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National Teaching Series Prescribing in Surgery Series Prescribing in Pre-op DATE: 12/03/2024 TIME: 18:30 Tutor: Dr Aisha Musa Prescribing in Surgery Series 2024DISCLAIMER The Prescribing in Surgery for Mind the Bleep has been created by junior doctors who have a passion for teaching, entirely on a voluntary basis. The lecture slides and teaching content are accurate to the best of the tutors’ knowledge. Please note, that neither the tutors nor Mind the bleep take responsibility for any unintentionalinaccuracies. Please kindly refer to the full T&C for your reference: https://www.mindthebleep.com/disclaimer/ Prescribingin SurgerySeries2024Surgical prescribing session Provisional date 1: VTE prophylaxis and analgesia 20/02/24 @ 18.30 2: Fluids and electrolyte imbalances 27/02/24 @ 18.30 3: Antibiotics and blood transfusions06/03/24 @ 18.30 4: Prescribing in pre-op 12/03/24 @ 18.30 5: Diabetes medications 19/03/24 @ 18.30 6: Surgical emergencies 1 09/04/24 @ 18.30 7: Surgical emergencies 2 16/04/24 @ 18.30 8: General surgery, colorectal, urolo23/04/24 @ 18.30 9: T+O, ENT, Paediatrics 30/04/24 @ 18.30 10: Surgical questions in PSA 07/05/24 @ 18.30 Prescribingin SurgerySeries2024Case 1 Case presentation A 78-year-old male is seen in the pre-operative clinic 2 DECISION OPTIONS weeks before his elective knee replacement for severe osteoarthritis in his left knee. Continue warfarin A PMH: Atrial fibrillation, Stroke 1 year ago, Osteoarthritis Stop warfarin 2 weeks before surgery B MH: Warfarin, Bisoprolol. Allergies: Nil. Stop warfarin 5 days before surgery C Weight 84 kg. Stop warfarin 5 days before surgery D Question: and prescribe treatment dose LMWH in interim Avoid surgery as he is very high risk for E Pre-operatively how will you manage his warfarin thrombosis Prescription? Prescribingin SurgerySeries2024Case 1 Case presentation A 78-year-old male is seen in the pre-operative clinic 2 DECISION OPTIONS weeks before his elective knee replacement for severe osteoarthritis in his left knee. Continue warfarin A PMH: Atrial fibrillation, Stroke 1 year ago, Osteoarthritis Stop warfarin 2 weeks before surgery B MH: Warfarin, Bisoprolol. Allergies: Nil. Stop warfarin 5 days before surgery C Weight 84 kg. Stop warfarin 5 days before surgery D Question: and prescribe treatment dose LMWH in interim Avoid surgery as he is very high risk for E Pre-operatively how will you manage his warfarin thrombosis Prescription? Prescribingin SurgerySeries2024BNF-NICE, 2024 [1] Prescribing in Surgery Series 2024Maidstone and Tunbridge Wells NHS trust, 2019 [2] Prescribing in Surgery Series 2024Maidstone and Tunbridge Wells NHS trust, 2019 [2] Prescribing in Surgery Series 2024Maidstone and Tunbridge Wells NHS trust, 2019 [2] Prescribing in Surgery Series 2024Maidstone and Tunbridge Wells NHS trust, 2019 [2] Prescribing in Surgery Series 2024 Case 2 Case presentation A 65-year-old male presents with urinary frequency, Hesitancy, straining, weak flow and has noticed blood in his DECISION OPTIONS urine. PMH: VTE 1 year ago secondary to malignancy. He has Continue Apixaban but monitor for signs of A undergone TURBT for bladder cancer. bleeding MH: Apixaban. Allergies: Nil Hold apixaban 24 hours before B Hold apixaban 48 hours before C His Creatinine clearance (CrCl) is 60. Hold apixaban 72 hours before D DRE- hard mass on palpation of prostate PSA > 3 ng/ml Apixaban is contraindicated with his CrCl E Multiparametric MRI prostate scan is conducted, and prostate biopsy is advised. He is scheduled for a prostate biopsy in 2 days to investigate for prostate cancer. Question Prior to his prostate biopsy how