Perioperative medicine

Question 1

In regards to short-acting insulin:
- How to manage it in the perioperative period?

Answer 1

Minor elective surgery
- AM: Omit dose if breakfast is skipped.
- PM: Take morning dose, omit lunchtime dose if fasting.

Minor + poor diabetic control
- Stop and switch to variable rate intravenous insulin infusion (VRIII).

Major elective surgery
- Stop and switch to variable rate intravenous insulin infusion (VRIII).

Emergency
- Stop and switch to variable rate intravenous insulin infusion (VRIII).

Question 2

In regards to long-acting insulin:
- How to manage it in the perioperative period?

Answer 2

Continue
- At reduced dose
- 80% of the usually dose.

Examples:
- Lantus (glagirne).
- Levemir (detemir).

Question 3

Variable rate intravenous insulin infusion

When to use VRIII in the perioperative period?

Answer 3

Indicated when:
- A starvation period of more than 1 meal is required;
- If the patient has not received any background insulin (major surgeries);
- Diabetes is poorly controlled.

Question 4

Perioperative period

In regards to oral diabetic medication:
- Which drugs are safe thorought the perioperative period?

Answer 4

• Metformin
• Pioglitazone
• DPP-4 inhibitors
• GLP-1 receptor agonists

Question 5

In regards to oral diabetic medication:
- Which drugs should be omited on the morning of the surgery?

Answer 5

Sulfonylureas.

Question 6

In regards to oral diabetic medication:
- Which drugs should be omited throught the whole day of the surgery?

Answer 6

SGLT2 inhibitors.

Question 7

What is the recommendation in regards to food and fluids in the pre-operative period?

Answer 7

Foods
- Stop 6h before elective surgery.

Fluids
- Clear fluids can be consumed until 2h prior to surgery.

Clear fluids
- Water
- Tea
- Squash
- Coffee without milk

Question 8

What is the management of warfarin in the perioperative period?

Answer 8

• It has to be stopped 5 days before ELECTIVE surgery.

**Bridge with heparin if:
- High risk of thromboembolism;
- Venous thromboembolism in the last 3 months.
- AF with previous stroke;
- AF with CHADSVASCs >=5;
- Recent TIA;
- Patients with mechanical heart valves.

Question 9

What is the management of **DOAC **for an elective surgery?

Answer 9

Stop DOAC 48h before surgery.

Question 10

What is the management of clopidogrel for an elective surgery?

Answer 10

Stop 7 days prior.

Question 11

What is the management of HgB before surgery?

Answer 11

Elective
- < 100 postpone and investigate for anaemia;
- < 80 blood transfusion and postpone surgery.

Emergency
- < 100 go ahead with surgery
- < 80 blood transfusion and surgery

Question 12

What is the perioperative management after MI?

Answer 12

No elective surgery for 6 months after MI.