Perioperation

Question 1

in general should medicines (that cause withdrawal syndromes perioperatively) be continued or stopped

Answer 1

continued

Question 2

generally should non essential medicines that increase surgical risk before surgery be continued or stopped

Answer 2

stopped

Question 3

antiplatelets for primary prevention should be stopped X days before surgery and why

Answer 3

7, to reduce bleeding complications

Question 4

in most adult elective surgery without GI disease it is usual to restrict oral solids for x hrs before surgery

Answer 4

6

Question 5

clear fluids can be given until x hrs before surgery

Answer 5

2

Question 6

how many hrs before surgery should oral solids be stopped

Answer 6

6

Question 7

why might some surgical procedures require the use of a single full dose of prophylactic antimicrobial prior

Answer 7

prevent surgical site infection

Question 8

true or false there is an increased risk of DDIs in the perioperative period

Answer 8

true

Question 9

would you consider stopping acei and aspirin prior to surgery yes or no

Answer 9

yes

Question 10

what are acei associated with following the induction of anasthesia

Answer 10

marked hypotension

Question 11

abrupt withdrawal of beta blockers can have adverse consequences especially in patients with concurrent x

Answer 11

angina

Question 12

any oral dosage forms to be continued can be given with clear fluids until x hrs before surgery

Answer 12

2

Question 13

when taking a history relating to surgery the anagram CASES is useful, what does it stand for

Answer 13

contraception
anticoagulation
steroids
ethanol
smoking

Question 14

surgical relevance of contraception

Answer 14

pregnancy and vte risk

Question 15

surgical relevance of anticoagulation

Answer 15

bleeding risk and consider continuation

Question 16

what is the surgical relevance of steroids

Answer 16

requirement for steroids in surgery to prevent addisonion crisis

Question 17

what is the surgical relevance of ethanol

Answer 17

risk of alcohol withdrawal and interaction with anaesthetic

Question 18

what is the surgical relevance of smoking

Answer 18

lung disease

Question 19

antiplatelets should be stopped x days before surgery to reduce the risk of bleeding

Answer 19

7 ideally

Question 20

coc pill should be discontinued at least x weeks before major elective surgery lasting more than 30 mins

Answer 20

4

Question 21

t/f coc may be continued in the case of minor surgery where the potential for prolonged immobilisation is low

Answer 21

true

Question 22

give an alternative that would be suitable to the combined oral contraceptive pill in the interim

Answer 22

progestogen only contraception

Question 23

herbal medicines should be stopped x days prior to surgery due to uncertainty of their contents and their effects

Answer 23

7

Question 24

does a clear fluid include tea and coffee

Answer 24

only if its without milk

Question 25

if a patient has gi problems or will be starved perioperatively will be oral route of drug admin be available, if not suggest an alternative route

Answer 25

no parenteral

Question 26

what advice can you give someone about their long acting insulin such as insulin determir dose prior to surgery

Answer 26

reduce night dose by 20% day before surgery

Question 27

can metformin be administered as normal the day prior to surgery

Answer 27

y

Question 28

under what 3 circumstances should metformin be omitted the day before surgery and the following 48hrs after

Answer 28

egfr below 60 using radiocontrast media vriii

Question 29

metformin should be stopped once a variable rate intravenous insulin infusion is started and should only be restarted at what point

Answer 29

when patient is eating and drinking normally

Question 30

what dose reduction would be required to a patients long acting insulin if they are started on a vriii

Answer 30

20%

Question 31

what insulin regimens must be stopped if vriii is being started

Answer 31

twice daily short acting

Question 32

vriii should not be discontinued without ensuring patients regular insulin has been restarted and admin with last x mins

Answer 32

30

Question 33

why would vriii be required in t1dm patients undergoing surgery

Answer 33

dependent on exogenous insulin if starved and insulin withheld hyperglycaemia ketoacidosis diuresis dehydration

Question 34

dependent on exogenous insulin if starved and insulin withheld hyperglycaemia ketoacidosis diuresis dehydration

Answer 34

blood glucose levels poorly controlled or major or emergency surgery

Question 35

what should happen to sulphonylureas like gliclazide on the morning of surgery

Answer 35

omit

Question 36

can pioglitazone be taken as normal on the day of surgery

Answer 36

y

Question 37

what actions should be made towards dpp4 inhibitors such as sitagliptin on the day of surgery

