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Flashcards in 7 Surgery - NOACs Deck (44):
1

Disadvantages of NOACs

-Potential interactions?
-BLEEDING

-Other s/e: GI upset/ abonormal LFT

-Lack of optimal revering agent
-Lack of data in preg/breast feeding/paeds

2

Caution NOAC with what
-CrCL?
-LFTs

CrCL 2x ULN

3

Is there are NOAC reersal agent in the pipeline?

Idarucizumab in phase 1

4

Emergency surgery protocol on NOAC

1. Stop NOAC - document last dose
2. Contact haem/surg/anaewthetist
3. APTT, PT, Fibrinogen, FBC, renal function, (+/- haemoclot TT).

If normal - no effect present

If prolonged - effect may be present

4. Maintain BP and urine output
5. Consider oral charcol if

5

Options of emergency surgery on NOAC.

Delay surgery?

delay 4-12h
consider haemodyalysis?
consider beriplex

if immediate surgery give beriplex IV bolus (10-15mins)

6

Elective surgery with NOACs - when to stop Dibigatran?

Non-major surgery
36hours before
(or 2-3 days before if reduce CrCl)

Major surgery
2 days before (or 3-5 days if reduced CrCl)

7

Elective surgery with NOACs- when to stop apixiban

Non-major surgery: miss morning of surgery

Major surgery: 2 days before

8

Elective surgery with NOACs- when to stop apixiban

Non-major surgery: miss morning of surgery

Major surgery: 2 days before

9

When to stop antiplates - Aspirin

continue unless v high bleed risk then stop 7 days pre-op.

Stop for primary prevention.

10

When to stop antiplatlets - Clopidogrel/pras/ticagrelor

Stop 7 days pre-op. Substitute with aspirin if posstible.

DO NOT STOP IF RISK OF CORONARY STENT CLOT.

11

When to stop dipydamole

is used alone continue, if in combination with aspirin stop the day before surgery

12

When to start anticoagulants after surgery?

morning after

13

When to start NOACs after surgery?

24-48h post op. Cover with LMWH until started but no need to overlap

14

why do we continue most cardiac medication through surgery?

Surgery increases HR and BP.
Always continue betablockers.

Some trusts stop ACE/ARB (hypotension)

15

Steroid use in minor surgery?

Usual steroid dose morning of surgery (or 25-50mg HC IV on induction)

Recommence usual oral dose after

16

Steroid use in moderate/major surgery

This is in the BNF

Must compensate for pituitary-adrenal supression from oral steroids and natural response to stress impaired

Steroid history is important - patients on over 10mg a day within 3 months of surgery

17

Steroid use in moderate/major surgery

This is in the BNF

Must compensate for pituitary-adrenal supression from oral steroids and natural response to stress impaired

Steroid history is important - patients on over 10mg a day within 3 months of surgery

18

when should diabetic pt be operated on?

1st on the list to min starvation time

19

when to stop sulphonyl ureas?

omit on day of surgery

20

when to stop metfomin?

take as normal

21

when to stop DPPIVi / GLP-1

omit on day of surgery

22

when to stop acarbose / neglatinide

omit on day of surgery if NBM

give morning dose if eating and op is in afternoon

23

when to reintroduce diabetic meds?

when oral intake is resumed

24

what to do with long acting insulin during surgery

continue

25

what to do with biphasic insulin during surgery

half the am dose

26

what do do with short/rapid acting insulin in surgery

omit am and lunch doses

27

When is a VRiii indicated in surgery? (2)

More than one meal missed
or
Uncontrolerble hyperglycemia in patient missing one meal only

28

All antidiabetic meds here are based on how many meals being missed for surgery?

just 1

29

Aim for BG during surgery

6-10mmol/l (accept 4-12)

30

Diabetes surgery - what is given?

2 lines through a venflon

1: 50units actrapid in 50ml saline
2: 500ml 5% dextrose over 5hours

31

Diabetes surgery - what is given?

2 lines through a venflon

1: 50units actrapid in 50ml saline
2: 500ml 5% dextrose over 5hours

32

Risk associated with POP during surgery?

COC?

POP - NO RISK

COC - 3x risk

33

When to stop COC?

4-6 weeks before - consider the risks of stopping!

Emergency surgery - give thrombopropylaxis

34

When to stop COC?

4-6 weeks before - consider the risks of stopping!

Emergency surgery - give thrombopropylaxis

35

Tamoxifen risk?

Risk of VTE?
weigh up with risk of stopping treatment.

Discuss with oncology.
Consider stopping 3 weeks before and after.

36

Risks with MAOI?
2 e.g.

potentially fatal drug interactions
-analgesics - tramadol increases seratonergic activity leading to CNS tox/convulsions
-sympathomimetics- risk of hypertensive crisis

37

What do with MAOI before surgery?

Consult prescriber and reduce to stop 2 weeks before

Caution with anesthesia if not stopped

38

What do with MAOI before surgery?

Consult prescriber and reduce to stop 2 weeks before

Caution with anesthesia if not stopped

39

Risk associated with lithium? (3)

Narrow theraputic range
fluid imbalance can precipitate tox
rennally excreted

40

Should Li be stopped?

Preferably stop 1-2 days before

41

If Li is continued: (3)

Monitor fluids
Avoid NSAIDs
Monitor levels (0.4-1mmol/l)

42

Continue PD meds?

CONTINUATION IS ESSENTIAL

consider alternative routes if NBM/not absorbing
(rotigatine patch/tweak timings)

43

Continue anticonvulsants?

CONTINUATION IS ESSENTIAL

consider alternative route (IV/repository) if not absorbing/NBM

44

Is stopping or not black an white?

No - consider risks of stopping/continuation in each case