Perioperative Prescribing Flashcards
What drug types should you continue?
Drugs which have withdrawal symptoms
-Bb
What drug types should you stop?
Non-essential medicines that increase surgical risk
-increase bleed risk (1ary prevention aspirin 7 days before, 2ndary prevention risk vs benefit)
-increase hypotension risk (ACEi, MAOi 2wks
What are the rules around NBM?
-without GI disease
-with GI disease/starved postoperatively
No PO solids - 6hrs prior
No PO clear liquids - 2hrs prior
Routine medications with clear fluids - 2hrs prior
Alternative drug routes needed
-reduced oral drug absorption due to decreased blood flow to gut, postop ileus
When would antimicrobial prophylaxis be suitable?
Single full dose 30-60mins before incision
Intraoperative/post operative doses only used for prolonged procedures or major blood loss
What drugs are often missed in a drug history
OTCs
Non oral meds - eye drops, creams, inhalers
Oral contraceptives
Complementary and alternative therapies
Vitamins, food supplements
Recreational drugs
What are the key drugs you want to ask for in a surgical history
CASES
Contraception
-pregnancy
-VTE risk
Anticoag
-bleeding risk
Steroids
-prevent Addisonian crisis
Ethanol
-alcohol withdrawal
-anaesthetic interaction
Smoking
-lung disease
Herbal medicine management
Stopped 7 days before surgery due to uncertainty of contents and effects
Contraceptive pill management
Stopped if VTE risk high
-stop COCP 4wks before => normal levels of coagulation
-restart 2wks after => when procoagulant effects of surgery wears off
-can use POP inbetween
If N/V risk increased, contraceptive pill absorption may decrease => may need additional cover
Diabetes management
Long acting once daily insulin - reduced by 20% day before, even if sliding scale used
Long acting twice daily - stopped if sliding scale used
Short acting - stopped if sliding scale used
Metformin - as usual unless
-GFR U60, radiocontrast used, sliding scale used
Who will benefit from sliding scale insulin
When would you stop using sliding scale insulin
Multiple missed meals
No/unknown postop GI absorption
Labile blood sugars, HbA1c 69+
T1DM + major surgery
T1DM + not given background insulin
Infection
Emergency surgery
Stopped when patient can eat+drink normally without N/V
Sulphonylureas, pioglitazones, DPP4 inh use
Sulphonylureas - omit on morning of surgery
Pioglitazone - normal
DPP4 inh - normal
GLP1 agonist - normal
SGLT2 inh - day before surgery
DOAC management
24hrs before - low bleeding risk
48hrs before - high bleeding risk
48hrs+ before - high bleeding risk + renal dysfunction
Dabigatran stopping, starting, reversal
T1/2 - 12hrs
80% renal excretion
Avoid in creatinine clearance U30ml/min
Stopping - depends on renal function
-low bleed risk - 2 days
-high bleed risk - 4 days
Restart - 48-72hrs post surgery, depending on bleeding/clotting risk and renal function
Monitor through renal function
Dabigatran filtered out in haemodialysis
Idarucizumab antidote
Rivaroxaban stopping, starting, reversal
T1/2 - 5-13hrs
66% renal excretion
Taken with food to increase absorption
Stopping - 24hrs
-if high bleed risk/spinal or epidural anaesthesia => 48hrs
Restart - consider bleeding/clotting risk and renal function
24hrs - low bleed risk/minor surgery
48hrs - high bleeding risk/major surgery
No routine monitoring needed
Andexanet alfa if specific criteria met
Apixaban stopping, starting, reversal
T1/2 - 12hrs
25% renally excreted
Stopping - 24hrs
-if high bleed risk/spinal or epidural anaesthesia => 48hrs
Restart - consider bleeding/clotting risk and renal function (48-72hrs post surgery)
No routine monitoring needed
Andexanet alfa if specific criteria met
