psa Flashcards
BNF guidance recommends that if INR > 1.5 on the day before surgery
phytomenadione (vitamin K) 1–5 mg orally, using the IV preparation
Non LMWH VTE thromboprophylaxsis
Apixiban 2.5 mg oral twice a day
Antiplatelets and surgery
usually stopped up to 7 days before surgery
Male UTI low GFR
trimethoprim 200 mg orally 12-hrly for 7 days
Starting ACEi what biochem can you expect
small rise <20% in creatinine
Side effects: ACEi – Amlodipine – Amiodarone – Carbamazepine – Clozapine – Gliclazide – Metformin – Statins –
ACEi – cough, hyperkalaemia Amlodipine – oedema Amiodarone – pulmonary fibrosis, thyroid dysfunction Carbamazepine – hyponatraemia Clozapine – agranulocytosis Gliclazide – hypoglycaemia Metformin – lactic acidosis Statins – myalgia
Enzyme inducers
PC BRAS –
phenytoin, carbamazepine, barbiturates, rifampicin, alcohol (chronic excess) sulphonylureas.
Others: topiramate, St John’s Wort, and smoking
Enzyme inhibitors
AO DEVICES – allopurinol, omeprazole, disulfiram, erythromycin, valproate, isoniazid, ciprofloxacin, ethanol (acute intoxication), sulphonamides.
Others: grapefruit juice, amiodarone, and SSRIs (fluoxetine, sertraline).
ACEi monitoring
Renal function and electrolytes should be checked before starting ACE inhibitors (or increasing the dose) and monitored during treatment (more frequently if side effects mentioned are present
Review in antidepressant
How long before consider change
After remission?
Key electrolyte
Patients should be reviewed every 1–2 weeks at the start of antidepressant treatment
4 weeks (6 weeks in elderly)
continued at the same dose for at least 6 months (about 12 months in the elderly), or for at least 12 months in patients receiving treatment for generalised anxiety disorder (as the likelihood of relapse is high). Patients with a history of recurrent depression should receive maintenance treatment for at least 2 years.
hypoNa - consider if drowsy
Satisfactory INR
Within 0.5
Warfarin and surgery
If INR>1.5 day before surg
When to resume if haemostasis adequate
should be stopped 5 days before elective surgery;
phytomenadione (vitamin K1) by mouth given the day before surgery if the INR is ≥1.5.
If haemostasis is adequate, warfarin sodium can be resumed at the normal maintenance dose on the evening of surgery or the next day.
LMWH and surgery ?
High risk of bleeding surgery?
The low molecular weight heparin should be stopped at least 24 hours before surgery;
if the surgery carries a high risk of bleeding, it should not be restarted until at least 48 hours after surgery.
Pt on warfarin and emergency surgery?
If cant be delayed ?
delayed for 6–12 hours can be given intravenous phytomenadione (vitamin K1) to reverse the anticoagulant effect.
If surgery cannot be delayed, dried prothrombin complex can be given in addition to intravenous phytomenadione (vitamin K1) and the INR checked before surgery.
Bisphosphonates monitoring
Correct disturbances of calcium and mineral metabolism (e.g. vitamin-D deficiency, hypocalcaemia) before starting treatment. Monitor serum-calcium concentration during treatment.
reduce vasomotor symptoms in women who cannot take an oestrogen,
Clonidine hydrochloride
monitoring HRT
at least annually and for osteoporosis alternative treatments considered
Insulin therapy perameters
In adults
between 4 and 9 mmol/litre for most of the time (4–7 mmol/litre before meals and less than 9 mmol/litre after meals).
In children
between 4 and 10 mmol/litre for most of the time (4–8 mmol/litre before meals and less than 10 mmol/litre after meals).
Methotrexate monitoring
have full blood count and renal and liver function tests repeated every 1–2 weeks until therapy stabilised, thereafter patients should be monitored every 2–3 months.
be advised to report all symptoms and signs suggestive of infection, especially sore throat
Local protocols for frequency of monitoring may vary.
Statin contraception
Adequate contraception is required during treatment and for 1 month afterwards.
statin monitoring
What if raised ALT ?
Before treatment
at least one full lipid profile (non-fasting)
triglyceride concentrations
thyroid-stimulating hormone
and renal function should also be assessed.
Liver function
NICE suggests that liver enzymes should be measured before treatment, and repeated within 3 months and at 12 months of starting treatment,
Those with serum transaminases that are raised, but less than 3 times the upper limit of the reference range, should not be routinely excluded from statin therapy. Those with serum transaminases of more than 3 times the upper limit of the reference range should discontinue statin therapy.
Creatine kinase
Before initiation of statin treatment, creatine kinase concentration should be measured in patients who have had persistent, generalised, unexplained muscle pain (whether associated or not with previous lipid-regulating drugs); if the concentration is more than 5 times the upper limit of normal, a repeat measurement should be taken after 7 days. If the repeat concentration remains above 5 times the upper limit, statin treatment should not be started; if concentrations are still raised but less than 5 times the upper limit, the statin should be started at a lower dose.
