PERIOPERATIVE MEDICINE Flashcards
(35 cards)
PRE-OP ASSESSMENT
what elements of a medication history are often missed?
- OTC meds
- non-oral medicines (eye drops, creams or inhalers)
- oral contraceptives
- complementary/alternative therapies
- borderline substances (vitamins, food supplements)
- illicit substances
PRE-OP ASSESSMENT
what particular medications should be asked during a medication history?
CASES
- contraception
- anticoagulation
- steroids
- ethanol
- smoking
NIL BY MOUTH
what are the rules for nil-by-mouth?
- restrict food for 6 hrs before surgery
- allow water and clear fluids (including tea and coffee without milk) until 2hrs before surgery
- allow routine medications with clear fluids until 2 hrs before surgery
which drugs should not be stopped before surgery?
CCBs
beta-blockers
which drugs should be stopped before surgery?
I LACK OP
- Insulin
- Lithium
- Anticoagulants/antiplatelets
- COCP/HRT
- K-sparing diuretics
- Oral hypoglycaemics
- Perindopril + other ACE inhibitors
VRIII
which patients are most likely to benefit from a VRIII?
- prolonged periods of starvation (more than 1 missed meal)
- no or unknown post-op enteral absorption
- labile blood sugar or HbA1c >69
- T1DM undergoing major surgery
- T1DM who have not received background insulin
- infection
additionally most patients with diabetes requiring emergency surgery will require a VRIII
VRIII
what should you do about twice daily insulin regimens whilst a patient is on a VRIII?
they must be stopped whilst VRIII is used
examples = biphasic or long-acting insulin given twice daily
VRIII
what should be done about long-acting once daily insulin regimens whilst on VRIII?
should be continued at 80% normal dose whilst on VRIII
VRIII
are VRIII required in all T1DM and T2DM?
no
T1DM
- required if starved for prolonged periods
- major surgery
T2DM
- only required in blood glucose levels are poorly controlled or for major/emergency surgery
- if they fail to make their own insulin, treat like T1DM in perioperative period
VRIII
when are VRIII withdrawn?
- when patient is able to eat and drink normally without nausea and vomiting
- do not discontinue without ensuring the patient’s regular insulin has been restarted + administered in previous 30 mins
- patient can be restarted on normal dose of insulin unless blood glucose indicates otherwise
DIABETES
what are the instructions for sulfonylureas (e.g. gliclazide) before surgery?
should be omitted on the morning of surgery
DIABETES
what are the instructions for pioglitazone before surgery?
taken as normal on the day of surgery
DIABETES
what are the instructions for DPP4 inhibitors (e.g. sitagliptin) before surgery?
taken as normal on the day of surgery
DIABETES
what are the instructions for SGLT-2 inhibitors (e.g. dapagliflozin) before surgery?
omitted on the morning of surgery
should also be omitted the day before surgery
DIABETES
what are the instructions for GLP-1 receptor agonists (e.g. liraglutide) before surgery?
taken as normal on the day of surgery
DIABETES
what are the rules for metformin?***
- if one meal missed, eGFR >60 + low risk of AKI = continue metformin in peri-operative period (just omit lunchtime dose)
- if >1 meal missed or high risk of AKI = metformin stopped when fasting begins (VRIII set up if metformin taken more than once daily)
DIABETES
what is the concern with continuing metformin during surgery?
- patient may develop lactic acidosis as metformin can build up
DOACS
what are the rules for DOACs before surgery?
- stop 24hrs before surgery with low bleeding risk
- stop 48hrs before surgery with high bleeding risk
this is extended further for patients with poor renal function
DOACS
when are they restarted after surgery?
- considered on case-by-case basis depending on bleeding risk, haemostasis + renal function
- typically 24-72hrs depending on drug
WARFARIN
when should you stop warfarin before surgery?
at least 4-5 days prior to surgery
WARFARIN
what should you give patients to bridge them from stopping warfarin to the post-op period?
when warfarin is stopped, start on LMWH
note LMWH should be stopped 24hrs before surgery
LMWH
when should it be stopped before surgery?
at least 24 hrs before surgery
CLOPIDOGREL
when should it be stopped before surgery?
7 days before surgery
ACE INHIBITORS
when should ACEi be stopped before surgery?
the day before
