Transcript Tablets from other doctors

Tablets from other doctors
Dr.K.Sudarshan
Consultant Anaesthetist
Ortho One Super specialty Hospital
Coimbatore
[email protected]
Why should we know

Become more common

Drug interactions between themselves and with
anaesthetic drugs

Modify the outcome of anaesthesia

Knowledge regarding the drugs to be continued
some stopped before anaesthesia
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Commonly used

Anti hypertensives/ other cardiac drugs

Anti diabetic medications

Anti psychotics/Anti depressants

Anti convulsants

Anti coagulants/ Anti platelets

Herbal/siddha medications
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Anti hypertensives

Thiazides/Diuretics – Hypokalemia, low volume state

Beta Blockers – Bradycardia, asthma,heart blocks

Clonidine –
Sedation,Rebound,hypertension,Bradycardia

Prazosin –
Exaggerated Hypotension

ACE inhibitors – Unexpected hypotension, NSAID’s antagonize
antihypertensive effect

Angiotensin II receptor antagonists – Prolonged hypotension,
bradycardia

Calcium Channel blockers – Careful in CHF patients
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What to do with antihypertensives

Continue till the morning of surgery in most cases

Exercise caution while performing regional anaesthesia

Safer to stop Losartan/Telmesartan,on the day prior to
surgery if spinal or epidural is planned especially in
elderly

Acceptable & useful to continue Beta blockers

Do not use additional Clonidine through spinal or
epidural route in a Beta blocked patient
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
Withdrawal of Antihypertensive Drugs Before Anesthesia
Cedric Prys-Roberts - A & A March 2002 vol. 94 no. 3 767-768

Refractory hypotension during general anesthesia despite preoperative
discontinuation of an angiotensin receptor blocker
Raha Nabbi1, Harvey J Woehlck1, Matthias L Riess1-3



Rev Esp Anestesiol Reanim. 2004 Jun-Jul;51(6):338-41.
POISE Studies - Perioperative beta-blockade, 2008:
It is recommended that patients already on beta-blockers be maintained on
their medication throughout the perioperative period
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AHA Recommendations for
Beta blocker therapy

Class I – To be continued in patients receiving treatment
for angina, symptomatic arrhythmias, hypertension

Class IIa – For patients with more than 1 risk factor who
are undergoing vascular surgery, or intermediate risk
surgery

Class IIb - Usefulness is uncertain in patients with single
risk factor undergoing intermediate risk surgery
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Other cardiac drugs

Commonly used ones
1. Nitrates
2. Sorbitrates
3. Digoxin
4. Diuretics
5. Amiodarone
6. Statins
7. Anti coagulants

Continue all the drugs till
the day of surgery except
Digoxin.

Continue Digoxin only if it
is used exclusively for
rate and rhythm control
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AHA Guidelines
Patients with previous PCI –
on dual antiplatelets
Bare metal
stents
Balloon
angioplasty
Drug eluting
stents
Time
since
PCI
< 14 days
Delay elective or
non urgent
surgery
>14 days
>30-45
days
Proceed to OT
with aspirin
<30-45
days
< 365 days
Delay elective or
non urgent
surgery
> 365 days
Proceed to OT
with aspirin
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Regional Anesthesia in the Patient Receiving Antithrombotic
or Thrombolytic Therapy
ASRA GUIDELINES
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SC Unfractionated Heparin (UFH)

5000units- BD - NO contraindication

5000units – TDS – or 10000units bd –
Exercise caution

Due to risk of heparin-induced
thrombocytopenia, check platelet count
before and after removal of catheter
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NSAIDS (including aspirin)

Cyclo-oxygenase inhibition thus reducing
prostaglandin and thromboxane synthesis

Used alone, there is no added significant
risk of spinal hematoma.

