Periop Med Management Flashcards
Basic decision guideline on periop med management?
- meds assoc w/ known morbidity if withdrawn abruptyl should be continued
- meds thought to increase risk of surgical complications and not essential for short term should be held
Diabetes meds - continue or d/c?
- anticipate glycemic control problems in periop period:
elevated pre-op BS (over 200) assoc w/ surgical complications (deep wound infection)
increased BS normal physiologic response to surgery/anesthesia - continue routine oral hypoglycemic agents until morning of surgery:
no oral agents morning of surgery (metformin)
switch to sliding scale SQ insulin
Insulin tx guidelines periop?
- short simple procedures:
decrease dose of intermediate acting insulin morning of procedure proportional to anticipated delay in next oral meal, hold short acting insulin - long/complex procedures:
switch to IV insulin w/ dextrose (+K+) infusion, monitor BS/lytes closely - post-op sliding scale
What CV drugs should be continued/ and d/c?
- BBs: potentially beneficial: take morning of procedure (reduces ischemia,helps control or prevent arrhythmia)
- ACEIs/ARBs:
increased risk periop hypotension if used day of surgery, decreased post-op HTN, no clear consensus/recommendations, hold dose morning of surgery? - CCBs: limited data, appear safe to take
- Alpha-s agonists (clonidine): potentially beneficial, potential adverse withdrawal (rebound HTN), switch to transdermal admin
- diuretics:
if possible d/c 48 hrs b/f surgery, risks of hypotension and hypokalemia (loop diuretics: most dangerous)
GI agents use pre/periop?
H2 blockers/PPIs:
- potentially beneficial because of stress related mucosal damage during surgery, more risk of gastric aspiration,
- PPI: raise pH and decrease vol of gastric acid
- take night b/f surgery
- continue to IV as indicated
Pulm agents use pre/periop?
- inhaled beta-agonists and anti-cholinergics:
beneficial post-op pulm effects, admin morning of surgery, continue through periop period
(reduced incidence of pulm complications bf surgery in asthma and COPD pts) - leukotriene inhibitors: may be used through morning of surgery, resume when pt tolerates PO meds
- corticosteroids: chronic use - continue during periop period, may need to give increased dose for 2-3 days b/c of stress of surgery
- theophylline: potential serious toxicity
recommend D/C night b/f surgery (interactions, narrow therapeutic window)
Use of antihyperlipidemic agents periop?
- niacin/fibric acid derivatives: D/C in periop period
- atorvastin/pravastatin:
d/c in periop period, risk of myopathy: rhabdomyolysis, statin safety studies underway
Thyroid med use periop?
thyroxine:
- may be safely withheld for 5-7 days
- resume PO when pt can take PO meds
- if pt can’t take PO longer periods - parenteral advised at 80% of oral dose
use of antiplatelet agents periop?
aspirin:
- increased bleeding risk if cont.
- increased risk of thrombosis if d/c
- usually d/c and pt started on LMWH
-d/c 10 days b/f surgery but if high CV risk continue
Dipyridamole:
- no data, short half life
Clopidogrel/Ticlodipine:
if an antiplatelet effect isn’t desired d/c 5 days b/f surgery (pt has drug eluding stent - need to be on this for 1 yr, if bare stent - 1 month)
Warfarin use periop?
- increased risk of bleeding w/ INR greater than 2
- d/c 2-4 days b/f surgery to bring INR to less than 2
- have to bridge w/ lovenox
- safely operate when INR below 1.5, in emergency: less than 2, depends on surgery (neuro surg - want lower)
- bridge back to warfarin a couple days post op
Antidepressant use periop?
- most antidepressants have long half life and can be held for 2-3 days
- they should be taken the morning of surgery and resumed post-op w/in 2-3 days
- serotonin: assoc w/ increased bleeding
When should NSAIDs be d/c b/f surgery?
- 7-10 days prior
What are preop meds that are started?
- abx
- midazolam (versed): if younger than 65 - 2.5-5mg IV 15 min prior to surgery
benefits:
anxiolytic, sedative, induction of periop anesthesia
When should herbal supplements be d/c b/f surgery?
- 2 wks b/f
