Premedication

1. •FBP; U&E and ECG should be available for all patients for the anaesthetist’s premedication visit.
   

2. •Anaesthetists will prescribe appropriate sedatives.
   

DVT prophylaxis

1. •See thromboprophylaxis advice
   

Antibiotics

1. •See advice on prophylactic antibiotics
   

Aspirin

In general elective operations should not be performed when aspirin has been ingested within the previous seven days. Ask consultant whether surgery is to proceed if the patient has been on aspirin. When surgery is postponed in patients taking Aspirin the delay to date of surgery is two weeks.

1. •See advice on antiplatet drugs
   

Clopidogrel (Plavix)

1. •Clopidogrel (Plavix) has a more profound and prolonged anti-platelet effect than Aspirin.
   

2. •Ideally it should be stopped 10 days prior to scheduled surgery.
   

3. •If it is necessary to operate within the 10 days or if a coronary stent prevents stopping, see advice on antiplatet drugs.
   

Warfarin

Patients who need to remain on oral anticoagulants should be admitted early and converted to low molecular weight Heparin. Note that some patients’ oral anticoagulants may be discontinued for a short term. (eg mechanical aortic valve not in AF).

1. •See anticoagulation advice
   

Oral contraceptive pill

In general elective operations should not be performed when a patient is on the oral contraceptive pill (OCP). Ask consultant whether surgery is to proceed if the patient has taken the pill within the last six weeks. When it is necessary to discontinue the OCP the patient must be told that they must prepare to take other birth control measures and must see their G.P. or other family planning adviser before actually stopping their OCP.

Bronchodilators

Existing bronchodilators should be changed from inhalers to nebulisers on admission. This is because it is difficult to manage a multi-dose inhaler or a breath actuated inhaler with the pain of a thoracotomy wound. Those on combination inhalers may need separate bronchodilator and steroid nebules.

Bronchodilators should be started on all COPD patients, asthmatics and those who have smoked till recently. They should NOT be routinely started on patients who do not have the above conditions and do not need them. Bronchodilators an be dangerous drugs when used in high doses in patients not used to them, causing tachyarrhythmias and even myocardial infarction.

1. •Salbutamol - give to all who have been on preop bronchodilators, asthmatics and those who have smoked till recently. Always give as nebulisers in the peri-operative period as pain impairs the ability to use an inhaler. Change to inhaler a few days before discharge and check that it is effective. (The patient may need a home nebuliser organised.)
   

2. •Bricanyl is an alternative to Salbutamol and has the advantage of being administered in an easy-to-use Turbohaler on discharge.
   

3. •Those on preoperative steroids by inhaler or oral should have Pulmicort respules (or Flixotide). This should also be added when there is a specific bronchitic element or for more severe patients.
   

4. •Atrovent can be added as a third line if necessary. When it is needed consider alternating the nebs at 3 hourly intervals.
   

Antacids

1. •Ranitidine - continue antacid medication in ICU patients till discharge from Ward.
   

2. •Antacids are usually not needed postop in oesophagectomy patients as they will have had a total vagotomy.
   

3. •Note that oral Famotidine (Pepcid) has advantages over Ranitidine (cheaper, smaller tablet, easier to swallow, longer duration of action, fewer side effects, more potent.)
   

4. •Those who genuinely require acid suppression should be commenced on a proton pump inhibitor (Losec, Nexium, Zoton or Pariet). Note that Nexium and Losec are dispersible and will pass a fine-bore NGT or a jejunostomy, Zoton comes in a suspension form but has difficulty with fine bore NGT. Nexium, Losec and Protium are all available as IV preparations.