Risk of medical renal disease
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Perioperative Management of Patients on Antiplatelet Therapy
Regional Anesthesia in the Patient
Receiving Antithrombotic or Thrombolytic
Therapy: American Society of Regional
Anesthesia and Pain Medicine EvidenceBased Guidelines (Third Edition)
Horlocker, Terese T.; Wedel, Denise J.;
Rowlingson, John C.; Enneking, F. Kayser;
Kopp, Sandra L.; Benzon, Honorio T.; Brown,
David L.; Heit, John A.; Mulroy, Michael F.;
Rosenquist, Richard W.; Tryba, Michael;
Yuan, Chun-Su
Regional Anesthesia and Pain Medicine.
35(1):64-101, January/February 2010.
doi: 10.1097/AAP.0b013e3181c15c70
Copyright © 2013 Regional Anesthesia and Pain Medicine. Published by Lippincott Williams & Wilkins.
15
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Perioperative Management of Patients on Warfarin
Regional Anesthesia in the Patient Receiving
Antithrombotic or Thrombolytic Therapy:
American Society of Regional Anesthesia and
Pain Medicine Evidence-Based Guidelines
(Third Edition)
Horlocker, Terese T.; Wedel, Denise J.;
Rowlingson, John C.; Enneking, F. Kayser; Kopp,
Sandra L.; Benzon, Honorio T.; Brown, David L.;
Heit, John A.; Mulroy, Michael F.; Rosenquist,
Richard W.; Tryba, Michael; Yuan, Chun-Su
Regional Anesthesia and Pain Medicine.
35(1):64-101, January/February 2010.
doi: 10.1097/AAP.0b013e3181c15c70
Copyright © 2013 Regional Anesthesia and Pain Medicine. Published by Lippincott Williams & Wilkins.
16
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LMWH – Therapeutic and Twicedaily dosing regimen
Enoxaparin (1 mg/kg every 12 hrs or 1.5 mg/kg daily)
Dalteparin (120 U/kg every 12 hrs or 200 U/kg daily )
Delay needle insertion at least 24 hours

Administer LMWH no earlier than 24 hours postoperatively
regardless of anesthetic technique

epidural catheter may be left indwelling overnight, but must be
removed before the first dose of LMWH

Restart LMWH 2 hours after removal of the catheter.
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Fondaparinux (Arixtra)

No recommendations offered by ASRA

Does not recommend placement of
epidural catheters.
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Current experience at
ORTHO ONE

523 cases of THR & TKR

Past five years

All patients receive ARIXTRA 2.5mg SC – 8 -9
hours after surgery

Continued for 3 days, one day off for catheter
removal and then continued for 3 more days.
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DIABETES

TYPE 1 DIABETES

TYPE 2 DIABETES

LATENT AUTOIMMUNE DIABETES IN ADULTS

GESTATIONAL DIABETES

PRE GESTATIONAL DIABETES
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Natural History of Type 2 Diabetes
Postprandial
glucose
Plasma
glucose
Fasting
glucose
126 mg/dL
Insulin resistance
Relative b-cell
function
Insulin secretion
-20
-10
0
10
20
30
Years of Diabetes
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Available oral anti diabetic agents
Thiazolidinediones
Meglitinides
Decrease glucose uptake
in skeletal muscle and
decreased lipolysis in
adipose tissue
Increase insulin secretion
from pancreatic b-cells
Sulfonylureas
Increase insulin secretion
from pancreatic b-cells
-Glucosidase inhibitors
Glimepride,
glyclazide
glibenclamide
Delay intestinal carbohydrate
absorption
CMAJ. 2005;172:213–226
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Drugs to avoid

