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National Teaching Series Prescribing in Surgery Series DATE: 20/02/2024 TIME: 18:30 Tutor: Dr Hermione Jemmett Prescribing in Surgery Series 2024Prescribing in Surgery Series 2024 National teaching Prescribing in Surgery Dr Hermione Jemmett Dr Sona Petrosyan Dr Aisha Musa Co-lead for Prescribing in Lead for Prescribing at Co-lead for Prescribing in Surgery series Mind the Bleep Surgery series MEET THE TEAM 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 unintentional inaccuracies. Please kindly refer to the full T&C for your reference: https://www.mindthebleep.com/disclaimer/ Prescribing in Surgery Series 2024Surgical 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, urology 23/04/24 @ 18.30 9: T+O, ENT, Paediatrics 30/04/24 @ 18.30 10: Surgical questions in PSA 07/05/24 @ 18.30 Prescribing in Surgery Series 2024Case 1 Case presentation A 53 year old female who is admitted with a 1-day hx of RUQ pain, fever and associated bilious vomiting. Her BMI is 41.9 (H 156cm, W 102kg). On examination she is DECISION OPTIONS Murphey’s positive. She is diagnosed with acute Warfarin 2mg A cholecystitis and is admitted under general surgery. She undergoes laparoscopic cholecystectomy. She stays in Dalteparin 5000 units OD B hospital for 5 days. Apixaban 2.5mg BD C Aspirin 75mg OD Bloods on admission D Dalteparin 10,000 units OD E Hb 130 CRP 121 Wcc 16.7 eGFR >60 Neutrophils 4.99 Bili 61 Lymphocyte 1.10 ALT 314 Platelets 261 ALP 109 Question Whilst an inpatient, what VTE prophylaxis should she be on as a 24-hour regime? Prescribing in Surgery Series 2024Case 1 Case presentation A 53 year old female who is admitted with a 1-day hx of RUQ pain, fever and associated bilious vomiting. Her BMI is 41.9 (H 156cm, W 102kg). On examination she is DECISION OPTIONS Murphey’s positive. She is diagnosed with acute Warfarin 2mg A cholecystitis and is admitted under general surgery. She undergoes laparoscopic cholecystectomy. She stays in Dalteparin 5000 units OD B hospital for 5 days. Apixaban 2.5mg BD C Aspirin 75mg OD Bloods on admission D Dalteparin 10,000 units OD E Hb 130 CRP 121 Wcc 16.7 eGFR >60 Neutrophils 4.99 Bili 61 Lymphocyte 1.10 ALT 314 *Local protocols use dose adjustment with VTE Platelets 261 ALP 109 prophylaxis - Dalteparin 5000 units BD Question Whilst an inpatient, what VTE prophylaxis should she be on as a 24 hour regime? Prescribing in Surgery Series 2024[1] Prescribing in Surgery Series 2024 [1] Prescribing in Surgery Series 2024 [1] Prescribing in Surgery Series 2024 [2] Prescribing in Surgery Series 2024 [3] Prescribing in Surgery Series 2024 [5] Prescribing in Surgery Series 2024Case 2 Case presentation 4 days after operation, she is clinically improving. She has a set of bloods: Bloods 4 days post-op DECISION OPTIONS Hb 127 CRP 48 Decrease dose to 2500 units OD A Wcc 8.2 eGFR 52 Neutrophils 4.89 Bili 22 No change B Lymphocytes 1.10 ALT 191 Platelets 145 ALP 100 Increase dose to 7500 units OD C Stop VTE prophylaxis D Initial bloods Stop Dalteparin and switch to fondaparinux E Hb 130 CRP 121 Wcc 16.7 eGFR >60 Neutrophils 4.99 Bili 61 Lymphocyte 1.10 ALT 314 Platelets 261 ALP 109 Question What, if any changes, would you make to the VTE prophylaxis prescription following these results? Prescribing in Surgery Series 2024Case 2 Case presentation 4 days after operation, she is clinically improving. She has a set of bloods: Bloods 4 days post-op DECISION OPTIONS Hb 127 CRP 48 Decrease dose to 2500 units OD A Wcc 8.2 eGFR 52 Neutrophils 4.89 Bili 22 No change B Lymphocytes 1.10 ALT 191 Platelets 145 ALP 100 Increase dose to 7500 units OD C Stop VTE prophylaxis D Initial bloods Stop Dalteparin and switch to fondaparinux E Hb 130 CRP 121 Wcc 16.7 eGFR >60 Neutrophils 4.99 Bili 61 Lymphocyte 1.10 ALT 314 Platelets 261 ALP 109 Question What, if any changes, would you make to the VTE prophylaxis prescription following these results? Prescribing in Surgery Series 2024Case 