Appendix I
Table I: Pain management
PAIN MANAGEMENT
Patient/ disease features
Preoperative actions
Postoperative actions
Potential harm
Check respiratory status
Check level of alertness, careful
titration of the dose against effect
Respiratory depression
Opioids
Impaired bowel function
Limit duration of opioid use (<3 days)
Impaired return of bowel
function after surgery
Opioids
PONV
-
If opioids are strictly indicated,
prescribe a combination of
controlled-release oxycodone and
naloxone
Prevention with: droperidol,
dexamethasone or ondansetron
Opioids
Pruritis
-
Pruritis
NSAIDs
GI bleeding
Prescribe a PPI with any NSAID if:
- Age of 65 years and over
- Previous history of GI-ulcer,
bleeding, or perforation
- Use of anticoagulants, aspirin, and
corticosteroids, SSRIs
- Presence of serious comorbidity,
such as renal or hepatic impairment,
diabetes, or hypertension
- Prolonged NSAID use or use of the
maximum recommended doses of
NSAIDs
Treat with: naloxone, naltrexone,
nalbuphine, droperidol or 5-HT3
antagonists
Prescribe a PPI with any NSAID if:
- Age of 65 years and over
- Previous history of GI-ulcer,
bleeding, or perforation
- Use of anticoagulants, aspirin,
and corticosteroids, SSRIs
- Presence of serious comorbidity,
such as renal or hepatic
impairment, diabetes, or
hypertension
- Prolonged NSAID use or use of
the maximum recommended
doses of NSAIDs
DRUGS
Opioids
Respiratory comorbidity
Nausea and vomiting
Peptic ulcera, GI-bleeding
PATIENT COMORBIDITIES
1
Renal Function Disorder
(GFR: ≤ 30 ml/min/1,73m2)
Check renal function
Avoid NSAIDs.
Alternatives: alfentanil,
buprenorphine, fentanyl,
ketamine, paracetamol, sufentanil
and oxycodon
Increased renal failure,
nefrotoxicity
Liver Function Disorder (ALT
three times upper limit of normal
or major liver resection)
Check liver function
Lower dosage of tramadol,
paracetamol, local analgesics
Increased liver failure,
hepatoxicity
Pregnant patient
Check pregnancy term with
gynaecologist
Safe drugs: paracetamol, codeine,
local bupivacaine,lidocaine,
mepivacaine, prilocaine
Harmful effects fetus
Pregnant patient
PONV
Check pregnancy term with
gynaecologist
metoclopramide
Nausea and vomiting,
harmful effects fetus
CONTRA INDICATED DRUGS/DRUG USE ALERTS
Known allergy for analgesic drug Avoid drug with registered allergy. If
Avoid drug with registered allergy. Allergic reaction
its use is strictly indicated, perform
If strictly necessary, have
graded challenge with 10% of
adrenaline available on demand
required dose and have adrenaline
available on demand
EVIDENCE BASED GUIDELINES [19-23]
PONV = Post-operative nausea and vomiting; NSAIDs = Non steroid anti-inflammatory and antireumatic drugs; PPI = Proton Pump inhibitor;
GI = gastrointestinal; GFR = glomerular filtration rate; ALT = Alanine transaminase
2
Table II: Respiratory management
RESPIRATORY MANAGEMENT
Patient/ disease features
Preoperative actions
DRUGS
Chronic corticosteroids
PATIENT COMORBIDITIES
Smoking habit
Obstructive sleep apnoea
Asthma and COPD
Young healthy athletic adult
males
Postoperative actions
Potential harm
Start systemic steroids stress
scheme intravenously or orally
Continue systemic steroids stress
scheme intravenously or orally
when oral intake is possible
Exacerbation COPD
Preferably smoking cessation or
reduction no later than 6-8 weeks
before surgery
Determine whether the patient with
obstructive sleep apnoea is a
candidate for ambulatory surgery
Monitor respiratory rate and
oxygen saturation
Increased risk of pulmonary
complications (e.g.
infections, apnoea)
Respiratory and cardiac
arrest, potentially death
Pulmonary function test for assessing
the lung function.