Stop Glipizide, Glibenclamide – 24hrs prior

Chlorpropramide – Stop 3 days prior to surgery

Stop Metformin – for major surgery – fear of lactic
acidosis

Drugs such as Metformin, Acarbose
– DOES NOT produce hypoglycemia
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What is practical
All peripheral surgery –Expected oral feeding within 4 – 6 hours
Preoperative control is good, do an FBS
Skip all types of OHA’s on the day of surgery
Proceed for surgery
Check blood sugar levels 2nd hourly
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All peripheral surgery –oral feeding within 4 – 6 hours
Preoperative control is not so good, do an FBS
Skip all types of OHA’s
Consider Insulin infusion
Proceed for surgery
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For Major surgery
Intra cavitory surgery –
Oral feeding not before 24 hours after surgery
Stop all oral hypoglycemic agents earlier
Convert them to insulin
Take up for surgery
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The goal of insulin replacement or
supplement therapy is to
Faithfully mimic the endogenous
insulin secretion pattern of a
healthy individual
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Basal Insulin
or
background
Secreted continuously between meals and throughout
night at a rate of 0.5 to 1 unit per hour – Producing a
serum concentration of 5 to 15 micro units per ml.
This reduces hepatic glucose but allows for glucose levels
sufficient for cerebral energy requirement.
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Meals Stimulated
Insulin
or
prandial
Secreted just before food peaks in 30 min – Serum
concentration return to basal level in 2 to 4 hours.
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Intermediate acting insulins
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Mixed regimen
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IDEAL
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What to do with insulin analogues

Basal insulin analogue - Glargine
Can safely be continued – No evidence of
HYPOGLYCEMIA what so ever
ASPART & LISPRO – Avoid bolus on the
day of surgery if starving, titrate with
infusions if necessary
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Antipsychotics/depressants


Potentiate the hypotensive and sedative effects
of general anaesthetic agents
Impaired temperature regulation

Interferes with muscle relaxants

Prolongation of QT interval and other
arrhythmias
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Specific drug groups

SSRI’s

Tricyclic anti depressants

MAO Inhibitors

Lithium
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SSRI’s

Most commonly used

Continue till the morning of surgery

Causes Serotonin availability – Brain stem
stimulation.- Avoid drugs like PETHIDINE, FORTWIN, TRAMADOL

Check Coagulation Profile frequently

Avoid Diazepam
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Tricyclic antidepressants

Continue till the day of surgery

Remember Exaggerated response to ephedrine

Avoid Atropine – Crosses BB barrier – post op.
confusion

Avoid Tramadol – CNS toxicity
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MAO inhibitors

Less commonly used these days

Monoclobemide – Stop 24hrs prior

Phnelzine, tranylcypromine – stop two weeks prior

Absolute contraindication – Pethidine,
tramadol,Panacuronium, Suxamethonium
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Lithium

Minor surgery – can be continued

Major surgery – stop 48hrs. Prior
Prolongs both depolarising & non
depolarising muscle relaxant action
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Anti convulsants
Remember coexisting sedation & enzyme induction
1. Sodium valproate – continue till morning of surgery
Keep in mind - Drug Sedation, Anticholinergic effect,
Hypotension, Prolonged QT interval
2. Carbamazepine - Reduces anaesthetic doses
3. Barbiturates – Sedative property
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Anti Parkinsons Drugs

Continue until start of anaesthesia

Avoid Halothane in patients on L dopa – causes arrhythmias

Metoclopromide, Phnergan worsens parkinsons disease.

Avoid clonidine – exaggerated hypotension
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Steroids

PROBLEMS -

The adrenal suppression
Long-term and other side-effects of steroid therapy


Dosages of less than 5 mg prednisolone per day and who stopped
their steroids more than three months ago are not significant and no
steroid cover is required.

10 mg/day or more of prednisolone (or equivalent) is generally taken
as the threshold dose for 'steroid cover'.
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Steroids continued….

Minor surgery –
25 mg hydrocortisone at induction of anaesthesia and then resume normal
medication postoperatively.

Moderate surgery –
Usual dose of steroids preoperatively and then 25 mg of hydrocortisone (IV)
at induction, followed by 25 mg IV every 8 hours for 24 hours. Usual
preoperative dose is then continued.

Major surgery - usual dose of steroids preoperatively, then a bigger 50 mg
of hydrocortisone IV at induction, followed by 50 mg IV every 8 hours for 4872 hours.
Continue this infusion until the patient has started light eating, then restart
the normal preoperative dose.

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OCP’s

Risk of DVT

Stop preoperatively

Advise alternative methods
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SUMMARY

Long acting OHA’s

Anticoagulants, Antiplatelets

MAO inhibitors

Digoxin

Lithium

Losartan & Beta blockers– Exercise caution

Siddha & Herbal medicines
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