Risk Assessment

1. Surgery-specific Risk assessment

Bleeding Risk

2. Patient-specific Risk

1. Cardiac: https://www.mdcalc.com/calc/1739/revised-cardiac-risk-index-pre-operative-risk
2. Pulmonary: https://linkinghub.elsevier.com/retrieve/pii/S1932-2275(15)00111-1
3. Overall: ACS Surgical Risk Assessment
4. Functional: METS

Risk optimization (elective surgery)

1. Bleeding Risk

• Anti-Platelet → in general, what five days ahead; Resume 24 to 48 hours.

  	Hold	Restart (post-op)
  ‣	4-7 days (continued for CABG)	< 48 hr
  ‣	3-5 days	< 24hr, +/- loading dose
  ‣	5 days	< 24hr, +/- loading dose
  ‣	7 days	< 24hr, +/- loading dose

• Anti-Coagulant

  • Thrombosis Canada Anti-Coagulant Stopping Algorithm

  	Situation	Hold on which day	Restart (< x hr post-op)
  ‣	Low risk of bleeding	-1 day (x2 for renal dysfunction)	< 24 hr (POD1)
  ‣	High risk of bleeding	-2 days (x2 for renal dysfunction)	< 48 hr (POD2)
  ‣ (VKA)	Low risk condition	-5 days-→ -1 day check INR, ‣ if INR > 1.5	< 24 hr (POD1)
  Warfarin → Bridging with LMWH or ‣	High risk condition (valvular AF, mechanical valve, etc.)	-5 days stop warfarin → -3 days start LMWH → -1 day check INR + 1/2 dose LMWH	< 24 hr (POD1)

  72 hr (cardiac surgery) |

  

2. Wound Healing Risk

• Minimize risk of wound-healing complication
  • High Protein Diet (1.5 g per kg)
  • Smoking cessation Therapy
  • Optimize Blood Sugar