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Pharmacotherapeutics Theory 2 > Pre and Post Operative Care > Flashcards

Pre and Post Operative Care Flashcards

1
Q

What is the Role of The Pharmacist in Pre and Post Operative Care?

A
  • Complete an accurate Medication History of the patients pre-admission
  • Work with the anaesthetist and the surgical team to make decisions on whether medications should be held or continued prior to surgery
  • Educate and if necessary organise the patients medication regimen pre-operatively (Webster Pack, Nursing home resident)
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2
Q

Pre-Operative Care – Anti-coagulation and Anti-platelets

  • What is there a balance between?
  • Patients are classed as what and how is this measured?
  • What other input may be required?
A
  • Balance between bleeding risk and thromboembolic complications
  • Class patient as ‘high risk’ or ‘low risk’ for thromboembolism
    • Guides decision as whether to hold anti-coagulation or if bridging therapy is required
    • Tools: CHA2DS2VASc, HAS-BLED
  • Haematology input may be required e.g. if a patient who has previously had heparin induced thrombocytopenia
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3
Q

Pre-Operative Care – Anti-coagulation and Anti-platelets

  • What are the Guidelines for High Risk Patients?
    • Warfarin held for?
    • Enoxaparin initiated for?
      • What must be assessed before initiating?
      • Last dose of enoxaparin before surgery?
  • What needs to be checked the morning of procedure?
  • If INR > 1.5?
A
  • Hold warfarin 5 days prior to procedure
  • Initiate enoxaparin 3 days before surgery
    • Assess the patients estimated CrCl before recommending a dose
    • Last dose of enoxaparin to be given 24hrs pre-operatively at half therapeutic dose – patient will need education on when to cease the enoxaparin
  • Check INR morning of procedure (aim INR <1.5) – patients bleeding risk reduced if INR <1.5
    • If INR >1.5, vitamin K indicated
      • Depending on the type and length of surgery, reversal of warfarin may be necessary even after holding for 5 days
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4
Q

Pre-Operative Care – Anti-coagulation and Anti-platelets

  • What are the Guidelines for Low-Risk Patients?
    • Is bridging therapy required?
    • Warfarin held when?
    • What needs to be checked?
A
  • No bridging therapy required
  • Hold warfarin for 5 days prior to procedure
  • Check INR morning of procedure (aim INR <1.5)
    • If INR >1.5, vitamin K indicated
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5
Q

Pre-Operative Care – Anti-coagulation and Anti-platelets

  • Warfarin Post Surgery
    • When can warfarin and enoxaparin be re-started?
      • What must patients have?
      • What needs to be monitored?
      • When can enoxaparin cease?
A
  • Warfarin and enoxaparin can usually be re-started 24-72 hrs post surgery
    • Patients need to have adequate haemostasis (Hb, platelets, INR etc) – bloods monitored daily to ensure this
      • Renal function monitored and enoxaparin dose adjusted accordingly
    • Enoxaparin can cease when INR therapeutic
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6
Q

Pre-Operative Care – Anti-coagulation and Anti-platelets

  • What risk must be reviewed to determine medication plan pre-operatively?
  • What changes the length of time they need to be held compared to warfarin?
  • What must be assessed?
  • When can they be re-started?
    • Minor procedures
    • Major procedures
A
  • Risk of bleeding vs thromboembolism must be reviewed to determine medication plan pre-operatively
  • DOACs have shorter t1/2 lives compared to warfarin which changes the length of time they need to be held pre-operatively
  • Renal function must be assessed
    • If GFR >80mL/min allow >24hrs between last dose of DOAC and surgery
  • Re-starting:
    • 24 hrs post-surgery for minor procedures
    • 48-72hrs for major procedures
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7
Q

Pre-Operative Care – Anti-coagulation and Anti-platelets

  • Pre-operative Interruption of Anti-Platelets
    • Low risk patients may need to hold?
    • High risk patients may need to hold?
A
  • Low-risk patients may need to hold anti-platelet therapy pre-operatively
    • E.g. patients on anti-platelet therapy for secondary prevention of MI
    • Hold anti-platelets 7 days pre-operatively
  • High risk patients on dual anti-platelet therapy usually continue aspirin and hold second anti-platelet
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8
Q