3 Case presentation A 73 year-old female is admitted to trauma and orthopaedics with a NOF fracture. She undergoes surgery and has pins to secure the fracture. Her PMHx includes osteoporosis, rheumatoid arthritis, glaucoma, long QT DECISION OPTIONS syndrome and gout. Allergies include codeine, tramadol. Paracetamol 500mg QDS, Morphine sulphate A She weighs 47kgs and is 140cm tall. 5mg QDS, Morphine sulphate 2.5mg PRN Bloods: Co-codamol 30/500 QDS, Morphine sulphate B Hb 109 5mg PRN Wcc 4.3 Morphine MST 10mg BD, paracetamol 500mg C Platelets 220 PRN Urea 8.0 Paracetamol 1g QDS, Morphine sulphate 5mg D eGFR 46 QDS, Morphine sulphate 2.5mg PRN Dihydrocodeine 30mg QDS, morphine E sulphate IR 5mg QDS, morphine sulphate 5mg Question PRN What analgesia would you prescribe her on admission? Prescribing in Surgery Series 2024Case 3 Case presentation A 73 year-old female is admitted to trauma and orthopaedics with a NOF fracture. She undergoes surgery and has pins to secure the fracture. Her PMHx includes osteoporosis, rheumatoid arthritis, glaucoma, long QT DECISION OPTIONS syndrome and gout. Allergies include codeine, tramadol. Paracetamol 500mg QDS, Morphine sulphate A She weighs 47kgs and is 140cm tall. 5mg QDS, Morphine sulphate 2.5mg PRN Bloods: Co-codamol 30/500 QDS, Morphine sulphate B Hb 109 5mg PRN Wcc 4.3 Morphine MST 10mg BD, paracetamol 500mg C Platelets 220 PRN Urea 8.0 Paracetamol 1g QDS, Morphine sulphate 5mg D eGFR 46 QDS, Morphine sulphate 7.5mg PRN Dihydrocodeine 30mg QDS, morphine E sulphate IR 5mg QDS, morphine sulphate 5mg Question PRN What analgesia would you prescribe her on admission? Prescribing in Surgery Series 2024Case 4 Case presentation A 73 year old female is admitted to trauma and orthopaedics with a NOF fracture. She undergoes surgery and has pins to secure the fracture. Her PMHx includes osteoporosis, rheumatoid arthritis, glaucoma, long QT DECISION OPTIONS syndrome and gout. Allergies include codeine, tramadol. Ondansetron, lactulose A She weighs 47kgs and is 140cm tall. Alendronic acid, metoclopramide, B Bloods: prochlorperazine Hb 109 Wcc 4.3 Cyclizine, macrogol, IVF C Colecalciferol, senna Platelets 220 D Urea 8.0 Naproxen, IVF E eGFR 46 Question What other medications would you want to prescribe alongside the analgesia as soon as she is admitted? Prescribing in Surgery Series 2024Case 4 Case presentation A 73 year old female is admitted to trauma and orthopaedics with a NOF fracture. She undergoes surgery and has pins to secure the fracture. Her PMHx includes osteoporosis, rheumatoid arthritis, glaucoma, long QT DECISION OPTIONS syndrome and gout. Allergies include codeine, tramadol. Ondansetron, lactulose A She weighs 47kgs and is 140cm tall. Alendronic acid, metoclopramide, B Bloods: prochlorperazine Hb 109 Wcc 4.3 Cyclizine, macrogol, IVF C Colecalciferol, senna Platelets 220 D Urea 8.0 Naproxen, IVF E eGFR 46 Question What other medications would you want to prescribe alongside the analgesia as soon as she is admitted? Prescribing in Surgery Series 2024 [2] Prescribing in Surgery Series 2024 [2] Prescribing in Surgery Series 2024 [5] Prescribing in Surgery Series 2024 Bulk- forming Osmotic laxatives Stimulant Stool softener laxatives laxatives laxatives Work by increasing Draw water from Stimulate the This type of laxative the ‘bulk’/weight of your body into the muscles that line works by letting the stool, which bowel to soften the your gut, which water/ fat into stool stimulates the bowel stool helps move stool to soften it and through the system make it easier to pass. 2-3 days 2-3 days 6-12 hours - Fybogel (ispaghula - Lactulose - Senna - Docusate husk) - Macrogol - Bisacodyl - Methylcellulose (duclolax) 'Gentle’ type of First line in most Avoid in post-op Less commonly laxative, less side surgical patients surgical patients used; best in mild effects, good as first where there is bowel constipation or to line in medical involved; acts prevent it patients quickly [5] Prescribing in Surgery Series 2024Case 5 Case presentation Following her surgery, she has some complications and has a short stay in HDU. Due to pain issues, they started a PCA (patient-controlled analgesia). Her pain is improving, DECISION OPTIONS and she is stepped down to the ward. The registrar asks 15mg MR Morphine sulphate BD A you to take her PCA down and prescribe appropriate oral 5mg Morphine sulphate PRN opioid medications. 