Perioperative Medication Management

Question 1

DM perio-op medication management;

• continue oral hypoglycemia agents until _____.
• how do we manage insulin in short simple procedures? long/complex?
• how do we manage insulin post-op?
• why do we worry about taking metoformin the day or surgery?

Answer 1

the morning of surgery, no oral agents the AM of surgery.

Short/Simple:
-decrease dose of intermediate acting insulin and hold short acting insulin the AM of surgery.

Long/Complex:
-switch to IV insulin w/ dextrose & K+

Post op sliding scale.

Metformin: dont give day of surgery or 72hrs post op b/c we worry about renal hypoperfusion and hypoglycemia

Question 2

Beta blockers:

• do we continue these perioperativelY?
• do we continue ACEI/ARBs/Ca channel blockers perioperatively?
• do we continue alpha-s agonists (clonidine)/Diuretics perioperatively?

Answer 2

YES, keep the beta blocker on board.

ACEI/ARB: take these off the day of surgery and use other form of HTN agent. increased risk of perioperative hypotension.

CCB: we think these are cardioprotective, continue to take.

Clonidine: keep this on board, potential adverse withdrawal (rebound HTN)

Diuretics: d/c 48hrs before, risk of hypotension and hypokalemia
*loop diuretics are very high risk d/t the electrolyte imbalances.

Question 3

• do we continue H2blocker/PPI perioperatively?
• do we continue inhaled beta agonists/anticholinergics/ leukotriene inhibitors perioperatively?
• do we continue corticoteroids perioperatively?
• do we continue theophylline perioperatively?
• -do we continue Niacin/statins perioperatively?

Answer 3

H2blocker/PPI: continue through perioperative period. they reduce gastric volume and gastric pH.

Inhaled beta agonists/anticholinegics:
-administer morning of surgery and continue through perioperative period. reduced pulmonary complications.

Leukotriene:
-use AM of surgery and resume when pt tolerates PO meds.

Steroids:
-chronic use; continue during perioperative period, may need to give increased dose for 2-3days b/c of stress of surgery

Theophylline: d/c night before surgery.

Niacin: d/c perioperativ period

Statins:
-continuation of statins, have antiinflamm effects.

Question 4

• do we continue thyroxine perioperatively?
• do we continue aspirin perioperatively?
• do we continue plavix perioperatively?

Answer 4

Thyroxine: hold 5-7days prior, resume when pt taking PO.

Aspirin:

• increased risk of bleeding if continued and increased risk of thrombosis if d/c. usually d/c and pt started on LMWH.
• *any vascular surgery or known vascular dz we keep this on board, but for other specialties like neurosurgery you need to have a discussion about this.

Plavix:
-if anti-platelet effect is not desired d/c 5 days before surgery

Question 5

How does aspirin work?

Answer 5

Aspirin works by irreversibly inhibiting cyclooxygenase which converts arachodonic acid to thromboxane A2

Thromboxane A2 is what signals platelet aggregation.

Question 6

• do we continue warfarin perioperatively?
• do we continue antidepressants perioperatively?
• do we continue NSAIDS perioperatively?

Answer 6

Warfarin: d/c 2-4days before surgery to bring INR less than 2.0-1.5.

Antidepressants:

• should be taken the morning of surgery and resumed post-op within 2-3days… but heather says keep on board unless CNS surgery.
• Serotonin increases bleeding.

NSAIDS:
d/c 7-10days prior to surgery

Question 7

Benefits of Versed (Midazolam)?

which abx is given preop?

Answer 7

Versed benefits:

• anxiolytic
• sedative
• induction of perioperative anesthesia

Abx: ancef, effective as a full 5 day course.