7 Surgery - NOACs Flashcards
Disadvantages of NOACs
- Potential interactions?
- BLEEDING
-Other s/e: GI upset/ abonormal LFT
- Lack of optimal revering agent
- Lack of data in preg/breast feeding/paeds
Caution NOAC with what
- CrCL?
- LFTs
CrCL 2x ULN
Is there are NOAC reersal agent in the pipeline?
Idarucizumab in phase 1
Emergency surgery protocol on NOAC
- Stop NOAC - document last dose
- Contact haem/surg/anaewthetist
- APTT, PT, Fibrinogen, FBC, renal function, (+/- haemoclot TT).
If normal - no effect present
If prolonged - effect may be present
- Maintain BP and urine output
- Consider oral charcol if
Options of emergency surgery on NOAC.
Delay surgery?
delay 4-12h
consider haemodyalysis?
consider beriplex
if immediate surgery give beriplex IV bolus (10-15mins)
Elective surgery with NOACs - when to stop Dibigatran?
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)
Elective surgery with NOACs- when to stop apixiban
Non-major surgery: miss morning of surgery
Major surgery: 2 days before
Elective surgery with NOACs- when to stop apixiban
Non-major surgery: miss morning of surgery
Major surgery: 2 days before
When to stop antiplates - Aspirin
continue unless v high bleed risk then stop 7 days pre-op.
Stop for primary prevention.
When to stop antiplatlets - Clopidogrel/pras/ticagrelor
Stop 7 days pre-op. Substitute with aspirin if posstible.
DO NOT STOP IF RISK OF CORONARY STENT CLOT.
When to stop dipydamole
is used alone continue, if in combination with aspirin stop the day before surgery
When to start anticoagulants after surgery?
morning after
When to start NOACs after surgery?
24-48h post op. Cover with LMWH until started but no need to overlap
why do we continue most cardiac medication through surgery?
Surgery increases HR and BP.
Always continue betablockers.
Some trusts stop ACE/ARB (hypotension)
Steroid use in minor surgery?
Usual steroid dose morning of surgery (or 25-50mg HC IV on induction)
Recommence usual oral dose after
Steroid use in moderate/major surgery
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
Steroid use in moderate/major surgery
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
when should diabetic pt be operated on?
1st on the list to min starvation time
when to stop sulphonyl ureas?
omit on day of surgery
when to stop metfomin?
take as normal
when to stop DPPIVi / GLP-1
omit on day of surgery
when to stop acarbose / neglatinide
omit on day of surgery if NBM
give morning dose if eating and op is in afternoon
when to reintroduce diabetic meds?
when oral intake is resumed
what to do with long acting insulin during surgery
continue
what to do with biphasic insulin during surgery
half the am dose
what do do with short/rapid acting insulin in surgery
omit am and lunch doses
When is a VRiii indicated in surgery? (2)
More than one meal missed
or
Uncontrolerble hyperglycemia in patient missing one meal only
All antidiabetic meds here are based on how many meals being missed for surgery?
just 1
Aim for BG during surgery
6-10mmol/l (accept 4-12)
Diabetes surgery - what is given?
2 lines through a venflon
1: 50units actrapid in 50ml saline
2: 500ml 5% dextrose over 5hours
Diabetes surgery - what is given?
2 lines through a venflon
1: 50units actrapid in 50ml saline
2: 500ml 5% dextrose over 5hours
Risk associated with POP during surgery?
COC?
POP - NO RISK
COC - 3x risk
When to stop COC?
4-6 weeks before - consider the risks of stopping!
Emergency surgery - give thrombopropylaxis
When to stop COC?
4-6 weeks before - consider the risks of stopping!
Emergency surgery - give thrombopropylaxis
Tamoxifen risk?
Risk of VTE?
weigh up with risk of stopping treatment.
Discuss with oncology.
Consider stopping 3 weeks before and after.
Risks with MAOI?
2 e.g.
potentially fatal drug interactions
- analgesics - tramadol increases seratonergic activity leading to CNS tox/convulsions
- sympathomimetics- risk of hypertensive crisis
What do with MAOI before surgery?
Consult prescriber and reduce to stop 2 weeks before
Caution with anesthesia if not stopped
What do with MAOI before surgery?
Consult prescriber and reduce to stop 2 weeks before
Caution with anesthesia if not stopped
Risk associated with lithium? (3)
Narrow theraputic range
fluid imbalance can precipitate tox
rennally excreted
Should Li be stopped?
Preferably stop 1-2 days before
If Li is continued: (3)
Monitor fluids Avoid NSAIDs Monitor levels (0.4-1mmol/l)
Continue PD meds?
CONTINUATION IS ESSENTIAL
consider alternative routes if NBM/not absorbing
rotigatine patch/tweak timings
Continue anticonvulsants?
CONTINUATION IS ESSENTIAL
consider alternative route (IV/repository) if not absorbing/NBM
Is stopping or not black an white?
No - consider risks of stopping/continuation in each case