10mg MR Morphine sulphate BD B Her PCA had the following prescription: - Morphine sulphate 1mg/1ml with 5 minute lockout 5mg MR Oxycodone TDS, 5mg IR oxycodone C PRN - Changed 24 hourly 10mg MR Morphine sulphate BD - In the last 24 hrs used a total of 15mls D 5mg Morphine Sulphate PRN 30mg MR Oxycodone BD, 2.5mg Morphine E sulphate PRN Question What regular and PRN oral opioid analgesia would you prescribe to provide the same amount of pain relief as the PCA? Prescribing in Surgery Series 2024Case 5 Case presentation Following her surgery, she has some complications and has a short stay in HDU. Due to pain issues, they started a PCA (patient-controlled analgesia). Her pain is improving, DECISION OPTIONS and she is stepped down to the ward. The registrar asks 15mg MR Morphine sulphate BD A you to take her PCA down and prescribe appropriate oral 5mg Morphine sulphate PRN opioid medications. 10mg MR Morphine sulphate BD B Her PCA had the following prescription: - Morphine sulphate 1mg/1ml with 5 minute lockout 5mg MR Oxycodone TDS, 5mg IR oxycodone C PRN - Changed 24 hourly 10mg MR Morphine sulphate BD - In the last 24 hrs used a total of 15mls D 5mg Morphine Sulphate PRN 30mg MR Oxycodone BD, 2.5mg Morphine E sulphate PRN Question What regular and PRN oral opioid analgesia would you prescribe to provide the same amount of pain relief as the PCA? Prescribing in Surgery Series 2024 [6] Prescribing in Surgery Series 2024 [6] Prescribing in Surgery Series 2024 [2] Prescribing in Surgery Series 2024Case 6 Case presentation Overnight the patient claims to see her dead husband and lots of animals in the room. You see in her notes that she was also having visual hallucinations in ICU. DECISION OPTIONS She has no signs of infection and is otherwise well. She Post-operative A denies hearing voices or hearing her thoughts broadcasted. Morphine Sulphate B Schizophrenia C Steroid-induced psychosis D Cyclizine E Question What is the likely cause of her hallucinations? Prescribing in Surgery Series 2024Case 6 Case presentation Overnight the patient claims she claims to see her dead husband and lots of animals in the room. You see in her notes that she was also having visual hallucinations in DECISION OPTIONS ICU. She has no signs of infection and is otherwise well. Post-operative A She denies hearing voices or hearing her thoughts broadcasted. Morphine Sulphate B Schizophrenia C Steroid-induced psychosis D Cyclizine E Question What is the likely cause of her hallucinations? Prescribing in Surgery Series 2024Case 7 Case presentation She is thought to be having visual hallucinations due to the morphine and the nurse asks if you can change her analgesia DECISION OPTIONS Switch morphine to alfentanil A Current medication 15mg MR Morphine sulphate BD Reduce the dose of morphine B 5mg Morphine sulphate PRN 500mg Paracetamol QDS Switch morphine to oxycodone C Cyclizine 50mg PRN Start olanzapine D Macrogol 1 sachet BD Change PRN medication to tramadol E Question What changes would you make to her prescription? Prescribing in Surgery Series 2024Case 7 Case presentation She is thought to be having visual hallucinations due to the morphine and the nurse asks if you can change her analgesia DECISION OPTIONS Switch morphine to alfentanil A Current medication 15mg MR Morphine sulphate BD Reduce the dose of morphine B 5mg Morphine sulphate PRN 500mg Paracetamol QDS Switch morphine to oxycodone C Cyclizine 50mg PRN Start olanzapine D Macrogol 1 sachet BD Change PRN medication to tramadol E Question What changes would you make to her