LAS VEGAS – . Watch out for overlapping medication orders. Beware of gabapentin mishaps, and embrace Tylenol – but not always.
Randy Dotinga/MDedge News
Dr. April Smith
April Smith, PharmD, associate professor of pharmacy practice at Creighton University, Omaha, offered these tips about postoperative care to surgeons at the 2019 Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.
“We’re probably one of the most underutilized professions you have on your team,” she said, adding that “we have to know what you’re doing to help you.”
As she explained, “if you’re going to have a new order set, let us know that, so we can be your allies in helping nurses and other people understand why we’re doing what we’re doing. I’m on the same floor, and the nurses are coming up to me and asking me questions. If I can explain to them why we’re doing these things, they’ll get on board a lot faster and save you a lot of phone calls. I know you’re surgeons and you hate that [phone calls].”
Better communication with pharmacists can also boost the stocking of enhanced-recovery medications in automatic dispensing machines, she said, so they’re ready when patients need them.
Dr. Smith offered these tips about specific postsurgery medications:
- Scopolamine is a “great drug for post-op vomiting and nausea,” Dr. Smith said. But do not use it in patients over 65, and it’s contraindicated in glaucoma. Beware of these notable side effects: Blurry vision, constipation, and urinary retention. Dexamethasone and ondansetron can be used as an alternative, she said.
- Use of the blood thinner enoxaparin after discharge may become more common as surgical stays become shorter, Dr. Smith said. She urged surgeons to keep its cost in mind: a 10-day course can be as little as $2 with Medicaid or as much as $140 (a cash price for patients without coverage).
- Make sure to adjust medications based on preoperative or intraoperative doses, she said, to avoid endangering patients by inadvertently doubling up on doses. And watch out for previous use of gabapentin, which is part of enhanced-recovery protocols. Patients who take the drug at home should be put back on their typical dose.
- Also, she warned, “don’t give gabapentin to someone who’s never had it before plus an opioid.” This, she said, can cause delirium.
- Consider starting liquids the night of surgery so patients can begin taking their home medications such as sleep, chronic pain, and psychiatric drugs. Patients will be more stable and satisfied, Dr. Smith said.
- Don’t prescribe hard-to-find medications like oxycodone oral solution or oral ketorolac. These drugs will send patients from pharmacy to pharmacy in search of them, Dr. Smith said.
- Embrace a “Meds to Beds” program if possible. These programs enlist on-site pharmacies to deliver medications to bedside for patients to take home.
- Consider Tylenol as a postoperative painkiller with scheduled doses and be aware that you can prescribe the over-the-counter adult liquid form. However, Dr. Smith cautioned that Tylenol is “not great” on an as-needed basis. Gabapentin and celecoxib (unless contraindicated) are also helpful for postop pain relief, and they’re inexpensive, she said. Three to five days should be enough in most minimally invasive surgeries.
- Don’t overprescribe opioids. “The more we prescribe, the more they will consume,” Dr. Smith said. Check the American College of Surgeons guidelines regarding the ideal number of postsurgery, 5-mg doses of oxycodone to prescribe to opioid-naive patients at discharge. No more than 10 or 15 pills are recommended for several types of general surgery (J Amer Coll Surg. 2018;227:411-8).
Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Smith reports no relevant disclosures.