will you manage his apixaban prescription? Prescribingin SurgerySeries2024 Case 2 Case presentation A 65-year-old male presents with urinary frequency, Hesitancy, straining, weak flow and has noticed blood in his DECISION OPTIONS urine. PMH: VTE 1 year ago secondary to malignancy. He has Continue Apixaban but monitor for signs of A undergone TURBT for bladder cancer. bleeding MH: Apixaban. Allergies: Nil Hold apixaban 24 hours before B Hold apixaban 48 hours before C His Creatinine clearance (CrCl) is 60. Hold apixaban 72 hours before D DRE- hard mass on palpation of prostate PSA > 3 ng/ml Apixaban is contraindicated with his CrCl E Multiparametric MRI prostate scan is conducted, and prostate biopsy is advised. He is scheduled for a prostate biopsy in 2 days to investigate for prostate cancer. Question Prior to his prostate biopsy how will you manage his apixaban prescription? Prescribingin SurgerySeries2024MDCalc 2024 [3] Prescribing in Surgery Series 2024Maidstone and Tunbridge Wells NHS trust, 2019 [2] Prescribing in Surgery Series 2024Maidstone and Tunbridge Wells NHS trust, 2019 [2] Prescribing in Surgery Series 2024Case 3 Case presentation A 29-year-old female presents to pre-operative clinic 1 week before her elective c-section. She is 37 weeks DECISION OPTIONS pregnant with twins. She does not require intraoperative steroid A PMH: Myasthenia gravis cover MH: Prednisolone 60 mg daily maintenance dose (taken for 4 months) Betamethasone 1 application B Triamcinolone 15 mg intra-articular injection C Allergies: Nil Methylprednisolone 1 g IV D Hydrocortisone 50 mg IV E Question What would you prescribe during her c-section at induction? Prescribingin SurgerySeries2024Case 3 Case presentation A 29-year-old female presents to pre-operative clinic 1 week before her elective c-section. She is 37 weeks DECISION OPTIONS pregnant with twins. She does not require intraoperative steroid A PMH: Myasthenia gravis cover MH: Prednisolone 60 mg daily maintenance dose (taken for 4 months) Betamethasone 1 application B Triamcinolone 15 mg intra-articular injection C Allergies: Nil Methylprednisolone 1 g IV D Hydrocortisone 50 mg IV E Question What would you prescribe during her c-section at induction? Prescribingin SurgerySeries2024BNF- NICE, 2024 [4] Prescribing in Surgery Series 2024Case 4 Case presentation A 48-year-old man is undergoing a minor procedure (skin abscess drainage) tomorrow morning. DECISION OPTIONS PMH: T2DM Day before reduce dose by 20% A MH: Metformin 500 mg twice daily, Humulin I 10 units No dose adjustment needed B once daily (evening) Allergies: Nil Omit Humulin I, day before procedure C HBA1C 60 mmol/mol Day before reduce dose by 60% D eGFR: 70 Day before reduce dose by 30% E Question Prior to his minor procedure tomorrow morning, how should we manage his Humulin I prescription? Prescribingin SurgerySeries2024Case 4 Case presentation A 48-year-old man is undergoing a minor procedure (skin abscess drainage) tomorrow morning. DECISION OPTIONS PMH: T2DM Day before reduce dose by 20% A MH: Metformin 500 mg twice daily, Humulin I 10 units No dose adjustment needed B once daily (evening) Allergies: Nil Omit Humulin I, day before procedure C HBA1C 60 mmol/mol Day before reduce dose by 60% D eGFR: 70 Day before reduce dose by 30% E Question Prior to his minor procedure tomorrow morning, how should we manage his Humulin I prescription? Prescribingin SurgerySeries2024BNF- NICE, 2024 [5] Prescribing in Surgery Series 2024Centre for Perioperative Care (CPOC), 2023 [6] Prescribing in Surgery Series 2024Case 5 Case presentation A 57-year-old man is scheduled for an outpatient Coronary angiogram tomorrow to diagnose coronary DECISION