What blood thinners would you stop?
Clopidogrel: 1 week prior (may not have to if risk too great)
Aspirin: No need to stop unless high bleeding risk
Warfarin: 1 week prior and cover with heparin
Blood pressure medications?
Do not take ‘ramipril, lisinopril, losartan, candesartan’ on day
Do not take amlodipine, nifedipine, diltiazem on day
Thiazide diuretics: stop day before
These are fine on the day: atenolol, bisoprolol, propranolol
Inhalers
they’re fine
Diabetes medications?
Metformin: omit on day and replace with insulin
Insulin: omit short acting on the day, continue long acting
Thyroxine?
continue
NSAIDS?
ibuprofen, diclofenac (short acting): discontinue 2-3 days prior
Narproxen, nabumetone (long acting): discontinue 1 week before
OCP?
HRT?
stop at least 4 weeks prior to surgery: DVT risk 5x
stop 4 weeks: DVT risk 1.5 x
Steroids?
do not discontinue, could lead to addisonian crisis
What drugs would you consider for surgery?
Anti-emetics: anxiety: benzodiazepines analgesia (discussed later) NSAIDs – balance against stroke risk Opioids – balance against vomiting risk Antivagal effects (common response to surgery) – antimuscarinics
How is VTE prevented prior to surgery?
VTE prophylaxis has been shown to reduce the incidence of DVT. It includes mechanical
methods (such as anti-embolism stockings and intermittent pneumatic compression
devices) and pharmacological treatments (such as heparin and other anticoagulant drugs
VTE assessment:
Mobility
ENSURE THAT risk factors – particularly any recent operations or a history of very POOR
MOBILITY in the 2-3 weeks before ADMISSION ARE carefully assessed before assuming
that no additional risks exists because of good current mobility
Thrombosis risk:
- cancer
-over 60
-dehydrated
-obesity
-inherited or acquired (thrombophilia)
-significant medical co-morbitities
-personal or past-degree relative with VTE
-oral contraceptive or HRT
-varicose veins with phlebitis
-given birth in last 6 weeks
-hip/knee replacement or hip fracture in last month
-significantly reduced mobility for 3 days or more in hospital
-Total anaesthetic + surgical time >90 minutes?
-Surgery involving pelvis or lower limb with a total
anaesthetic + surgical time >60 minutes
-Acute surgical admission with inflammatory or intraabdominal conditional
-Surgery with significant reduction in mobility
-Consider additional risk in inpatients in the first three
months of initiation with anti-psychotics4
(particularly
quetiapine and haloperidol)
Bleeding risk: antiplatelets? active or acquired bleeding? high blood pressure thrombocytopaenia recent acute stroke recent surgery with high risk of bleeding untreated inherited blood disorders