Optimize lung function with inhaled
bronchodilators in combination with
corticosteroid therapy (if necessary)
None
Effective analgesia. Continuation
of prescribed respiratory
medication. Early mobilisation,
deep breathing and positive
pressure breathing
Monitor respiratory rate and
oxygen saturation
Exacerbation COPD
Monitor respiratory rate and
oxygen saturation, alternatives:
local or regional anaesthesia,
gabapentine
Respiratory depression,
apnoea
CONTRA INDICATED DRUGS/DRUG USE ALERTS
Hypnotics, sedatives and opioids Secure airway
- Monitor oxygenation and
ventilation closely (especially
when sedatives, anaesthetics and
analgesics are administrated),
- Local or regional anaesthesia is
recommended instead of
sedatives, anaesthetics and
analgesics
Increased risk of pulmonary
edema secondary to
postextubation
laryngospasm
EVIDENCE BASED GUIDELINES ref [24-26]
COPD = Chronic Obstructive Pulmonary Disease
3
Table III: Infection management
INFECTION MANAGEMENT
Patient/ disease features
Preoperative actions
DRUGS
Antibiotic prophylaxis (according Give antibiotic prophylaxis < 30 min
to national guidelines)
before:
- Clean surgery involving the
placement of a prothesis or implant
- Clean-contaminated surgery
- Contaminated surgery
Antibiotic treatment
Give antibiotic treatment (in addition
(According to national
to prophylaxis) to patients having
guidelines)
surgery on a dirty or infected wound
Dressing
-
COMORBIDITIES
Renal Function Disorder (GFR:
≤ 30 ml/min/1,73m2) or patient
on dialysis
Valvular heart disease
Adjust the dose of antibiotic if
excreted by the kidney
Endocarditis prophylaxis
recommended only in dental
procedures manipulating or
perforating oral mucosa, amoxicillin 2
g orally, 30 to 60 minutes prior to the
procedure, Not recommended in GI or
GU procedures
MRSA carrier
In case of high risk surgery:
prophylaxis: intranasal mupirocin and
a glycopeptide should be considered
for antibiotic prophylaxis
Diabetes
Optimize blood glucose levels
Smoking
Encourage stop smoking
Hair
Do not remove hair routinely. If hair
needs to be removed, use electric
clippers with a single use head on the
day of surgery
CONTRA INDICATED DRUGS/ DRUG USE ALERTS
Postoperative actions
Potential harm
-
Continue antibiotic treatment.
Register stop date
SSI, generalized infection
Protect the surgical wound with a
dressing 24-48 hours
postoperative, beyond 48 hours is
not recommended. Change
dressings with hand hygiene and
a sterile technique
Adjust the dose of antibiotic if
excreted by the kidney and
monitor drug concentrations when
possible
-
If a SSI needs antibiotic treatment:
antibiotic regimen should include
activity against locally prevalent
MRSA stains
Optimize blood glucose levels
-
Too high or low plasma
levels of the drug
Endocarditis
SSI
4
History of anaphylaxis,
immediately after penicillin
Do not administer prophylaxis with
penicillin and beta-lactams
Use alternatives according to local
guidelines
EVIDENCE BASED GUIDELINES ref [27-34]
Do not administer therapy with
penicillin and beta-lactams
Allergic reaction
Use alternatives according to local
guidelines
5
Table IV: Diabetes management
DIABETES MANAGEMENT
Patient/ disease features
DRUGS
Non-insulin medication (tablets):
