Miscellaneous

Question 1

What drugs should be stopped before surgery? And When?

Answer 1

I LACK OP

Insulin - Variable

Lithium - Day before

Anticoagulants/anti platelets - Variable

COCP/HRT - 4 weeks before surgery

K-sparing diuretics - Day of surgery

Oral hypoglycemics - Variable

Perindopril and other ACEi - Day of surgery

Variable between hospitals and operations

Question 2

Why are oral hypoglycemic drugs and insulin stopped?

Answer 2

Patients are ‘nil by mouth’ before surgery, thus metformin should be stopped because it will cause lactic acidosis. The other oral hypoglycemics and insulin will cause hypoglycemia unless stopped. In all cases, a sliding scale should be started instead where hourly blood glucose monitoring adjusts the hourly dose of insulin given to provide a much tighter control

Question 3

What blood clot prophylaxis should be given?

Answer 3

Majortiy would be given LMWH (e.g. dalteparin 5000 units daily s/c) and compression stockings for prevention of venous thromboembolism

Pharmacological blood clot prohpylaxis is contraindicated if they are at risk of bleeding!!!

Mechanical blood clot prohpylaxis is contraindicated in peripheral arterial dosease (usually indicated by absent foot pulses) which may cause acute limb ischemia

Question 4

What antiemetics should be prescribed in a nauseasted vs a nonnauseated patient?

Answer 4

1. Nauseated: Regular antiemetic
   
   1. Cyclizine 50mh 8-hourly IM/IV/oral for most cases but causes fluid retention
   2. Metoclopramide 10mg 8-hourly IM/IV if heart failure
2. Not nauseated: As required antiemetic
   
   1. Cyclizine 50mg up to 8-hourly IM/IV/oral for most cases but causes fluid retention
   2. Metoclopramide up to 10mg 8-hourly IM/IV if heart failure

Question 5

What pain relief should be prescribed?

Answer 5

1. No pain:
   
   1. None regularly
   2. PRN - paracetamol 1g up to 6-horly PO
2. Mild pain:
   
   1. Paracetanol 1g 6-hourly,
   2. PRN - Codeine 30mg up to 6-hourly oral
      
      1. Tramadol is suitable replacement
3. Severe pain:
   
   1. Co-codamol 30/500, 2 tablets 6-hourly
   2. PRN - Morphine sulphate 10mg up to 6-hourly oral
      
      1. In order of increasing effectiveness, morphine sulphae may be given orally (as Oramorph), subcutaneously or intravenously. Oramorph is a liquid and comes in two strengths (the more concentrated is rarely used in hospitals) thus the strength must be specified and is usually 10mg/5ml

• An NSAID (e.g. Ibuprofen 400mg 8 hourly) may be introduced at any stage regularly or ‘as required’ if not contraindicated
• Neuropathic pain (i.e. pain arising from nerve damage or disease and usually described as ‘shooting’, ‘stabbing’ or ‘burning’) the firs line of treatment is amitriptyline (10mg oral nightly) or pregabalin (75mg oral 12 hourly); dulozetine (60mg oral daily) is indicated in painful diabetic neuropathy

Question 6

A patient on methotrexate has sepsis, what should be done?

Answer 6

If a patient on methotraxate has sepsis, this medication is withheld pending the exclusion of neutropenic sepsis.

Question 7

What are the causes of SIADH?

Answer 7

SIADH: Syndrome of inappropriate anti-diuretic hormone

1. S: Small cell lung tumours
2. I: Infection
3. A: Abscess
4. D: Drugs (especially carbamezepine and antipsychotics)
5. H: Head injury

Question 8

How do we manage constipation?

1. Type
   
   1. example
   2. contraindication
   3. comments

Answer 8

1. Stool softner
   
   1. Docusate sodium, Arachis oil (rectal)
   2. Arachis oil: nut allergy
   3. Good for faecal impaction
2. BUlking agents
   
   1. Isphagula hust
   2. Faecal impaction, colonic atony
   3. Can take days to develop effect
3. Stimulant laxatives
   
   1. Senna, Bisacodyl
   2. Bisacodyl: Acute abdomen
   3. May exacerbate abdominal cramps
4. Osmotic laxatives
   
   1. Lactulose, Phosphate enema
   2. Phosphat enema: Acute abdomen
   3. May exacerbate bloating

Question 9

How do we manage diahhroea?

Answer 9

Chronic diarrhoea that is proven to be non-infectious with negative stool cultures and microscopy may be treated with loperamide 2mg oral up to 3 hourly or codeine 30mg oral up to 6-hourly (which also provide relief of pain)

Question 10

How do we manage insomnia?

Answer 10

1. Check if drugs are causing this
2. Zoplicone 7.5mg oral nightly in adults (3.75mg in elderly)

Question 11

When do we blood transfuse anaemic patients?

Answer 11

Blood transfusion in iron-deficiency anaemia is generally reserved for patients who:

• Are severely symptomatic and cannot tolerate or wait for the effect of iron-replacement (in iron-deficiency anaemia the Hb usually rises by 10 g/L/week on oral iron replacement), or
• Have Hb <70 g/L (some recommend using a higher cut-off of 100 g/L in patients with ischaemic heart disease).

Ferrous sulfate/gluconate/fumarate are all used as oral iron supplements. The most common side effect is constipation; by far, the most common reason for treatment failure is poor compliance due to this (plus it also causes black offensive stools). Non-compliance should be considered when the haemoglobin fails to rise on treatment.

Oral iron replacement should be given until the haemoglobin is in the normal range then for a further 3 months to replenish stores.