Key topics

Question 1

What drugs do you need to stop prior to surgery?

Answer 1

I LACK OP

• Insulin (sliding scale)
• Lithium (day before)
• Anticoagulants/antiplatelets
• COCP/HRT (4 weeks before)
• K-sparing diuretics (day of surgery)
• Oral hypoglycaemics
• Perindopril/ACEi (day of surgery)

Question 2

What are the important safety considerations for NSAIDS?

Answer 2

• No urine (renal failure)
• Systolic dysfunction (HF)
• Asthma
• Indigestion
• Dyscrasia (clotting abnormality)

Question 3

What are the important safety considerations for steroids?

Answer 3

• Stomach ulcers
• Thin skin
• oEdema
• Right and left heart failure
• Osteoporosis
• Infection (including Candida)
• Diabetes + hyperglycaemia
• Syndrome (Cushing’s)

Question 4

What is the difference between enzyme inducers and enzyme inhibitors?

Answer 4

• Enzyme inducers increase enzyme activity and so decrease drug concentration (e.g., decrease INR in warfarin)
• Enzyme inhibitors decrease enzyme activity and so increase drug concentration (e.g., increase INR in warfarin)

Question 5

What are some enzyme inducers?

Answer 5

PC BRAS
- Phenytoin
- Carbamazepine
- Barbiturates
- Rifampicin
- Alcohol (chronic)
- Sulphonylureas (e.g., gliclazide)
Also = smoking,

Question 6

What are some enzyme inhibitors?

Answer 6

AO DEVICES
- Allopurinol
- Omeprazole
- Disulfiram
- Erythromycin/clarithromycin 
- Valproate
- Isoniazid
- Ciprofloxacin
- Ethanol (acute)
- Sulphonamides
Also = grapefruit juice, imidazoles (e.g., ketoconazole), SSRIs

Question 7

A patient is tachycardic and hypotensive, what fluids would you give?

Answer 7

• 500ml 0.9% NaCl given over <15 minutes (or 250ml in heart failure)

Question 8

For maintenance fluids, what are the daily requirements…

i) total fluid?
ii) ml/kg/day of water?
iii) K/Na/Cl mmol/kg/day?
iv) glucose g/day?
v) max K given in an hour?

Answer 8

i) 3L fluid per 24h (2L if elderly), 1 salty and 2 sweet
ii) 25-30ml/kg/day of water
iii) 1mmol/kg/day of K, Na and Cl
iv) 50–100g/day of glucose
v) Rate no more than 10mmol/h

Question 9

BNF cheat sheets

i) high INR management?
ii) opioid conversion?
iii) hyperkalaemia management?
iv) abx guidelines?
v) insulin types?

Answer 9

i) Oral anticoagulants
ii) Prescribing in palliative care
iii) Fluids and electrolytes
iv) Antibacterials
v) Insulin

Question 10

What are the reasons for considering immediate fluid resuscitation and what fluids do you give?

Answer 10

• HR >90bpm, SBP <100mmHg, CRT >2s or cool peripheries, NEWS ≥5
• 0.9% NaCl 500ml STAT bolus <15 minutes

Question 11

What BP measurement should you stop the COCP with?

Answer 11

> 160/95mmHg

Question 12

At what eGFR drop should you consider stopping or reducing the dose of ACEi?
What rise in creatinine is accetable?

Answer 12

• 25%

- <20%

Question 13

If the pre-dose (trough) plasma concentration for a drug is too high, what action is required?

Answer 13

Increase the interval

Question 14

If the post-dose (peak) plasma concentration for a drug is too high, what action is required?

Answer 14

Reduce the dose

Question 15

What class of medication is contraindicated in ischaemic ulcers/PVD?

Answer 15

Beta blockers

Question 16

How do you transition someone from their VRII to their normal s/c regime?

Answer 16

• Once able to eat and drink, usual s/c fast acting insulin resumed with the next meal
• Leave the VRII running for 30–60m too in order to ensure stable BMs

Question 17

Give examples of rapid acting insulins and when they are given

Answer 17

• Novorapid (aspart), Humalog (Lispro) and Apidra (Glulisine)
• Start of meal

Question 18

Give examples of short acting insulins and when they are given

Answer 18

• Actrapid and Humulin S

- 15–30m before a meal

Question 19

Give some examples of intermediate acting insulins and when they are given

Answer 19

• Humulin I, Insulatard, Insuman basal

- OD/BD or as part of a mix

Question 20

Give some examples of long acting insulins and when they are given

Answer 20

• Lantus (Glargine), Levemir (Detemir) and Tresiba (Degludec)
• OD