OPTIONS heart disease. Continue metformin twice daily A PMH: T2DM MH: Metformin 500 mg BD Allergies: Penicillin Reduce to metformin once daily B Omit metformin on the day of the procedure C eGFR: 55 but continue the next day Omit metformin on the day of the procedure D and for the following 48 hours Omit metformin on the day of the procedure E and for the following 72 hours Question Prior to his Coronary angiogram tomorrow, how should we manage his metformin prescription? Prescribingin SurgerySeries2024Case 5 Case presentation A 57-year-old man is scheduled for an outpatient Coronary angiogram tomorrow to diagnose coronary DECISION OPTIONS heart disease. Continue metformin twice daily A PMH: T2DM MH: Metformin 500 mg BD Allergies: Penicillin Reduce to metformin once daily B Omit metformin on the day of the procedure C eGFR: 55 but continue the next day Omit metformin on the day of the procedure D and for the following 48 hours Omit metformin on the day of the procedure E and for the following 72 hours Question Prior to his Coronary angiogram tomorrow, how should we manage his metformin prescription? Prescribingin SurgerySeries2024BNF- NICE, 2024 [5] Prescribing in Surgery Series 2024Case 6 Case presentation A 60-year-old male is scheduled for a hip replacement today for his severe right hip osteoarthritis. DECISION OPTIONS PMH: T2DM, Osteoarthritis. Continue standard rate VRII A MH: Metformin 500 mg BD, Lantus 10 units OD (morning). Prescribe reduced rate VRII B Prescribe increased rate VRII C He is started on standard rate VRII. Stop VRII and give 20% glucose 100 ml IV His Lantus is reduced to 8 units. D Metformin is held whilst on VRII. Give VRII at rate of 2 units/hr E CBG (Capillary blood glucose) is measured hourly. Nurse informs you that his CBG is now 2. Question Considering his CBG is 2, how should we manage his VRII prescription? Prescribingin SurgerySeries2024Case 6 Case presentation A 60-year-old male is scheduled for a hip replacement today for his severe right hip osteoarthritis. DECISION OPTIONS PMH: T2DM, Osteoarthritis. Continue standard rate VRII A MH: Metformin 500 mg BD, Lantus 10 units OD (morning). Prescribe reduced rate VRII B Prescribe increased rate VRII C He is started on standard rate VRII. Stop VRII and give 20% glucose 100 ml IV His Lantus is reduced to 8 units. D Metformin is held whilst on VRII. Give VRII at rate of 2 units/hr E CBG (Capillary blood glucose) is measured hourly. Nurse informs you that his CBG is now 2. Question Considering his CBG is 2, how should we manage his VRII prescription? Prescribingin SurgerySeries2024JBDS-IP, 2016 [7] Prescribing in Surgery Series 2024BNF- NICE, 2024 [5] Prescribing in Surgery Series 2024Doncaster and Bassetlaw NHS trust, 2021 [8] Prescribing in Surgery Series 2024Doncaster and Bassetlaw NHS trust, 2021 [8] Prescribing in Surgery Series 2024Case 7 Case presentation A 63-year-old female is scheduled for an elective Haemorrhoidectomy tomorrow morning. DECISION OPTIONS PMH: T2DM. Continue as normal A MH: Metformin 500 mg BD Pioglitazone 30 mg OD. Omit the day before surgery B Allergies: Nil eGFR: 80 Omit on the morning of the surgery C Reduce dose by 20% D Omit on the morning of the surgery and the E following 24 hours after Question How would you manage her Pioglitazone prescription pre- operatively? Prescribingin SurgerySeries2024Case 7 Case presentation A 63-year-old female is scheduled for an elective Haemorrhoidectomy tomorrow morning. DECISION OPTIONS PMH: T2DM. Continue as normal A MH: Metformin 500 mg BD Pioglitazone 30 mg OD. Omit the day before surgery B Allergies: Nil eGFR: 80 Omit on the morning of the surgery C Reduce dose by 20% D Omit on