medicine management in patients awaiting elective surgery

Medicine Management in Patients Awaiting Elective Surgery

Presented by Joyce McSwan (Managing Director) MedRN

BPharm.MAACPA.MAPMA.MPSA.MAPSOC Accredited Consultant Pharmacist

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

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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

Key Focus of medication management

• Patient Safety

• Functional recovery

• Long term outcomes

Limited evidence for guidance

• Scant RCT to guide

• Recommendations from:

– Expert consensus

– Case reports

– In vitro studies

– Pharmaceutical companies

– Other known data

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


2. When to stop and when to resume?

• Limited guidance from literature

– Withdrawal effects

– Disease progression

– Drug interactions with anaesthetic and post operative medicines.

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


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.

Study shows ……

• Medication use has important perioperative consequences

• Odds ratio for postop complication = 2.7 if patients were taking a drug unrelated to surgery.


• 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.


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.


6. Additional Considerations

A) Stress response to surgery

– A challenge for homeostasis

– Increased sympathetic tone

– Release of pituitary hormones


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

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.

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

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

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

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)

Opioid Dependency

Risk

Falls risk

Memory impairment

Worsened pain / CNS changes

Mental health decline

Deconditioning

Long term Pain, awaiting surgery

Elective Surgery Wait

List

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

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.

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

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

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

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

Advertising slogans:

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

medicine management in patients awaiting elective surgery

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