acarbose, meglitinide,
sulphonylurea
Insulin, 3,4 or 5 injections daily
Basal bolus regimens
Insulin, 3,4 or 5 injections daily
premixed insulin
Non-insulin medication (tablets):
DPP-4 inhibitor, GLP-1 analogue
Non-insulin medication (tablets):
metformin (procedure not
requiring contrast medium),
Pioglitazone
Insulin, once daily
Insulin, twice daily
Insulin, twice daily: separate
injections of short acting and
intermediate acting
COMORBIDITIES
Renal Function Disorder (GFR:
≤ 30 ml/min/1,73m2)
Preoperative actions
Postoperative actions
Potential harm
Restart the normal pre-surgical
regimen if the patient can eat and
drink without nausea and vomiting
Poor glycemic control
Omit morning dose
Omit the morning and lunchtime
short acting insulins. Keep the basal
unchanged. Check blood glucose on
admission
Halve the morning dose and omit
lunchtime dose. Check blood glucose
on admission
Omit on the day of surgery
Administer as normal
Administer as normal
No dose change, check blood
glucose on admission
Halve the usual morning dose, check
blood glucose on admission
Give half of intermediate acting only
in the morning. Check blood glucose
level on admission
Leave evening meal dose
unchanged
Check renal function, Sodium level,
Potassium level, glucose the day
before surgery. Omit metformin when
fasting starts
Monitor renal function, Sodium,
Potassium, glucose regularly
Hyperkalemia
Restart the normal pre-surgical
regimen if the patient can eat and
drink without nausea and vomiting
CONTRA INDICATED DRUGS/DRUG USE ALERTS
Contrast medium
If a patient on metformin has a GFR
Restart metformin 48 hours after
less than 50 mL/min/1.73m2: Omit
the procedure or postpone if GFR
Metformin on the day of the
is not recovered yet
procedure
EVIDENCE BASED GUIDELINES ref [35-37]
DPP-4 = Dipeptidyl peptidase-4 inhibitor GLP = Glucagon-like peptide; GFR = glomerular filtration rate
6
7
Table V: Cardiovascular management
CARDIOVASCULAR MANAGEMENT
Patient/ disease features
Preoperative actions
DRUGS
Diuretics used for hypertension
Omit on the day of surgery. Check
electrolytes (K, Mg) and correct for
possible electrolyte disturbances
Diuretics used for hearth failure
Continue intravenously perioperative
- Calcium channel-blockers
Continue regular oral regimen until
- Beta blocking agents
surgery
- Lipid modifying agents
ACE inhibitors/
Omit 24 hours prior to surgery
angiotensin II receptor blockers/
renin inhibitor
COMORBIDITIES
Endocarditis prophylaxis in
patients with valvular heart
disease
Recommended only in dental
procedures manipulating or
perforating oral mucosa. Not
recommended in GI or GU
procedures
CONTRA INDICATED DRUGS/ DRUG USE ALERTS
Haloperidol, cisapride,
Avoid use when the patient has an
citalopram
known prolonged QTc interval or
torsades des pointes
EVIDENCE BASED GUIDELINES ref [33, 38-42]
Postoperative actions
Potential harm
Check electrolytes (K and Mg)
Restart when oral intake is
possible
Restart orally when oral intake is
possible
Fluid/electrolyte
imbalance
Hypopotassemia < 2.5
Heart failure
(rebound) hypertension
Restart when patient is
hemodynamic stable
continuation of
preoperative use can
exacerbate intraoperative
hypotension
-
Endocarditis
ECG monitoring.