the morning of the surgery and the E following 24 hours after Question How would you manage her Pioglitazone prescription pre- operatively? Prescribingin SurgerySeries2024BNF- NICE, 2024 [5] Centre for Perioperative Care (CPOC), 2023 [6] Prescribing in Surgery Series 2024Case 8 Case presentation A 34-year-old female is seen in the pre-operative clinic. She is scheduled for an elective inguinal hernia repair in 6 DECISION OPTIONS weeks. Stop COCP 3 weeks before surgery A PMH: Eczema MH: COCP Allergies: Nil Continue COCP but monitor for signs of B thrombosis Stop COCP 4 weeks before surgery and provide C alternative contraceptive Question Stop COCP 2 weeks before surgery D Prior to her elective hernia repair how will you manage her COCP prescription? Stop COCP 1 day before surgery and provide E alternative contraceptive Prescribingin SurgerySeries2024Case 8 Case presentation A 34-year-old female is seen in the pre-operative clinic. She is scheduled for an elective inguinal hernia repair in 6 DECISION OPTIONS weeks. Stop COCP 3 weeks before surgery A PMH: Eczema MH: COCP Allergies: Nil Continue COCP but monitor for signs of B thrombosis Stop COCP 4 weeks before surgery and provide C alternative contraceptive Question Stop COCP 2 weeks before surgery D Prior to her elective hernia repair how will you manage her COCP prescription? Stop COCP 1 day before surgery and provide E alternative contraceptive Prescribingin SurgerySeries2024 BNF- NICE, 2024 [9] Prescribing in Surgery Series 2024BNF- NICE, 2024 [10] Prescribing in Surgery Series 2024References th [1] NICE (2024) BNF, NICE Oral anticoagulants. Available at: https://bnf.nice.org.uk/treatment-summaries/oral-anticoagulants/ (Accessed: 6 March 2024) [2] Maidstone and Tunbridge Wells NHS trust (2019). Algorithm for the peri-operativemanagement of Anticoagulants and Antiplatelet agents in Adult patients. Available at: https://www.mtw.nhs.uk/wp-content/uploads/2015/09/Algorithm-for-Perioperative-Management-of- Anticoagulation1.pdf (Accessed: 6 March 2024) [3] MDCalc (2024) Creatinine clearance (Cockroft-Gault Equation). Available at: https://www.mdcalc.com/calc/43/creatinine-clearance- th cockcroft-gault-equation (Accessed: 6 March 2024) [4] NICE (2024) BNF, NICE Hydrocortisone. Available at: https://bnf.nice.org.uk/drugs/hydrocortisone/ (Accessed: 11 March 2024) [5] NICE (2024) BNF, NICE Diabetes, surgery and medical illness. Available at: https://bnf.nice.org.uk/treatment-summaries/diabetes-surgery- th and-medical-illness/ (Accessed: 6 March 2024) [6] Centre for Perioperative Care (CPOC) (2023) Guideline for Perioperative Care for People with Diabetes Mellitus Undergoing Elective And Emergency Surgery. Available at: https://cpoc.org.uk/sites/cpoc/files/documents/2023-10/CPOC-DiabetesGuideline2023.pdf (Accessed: 7 th March 2024) [7] JBDS-IP (2016) Management of adults with diabetes undergoing surgery and elective procedures: Improving standards. Available at: https://www.diabetes.org.uk/resources-s3/2017-09/Surgical%20guideline%202015%20- %20summary%20FINAL%20amended%20Mar%202016.pdf (Accessed: 7 March 2024) th [8] Doncaster and Bassetlaw NHS trust (2021) Variable rate Intravenous Insulin Infusion Guidelines for Adults. Available at: file:///C:/Users/User/Downloads/patt76.pdf (Accessed: 7 March 2024) [9] NICE (2024) BNF, NICE Contraceptives, hormonal. Available at: https://bnf.nice.org.uk/treatment-summaries/contraceptives-hormonal/ th (Accessed: 7 March 2024) [10] NICE (2024) BNF, NICE Surgery and long-term medication. Available at: https://bnf.nice.org.uk/treatment-summaries/surgery-and-long- term-medication/ (Accessed: 7 March 2024) Prescribing in Surgery Series 2024Feedback form