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MY REVISION - PSA > PERIOPERATIVE MEDICINE > Flashcards

PERIOPERATIVE MEDICINE Flashcards

1
Q

PRE-OP ASSESSMENT
what elements of a medication history are often missed?

A
  • OTC meds
  • non-oral medicines (eye drops, creams or inhalers)
  • oral contraceptives
  • complementary/alternative therapies
  • borderline substances (vitamins, food supplements)
  • illicit substances
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2
Q

PRE-OP ASSESSMENT
what particular medications should be asked during a medication history?

A

CASES

  • contraception
  • anticoagulation
  • steroids
  • ethanol
  • smoking
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3
Q

NIL BY MOUTH
what are the rules for nil-by-mouth?

A
  • restrict food for 6 hrs before surgery
  • allow water and clear fluids (including tea and coffee without milk) until 2hrs before surgery
  • allow routine medications with clear fluids until 2 hrs before surgery
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4
Q

which drugs should not be stopped before surgery?

A

CCBs
beta-blockers

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5
Q

which drugs should be stopped before surgery?

A

I LACK OP

  • Insulin
  • Lithium
  • Anticoagulants/antiplatelets
  • COCP/HRT
  • K-sparing diuretics
  • Oral hypoglycaemics
  • Perindopril + other ACE inhibitors
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6
Q

VRIII
which patients are most likely to benefit from a VRIII?

A
  • prolonged periods of starvation (more than 1 missed meal)
  • no or unknown post-op enteral absorption
  • labile blood sugar or HbA1c >69
  • T1DM undergoing major surgery
  • T1DM who have not received background insulin
  • infection

additionally most patients with diabetes requiring emergency surgery will require a VRIII

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7
Q

VRIII
what should you do about twice daily insulin regimens whilst a patient is on a VRIII?

A

they must be stopped whilst VRIII is used

examples = biphasic or long-acting insulin given twice daily

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8
Q

VRIII
what should be done about long-acting once daily insulin regimens whilst on VRIII?

A

should be continued at 80% normal dose whilst on VRIII

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9
Q

VRIII
are VRIII required in all T1DM and T2DM?

A

no

T1DM
- required if starved for prolonged periods
- major surgery

T2DM
- only required in blood glucose levels are poorly controlled or for major/emergency surgery
- if they fail to make their own insulin, treat like T1DM in perioperative period

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10
Q

VRIII
when are VRIII withdrawn?

A
  • when patient is able to eat and drink normally without nausea and vomiting
  • do not discontinue without ensuring the patient’s regular insulin has been restarted + administered in previous 30 mins
  • patient can be restarted on normal dose of insulin unless blood glucose indicates otherwise
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11
Q

DIABETES
what are the instructions for sulfonylureas (e.g. gliclazide) before surgery?

A

should be omitted on the morning of surgery

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12
Q

DIABETES
what are the instructions for pioglitazone before surgery?

A

taken as normal on the day of surgery

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13
Q

DIABETES
what are the instructions for DPP4 inhibitors (e.g. sitagliptin) before surgery?

A

taken as normal on the day of surgery

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14
Q

DIABETES
what are the instructions for SGLT-2 inhibitors (e.g. dapagliflozin) before surgery?

A

omitted on the morning of surgery
should also be omitted the day before surgery

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15
Q

DIABETES
what are the instructions for GLP-1 receptor agonists (e.g. liraglutide) before surgery?

A

taken as normal on the day of surgery

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16
Q

DIABETES
what are the rules for metformin?***

A
  • if one meal missed, eGFR >60 + low risk of AKI = continue metformin in peri-operative period (just omit lunchtime dose)
  • if >1 meal missed or high risk of AKI = metformin stopped when fasting begins (VRIII set up if metformin taken more than once daily)
17
Q

DIABETES
what is the concern with continuing metformin during surgery?

A
  • patient may develop lactic acidosis as metformin can build up
18
Q

DOACS
what are the rules for DOACs before surgery?

A
  • stop 24hrs before surgery with low bleeding risk
  • stop 48hrs before surgery with high bleeding risk

this is extended further for patients with poor renal function

19
Q

DOACS
when are they restarted after surgery?

A
  • considered on case-by-case basis depending on bleeding risk, haemostasis + renal function
  • typically 24-72hrs depending on drug
20
Q

WARFARIN
when should you stop warfarin before surgery?

A

at least 4-5 days prior to surgery

21
Q

WARFARIN
what should you give patients to bridge them from stopping warfarin to the post-op period?

A

when warfarin is stopped, start on LMWH

note LMWH should be stopped 24hrs before surgery

22
Q

LMWH
when should it be stopped before surgery?

A

at least 24 hrs before surgery

23
Q

CLOPIDOGREL
when should it be stopped before surgery?

A

7 days before surgery

24
Q

ACE INHIBITORS
when should ACEi be stopped before surgery?

A

the day before

25
Q

ORAL CONTRACEPTION
when should COCP be stopped before surgery?

A

4-6 weeks before surgery

26
Q

CONTRACEPTION
when should COCP be restarted following surgery?

A

2 weeks after surgery (when patient is mobile)

27
Q

ANAEMIA
what is the management of anaemia pre-operatively?

A

oral iron if >6 weeks until planned surgery
IV iron if <6 weeks until planned surgery

transfusion if profound anaemia + surgery cannot be delayed

28
Q

STEROIDS
are steroids stopped before surgery?

A

no take normal dose on morning of surgery

29
Q

STEROIDS
what is the management of steroids during and after surgery?

A

100mg IV hydrocortisone at induction

continuous infusion of IV hydrocortisone at rate of 200mg over 24hrs

when enteral feeding is re-established prescribe 10mg oral prednisolone + taper down to normal dose

30
Q

HERBAL MEDICINES
when should they be stopped before surgery?

A

7 days before surgery

31
Q

MAOIs
when should MAOIs be stopped before surgery?

A

14 days before surgery

32
Q

LITHIUM
when should lithium be stopped before surgery?

A

minor surgery = can be continued
major surgery = stopped 24hrs before surgery

33
Q

VTE PROPHYLAXIS
what is used for VTE prophylaxis?

A
  • compression stockings
  • mechanical calf compression
  • anticoagulants (LMWH e.g. dalteparin)
34
Q

PONV
what factors affect the risk of post-op N+V?

A
  • female
  • inhaled anaesthesia
  • drugs causing GI irritation (ferrous sulfate)
  • delayed gastric emptying (e.g. opioids)
  • type of surgery (abdo, ENT + gynae)
35
Q

PONV
what is the management?

A

MEDICAL
- 1st line = 5HT3 receptor antagonist ONDANSETRON (risk of QT prolong + constipation)
- H1 receptor antagonist CYCLIZINE (avoid in HF)
- D2 receptor antagonist PROCHLORPERAZINE (risk of extrapyramidal side effects)

MY REVISION - PSA (5 decks)

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