prescription? Prescribing in Surgery Series 2024Case 8 Case presentation Her morphine regime to switched to oxycodone with the same overall analgesic effect. Current medication DECISION OPTIONS 15mg MR Morphine sulphate BD 45mg MR Oxycodone BD A 5mg Morphine sulphate PRN 15mg IR Oxycodone PRN 500mg Paracetamol QDS Cyclizine 50mg PRN 10mg MR Oxycodone BD B Macrogol 1 sachet BD 5mg IR Oxycodone PRN 15mg MR Oxycodone BD C 5mg IR Oxycodone PRN 7.5mg MR Oxycodone BD D 2.5mg IR Oxycodone PRN Question 10mg MR Oxycodone BD E How much oxycodone would she need in a BD and PRN 3mg IR Oxycodone PRN regime? Prescribing in Surgery Series 2024Case 8 Case presentation Her morphine regime to switched to oxycodone with the same overall analgesic effect. Current medication DECISION OPTIONS 15mg MR Morphine sulphate BD 45mg MR Oxycodone BD A 5mg Morphine sulphate PRN 15mg IR Oxycodone PRN 500mg Paracetamol QDS Cyclizine 50mg PRN 10mg MR Oxycodone BD B Macrogol 1 sachet BD 5mg IR Oxycodone PRN 15mg MR Oxycodone BD C 5mg IR Oxycodone PRN 7.5mg MR Oxycodone BD D 2.5mg IR Oxycodone PRN Question 10mg MR Oxycodone BD E How much oxycodone would she need in a BD and PRN 3mg IR Oxycodone PRN regime? Prescribing in Surgery Series 2024GENERAL PRINCIPLES OF OPIOID ANALGESIA OPIOID Codeine Morphine Oxycodone Alfentanil Commonly Given as baseline 1 line opioid choice, Used as 2 ndline when a Patients with renal used: analgesia for moderate used in almost all switch from morphine is impairment; fast acting pain; frequently used in surgeries required; elderly or renal analgesia is required smaller operations impairment Issues Renally excreted, causes IV- causes Controlled drug, highly Controlled drug, needs to be constipation, 5-10% are hallucinations, very addictive given frequently (burden on slow metabolizers who addictive, controlled staff), has to be given will not respond to it drug, constipation IV/subcut +nausea Benefits: Good as initial treatment; Readily available, Very good side effect Very fast time to peak discharge patient’s home usually has good profile, preferred over analgesia (<5 mins), excreted with it analgesic effect, morphine in elderly and quickly – doesn’t accumulate oromorph is not a CD those with low eGFR so good in those who are subject to prescribing opiate toxic or have reduced requirements eGFR; less constipating [7] Prescribing in Surgery Series 2024[8] Prescribing in Surgery Series 2024References [1] Risk assessment for venous thromboembolism (VTE) - nice. Available at: https://www.nice.org.uk/guidance/ng89/resources/department-of-health-vte-risk-assessment-tool-pdf- 4787149213 (Accessed: 01 February 2024). [2] NICE (2022) BNF, NICE. Available at: https://bnf.nice.org.uk/drugs/. [3] ANTICOAGULATION IN EXTREMES OF BODY WEIGHT (2018). Available at: https://thrombosisuk.org/downloads/Dr%20JPeters%20Anticoagulation%20in%20extremes%20of%20bod y%20weight%20v3.pdf. [4] Hah, J. (2018) LOW MOLECULAR WEIGHT HEPARIN PROPHYLAXIS IN RENAL IMPAIRMENT. Available at: https://thrombosisuk.org/downloads/JA%20VTE%20Prophylaxis%20Renal%20Impairment%20JHah%20 May18.pdf. [5] NHS (2019) Overview - Laxatives, NHS. Available at: https://www.nhs.uk/conditions/laxatives/. [6] Relative Doses of Opioids – West Midlands Palliative Care (no date). Available at: https://www.westmidspallcare.co.uk/wmpcp/guide/pain/relative-doses-of-opioids/. [7] Wessex Palliative Physicians (2019) THE PALLIATIVE CARE HANDBOOK A Good Practice Guide Ninth EDITION in association with all the Wessex Specialist Palliative Care units THE PALLIATIVE CARE HANDBOOK A Good Practice Guide Wessex Palliative Physicians. Available at: https://www.ruh.nhs.uk/for_clinicians/departments_ruh/palliative_care/documents/palliative_care_hand book.pdf. [8] (The Palliative Care Handbook A Good Practice Guide. Available at: https://www.ruh.nhs.uk/for_clinicians/departments_ruh/palliative_care/documents/palliative_care_hand book.pdf (Accessed: 19 February 2024). Prescribing in Surgery Series 2024