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cessation , lifestyle modification , reduction in alcohol intake , optimal nutrition and weight management .
Optimising pre-existing anaemia It has been estimated that approximately 40 % of patients presenting for surgery are anaemic . 20 Preoperative anaemia is associated with significantly higher rates of morbidity and mortality and increased need for blood transfusion .
Patients undergoing major surgery ( defined as blood loss > 500ml expected or possible ) should be optimised if their haemoglobin concentration is less than 130g / l on screening .
Detection of pre-operative anaemia should be carried out as soon as possible , at least 14 days before elective surgery . 21
Figure 2 suggests a treatment algorithm for different types of anaemia from diagnosis to surgery based on an international consensus statement as described by Munoz et al . 22
Treatment of iron deficiency anaemia should be carried out with iron supplementation , and there is good evidence that this results in higher haemoglobin concentrations , lower transfusion rates and better quality of life . 21 When the interval between investigation and surgery is sufficient (> 6 weeks ), oral iron treatment may be considered . 21 Pharmacists can play a key role in optimising preoperative anaemia by identifying affected patients in the first instance , interpreting laboratory results and working with the wider multi-disciplinary team to ensure a management plan is in place to correct the anaemia .
Optimising anticoagulation control An increasing number of patients considered for surgery are on anticoagulants hence it is important that these are managed appropriately in the peri-operative period to reduce the incidence of thrombotic events . The British Society of Haematology has published guidelines on the peri-operative management of anticoagulation . 23 Pharmacists can support pre-assessment clinics by ensuring these patients have an appropriate management plan in place .
For those patients on warfarin , this should be stopped for five days prior to surgery and bridgingdose heparin should be considered in high-risk patients , with the last dose at least 24 hours prior to surgery for those on a once-daily regimen .
For patients on direct oral anticoagulants , the peri-operative management approach is based
on an approximate calculation of the half-life of the drug and renal function . This is combined with consideration of the bleeding risk of the proposed procedure and a clinical evaluation of the patient ’ s individual risk factors for bleeding and thrombosis . Where available , local guidelines should be consulted and advise sought from specialist haematology teams in complex patients .
Conclusion This article summarises some of the strategies that can be employed in this crucial pre-operative period to optimise patients for surgery to achieve the best possible patient outcomes . It is recognised that the surgery waiting lists in the UK already under pressure have been further increased by the COVID-19 pandemic . These waiting lists provide a unique opportunity for multidisciplinary teams to work collaboratively , further supporting the concept of enhanced recovery .
Key points
• Pharmacists can play a crucial role in enhanced recovery pathways in optimising patients comorbidities for surgery as medicine experts .
• Shared decision making with a patientcentred approach is key to success of these pathways .
• The value of pharmacists within multidisciplinary teams should not be under recognised .
• The opportunity to optimise patients should be seen as for life , not just for surgery .
• It is essential that preparation and assessment starts as early as possible in the patient ’ s surgical journey .
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expert review . Anaesthesia 2019 ; 74:43 – 8 . 15 Lee AHY et al . Pre-operative optimisation for chronic obstructive pulmonary disease : a narrative review . Anaesthesia 2021 ; 76 ( 5 ): 681 – 94 . 16 National Institute for Health and Care Excellence . Chronic obstructive pulmonary disease in over 16s : diagnosis and management . Guideline NG115 . www . nice . org . uk / guidance / ng115 ( accessed Sept 2021 ). 17 Levy N , Dhatariya K . Preoperative optimisation of the surgical patient with diagnosed and undiagnosed diabetes : a practical review . Anaesthesia 2019 ; 74 ( Suppl 1 ): 58 – 66 . 18 Barker P et al . Perioperative management of the surgical patient with diabetes . Anaesthesia 2015 ; 70:1427 – 40 . 19 Centre for Peri-operative Care . Peri-operative care of people with diabetes undergoing
surgery 2021 . https :// cpoc . org . uk / guidelines-resourcesguidelines-resources / guidelinediabetes ( accessed Sept 2021 ). 20 Munting KE , Klein AA . Optimisation of pre-operative anaemia in patients before elective major surgery – why , who , when and how ? Anaesthesia 2019 ; 74:49 – 57 . 21 National Institute for Health and Care Excellence . Blood transfusion . Quality standard ( QS138 ). www . nice . org . uk / guidance / qs138 ( accessed Sept 2021 ). 22 Muñoz M et al . International consensus statement on the peri-operative management of anaemia and iron deficiency . Anaesthesia 2017 ; 72 ( 2 ): 233 – 47 . 23 Keeling D , Tait RC , Watson H . British Committee of Standards for Haematology . Peri-operative management of anticoagulation and antiplatelet therapy . Br J Haematol 2016 ; 175 ( 4 ): 602 – 13 .
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