Lecture 1 - Surgery and Long-term Conditions

Question 1

Define emergency

Answer 1

Admitted via A and E or GP

Question 2

Define elective

Answer 2

Planned procedure

Question 3

Examples of emergency surgery

Answer 3

Abdominal pain, trauma, ischaemic stroke, leaking aneurysm

Question 4

Examples of elective surgery

Answer 4

Joint replacement - hip, shoulder, and knee replacements
Surgery for cancers e.g. hysterectomy, bowel resection
Coronary artery bypass graft
Aneurysm repair
Thyroid surgery

Question 5

Define a preoperative fast

Answer 5

6 hours for food (e.g. night before), up to 170ml/hr non-milky fluids (e.g. water, squash, tea)

Question 6

What is the risk of anticoagulants and surgery?

Answer 6

Increased risk of bleeding

Question 7

Name the reasons for anticoagulation

Answer 7

Mechanical heart valves
DVT/ PE
AF

Question 8

When should you restart warfarin after surgery?

Answer 8

ASAP, depends on bleeding risk, it takes a while to do its job

Question 9

What should you anticoagulate?

Answer 9

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

Question 10

When you need to do emergency surgery and patient is on warfarin what is given to reverse its effects?

Answer 10

Vitamin K - reversal within 4-24 hours e.g. phytomenadione 5mg IV single dose

Question 11

What should you stop an anticoagulant early ?

Answer 11

poor renal function
weigh up individual bleeding risk vs thrombus risk
based of half-life of the drug

Question 12

When should stop Aspirin?

Answer 12

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

Question 13

When should you stop clopidogrel?

Answer 13

Stop 7 days pre-operatively
Substitute with aspirin if possible
if high risk of coronary/ cerebral thrombosis consider stopping 5 days pre-op

Question 14

When should you restart DOACs?

Answer 14

ASAP depends on bleeding risk
24-72 hours post op

Question 15

When should you restart platelets?

Answer 15

Continue from morning after surgery

Question 16

Why might ACEI/ARB and diuretics be omitted?

Answer 16

Due to risk of hypotension

Question 17

What cardiac medication should you always continue?

Answer 17

Beta-blockers, digoxin, antiarrhythmics

Question 18

When should you stop steroids?

Answer 18

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

Question 19

What non-insulin agents can be continued or stopped? and when should they be restarted?

Answer 19

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

Question 20

When should you stop and restart short-acting agents?

Answer 20

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

Question 21

When should you stop and restart long/intermediate acting agents?

Answer 21

Continue at 80-100% of normal dose throughout surgery

Question 22

When should you stop and restart mixed insulins?

Answer 22

Halve usual morning dose
Restart the evening of surgery

Question 23

Define VRIII and when is it used?

Answer 23

Variable Rate Intravenous Insulin Infusion
more than one missed meal (major surgery)

Question 24

When should you stop tamoxifen?

Answer 24

Consider if risk of VTE outweighs risk of stopping treatment
Consider stopping up to 4 weeks before and after major surgery

Question 25

When should you stop lithium?

Answer 25

Preferably stop 1-2 days before major surgery

Question 26

When should you stop MAOIs and restart them?

Answer 26

Reduce down to stop 2 weeks before surgery and switching onto a different antidepressant
Switch to reversible MAOI e.g. moclobemide, omit morning of surgery
Avoid tramadol

Question 27

If lithium is continued what should you monitor?

Answer 27

monitor lithium levels (target 0.3-1mmol/L)
monitor fluid balance
avoid NSAIDs

Question 28

What critical medicines cannot be stopped?

Answer 28

Anticonvulsants and Parkinson’s medication

Question 29

When you need to do emergency surgery what can be given to reverse the effects of HRT/ oral contraceptives?

Answer 29

Give thromboprophylaxis