Surgery - Give, Omit or Discuss?

Question 1

“Cardiac” or blood pressure medication

Answer 1

GIVE

EXCEPT ACEi, AT2 antagonists and diuretics

Question 2

Aspirin

Answer 2

Usually safe to continue unless there is a high post-op bleed risk associated with the procedure

However, usually safe to STOP aspirin if used for primary prevention and this should stop 7 days pre-op

Question 3

Epilepsy or Parkinson’s medication

Answer 3

GIVE

Question 4

Asthma drugs or inhalers

Answer 4

GIVE

Question 5

PPIs

Answer 5

GIVE

Question 6

Thyroid medication

Answer 6

GIVE

Question 7

Major and minor tranquilisers which are taken regularly at home

Answer 7

GIVE

Question 8

Antidepressants

Answer 8

GIVE

EXCEPT irreversible MAOIS which need 2 weeks to stop pre-op

Question 9

Nicotine patches

Answer 9

GIVE

Question 10

Steroids taken regularly, including inhalers

Answer 10

GIVE

Question 11

Immunosuppressants and cancer drugs

Answer 11

GIVE

Question 12

Analgesics

Answer 12

GIVE

Question 13

Diabetic treatment

Answer 13

Oral diabetic medication usually OMITTED on the morning of surgery

Continuation and dosing of usual insulin on the day of surgery depends upon the usual insulin regime and time of operation

The need for additional subcutaneous insulin or VRIII is NOT routine practice and depends upon the blood glucose levels and number of meals likely to be missed.

Question 14

Clopidrogrel

Answer 14

STOP 7 days pre-op

Question 15

Dipyridamole

Answer 15

STOP (if used alongside another antiplatelet) 24 hours pre-op

GIVE if used on its own

Question 16

Warfarin

Answer 16

STOP

Take last dose of warfarin six days before surgery
Start LMWH 2 days after stopping warfarin
OMIT LMWH on the morning on the surgery and stop unfractionated heparin 6 hours before surgery

Question 17

NOACs

Answer 17

STOP several days before surgery to allow for reduction in their anticoagulant effect (depending on renal function and half life)

Question 18

Lithium

Answer 18

OMIT 24 hours pre-op unless a minor procedure

Question 19

Medications with are not essential in the short term (e.g. vitamins, iron, laxatives, osteoporosis treatment, antacid meds)

Answer 19

STOP

Question 20

Anticholinesterases for dementia

Answer 20

STOP Galantamine and Rivastigmine 24 hours pre-op

Donepezil not normally stopped due to long half-life, and would need to be stopped 2-3 weeks in advance (too much of a risk of decline of patient to do this)

Question 21

Combined oral contraceptive pill or HRT

Answer 21

STOPPED 4 weeks before elective surgery

If not possible, ensure anti-embolism stockings and prophylactic LMWH.

Question 22

ACEi

Answer 22

DISCUSS

These medicines may drop the BP during anaesthesia.

Local guidelines differ as to stopping or giving on the day of surgery.

Question 23

Diuretics

Answer 23

DISCUSS

These medicines may drop the BP during anaesthesia.

Local guidelines differ as to stopping or giving on the day of surgery.