Frimley GuidelinesFrimley Health Guidelines

Administration of preoperative medications for patients awaiting emergency surgery

Key Points

Most medications should be continued throughout the perioperative period.
Patients can still take oral medications even if nil by mouth and awaiting surgery.
If in doubt seek advice from a senior colleague or expert

Version:	3.0
Date Issued:	31 January 2022
Review Date:	February 2027
Key words:	Preoperative, perioperative, medication, nil-by-mouth

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Abbreviations

ACE inhibitor	Angiotensin converting enzyme inhibitor
ACS	Acute coronary syndrome
DES	Drug eluting stent
NSAID	Non-steroidal anti-inflammatory drug
PCI	Percutaneous coronary intervention
PE	Pulmonary embolus

1.0 The Guideline

If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date. This guideline is for use in Frimley Health Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

2.0 Patients who are nil by mouth

2.1 Patients who are nil by mouth whilst awaiting emergency/urgent surgery should not have oral medications withheld just because of their fasting status. Patients who are “nil by mouth” because they are awaiting surgery should still receive oral medications. They may be administered with a small volume of water, for example ½ a plastic cup.

2.2 Medications

In general, medications should be continued throughout the perioperative period. However, some medications should be omitted. The advice below outlines when this is applicable, and the rationale behind this advice.

It should be remembered that in some circumstances oral absorption may be unreliable, and so alternative routes of administration may be required, for example bowel obstruction, pancreatitis, critical illness. Seek advice from a senior doctor or pharmacist if in doubt.

If medications have been withheld preoperatively, they should, in general, be restarted the day following surgery. However, be cautious with antihypertensives until hypotension has resolved.

Table 1- Perioperative medications

*Although see advice regarding hypotension

** Monitor renal function regularly during acute illness, electrolyte imbalance may occur and the acutely unwell patient will be more prone to this.

Table 2 – Further guidance on perioperative administration

Drug class	Rationale
Analgesics should be given (including paracetamol, NSAIDs, opioids, via any route)	Patient experiences avoidable pain
Anticoagulants (also see separate perioperative guidance). Prophylactic anticoagulation e.g., dalteparin 5000 units od should not be given after 20.00 the night before surgery. Patients with acute thromboembolic events must continue with anticoagulation. If in doubt seek senior advice	Unable to perform regional anaesthesia if patients have received anticoagulation in the preceding 12 hours Progression of thrombus and risk of serious embolic episode (stroke/PE)
Antiepileptic agents should be given	Loss of seizure control
*Antihypertensives/ (except ACE inhibitors and Angiotensin II receptor antagonists) should be given	Complications of acute hypertension
Antimicrobials (including antibiotics, antifungals, antivirals and antimalarials) should be given	Potential worsening of systemic infection and deterioration of condition
Anti-Parkinsonian agents	Loss of symptom control
Antiplatelets Antiplatelet agents should be continued if PCI performed for ACS within the past year, unless discussed with a cardiologist. Clopidogrel can be discontinued for a short period if PCI with DES has been performed electively for angina and >3 months previously. However, Aspirin should be continued. If in doubt, discuss with relevant cardiologist.	Increased risk of poor outcomes following MI Risk of acute stent thrombosis in patients following angioplasty
Antiretrovirals should be given	Potential for deterioration of viral disease
Benzodiazepines and parenteral vitamins for the management of acute alcohol withdrawal syndromes should be given	Severe and potentially irreversible withdrawal symptoms
Beta-blockers should be given	May cause tachyarrhythmias
Bronchodilators should be given	Deterioration in clinical condition
Calcium resonium, glucose/insulin should be given	Emergency treatment of symptomatic hyperkalaemia
Corticosteroids should be given	Treatment failure in acute conditions. Risk of Addisonian crisis in steroid dependency
Enteral/parenteral electrolyte replacement (including potassium, calcium, magnesium, phosphate) for the urgent treatment of symptomatic deficiencies should be given	Deterioration in clinical condition
Glucose/glucagon should be given	Failure to treat symptomatic hypoglycaemia (medical emergency) with risk of patient harm
Glucose infusions in normoglycaemic patients receiving intravenous insulin infusions should be given	Risk of hypoglycaemia
Immunosuppressants drugs for transplant patients must be given Inform relevant team of patient admission and seek further advice.	Risk of transplant rejection due to sub-therapeutic levels
Immunosuppressant drugs for autoimmune conditions	Discuss all cases urgently with the initiating team in order to make the decision regarding continued prescription. There will a balance of disease control vs sepsis risk. (Note that methotrexate excretion will be delayed by renal impairment and it is potentiated by several common antibiotics)
Insulin (but see Trust intranet “Guideline for the management of adults with diabetes undergoing surgery and elective procedures”)	Poor glycaemic control and potential for symptomatic hyperglycaemia
Naloxone should be given	Failure to treat opioid toxicity (medical emergency) with risk of patient harm
Oral hypoglycaemic agents (but see Trust intranet “Guideline for the management of adults with diabetes undergoing surgery and elective procedures”)	Poor glycaemic control and potential for symptomatic hyperglycaemia
Oxygen should be given	Increased risk of harm from prolonged hypoxia
Parenteral bisphosphonates in the treatment of severe symptomatic hypercalcaemia should be given	Severe metabolic consequences
Resuscitation drugs and reversal agents including plasma expanders should be given	Failure to treat medical emergencies with risk of patient harm

Reference

For further information & advice see Blow, S. (2016) The Handbook of Peri-Operative Medicines. 1st Ed.

Full version control record

Version:	3.0
Guidelines Lead(s):	Dr Thomas Heinink – Consultant anaesthetist FPH Dr Pushkar Dadarkar – Consultant anaesthetist WPH
Contributor(s):	Rashmi Selli - Principal Pharmacist Surgery
Lead Director / Chief of Service:	Dr Subodh Tote – Chief of Service for Theatres, Anaesthetics, and Critical Care
Library check completed:
Ratified at:	Anaesthetic Clinical Governance Meeting 28 November 2018 Review date extended at Anaesthetics Clinical Governance Meeting 14 February 2024 Medicines Safety Group 1 January 2019
Date Issued:	31 January 2022
Review Date:	February 2027
Pharmaceutical dosing advice and formulary compliance checked by:	Rashmi Selli, 3 July 2019
Key words:	Preoperative, perioperative, medication, nil-by-mouth

This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date. This guideline is for use in Frimley Health Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

Version History

2.0

August 2019

Consultant anaesthetist FPH

Consultant anaesthetist WPH

Final

3.0

January 2022

Guideline Administrator

Final

Guideline Template change.

3.0

February 2024

Consultant anaesthetist FPH

Consultant anaesthetist WPH

Review date extended by 3 years at CG meeting.

Related Document

Management of adults with diabetes undergoing surgery and elective procedures