Perioperative Medications Management

Question 1

1. Medications associated w/ known morbidity if withdrawn abruptly should be what?
2. Medications thought to increase risk of what should be held? 2

Answer 1

1. continued
2. • surgical complications AND
   • not essential for short-term

Question 2

Insulin Treatment
1. For short simple procedures?
2

2. Long/complex procedures?
   2
3. Post op?

Answer 2

1. Short simple procedures
   - Decrease dose of intermediate-acting insulin morning of procedure proportional to anticipated delay in next oral meal
   - Hold short-acting insulin
2. Long/complex procedures
   - Switch to IV insulin w/ dextrose (+ K+) infusion
   - Monitor BS/electrolytes closely
3. Post-op sliding scale

Question 3

Diabetes Medications
1. Anticipate glycemic control problems in perioperative period? 2

2. Continue routine oral hypoglycemic agents until when?
3. No what the morning of surgery?
4. Switch to what?
5. High risk of what?

Answer 3

1.

• Elevated pre-op BS (>200) associated w/ surgical complications (deep wound infection)‏
• Increased BS normal physiologic response to the surgery/anesthesia

2. morning of
3. No oral agents morning of surgery
4. Switch to sliding-scale SQ insulin
5. • hypoglycemia episodes
   • DKA

Question 4

Cardiovascular Drugs
1. Which drugs are potentially beneficial and you should take the morning of?

2. ACEIs/ARBs:
   -disadvanatge?
   -advanatge?
   Hold dose?
3. CCB?

Answer 4

1. BB
2. ACEIs/ARBs:
   -Increased risk perioperative hypotension if used the day of surgery
   -Decreased post-op hypertension
   Hold dose morning of surgery

No clear consensus/recommendations

3. CCBs: limited data/appear safe to take

Question 5

1. Which drug is potentially beneficial but has potential adverse withdrawl affects (rebound HTN)?
2. Switch to what kind of administration?
3. Diuretics: Manage how?
4. Diuretic risk factors? 2
5. Which are the most concerning of the diuretics?

Answer 5

1. Alpha-s agonists (Clonidine)‏
   (rebound HTN!)
2. Trandsermal administration
3. If possible D/C 48 hrs before surgery
4. Risks of
   -hypotension and
   -hypokalemia
   They are going to lower volume and you may need that volume.
5. Loop

Question 6

Gastrointestinal Agents

1. H2 blockers/PPIs potentially beneficial why?
2. Decreases insidence of what complication?
3. Take when?
4. Continue through what?
5. Switch to what as indicated?

Answer 6

1. Potentially beneficial—because there is a lot of stress related mucosal damage. Will be able to decrease acid and increase pH levels.
2. chemical pneumonitis
3. Take night before surgery
4. Continue through perioperative period
5. Switch to IV as indicated

Question 7

BB advantages? 3

Risks? 2

Answer 7

1. reduced ischemia due to inflammation
2. prevents arrthrymias
3. Decreased angina
4. Rebound HTN
5. and tachycardia

Question 8

Pulmonary Agents

1. Inhaled beta-agonists and anti-cholinergics beneficial for what?
2. Administer when?
3. Continue through?

Answer 8

1. Beneficial post-op pulmonary effects
2. Administer morning of surgery
3. Continue through perioperative period

Question 9

Pulmonary agents
Leukotriene inhibitors
1. May be used until when?
2. Resume when?

Answer 9

1. May be used through morning of surgery

2. Resume when patient tolerates PO meds

Question 10

Pulmonary agents:
Corticosteroids
Chronic use—continue during 1.___________ period, may need to give increased dose for ____ days because of stress of surgery

Answer 10

1. perioperative, 2-3

Question 11

Pulmonary Agents:
Theophylline affects and recommendations?
2

Answer 11

1. Potential serious toxicity

2. Recommend D/C night before surgery

Question 12

Antihyperlipidemic Agents
1. Niacin/fibric acid derivatives management?

2. Atorvastin/pravastatin
   - risk of?

Answer 12

1. D/C in perioperative period
2. Risk of myopathy (rhabdomyalysis)‏
   - Statin safety studies underway/leaning towards continuation

Question 13

Thyroid Medications
Thyroxine
1. May be safely held for how long?
2. Resume when?
3. If pt can't take PO longer periods parenteral advised at what dose?

Answer 13

1. May be safely withheld for 5-7 days
2. Resume PO when pt can take PO meds
3. 80% of the oral dose

Question 14

Antiplatelet Agents
Aspirin
1. Increased risk of what if continued?
2. Increased risk of what if D/Cd?

3. What usually happens?
4. When do you have to stop it if you do?
5. May want to keep it on for CV surg but DEFINITELY not for what?

Answer 14

1. Increased risk of bleeding if continued
2. Increased risk of thrombosis if discontinued
3. Usually discontinued and pt started on low molecular weight heparin
4. 7 to 10 days
5. Neuro surge

Question 15

Antiplatelet Agents
1. Dipyridamole: No data but what do we know about it?

2. Clopidogrel/Ticlodipine
   If an antiplatelet effect is not desired D/C how early?

Answer 15

1. Short half life

2. 5 days before surgery

Question 16

Warfarin:

1. Increased risk?
2. D/C when and why?

Answer 16

1. Increased risk of bleeding with INR > 2.0

2. D/C 2-4 days before surgery to bring INR to less than 2.0

Question 17

Antidepressants

1. Most antidepressants have a _____ half life and
2. can be held for how long?
3. They should be taken when and continued when?

4.

Answer 17

1. long
2. 2-3 days
3. morning of surgery and resumed post-op within 2-3 days

Question 18

NSAID management for surgery?

Answer 18

These should be D/C 7-10 days prior to surgery

Question 19

Pre-operative Medications
1. What to use an antibiotic: What should we use?

2. In who and what dose?
3. Benefits? 3

Answer 19

1. Midazolam (Versed)‏

2. Age

Question 20

When should they get off their at home supplements and herbal medications?

Answer 20

2 weeks