Diabetes
Patients at high risk of diabetes mellitus should have fasting blood-glucose concentration or HbA1C checked before starting statin treatment, and then repeated after 3 months.
when titrating drugs, for example, thyroxine to get TSH in range….
Make the smallest incremental change possible
When can you start POP
“You can start the pill at any time if you are sure you are not pregnant. You will need to use condoms for the first seven days of taking the pill.”
POP - If one pill is missed or a new pack is started more than three hours* late ¹
Take the missed pill straight away, if you have missed more than one pill, only take one pill.”
“Take the next pill at the usual time you would take it, this might mean you have to take two pills in one day. Don’t worry, this is not harmful.”
“Unfortunately, you are not protected from pregnancy and therefore you should use condoms for the next two days. Continue to take your pills as you normally would.”
“If you have had sex in the time you have missed your pill, you may need to seek advice for emergency contraception.”
POP - If one pill is missed less than three hours* late
“Take the pill as soon as you remember to take it and then take your next pill at the usual time you would take it. You will be protected from pregnancy.”
*12 hours if it is the desogestrel progesterone only pill
COCP - 1 pill missed
“Take the missed pill straight away and continue taking the rest of the pack as normal. Emergency contraception is not needed.”
COCP - 2 Pills missed
“Take the most recent pill you missed straight away and leave any of the pills you missed before then. Use condoms or avoid sex for the next 7 days. If you have had sex in the previous seven days you need to seek advice for emergency contraception.”
What to do with the rest of the pack after a missed pill
If seven or more pills left in the pack:
If less than 7
“If there are seven or more pills left, then you should finish the pack and have the usual 7-day break”.
“If there are less than seven pills left in the pack then the pack should be finished and a new pack should be started the next day. This means taking the pills back to back.”
Initial resus fluids
500 ml bolus of a crystalloid solution in <15mins
can repeat up to 2000ml
Daily maintenance fluid requirements ?
Who does it change for>
25-30 ml/kg/day of water
1 mmol/kg/day of potassium, sodium and chloride and
50-100 g/day of glucose to limit starvation ketosis
[Elderly patients
Patients with renal impairment or cardiac failure
Malnourished patients at risk of refeeding syndrome
=20-25 ml/kg/day]
Maintenance fluids in obese
When prescribing routine maintenance fluids for obese patients you should adjust the prescription to their ideal body weight.
When use heparin over LMWH
in severe renal impairment
Unconcious hypo in hospital inital Mx
15 g glucose IV using a 20% solution
Glucagon 1mg IM is second line
Monitor BB in AF
Rate - rate control
Min urine output in fluid replacement
0.5ml/kg/hr
Usual urine output in 70kg
A healthy person will pass approximately 1 ml/kg/hour. This roughly equates to 1700 ml per day in a 70 kg
Na / K requirements per day
Sodium 100-150 mmol per day (1‒2 mmol/kg/day).
Potassium 30-60 mmol per day (0.5‒1 mmol/kg/day).
ACEi and surg
ACE inhibitors as a class are associated with marked hypotension following induction of anaesthesia.
Pre surg drugs - CASES Contraception Anticoagulants Steroids Ethanol Smoking
Contraception - VTE Anticoagulants - bleeding Steroids - need to prevent adisonian crisis Ethanol - withdrawal Smoking - lung disease
COCP and surg
The contraceptive pill only needs to be discontinued perioperatively if there is a high risk of thromboembolism
Missed 1 meal Insulin
Long acting ?
short ?
2 meals
long - lower by 20%
short - omit
2 meals - variable insulin infusion
When should metformin be ommited
on the day of the procedure and for the following 48 hours if:
eGFR is less than 60 ml/min/1.73m2,
radiocontrast media is to be used
VRIII is being used.
While on VRIII - long acting vs short acting insulin
long - continue at 80% dose
short - omit until eating and drinking normally without N+V
Restarting NOACs pre / post surg
stop these for a minimum of 24 hours prior to surgery, and 48 hours for those with poor renal function (CrCl 15-29 ml/min or less)
Reinitiation should be considered on a case-by-case basis depending on the bleeding risk of the procedure, haemostasis, and the patient’s renal function. This is typically 48-72 hours post-surgery.
MAOIs surg
The BNF advises they should be stopped 2 weeks before surgery due to the risk of hypo- and hypertension
BBs if prescribed for ischaemic heart disease - surg
they should not be abruptly discontinued, as the patient will be at higher risk of perioperative cardiovascular adverse events if stopped.
statin and surg
There is no need to omit these in the perioperative period.
lithium and surg
This is usually omitted the day before surgery and re-started postoperatively providing U&Es are normal.
Skin incision and Abx
a single full dose of a prophylactic antimicrobial should be administered 30-60 minutes before skin
Food and drink pre surg
In most adult elective surgery, without gastrointestinal disease, it is usual to restrict oral solids for 6 hours before surgery.