Maximum dose Citalopram: 40mg
Cardiac dysrhythmia
ACE = Angiotensin converting enzyme; GI = gastrointestinal; GU = genitourinary
8
Table VI: Anticoagulant management
ANTICOAGULANT MANAGEMENT
Patient/ disease features
Preoperative actions
DRUGS
VKA: Low thrombo-embolic riska Discontinue phenprocoumon 4 days
prior to surgery or Acenocoumarol 2
days prior to surgery. Standard
LMWH prophylaxis administered
periprocedurally
VKA: High thrombo-embolic
Discontinue phenprocoumon 4 days
riska
prior to surgery or acenocoumarol 2
days prior to surgery. Start a
therapeutic LMWH 3 days before
procedure with last dose 24 h before
procedure Standard LMWH
prophylaxis administered
periprocedurally
VKA: Procedures with low
Continue VKA therapy with
bleeding risk
INR in therapeutic range
VKA: Procedures with high
Discontinue VKA therapy and treat
bleeding risk
with a LMWH as described for low- or
high-risk patient
VKA: Urgent surgical procedure
Antithrombotic agents
Rivaroxaban
Dabigatran
Platelet aggregation inhibitors
Clopidogrel
Platelet aggregation inhibitors
Acetylsalicylic acid
Fresh-frozen plasma or prothrombin
complex concentrate or or
recombinant factor VIIa (rFVIIa) in
addition to low-dose i.v. or oral
vitamin K is recommended
Check if stopped at least 24 hours
before surgery
Check with cardiologist if stop is
allowed. If bare metal stent is placed
within 6 weeks prior to surgery:
continue. If drug eluted stent is placed
within 12 months prior to surgery:
continue
Check PPI interaction: replace
esomeprazol/ omeprazol for other PPI
Continue, except when intracranial
surgery will be performed, omit 10
days before
Postoperative actions
Potential harm
Start VKAs on the day of surgery
Stop LMWH with INR in
therapeutic range or after at
least 5 days
Bleeding, thromboembolic event
Start VKAs on the day of surgery
and LMWH on day 1, 2 or 3,
depending on Haemostasis Stop
LMWH when INR in therapeutic
range (after at least 5 days)
Bleeding, thromboembolic event
thrombo-embolic event
Start VKAs on the day of surgery
Stop LMWH with INR in
therapeutic range or after at least
5 days
Start VKAs on the day of surgery
Stop LMWH with INR in
therapeutic range or after at least
5 days
Bleeding, thromboembolic event
Start LMWH until discharge.
Restart Rivaroxaban after
discharge
Continue or restart as soon as
possible
Check PPI interaction: replace
Esomeprazol/ Omeprazol for other
PPI
Bleeding
Continue or restart as soon as
possible
thrombo-embolic event,
bleeding
Bleeding
thrombo-embolic event
9
COMORBIDITIES
Patient undergoing major
general surgery
Heparin Induced
thrombocytopenia
Thromboprophylaxis is
recommended: LMWH, LDUH or
Fondaparinux
Omit heparin or LMWH. Alternative:
Lepirudine and monitor APTT
or Danaparoide
LMWH and Rivaroxaban and
Dabigatran not recommended.
Alternative: unfractioned Heparin
Liver Function Disorder (ALT
LMWH and Rivaroxaban and
three times upper limit of normal Dabigatran not recommended.
or major liver resection)
Alternative: unfractioned Heparin
CONTRA INDICATED DRUGS/ DRUG USE ALERTS
Antibiotics or PPI
Thromboprophylaxis is
recommended: LMWH, LDUH or
Fondaparinux
Start VKAs on the day of surgery
Stop Lepirudine or Danaparoide
with INR in therapeutic range
Renal Function Disorder (GFR:
≤ 30 ml/min/1,73m2)
thrombo-embolic event
Thrombocytopenia,
bleeding
Impaired renal function
Impaired liver function
Check INR frequent in patient on
VKA
Increased INR
Secondary Bleeding
EVIDENCE BASED GUIDELINES ref [41, 43-47]
a
Low thrombo-embolic risk: Biological prosthetic heart valve (>3 months); Mitral valve repair (>3 months); Atrial fibrillation without any
high risk (Prior ischaemic stroke, transient ischaemic attack or systemic embolism, mitral stenosis or prosthetic heart valve) or
without > 1 moderate risk factor (Age > 75 years, hypertension, heart failure, left ventricular ejection fraction <35%, diabetes mellitus)
VTE (>3 months) and mild thrombophilia.
High thrombo-embolic risk when the patient does not comply with these criteria.
VKA = Vitamine K antagonist; LMWH = Low molecular weight heparin; INR = international normalized ratio; PPI = proton pump inhibitor;
LDUH = Low-Dose Unfractionated Heparin
10