Lecture 1 - Surgery and Long-term Conditions Flashcards
Define emergency
Admitted via A and E or GP
Define elective
Planned procedure
Examples of emergency surgery
Abdominal pain, trauma, ischaemic stroke, leaking aneurysm
Examples of elective surgery
Joint replacement - hip, shoulder, and knee replacements
Surgery for cancers e.g. hysterectomy, bowel resection
Coronary artery bypass graft
Aneurysm repair
Thyroid surgery
Define a preoperative fast
6 hours for food (e.g. night before), up to 170ml/hr non-milky fluids (e.g. water, squash, tea)
What is the risk of anticoagulants and surgery?
Increased risk of bleeding
Name the reasons for anticoagulation
Mechanical heart valves
DVT/ PE
AF
When should you restart warfarin after surgery?
ASAP, depends on bleeding risk, it takes a while to do its job
What should you anticoagulate?
If patient is a low or moderate risk - cover with a prophylactic dose LMWH until INR therapeutic
if patient is at high risk - cover with treatment dose LMWH until INR therapeutic for 2 days
When you need to do emergency surgery and patient is on warfarin what is given to reverse its effects?
Vitamin K - reversal within 4-24 hours e.g. phytomenadione 5mg IV single dose
What should you stop an anticoagulant early ?
poor renal function
weigh up individual bleeding risk vs thrombus risk
based of half-life of the drug
When should stop Aspirin?
if low dose (<150mg) - continue unless very high bleed risk, then stop 5 days prior to surgery
if high dose (>150mg) - consider reducing to <150mg 7 days prior to surgery
When should you stop clopidogrel?
Stop 7 days pre-operatively
Substitute with aspirin if possible
if high risk of coronary/ cerebral thrombosis consider stopping 5 days pre-op
When should you restart DOACs?
ASAP depends on bleeding risk
24-72 hours post op
When should you restart platelets?
Continue from morning after surgery
Why might ACEI/ARB and diuretics be omitted?
Due to risk of hypotension
What cardiac medication should you always continue?
Beta-blockers, digoxin, antiarrhythmics
When should you stop steroids?
minor surgery - usual steroid dose morning of surgery, or hydrocortisone 25-50mg IV on induction
moderate or major surgery - usual steroid dose morning of surgery and hydrocortisone 100mg IV on induction
hydrocortisone 25-50mg IV TDS for:
- moderate surgery - 24 hours post-op
- major surgery - 48-72 hours post op
then recommend usual oral dose when IV stops
What non-insulin agents can be continued or stopped? and when should they be restarted?
Continue metformin, pioglitazone, and DPP4 inhibitors, GLP-1 analogues
Omit SGLT2 inhibitors 24-72 hours pre-op
Omit sulphonylureas in the morning of surgery and afternoon for PM procedure
restart post-op - when E and D again and VRII stopped
When should you stop and restart short-acting agents?
Omit doses if not eating for that meal, miss dose of insulin
Can have morning dose if PM surgery
Restart when VRII stopped and E and D retuned to normal
When should you stop and restart long/intermediate acting agents?
Continue at 80-100% of normal dose throughout surgery
When should you stop and restart mixed insulins?
Halve usual morning dose
Restart the evening of surgery
Define VRIII and when is it used?
Variable Rate Intravenous Insulin Infusion
more than one missed meal (major surgery)
When should you stop tamoxifen?
Consider if risk of VTE outweighs risk of stopping treatment
Consider stopping up to 4 weeks before and after major surgery
