7 Surgery - NOACs

Question 1

Disadvantages of NOACs

Answer 1

• Potential interactions?
• BLEEDING

-Other s/e: GI upset/ abonormal LFT

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

Question 2

Caution NOAC with what

• CrCL?
• LFTs

Answer 2

CrCL 2x ULN

Question 3

Is there are NOAC reersal agent in the pipeline?

Answer 3

Idarucizumab in phase 1

Question 4

Emergency surgery protocol on NOAC

Answer 4

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

Question 5

Options of emergency surgery on NOAC.

Answer 5

Delay surgery?

delay 4-12h
consider haemodyalysis?
consider beriplex

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

Question 6

Elective surgery with NOACs - when to stop Dibigatran?

Answer 6

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)

Question 7

Elective surgery with NOACs- when to stop apixiban

Answer 7

Non-major surgery: miss morning of surgery

Major surgery: 2 days before

Question 8

Elective surgery with NOACs- when to stop apixiban

Answer 8

Non-major surgery: miss morning of surgery

Major surgery: 2 days before

Question 9

When to stop antiplates - Aspirin

Answer 9

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

Stop for primary prevention.

Question 10

When to stop antiplatlets - Clopidogrel/pras/ticagrelor

Answer 10

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

DO NOT STOP IF RISK OF CORONARY STENT CLOT.

Question 11

When to stop dipydamole

Answer 11

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

Question 12

When to start anticoagulants after surgery?

Answer 12

morning after

Question 13

When to start NOACs after surgery?

Answer 13

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

Question 14

why do we continue most cardiac medication through surgery?

Answer 14

Surgery increases HR and BP.
Always continue betablockers.

Some trusts stop ACE/ARB (hypotension)

Question 15

Steroid use in minor surgery?

Answer 15

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

Recommence usual oral dose after

Question 16

Steroid use in moderate/major surgery

Answer 16

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

Question 17

Steroid use in moderate/major surgery

Answer 17

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

Question 18

when should diabetic pt be operated on?

Answer 18

1st on the list to min starvation time

Question 19

when to stop sulphonyl ureas?

Answer 19

omit on day of surgery

Question 20

when to stop metfomin?

Answer 20

take as normal

Question 21

when to stop DPPIVi / GLP-1

Answer 21

omit on day of surgery

Question 22

when to stop acarbose / neglatinide

Answer 22

omit on day of surgery if NBM

give morning dose if eating and op is in afternoon

Question 23

when to reintroduce diabetic meds?

Answer 23

when oral intake is resumed

Question 24

what to do with long acting insulin during surgery

Answer 24

continue

Question 25

what to do with biphasic insulin during surgery

Answer 25

half the am dose

Question 26

what do do with short/rapid acting insulin in surgery

Answer 26

omit am and lunch doses

Question 27

When is a VRiii indicated in surgery? (2)

Answer 27

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

Question 28

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

Answer 28

just 1

Question 29

Aim for BG during surgery

Answer 29

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

Question 30

Diabetes surgery - what is given?

Answer 30

2 lines through a venflon

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

Question 31

Diabetes surgery - what is given?

Answer 31

2 lines through a venflon

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

Question 32

Risk associated with POP during surgery?

COC?

Answer 32

POP - NO RISK

COC - 3x risk

Question 33

When to stop COC?

Answer 33

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

Emergency surgery - give thrombopropylaxis

Question 34

When to stop COC?

Answer 34

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

Emergency surgery - give thrombopropylaxis

Question 35

Tamoxifen risk?

Answer 35

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

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

Question 36

Risks with MAOI?

2 e.g.

Answer 36

potentially fatal drug interactions

• analgesics - tramadol increases seratonergic activity leading to CNS tox/convulsions
• sympathomimetics- risk of hypertensive crisis

Question 37

What do with MAOI before surgery?

Answer 37

Consult prescriber and reduce to stop 2 weeks before

Caution with anesthesia if not stopped

Question 38

What do with MAOI before surgery?

Answer 38

Consult prescriber and reduce to stop 2 weeks before

Caution with anesthesia if not stopped

Question 39

Risk associated with lithium? (3)

Answer 39

Narrow theraputic range
fluid imbalance can precipitate tox
rennally excreted

Question 40

Should Li be stopped?

Answer 40

Preferably stop 1-2 days before

Question 41

If Li is continued: (3)

Answer 41

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

Question 42

Continue PD meds?

Answer 42

CONTINUATION IS ESSENTIAL

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

Question 43

Continue anticonvulsants?

Answer 43

CONTINUATION IS ESSENTIAL

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

Question 44

Is stopping or not black an white?

Answer 44

No - consider risks of stopping/continuation in each case