focus on identification of organ dysfunction and acute exacerbations
- Neuro: Stroke- residual deficits?
- Pulmonary: Pulmonary hypertension/pulmonary infarctions (pulmonary components)
- do they use O2 at night or during the day?
- CV: Heart failure
- Renal insufficiency- are they on HD? Do they urinate a lot because they’ve lost the ability to concentrate urine?
- Dehydration (loss of renal concentration ability)
- Splenomegaly- infected now?
What are some diagnostics you would obtain preoperatively for a sickle cell disease patient?
- CBC **
- Hct- perioperative transfusion may be necessary. Consult with hematologist.
- BUN, Cr→ kidney insuff.
- EKG
- CXR
- ECHO and ABG as indicated
- Pulse ox
- +/- invasive monitors
What are some preoperative considerations of a patient with Aplastic Anemia?
- CBC!
- WBC differential- help Infectious Disease (ID) determine what ABX needed for coverage
- Coags!
- need labs → want to look at their WBCs too
- May need preop infusions of RBC/Platelets/Coags etc (usually will get them to be optimized b4 sx)-
- Type and crossmatch concerns
- ncreased difficulty with multiple transfusions. Need T&C early on
- Baseline medications?
- Steroids?
- Airway hemorrhage possible with DVL
- Preoperative airway plans? Dep on your comfort lvl & how good you are at DL vs glidescope etc
- Reverse isolation
- Prophylactic antibiotics based on CBC studies (degree of neutropenia)
- Bypass preop, take from room to OR
- Monitors
- +/- invasive monitors (a. line); based on CBC and surgical risk
- almost always invasive monitors will be necessary.
- Anticipate taking out their A line if not going to ICU. → hold for 20 minutes
- Regional? Dep on coag status, plt lvls etc
Describe considerations for perioperative transfusion
C- Coexisting conditions/comorbidities
A- Anticipated blood loss
R- Risk vs benefit
D- degree of anemia
What are some preoperative considerations of a patient with Thalassemia?
- Potential for difficult airway secondary to maxillary deformities
- frontal head and maxillary growth
- FIBEROPTIC intubation
- frontal head and maxillary growth
- Cardiac arrhythmias due to high CO heart failure
- Echo, EKG may be necessary
- Coagulopathy
- Regional?
- Coags – if major sx
- Monitoring
- Routine
- +/- invasive monitors with presence of heart failure or invasive sx
- Check electrolytes
- CBC
Describe some findings of a physical exam for a patient with anemia
- pallor
- high HR
- palpitations
- murmurs
- dyspnea
- fatigue
- hepatosplenomegaly
What is a TEG? Information you can obtain from it? Treatment considerations?
Thromboelastography → provides real time visual representation of blood coagulation and fibrinolysis (clotting and breakdown of clot)
- R time - time to start clot
- *Coag factors
- Low (Anticoagulants) → FFP
- K time- time for fixed strength
- *fibrinogen
- Tx: Cryo
- Alpha angle- speed of fibrin accumulation
- *fibrinogen
- Tx: Cryo
- Max amplitude- highest amp of TEG
- *plts
- tx: plts, cryo, DDAVP
- Lysis at 30 - clot breakdown
- *excessive clotting
- Tx: TXA, Amicar
What would you enquire to a patient with a coagulopathy disorder?
- M- medications and herbals
- (g’s and fish oil)
- S. - steroids → duration of treatment
- C.- coexisting conditions (renal/liver ds, malnutrition, cancer, recent drug exposure)
- P.- petechiae → bruising, hematomas, jaundice, and frank bleeding
- F- family history
- E- episodes of bleeding/history of transfusions) → recent changes?
- D- diagnosis (hemophilia, vWD, thrombocytopenia, polycythemia)
Your patient has hemophilia. What are some preoperative considerations for your patient?
- History of unexplained bleeding
- spontaneous hemorrhage involving joints and deep muscles
- Coagulation studies:
- anticipate prolonged aPTT, normal PT
- Consult hematologist
- Detailed plan for monitoring and replacement of factors
Your patient has vWF deficiency. What are some preoperative considerations for your patient?
- History of easy bruising, mucosal bleeding v comm, epistaxis, menorrhagia, spontaneous hemorrhage (type III)
- Coagulation studies:
- anticipate prolonged bleeding time, and aPTT, RPFA bc bleeding time not specific
- Often factor VIII is low resulting in prolonged aPTT
- Depending on type and severity consult hematologist (type 3 consult)
- Tx: Desmopressin (in type 1 or 2), factor VIII or cryoprecipitate may be required preop
Your patient has polycythemia. What are some preoperative considerations for your patient?
- Polycythemia HCT >54%; increase viscocsity increases r/f clots
- Increased r/f thrombosis and cardiac disease (MI, HF, recent hx DVT or recent infactions)
- Focus on pulm and CV system
- Cyanosis, clubbing, wheezing, murmurs, exercise tolerance
- Diagnostic studies should include:
- Pulse ox
- EKG
- CBC
- ABG
- CXR (if hgb is excessive)
- Consult hematology and potentially postpone elective surgery
Which patients would be at an increased risk for a thromboembolic disorder and preoperative considerations for that patient?
- Hereditary hypercoagulable states (antithrombin III, protein C or S deficiencies)
- Pregnancy
- obesity
- Cancer
- Multiple episodes of past thromboembolisms
- Atrial fibrillation
- Mechanical heart valves
- Inflammation associated w/ sx can increase risk of blood clots on its own
- Careful history focusing on prior thrombotic events, family history and concurrent drug therapies; random screening is not beneficial
Your patient is on Coumadin. What are some preoperative considerations you have for your patient?
- Inhibits vit k dependent clotting factors (II, VII, IX, X)
- Minor procedures → do NOT require d/c
- Dental, endoscopic, cataract, superficial operations
- Other more invasive procedures require withholding Coumadin 4-5 days preoperatively
- Monitor PT/INR - Get 3 days prior and day of sx (PT would be above 10-14 sec (Normal value))
- INR < 1.5 -considered safe for surgical procedures/neuraxial blockade
- Consult hematologist, cardiologist or treating physician concerning need for bridging treatment with heparin
- Reversal with vitamin K, 4-factor PCCs, FFP
- FFP- emergent reversal
- Vit K- 12-24 hrs to start working
- PCC (prothrombin complex concentrate)
Your patient is on Heparin. What are some preoperative considerations you have for your patient?
- Discontinue:
- surgical procedures: 6 hours before
- neuraxial block placement: 6-8 hours before
- Wait at least 1 hour after block to give/restart
- Monitor aPTT/ACT
- Expect your aPTT > 25-35 seconds and ACT > 90-120 sec
- Reverse with protamine if required
Your patient is on LMWH. What are some preoperative considerations you have for your patient?
- Therapeutic: hold 24 hours preoperatively for surgical and neuraxial block placement
- Prophylactic: hold 12 hours preoperatively for surgical and neuraxial block placement
- Subsequent dose of LMWH must occur > 2 hours after neuraxial block
- Monitoring is rarely required
- PT and aPTT normal
- Evaluate anti-factor Xa activity if required
- If emergent reversal is required- protamine is only partially effective
