surgery

PART 1: INTRODUCTION TO SURGICAL CARE

Section 1: Learning Outcomes (Page 2)

At the end of the session, students will be able to:

• Outline the basic physiological changes that impact on the pharmaceutical care of surgical patients.

• Outline the basic principles involved in the pharmaceutical management of the surgical patient with respect to:

  • Management of long-term medicines.

• Outline principles of managing post-operative pharmaceutical care issues.

Section 2: Types and Grades of Surgical Procedures (Page 3-4)

2.1. Types of Surgical Procedure (Page 3):

• Day surgery: Patient admitted and discharged on the same day.

• Planned (elective) or unplanned (emergency): Elective surgery is scheduled in advance; emergency surgery is unplanned, often life-saving.

• Open surgery: Involves a large incision, closed with staples or stitches.

• Keyhole surgery: Performed through small incisions using a fibre-optic light and camera.

• Laparoscopic surgery: Keyhole surgery specifically within the abdomen.

• Microsurgery: Delicate surgery on small structures like arteries, nerves, or eyes, using a microscope.

• Cosmetic surgery: Performed to change appearance for cosmetic reasons (not medically necessary).

2.2. Grades of Elective Surgery (Page 4):

• Minor: e.g., excision of skin lesion.

• Intermediate: e.g., inguinal hernia repair, varicose vein stripping.

• Major: e.g., total hip replacement, thyroidectomy, colorectal resection.

• Major +: e.g., aortic aneurysm repair, oesophagectomy, pancreaticoduodenectomy (Whipple procedure).

Reference: NG45 (NICE Guideline)

PART 2: PHYSIOLOGICAL CHANGES DUE TO SURGERY

Section 3: Physiological Changes Impacting Pharmaceutical Care (Page 5)

Surgery induces a significant stress response, leading to various physiological changes that affect drug therapy:

PART 3: THE SURGICAL PATIENT PATHWAY

Section 4: Surgical Patient Pathway (Page 6)

• Elective patients: Planned pathway, includes pre-operative assessment.

• Emergency patients: Unplanned admission, often less preparation time.

• Peri-operative: Encompasses pre-operative + intra-operative + post-operative care.

Image Description (Page 6): A flowchart illustrating the surgical patient pathway from pre-operative assessment through to discharge.

Section 5: Pre-Operative Assessment (Page 7)

Purpose:

• To ensure the patient is fully informed and prepared for anaesthesia, surgery, and discharge.

• To minimise risks of surgery and anaesthesia.

• To improve patient outcome post-operatively.

Key Elements:

• Careful pre-op planning can help with enhanced recovery.

• Identify and manage anaemia and nutritional status.

• Obtain an accurate drug history, including:

  • Over-the-counter (OTC) medicines

  • Herbal and homeopathic preparations

  • Injections (e.g., insulin, anticoagulants)

• Check MRSA status – patients with previous or current carriage need decolonisation treatment for 5 days before surgery.

• Provide showering/bathing instructions.

Section 6: Planning for Patients on Steroids (Page 8)

Risk: Patients on corticosteroids are at risk of developing adrenal insufficiency (adrenal crisis) during the stress of surgery because their natural cortisol production is suppressed.

Identifying at-risk patients:

• Patients with a past medical history of adrenal insufficiency on replacement therapy.

• Patients receiving or have received repeated courses of ≥10 mg prednisolone (or equivalent) within 3 months of surgery, especially if taken for >3 weeks.

• Use of 5 mg prednisolone or equivalent for >5 days in the 2 weeks before surgery.

Action: These patients require stress-dose steroids (e.g., IV hydrocortisone) during the peri-operative period to prevent adrenal crisis.

Section 7: Nil by Mouth (NBM) – Rationale and Medication Management (Pages 9-11)

7.1. NBM Rules (Page 9):

• No FOOD, including milk in tea/coffee – for 6-8 hours before surgery.

• No DRINKS (water/clear fluids) – for about 2 hours before surgery.

• Some medication can be taken with small sips of water.