Clear fluids can be given until 2 hours before surgery.
Medications taken at night
statins
amitriptyline
Contra in pregnancy
ACE inhibitors, angiotensin II receptor antagonists statins warfarin sulfonylureas retinoids (including topical) cytotoxic agents
Abx : tetracyclines aminoglycosides sulphonamides and trimethoprim quinolones:
CI to COCP
Over 35 years and smoking more than 15 cigs/day is an absolute contraindication to the COCP.
When to check levels of
Lithium
Ciclosporin
Digoxin
Lithium
range = 0.4 - 1.0 mmol/l
take 12 hrs post-dose
Ciclosporin
trough levels immediately before dose
Digoxin
at least 6 hrs post-dose
Drugs to avoid in renal failure
antibiotics: tetracycline, nitrofurantoin
NSAIDs
lithium
metformin
Drugs accumulate in renal failure
digoxin, atenolol methotrexate sulphonylureas furosemide opioids
Avoid in breast feeding
antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides psychiatric drugs: lithium, benzodiazepines aspirin carbimazole methotrexate sulfonylureas cytotoxic drugs amiodarone
Drugs ok in breast feeding
antibiotics: penicillins, cephalosporins, trimethoprim
endocrine: glucocorticoids (avoid high doses), levothyroxine*
epilepsy: sodium valproate, carbamazepine
asthma: salbutamol, theophyllines
psychiatric drugs: tricyclic antidepressants, antipsychotics**
hypertension: beta-blockers, hydralazine
anticoagulants: warfarin, heparin
digoxin
How much morphine for breakthrough
1/6 of daily dose
2 drugs for long term prognosis heart failure
ACEi
BB
long term Steroids and illness
double dose
Drugs that worsen seizure control epilepsy
alcohol, cocaine, amphetamines ciprofloxacin, levofloxacin aminophylline, theophylline bupropion methylphenidate (used in ADHD) mefenamic acid
Digoxin toxicity monitor?
ECG
Digoxin levels
U+E - K
COPD oxygen therapy initial in exacerbation
28% Venturi mask at 4 l/min
Conversion of morphine to oxycodone
conversion factor of 1.5
150mg morphone = 100mg oxy
When do you need a tapering dose of corticosteroids
received more than 40mg prednisolone daily for more than one week
received more than 3 weeks treatment
recently received repeated courses
Key over counter pain killer to avoid if breastfeeding
Aspirin - risk of reyes
CI drugs in asthma
NSAIDs
beta-blockers
adenosine
Working out volume if eg 120mg/5ml
Dose = x
x /120 *5
[divide by top, then multiply by bottom]
High peak / trough in gentamycin
if the trough (pre-dose) level is high the interval between the doses should be increased
if the peak (post-dose) level is high the dose should be decreased
fluids in stroke
5% glucose should be avoided in patients who have had a stroke due to the increased risk of cerebral oedema.
Drugs that decrease hypogycaemic awareness in diabetes
BBs
Analgesic ladder
Step 1 Non-opioid analgesics
paracetamol
non-steroidal anti-inflammatory drugs (NSAIDs), including aspirin
Step 2 Mild opioid analgesics
codeine
dihydrocodeine
Step 3 Strong opioid analgesics
morphine
first line statin in CVD
Primary prevention?
Atorvastatin 80mg is now the first-line statin for patients with established cardiovascular disease, such as this patient with peripheral arterial disease.
Due to it’s longer half-life atorvastatin may be taken in the morning, unlike simvastatin.
For primary prevention, atorvastatin 20mg is now the first-line statin
500mcg/kg/hour. As she regularly takes ‘Uniphyllin Continus’ it is decided not to give a loading dose. She weighs 70kg. The nurse prepares a 1 litre bag of normal saline which contains 1g of aminophylline.
What is the correct infusion rate for the aminophylline?
The dose required is 500mcg/kg/hour. For a patient who weighs 70kg this equates to 0.5mg/kg/hour * 70kg = 35mg/hour.
The 1 litre bag of normal saline contains 1g of aminophylline. The concentration is therefore 1mg/ml.
The correct infusion rate is therefore 35ml/hour
Class of drug that should be avoided in heart failure as they may cause fluid retention
NSAIDS
Methotrexate main monitoring
FBC, LFT, U&E
Azathioprine main monitoring
FBC, LFT
Lithium main monitoring
Lithium level, TFT, U&E
Sodium valproate main monitoring
LFT
Glitazones main monitoring
LFT
Statin main monitoring
LFT
Amiodarone main monitoring
TFT, LFT
ACEi main monitoring
U+E
Drugs to avoid in IHD
NSAIDs
oestrogens: e.g. combined oral contraceptive pill, hormone replacement therapy
varenicline
HRT main monitoring
blood pressure
Insulin in DKA
Stop short acting
Continue long acring
Start Fixed rate insulin infusion
