Medical conditions: ask specifically about hypertension, diabetes (should be put first on list), asthma/COPD, cardiovascular disease, liver disease.Determine if conditions are adequately controlled.
For an immediate pre-operative assessment (day prior to the operation)
Correct INR if abnormal (>1.4)
Aggressive correction (if on warfarin for AF): 5-10mg IV vitamin K, then repeat INR in 6 hours β if still high, discuss with haematology regarding giving prothrombin complex concentrate pre-operatively
Cautious correction (if on warfarin for artificial heart valve/recent PE): discuss with senior and haematology β will usually require reversal of warfarin and cover with unfractionated heparin infusion, which will be stopped 4 hours pre-operatively and restarted after
If INR raised due to liver disease: 10mg IV vitamin K, then repeat INR in 6 hours β if still high, discuss with haematology who may advise FFP/cryoprecipitate
Blood transfusion if Hb <9g/dL, or <10g/dL if elderly/cardiovascular/respiratory disease
Consider platelet concentrate transfusion if platelets <50×109/L (discuss with haematology if cause unclear)
Correct electrolyte abnormalities
Note, if there are significant abnormalities, bloods must be repeated again pre-operatively (e.g. at 6am) to show they have been corrected.
For an early pre-operative assessment (>1 week pre-operatively)
INR may be corrected by stopping warfarin as below
Anaemia should be investigated and the cause treated β e.g. with iron tablets/infusion for iron-deficiency anaemia
If there are any concerns, contact the consultant or an anaesthetist.
Medications
IV fluids: only prescribe fluids overnight (when NBM) if instructed by consultant, or if patient needs variable rate insulin infusion, or is dehydrated
New medications
Operation preparation: give drugs required for specific operation (specified in pre-operative checklist), e.g. bowel prep for colorectal
VTE prophylaxis: prophylactic LMWH should usually be given the night before the operation, but omit any doses when the operation is due to start in <12 hours
Antiemetics and analgesia: as required
Regular medicines
Vital drugs should usually be taken on the day of the operation: cardiovascular medications (excluding antihypertensives), antipsychotics, Parkinsonβs medications, inhalers, glaucoma medications, immunosuppressants, thyroid medications, drugs of dependence (e.g. benzodiazepine)
Most other drugs should not be taken on the day of the operation (restarted the day after)
Some medications must be stopped/changed pre-operatively:
Medications that should be stopped/changed pre-operatively
Medication
Time to stop pre-operatively
Details
Warfarin
5 days
Therapeutic-dose LMWH can be prescribed in the interim in most cases; patients with high risk indication (e.g. mechanical heart valve) may need to be admitted for unfractionated heparin infusion
Direct oral anticoagulants
24 hours for minor surgery; 48 hours for major surgery
If patient has a cardiac stent or other high risk indication, liaise with cardiology and surgeon to make decision regarding stopping
Insulin
Avoid morning dose
Prescribe variable rate insulin infusion with surgical fluid [5% dex/0.45% NaCl/0.15% KCl @ 80ml/h] from midnight the night before (unless minor surgery)
Oral hypoglycaemics
Avoid on day of operation
Prescribe variable rate insulin infusion as above if blood glucose not well controlled. Also avoid metformin for two days after (due to risk of lactic acidosis).
Diuretics/ACE inhibitors
Avoid on day of operation
Long-term corticosteroids
Change to equivalent dose hydrocortisone
Liaise with anaesthetist
COCP
4 weeks
Restart 2 weeks after
Forms
VTE prophylaxis Proforma
Consent form (complete this only if you have sufficient knowledge, if not call registrar/consultant)
Fasting and admission
Fasting guidelines
β2-6 ruleβ = NBM for 2 hours pre-operatively; clear fluids only for 6 hours pre-operatively
If you are unsure of the operation time, prepare the patient for 8am (e.g. say clear fluids only from 2am, NBM from 6am).
Pre-operative patients only generally need admission the night before if they are diabetic (and therefore require a variable rate insulin infusion from midnight); or if they need specific medications which must be given overnight; or if INR/Hb/platelets need correction