Pre-Operative Care – Diabetes Medications

  • Diabetes Medicine Management in the Pre-Operative Setting
    • Diabetics have a high what? Following surgery?
    • Hyperglycaemia increases patients risk of what?
    • What measurement should all diabetics have taken pre-operatively?
    • Insulin-dependent diabetics (both Type 1 and Type 2) should be scheduled what?
A
  • Diabetics have a higher incidence of morbidity and mortality following surgery
  • Hyperglycaemia increases the patients risk of post-operative complications e.g. post-op infection
  • All diabetics should have their HbA1c taken pre-operatively. When HbA1c >8%, the procedure may need to be re-scheduled
  • Insulin-dependent diabetics (both Type 1 and Type 2) should be scheduled first on the operating list
    • Fasting and/or holding diabetes medication can lead to hypoglycaemia
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9
Q

Pre-Operative Care – Diabetes Medications

  • What are the Guideline Recommendations for Metformin?
    • When should it be held?
    • What may it increase the risk of?
    • Consider holding SR when?
    • When can it be restarted?
A
  • Hold morning of surgery – may increase risk of renal insufficiency and increase patients risk of lactic acidosis
  • Consider holding SR preparations evening before surgery
  • Can re-start post-operatively when CrCl > 30mL/min
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10
Q

Pre-Operative Care – Diabetes Medications

What are the Guideline Recommendations for Sulfonylureas?

  • When is it held?
  • Consider holding SR preparations when?
A
  • Hold morning of surgery – patient will be fasting, therefore reduce risk of hypoglycaemia
  • Consider holding slow release preparations evening before surgery
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11
Q

Pre-Operative Care – Diabetes Medications

What are the Guideline Recommendations for GLP-1 analogues (exenatide, liraglutide)?

  • When is it held and restarted?
  • What are known adverse effects?
A
  • Hold morning of surgery – restart when patient eating and drinking again post-operatively
  • Known adverse effects of GLP-1 analogues are GI upset and delayed gastric emptying
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12
Q

Pre-Operative Care – Diabetes Medications

What are the Guideline Recommendations for Thiazolidinediones (rosiglitazone, pioglitazone)?

  • When is it held?
  • What can it contribute to?
A
  • Hold morning of surgery
  • Can contribute to fluid retention
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13
Q

Pre-Operative Care – Diabetes Medications

What are the Guideline Recommendations for DPP-4 inhibitors (sitalgliptin)?

  • When are they held?
  • What are they restarted?
A
  • Hold morning of surgery
  • Can restart when patient eating and drinking again post-operatively
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14
Q

Pre-Operative Care – Diabetes Medications

What are the Guideline Recommendations for SGLT2 inhibitors?

  • What are they associated with?
  • Severe ketosis can occur when?
  • When is it held?
  • What was the previous recommendation?
A
  • Associated euglycemic diabetic ketoacidosis
  • Severe ketosis can occur when BGL < 16mmol/L
  • Hold 3 days pre-op (48 hrs prior to the day of surgery – day of surgery = day 0)
  • Previously the recommendation was to hold the morning of surgery
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15
Q

Pre-Operative Care – Diabetes Medications

What are the Guideline Recommendations for Pre-op Insulin Modification on the Day of Procedure?

  • Long acting insulins?
  • Ultra-short, short and intermediate acting insulins?
A
  • Long-acting insulins can be halved or held the evening prior and morning of surgery
  • Ultra-short, short and intermediate acting insulins can be held morning of surgery
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16
Q

Post-Operative Care – Nausea and Vomiting

  • What are known risk factors?
A
  • Preoperative nausea and vomiting
  • Female gender
  • Previous hx of motion sickness and/or PONV
  • Non-smoker
  • Age < 50 years
  • Type of anaesthesia
  • Opioid use
  • Type and length of surgery
17
Q

Post-Operative Care – Nausea and Vomiting

  • How is PONV predicted?
A
  • Apfel’s simplified scoring system predicts the likelihood a patient will have PONV
  • Each Apfel point increases the incidence of PONV by approximately 20%
18
Q

Post-Operative Care – Nausea and Vomiting

  • Prophylaxis Treatment of PONV
    • Who receives preventative treatment?
    • What drugs are used? Are they equally effective?
    • What affects their risk?
A
  • Patient’s identified as high-risk of PONV should be considered for preventative treatment
  • Ondansetron, droperidol and dexamethasone have all been shown to be similarly effective
  • Type of anaesthesia will affect their risk
    • Using propofol instead of a volatile anaesthetic (isoflurane, desflurane) reduces PONV by up to 19%
    • Substituting nitrogen for nitrous oxide can reduce PONV by up to 12%
19
Q