Answer 37

take as normal

Question 38

what actions should be made towards glp1 receptor antagonists such as liraglutide on the day of surgery

Answer 38

take as normal

Question 39

should sglt2 inhibitors like dapagliflozin be continued or omitted on the morning of surgery

Answer 39

omitted

Question 40

2 diabetic drug classes that must be omitted on the day of surgery

Answer 40

sulphonylureas and sglt2 inhibitors

Question 41

currently manufacturers advise stopping DOACs x hrs prior to surgery with low bleeding risk

Answer 41

24

Question 42

doacs should be stopped x hrs before surgery with high bleeding risk

Answer 42

48

Question 43

vitamin k antagonists should be stopped at least x days before surgery

Answer 43

4-5

Question 44

dabigatran omission is dependent on x function

Answer 44

renal

Question 45

what 2 parameters can be used to assess the level of anticoagulation of UFH

Answer 45

act or aptt

Question 46

what is often the anticoagulant drug of choice in high risk patients

Answer 46

UFH

Question 47

interim anticoag with LMWH must be stopped x hrs before surgery

Answer 47

24

Question 48

when can LWMH be restarted

Answer 48

when risk of bleeding has passed usually 48 hrs

Question 49

warfarin should be stopped X days before operative day

Answer 49

4-5

Question 50

why should patients that are maintained on long term corticosteroids not have their meds stopped peri operatively

Answer 50

underlying condition may flare up with withdrawal patients HPA axis will be suppressed with maintenance doses of 10mg prednisolone or equivalent daily

Question 51

if a patient is taking prednisolone long term prior to surgery what induction dose of hydrocortisone iv should they recieve as part of their perioperative management plan

Answer 51

100mg

Question 52

if a px on prednisolone they should receive usual dose on morning of surgery t/f

Answer 52

true

Question 53

following an induction dose patients on hydrocortisone should receive a continous infusion at what rate

Answer 53

100mg 200mg over 24hrs

Question 54

when enteral nutrition is restablished what dose of oral prednisolone daily should be prescribed before tapering back down to the patients normal dose

Answer 54

10mg

Question 55

most abx can be given by bolus injection on arrival to theatre, it should be admin x mins before skin incision to minimise risk of infection

Answer 55

30-60

Question 56

what treatments exist for perioperative nausea and vomiting

Answer 56

antihistamines like cyclizine 5ht3 antagonists like ondansetron phenothiazines like prochlorperazine dexamethasone

Question 57

after spleenectomy patients will need the annual flu vaccine unless they are allergic to

Answer 57

egg

Question 58

why is long term abx therapy needed after speelnectomy

Answer 58

prevent pneumococcal infection

Question 59

Which ONE of the following medicines is MOST likely to be accidently omitted when taking a drug history? Apixaban Entresto® Lansoprazole Microgynon® Ramipril

Answer 59

microgynon (oral contraceptives)

Question 60

microgynon (oc) should be stopped at least x weeks before surgery

Answer 60

4

Question 61

On the operative day, which ONE of the following medicines would you recommend was omitted? Atorvastatin 20 mg Calcichew D3 Forte Hydrocortisone 20 mg Metoprolol 50 mg Perindopril 4 mg

Answer 61

not standard practice to omit medicines unless clinical reason; this avoids confusion and increases likelihood that important drugs are administered. ACE inhibitors associated with hypotension following anaesthesia. omit

Question 62

drugs causing gi irritation can increase nausea and vom eg

Answer 62

ferrous sulphate

Question 63

what anasthesia may increase nausea vom risk

Answer 63

inhaled anaesthesis esp nitrous oxide

Question 64

t/f females more at risk of periop nausea and vom

Answer 64

true

Question 65

MAOIs eg phenelzine should be stopped X weeks before surgery, due to the risk of hypo- and hypertension.

Answer 65

2

Question 66

Which ONE of the following medicines is MOST likely to increase the risk of hypotension if co-prescribed with propofol? Chlorphenamine Digoxin Haloperidol Levothyroxine Tamoxifen

Answer 66

haloperidol Antipsychotics interact with anaesthetic agents and can cause hypotension. The BNF states ‘both propofol and haloperidol can increase the risk of hypotension’. Many other drug classes also interact with anaesthetic agents to cause hypotension, so always consult the BNF.

Question 67

Stopping rules for X are dependent on the risk of bleeding and the patient’s renal function as creatinine clearance.

Answer 67

dabigatran