Medicine Management in Patients Awaiting Elective Surgery


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Joyce McSwan, Managing Director, MedRN & Mackay Representative, from the Australian Pain Management Association delivered this presentation at the 2012 Elective Surgery Redesign Conference. For more information about our wide range of medical and health events covering a broad range of industry issues, please visit

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Medicine Management in Patients Awaiting Elective Surgery

  1. 1. Medicine Management in Patients Awaiting Elective Surgery Presented by Joyce McSwan (Managing Director) MedRN BPharm.MAACPA.MAPMA.MPSA.MAPSOC Accredited Consultant Pharmacist
  2. 2. Learning Objectives • Understand the principles of medicine management pre and post elective surgery • Discuss the challenges of ‘accidental addicts’ • Discuss the whole person approach in medicine management © Copyright MedRN – - 2012
  3. 3. The importance of medication management in pre and post elective surgery • Surgical patients – many are elderly • Polypharmacy • Compromised renal or hepatic function and disease • Not adequately educated about their medication regimens
  4. 4. Key Focus of medication management • Patient Safety • Functional recovery • Long term outcomes
  5. 5. Limited evidence for guidance • Scant RCT to guide • Recommendations from: – Expert consensus – Case reports – In vitro studies – Pharmaceutical companies – Other known data
  6. 6. General considerations in perioperative medication management 1. A comprehensive medication history is fundamental • Understand a patient’s comorbidities • Assess the risk of perioperative decompensation • Look at the complete inventory: – All prescription medications – All over-the-counter (OTC) agents (including – Non- Steroidal anti-inflammatory drugs [NSAIDs] – All vitamins – All herbal medications
  7. 7. General considerations in perioperative medication management 2. When to stop and when to resume? • Limited guidance from literature – Withdrawal effects – Disease progression – Drug interactions with anaesthetic and post operative medicines.
  8. 8. General considerations in perioperative medication management 3. Withdrawal Potential • Abrupt withdrawal • Unnecessary complications • Understanding pharmacokinetics • Comprehensive list as part of protocol • Risk vs. benefit of cessation • Legal issues with inappropriate cessation • Medicines to consider: – SSRIs – Beta-blockers – Clonidine – Statins – Corticosteroids – Opioids
  9. 9. General considerations in perioperative medication management 4. Patients on chronic drugs are more likely to have complications: 1025 surgical patients 49% - taking medicines (other than vitamins) unrelated to the procedure 1 1. Kennedy JM, van Rij AM, Spears GF, Pettigrew RA, Tucker IG. Polypharmacy in a general surgical unit and consequences of drug withdrawal. Br J Clin Pharmacol 2000; 49:353–362.
  10. 10. Study shows …… • Medication use has important perioperative consequences • Odds ratio for postop complication = 2.7 if patients were taking a drug unrelated to surgery.
  11. 11. General considerations in perioperative medication management • Complication risk elevated for: – CV drugs or CNS agents – Nil by mouth order for more than 24 hours before or after surgery - alternative route considered – > 1 hour operation duration. • This study reflects destabilization of the disease processes for patients taking chronic medications that require interruption.
  12. 12. General considerations in perioperative medication management 5. Unintended discontinuation of chronic drugs • Resumption overlooked • Increase risk of medical errors in transition between hospital discharge to primary care. • Study found 11.4% patients who had elective surgery did not resume their indicated chronic warfarin therapy within 6 months after pre- surgical discontinuation. 2 2. Bell CM, Bajcar J, Bierman AS, Li P, Mamdani MM, Urbach DR. Potentially unintended discontinuation of long-term medication use after elective surgical procedures. Arch Intern Med 2006; 166:2525–2531.
  13. 13. General considerations in perioperative medication management 6. Additional Considerations A) Stress response to surgery – A challenge for homeostasis – Increased sympathetic tone – Release of pituitary hormones