Post-Operative Care – Nausea and Vomiting

  • Opioids contribute to PONV
    • What can reduce PONV?
    • NSAIDs?
    • IV Paracetamol?
A
  • Multi-modal analgesia that include opioid-sparing medications can reduce PONV e.g. ketamine, pregabalin, NSAIDs
  • NSAIDs have a 30%-50% opioid sparring effect and a reduction in PONV by 30%
  • IV paracetamol administered pre-operatively to reduce PONV (due to the analgesia)
20
Q

Post-Operative Care – Nausea and Vomiting

  • What is rescue therapy for PONV?
A
  • Is the patient experiencing nausea or vomiting within 48 hours of surgery?
  • Presence of contributing factors:
    • Inadequate pain relief
    • Opioid use
    • Hypotension
    • Hydration
    • Ileus
    • Blood in throat or stomach
    • Sudden movement
  • Did the patient receive any anti-emetic intra-operatively? E.g. prophylactic treatment
21
Q

Post-Operative Care – Nausea and Vomiting

  • What are the Risks associated with Ondansetron?
A
  • Serotonin syndrome
  • Long QT interval
  • Pregnancy
  • Apomorphine
22
Q

Post-Operative Care – Nausea and Vomiting

What are the Risks associated with Droperidol?

A
  • Significant cardiac disease e.g. bradycardia, long QT
  • Other drugs prolonging to QT e.g. amiodarone
  • Parkinson’s disease
  • Phaeochromocytoma
23
Q

Post-Operative Care – Nausea and Vomiting

What are the Risks associated with Dexamethasone?

A

Active Infection

24
Q

Post-Operative Care – Nausea and Vomiting

What are the Risks associated with Cyclizine?

A

Sedation

25
Q

Post-Operative Care – Nausea and Vomiting

How are the risks associated with anti-emetics managed?

A
  • Alternate anti-emetic available?
  • Can the patient be monitored? E.g. ECG
  • Lower dose more suitable?
  • Risk vs benefit of the patient receiving the anti-emetic?
26
Q

Prophylactic Antibiotics

  • When are they indicated?
  • What is the choice of abx based on?
A
  • Prophylactic abx aren’t always indicated. They are considered if post-operatively there is a significant risk of infection
  • The choice of abx should be based on which organism is most likely to cause the infection post-operatively e.g. staphylococcus aureus for plastic surgery
27
Q

Prophylactic Antibiotics

  • What considerations are taken into account prior to prescribing?
A
  • Individual risk factors
    • High risk of MRSA
    • Renal function
    • Allergies
  • Type of surgery
    • E.g. small bowel resection vs. vascular surgery
  • Timing of abx administration
    • IV bolus should be administered 15-30 mins prior to incision
    • IV infusion should begin 30-120 mins prior to incision
28
Q

Prophylactic Antibiotics

Guidelines for Plastic Surgery

  • Types of Surgery
  • Treatment Regimen
    • First line
    • MRSA risk
    • Penicillin Allergy
A
  • Types of Surgery
    • Open reduction and internal fixation of fractures
    • Insertion of implants, mesh, prosthesis, screws, plates etc
    • Minor excisions and removal of non-infected lesions don’t require abx prophylaxis
  • Treatment
    • First line = cefazolin 2g IV – coverage of staphylococcus aureus
    • High-risk of MRSA = add vancomycin 1g IV infusion to cefazolin
    • Severe penicillin allergy = substitute cefazolin for vancomycin 1g IV infusion
29
Q

Prophylactic Antibiotics​

  • GI Surgery
    • Types?
  • Treatment Regimen?
    • MRSA?
    • Penicillin Allergy?
A
  • Types:
    • Colorectal: small bowel resection, appendectomy
    • Liver resection
    • Exploratory laparotomy/division of adhesions
    • Abx will need to provide anaerobic cover and potentially gram-negative bacilli
  • Choice of Prophylactic Abx:
    • Metronidazole 500mg IV PLUS either
      • Cefazolin 2g IV or gentamicin 2mg/kg IV
      • High risk of MRSA = add vancomycin 1g IV infusion
      • Penicillin allergy = substitute cefazolin with vancomycin 1g IV infusion

Pharmacotherapeutics Theory 2 (17 decks)

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