Advanced surgery and peri-operative management

why avoid anxiolytic/sedating med after surgery

can lead to delirium

What is meant by adjuvant pain medication

Additional meds used, e.g., gabapentin/pregab, which are usually used for seizures

opiod considerations

• identify opiod tolerant pt pre op

• identify risk factors and opiod misuse

• identify and treat chronic post-surgical pain appropriately

which med form preffered for opiods

immediate release opiods preferred

what is patient controlled analgesia?

Contains a strong opiod- fentanyl or morphine

pt press button to get a small bolus dose every 3-5 minutes.

Reduced waiting times for doses, reduces anxiety, improves patient experience

epidural cautions

anticoagulated patients- risk of haematoma when inserted / removed

risks of epidural

1. motor nerve block

2. infection

3. dural puncture

4 levels of infection in surgery

1. clean - no surgeries involving GI tract

2. clean contaminated - GI included but elective

3. contaminated - fresh wound, emergency GI surgeries

4. dirty contaminated - trauma and GI perforations

abx considerations in surgery

1. level of contamination

2. duration of abx

3. time given before surgery

surgical management

pain relief

PONV

laxatives

anti-emetics

VTE-P

nutritional drinks

clopidrogel - when to hold for surgery

hold 7 days pre

sub with aspirin if possible bc u only hold that one day of op

aspirin - when to hold for surgery

hold day of operation

Apixaban - when to hold for surgery

24 hrs and 48hr before for major surgery

Rivaroxaban- when to hold for surgery

24 hrs for minor

48hr before major surgery

when are most anticoagulants/platelets started after surgery

24-48 hours post op

When is bridging therapy used for

switching warfarin for a short acting anticoagulant during period of interruption.

Meds required after a full thyroidectomy

• total replacement post-op, e.g., levothyroxine, calcium, vitamin D replacement

What meds should be stopped before a coronary artery bypass graft?

(a procedure to improve blood flow to the heart by creating new routes around narrowed or blocked arteries).

• anti anginals bc pt should no longer develop chest pain as diseased arteries are bypassed.

If get pancreas removed, what meds to start after

meds to replace exocrine and/or endocrine functions of pancreas

• creon (pancreatin enzymes)

• omeprazole capsules

• insulin

What is dumping syndrome

a drug must have sufficient residence time at its absorption site for it to be optimal

if movement is too fast, the drug will pass through the system without being absorbed.

Effect of gastric volume after Upper GI surgery

• All procedures result in reduced available SA of stomach

• Only limited number of drugs are absorbed through the stomach wall

• Disintegration in aquous solution more rapidly absorbed than those in oily solutions, suspensions, or solid forms

why avoid MR or enteric formulation after GI surgery

reduced gasric volume = altered PH , altered release

medicines to avoid following upper gastric surgery

Solid oral medicines may get stuck

avoid effervescent formulations

avoid NSAIDs/aspirin unless definite indication

caution with liquids in large volumes e.g paracetamol suspension

other consideratoins for upper Gi surgery

• inc risk of VTE

• anastomatic leaks ; inc risk by smoking, NSAIDs

• N+V

• infection

• nutrition changes: may need supplementation

• unreliable absoroption of oral contraception; consider patches, implants; coils

what to stop after colorectal surgery

• management of anaemia

• inflammatory bowel disease medication

• IBS medication