Hematologic disorders are diseases of circulating blood cells and plasma proteins that play a role in oxygen delivery, inflammation, infection control, hemostasis, and thrombosis. Given that surgery can result in bleeding and induce hemostatic changes that promote thrombosis, it is not surprising that patients with hematologic disorders present serious preoperative management challenges. The ability of hospitalists to manage diseases associated with blood disorders, and hemostatic and thrombotic risks associated with surgery is vital to the welfare of these patients. This chapter will discuss preoperative assessment of patients with hematologic disorders, and review the risk of perioperative hematologic complications and specific management strategies to reduce perioperative risks in this vulnerable patient population.
PREOPERATIVE ASSESSMENT OF PATIENTS WITH HEMATOLOGIC DISORDERS
HISTORY AND PHYSICAL EXAMINATION
The most important aspect in the preoperative assessment of patients with a hematologic disorder is a thorough history. This is especially true for patients with hemostatic disorders (Table 54-1). Though the patient may have a known hemostatic diagnosis, the clinical phenotype of these patients may vary considerably. Occasionally, a patient may report an unexpected personal and/or family history of bleeding or thrombosis, or a hematologic diagnosis as a child with no subsequent follow-up. Depending on the severity of the presumed diagnosis, these subjective accounts may need to be confirmed objectively. The physical examination is rarely helpful in such situations. However, the presence of petechiae, purpura, ecchymoses, jaundice, ascites, and splenomegaly may alert one to the presence of potential hematologic disorder.
TABLE 54-1Recommended Questions to Ask in Patients with Known or Suspected Hemostatic Disorders ||Download (.pdf) TABLE 54-1 Recommended Questions to Ask in Patients with Known or Suspected Hemostatic Disorders
Have you or anyone in your family ever been labeled a “bleeder”? Has someone in the family ever experienced abnormal bleeding?
Have you ever bled with surgery or following childbirth? What surgical procedures have you had, including major surgery, minor surgery, biopsies, and dental extractions?
Did a surgeon or dentist ever have to re-explore the wound site or did you ever have to return to the operative suite for hemorrhagic control?
Have you ever had excessive menstrual periods? How long do your periods last? How many pads or tampons are needed each day? Have you ever required iron supplementation for anemia due to a menstrual blood loss?
Do you bruise excessively? Are these bruises multiple? Are they confined only to the outer thighs or other areas that are subject to trauma? Are any of these bruises palpable (ie, are they true hematomas) or are they level with the surface of the skin?
Do you have nosebleeds now or was there ever a time in your life when you did have spontaneous nosebleeds?
Have you ever required a blood or plasma transfusion and, if so, why?
Have you ever bruised or experienced hemorrhage following trauma, ...