7.2. Why NBM? – The Risk of Aspiration (Page 10):

• The aim is to have the stomach as empty as possible.

• Risk: Aspiration of stomach contents into the lungs.

• Consequences:

  • Aspiration pneumonia – can be fatal.

  • Damage to lung tissue from acid, enzymes, and other contents.

• Special Note: GLP-1 agonists and dual GIP/GLP-1 agonists (e.g., liraglutide, semaglutide, tirzepatide) may increase aspiration risk due to delayed gastric emptying. Guidelines may advise withholding these drugs before surgery.

7.3. To Stop or Not to Stop? (Page 11):

• Many medications can be taken up to 2 hours before surgery with a sip of water.

• It is IMPORTANT to give critical medications, e.g., epilepsy drugs (antiepileptics), to prevent seizures.

• However, some medications can interact with or increase anaesthetic/surgical risk and may need to be omitted.

• Principle: Omit the patient's regular medicines for the shortest time possible.

Section 8: The Peri-operative Handbook – A Decision-Making Tool (Page 12)

A peri-operative handbook provides monographs for medications, including:

• Decision-Making: Assess risk vs. benefit.

  • Does the drug increase the risk of surgery or anaesthesia?

  • Is it a critical drug for the patient? What are the risks if omitted? (e.g., destabilising chronic illness, slow post-op recovery).

  • How significant is the risk? Can it be managed?

  • Surgery type: High-risk or low-risk procedure?

  • Stop for the shortest time possible.

Section 9: Which Medications May Need to Be Stopped? (Page 13)

If NBM for a prolonged period:

• Find out the risks and side effects of stopping.

• Only stop if you have to.

• Replace with alternatives if possible (e.g., IV equivalents).

• Inform medical teams about what to expect (withdrawal symptoms).

• Give information (if available) on managing side effects.

PART 4: POST-OPERATIVE PHARMACEUTICAL CARE

Section 10: Learning Outcomes for Post-Op Care (Page 16)

At the end of this part, students will be able to outline the basic principles involved in the pharmaceutical management of the surgical patient with respect to:

Students should also have an overview of the role of a surgical pharmacist and an understanding of enhanced recovery and its application to surgery.

Section 11: The 4As of Post-Op Pharmaceutical Care (Pages 17, 24, 31)

Remember the 4As:

1. Anticoagulants (VTE prophylaxis)

2. Analgesia (pain management)

3. Antiemetics (PONV management)

4. Antibiotics (prophylaxis and treatment)

PART 5: VENOUS THROMBOEMBOLISM (VTE) PROPHYLAXIS

Section 12: VTE Prophylaxis (Pages 18-20)

12.1. Background (Page 18):

• VTE includes Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) .

• Estimated 25,000 people in the UK die each year from preventable hospital-acquired VTE.

• Estimated cost to the NHS: £640 million.

• Guideline: NICE guideline [NG89] (Updated 2019) .

12.2. Risk Assessment and Treatment (Page 19):

12.3. Extended Prophylaxis (Page 20):

• Example: Elective Hip Replacement (THR): Choose any one of:

  • LMWH for 10 days followed by aspirin (75 or 150 mg) for a further 28 days.

  • LMWH for 28 days combined with anti-embolism stockings (until discharge).

  • Rivaroxaban, Apixaban, or Dabigatran (within marketing authorisation) as an option for VTE prevention.

• Practical Considerations:

  • Patient needs to self-administer subcutaneous injections.

  • Pre-filled syringe with correct dose.

  • Consider supply (e.g., take-home supply).

  • Consider sharps disposal.

PART 6: POST-OPERATIVE PAIN MANAGEMENT

Section 13: Definition of Pain (Page 22)

Section 14: The WHO Analgesic Ladder (Pages 23-25, 29)

Principles of Pain Management:

• By the mouth (oral route preferred).

• By the clock (regular dosing, not "as required" for continuous pain).

• By the ladder (stepwise approach).

• By the patient (individualised treatment).

The Ladder:

• Remember: At each step, the appropriate medication and dose is the one that controls pain with the fewest side effects.