  14. 14. General considerations in perioperative medication management 6. Additional Considerations B) Unreliable absorption of oral medications post operatively – Villous atrophy – Diminished blood flow to GIT – Oedema – Mucosal ischaemia – Diminished motility from postoperative ileus – Use of narcotics
  15. 15. Key Points in perioperative medication management • Continue medications with withdrawal potential • Discontinue medications that increase surgical risk and are not essential for short-term quality of life • Use clinical judgment when neither of the above two principles applies – Other medications are given in the narrow perioperative time – Alteration in the metabolism and elimination of chronic drugs may be altered.
  16. 16. Elective surgery waiting times • Reduction in waiting times – 2007-2008 : 3% – 2011-2012 : 2.7% • 11.9% > 1 year: Total Knee replacement • 5.4% > 1 year: Orthopaedic surgery • 5.6% > 1 year: Ear, nose and throat surgery • 0.1% > 1 year: Cardiothoracic surgery Australian Institute of Health and Welfare: Australian Hospital Statistics 2011-2012
  17. 17. Challenges of medication management in the waiting period • 11.9% > 1 year: Total Knee replacement • 5.4% > 1 year: Orthopaedic surgery • Definition of Chronic Pain: IASP - An unpleasant sensory and emotional experience caused by actual or potential tissue damage or described in terms of such damage Chronicity - > 3-6 months
  18. 18. Neuropathic Progression • Pain connections change • Sensitivity of cells change • Permanent change • Pain continues in the absence of any other • Changes long after the initial injury has healed NEUROPLASTICITY
  19. 19. Potential risk for opioid addiction while waiting….. • “Accidental Addicts” - true addiction or pseudoaddiction • Risk of addiction worsened by elective surgery waiting lists. – Little self management options – Taking more analgesics – Accessibility of OTC analgesics • In trials, database program that records opioid prescription history of patients (PSA, Tasmania)
  20. 20. Opioid Dependency Risk Falls risk Memory impairment Worsened pain / CNS changes Mental health decline Deconditioning Long term Pain, awaiting surgery Elective Surgery Wait List
  21. 21. Whole Person Approach to Medicine Management • Generalist approach – Seeing the person as a whole and in the context of their family and wider social environment – Demonstrating concern not only for the needs of the presenting patient, but also for the wider group of patients or population – Engaging in effective multi-professional working and co-learning
  22. 22. Whole Person Approach to Medicine Management • Biographical perspective • Developing therapeutic rapport • An enabling process for the patient: • Move individual from where they are • Increasing understanding and knowledge • Supporting emotional capabilities • Empowerment making decisions about undergoing investigations and treatment options.
  23. 23. Applying it to the landscape of elective surgery • Medicine Management = National Medicines Policy • Quality Use of Medicines • Quality-Safety-Efficacy • Applies to pre and post operative settings
  24. 24. Quality Use of Medicines • Choosing suitable medicines if a medicine is considered necessary so that the best available option is selected taking into account: o The individual o The clinical condition o Risks and benefits o Dosage and length of treatment o Any co-existing conditions o Other therapies o Monitoring considerations o Costs for the individual, the community, and the health system as a whole
  25. 25. Waiting positively • Pre-operative focus : – “Pre-hab” programs – Increase education on realistic expectations, goal setting, pacing  SELF MANAGEMENT – Present other options for consumers through greater health networks = A proactive approach
  26. 26. Waiting positively • Pre-operative focus : – Optimise medicine therapy but minimise dependence on medicines through education and utilisation of programs currently available: • Home Medicines Review • Credible resource - Australian Pain Management Association’s pain support groups • Alcohol and drug use • Analgesic intolerance • Holistic evaluation of lifestyle, injury prevention, gaining information about the operation
  27. 27. Advertising slogans:
  28. 28. Healing patiently • Resumption of medication unrelated to surgery • Patient’s expectations of chronic pain in acute pain setting • Multi-modal drug approach = minimise side effects • Being honest with the pain  restoration of functionality • Biographics – support network in place
  29. 29. Thank you © Copyright MedRN – - 2012