• Medication choice is based on type and severity of pain, action, and duration of action.

• Frequent dose adjustment may be necessary.

• Painful procedures (e.g., dressing change, physiotherapy) may require top-up pain relief.

Section 15: Patient-Controlled Analgesia (PCA) (Page 26)

• PCA is a method of delivering strong opioids (Step 3) where the patient self-administers small, preset doses.

• Common opioids used: Morphine (gold standard), Oxycodone, Fentanyl.

• Set up: Typically initiated in theatre or recovery.

• Advantages: Gives patient control, provides rapid relief for breakthrough pain, bypasses variable oral absorption (especially important post-op when gut motility may be reduced).

Section 16: Managing Opioid Side Effects (Page 27)

Section 17: Adjuvant Analgesics (Page 28)

• Definition: Weak or non-analgesic when administered alone, but can enhance analgesic action when co-administered with analgesic agents.

• Common uses:

  • Pain poorly responsive to opioids (e.g., neuropathic pain).

  • Opioid-sparing effect (allowing lower opioid doses and fewer side effects).

Section 18: The Pharmacist's Role in Pain Management (Page 30)

PART 7: POST-OPERATIVE NAUSEA AND VOMITING (PONV)

Section 19: PONV – Causes and Impact (Page 32)

• Causes:

  • Opioid side effect (common).

  • Anaesthetic side effect.

• Incidence: Rates change with surgery type.

• Timing: First 48 hours after surgery.

• Impact:

  • Common.

  • Distressing for the patient.

  • Leads to delays in post-op recovery and discharge.

Section 20: Risk Assessment and Management of PONV (Pages 33-34)

20.1. Risk Factors (Page 33):

• Patient Factors: Female gender, non-smoker, history of PONV or motion sickness.

• Surgical Factors: Type of surgery (e.g., laparoscopic, gynaecological, cholecystectomy).

• Anaesthetic Factors: Use of volatile anaesthetics, nitrous oxide, postoperative opioids.

Image Description (Page 33): A flowchart or scoring system (e.g., Apfel score) for assessing PONV risk.

20.2. Management (Page 34):

• High-risk patients should receive anti-emetics pre-operatively and regularly post-operatively.

PART 8: ANTIBIOTIC PROPHYLAXIS

Section 21: Principles of Antibiotic Prophylaxis (Page 36)

• Only use if there is clear evidence of benefit for that surgery type (e.g., open surgery to abdominal area).

• If necrotic tissue, pus, or other known infections are present – treat the infection and give prophylaxis.

• Single dose is often sufficient – longer surgery may need an additional intra-operative dose.

• 24 hours max – no evidence of reduced infection rate beyond 24 hours.

• Give the (first) dose within 30 minutes before incision – aim for maximum tissue levels at the time of incision.

• Drugs with long infusion times (e.g., vancomycin) need to be commenced earlier – start 30-60 minutes before incision.

• MRSA colonisation – add vancomycin (or teicoplanin) to standard prophylaxis.

• Monitor for Surgical Site Infection (SSI) post-operatively.

Reference: Surgical site infections: prevention and treatment (NG125)

PART 9: ROLES OF THE SURGICAL PHARMACIST

Section 22: Roles of the Surgical Pharmacist (Page 37)

The surgical pharmacist is involved in multiple aspects of peri-operative care:

PART 10: ENHANCED RECOVERY

Section 23: What is Enhanced Recovery? (Page 38)

• Definition: Enhanced recovery is an evidence-based approach that helps people recover more quickly after having major surgery.

• Key Principles:

  1. Patients should be as healthy as possible before receiving surgery (prehabilitation).

  2. Receive the best possible care during their operation.

  3. Receive the best care while recovering (optimal pain control, early mobilisation, early nutrition).

• Research shows that the earlier a person gets out of bed and starts walking, eating, and drinking after an operation, the shorter their recovery time will be.

• Currently used in: Breast surgery, colorectal surgery, gynaecological surgery, musculoskeletal surgery, urological surgery.

SUMMARY TABLE: THE 4As OF POST-OP CARE