Medication

PRE-OPERATIVE

Prior to undergoing any surgical procedure it is important that any medical conditions be discussed with your surgeon and anaesthetist, as some of the medications you may be on can affect your anaesthetic or surgery. It is not always possible for your medical history to have been fully relayed to your surgeon or anaesthetist by your referring GP, and as such any important medical conditions you have should be advised of prior to surgery and this will allow for consideration of which medications to continue with and which to stop and when to do so.

Special consideration is given to two groups of medications – (1) Blood thinners – (i) anticoagulants (Coumadin, Pradaxa, Warfarin, Xarelto) and  (ii) anti-platelet agents (Aspro, Astrix, Cartia, Clopidogrel, Iscover, Persantin, Plavix) and (2) Diabetic medications – (i) oral hypoglycaemics  (Actos, Diabex, Diamicron, Glibenclamide, Metformin etc) and (ii) insulin preparations (Apidra, Humalog, Humulin, Lantus, Novorapid, Novomix etc).

Anticoagulants (blood thinners) can adversely affect your surgery by resulting in excessive bleeding and associated swelling, bruising, stiffness and delayed wound healing, slower return of range of motion and increased infection risk, as well as increased risk of requiring a blood transfusion. As such if you are on anticoagulants, Dr Gallagher will attempt to liaise with whoever has prescribed them to see if it is safe to stop them for a period of 3-5 days if anti coagulants (Coumadin, Pradaxa, Warfarin, Xarelto) or 7-10 days for Aspirin based or anti-platelet agents (Aspro, Astrix, Cartia, Clopidogrel, Iscover, Persantin, Plavix) prior to surgery. You may need to go onto some shorter acting anti-coagulation with self administered injections of a heparin (Clexane) in place of your usual longer acting anti-coagulation if deemed necessary by your medical specialist. If there is uncertainty about your medical condition and the relevant anticoagulation treatment at the time of surgery, an appointment will be made for you to be seen by a peri-operative physician (Dr Vincent D’Intini) prior to surgery to advise on what steps need to be taken to minimise both your medical and surgical risks.

Diabetic medications require careful consideration with the preoperative fasting requirement and is usually best managed by the attending anaesthetist, who will help determine your order on the operating list, and usually at the start or towards the earlier part of each list to minimise your fasting time and with an appropriate reduction in your oral hypoglycaemic and or insulin medications. On occasion it will be necessary to commence an intravenous drip prior to surgery to administer intravenous fluids and medications for your blood sugar management whilst you are fasting and this may require insertion of a cannula in day surgery or uncommonly admission to hospital the evening prior to surgery. Occasionally, if your diabetic control is complex or your blood sugar levels are persistently high on pre-operative blood tests, it will be necessary to liaise with your Endocrinologist (Endocrine Specialist) if you have one, or if not, and there is uncertainty about your diabetes and the relevant treatment at the time of surgery, an appointment will be made for you to be seen by a peri-operative physician (Dr Vincent D’Intini) prior to surgery to advise on what steps need to be taken to minimise both your medical and surgical risks.

If you have a pre-existing medical condition that is complex or several medical conditions an appointment may need to be made for you to be seen by a peri-operative physician (Dr Vincent D’Intini) prior to surgery to advise on what steps need to be taken to minimise both your medical and surgical risks. In general terms though, aside from the blood thinning and diabetic medications (as outlined above), all other medications (blood pressure, cholesterol, depression, thyroid etc) should be taken as normal with a small sip of water at least 2 hours and preferably 4 hours before surgery unless advised otherwise by your anaesthetist who should normally have contacted you at least a day prior to your surgery. If you are unsure whether to take a particular medication or not prior to your surgery you can contact your anaesthetist directly as follows (PUT Dr Galluzzo, Dr Ghidella, Dr Hammonds NAME AND CONTACT DETAILS including Rooms No Mob No and Email) or my rooms on 38347064 or info@qldkneesurgery.com.au

 

POST-OPERATIVE

Following surgery, patients will generally receive pain relief with simple analgesia (Panadol), oral narcotics (Targin, Endone, Tramadol, Panadeine Forte, Mersyndol Forte), and where major surgery has been performed such as a knee replacement or knee reconstruction, a patient controlled administration device (PCA) for intravenous narcotics (Morphine, Fentanyl) may be used for 1 or 2 days. Anti-inflammatory medications are also routinely used unless there are medical contra-indications such as previous gastrointestinal ulcers, renal impairment, high blood pressure or asthma with aspirin or non steroidal hypersensitivity or other allergies to such medication as they can promote or exacerbate these conditions. Commonly used anti-inflammatory medications including Non Steroidal Anti Inflammatory Drugs (NSAID’s) such as Indomethacin (Arthrexin, Indocid) , Ibuprofen (Brufen) , Meloxicam (Mobic). To minimise your risk of developing excessive stomach acid production and possible gastritis, gastro-oesophageal reflux or an ulcer, an acid inhibitor known as a Proton Pump Inhibitor (PPI) medication – Esomeprazole (Nexium) is prescribed. As patients may also become nauseous after an anaesthetic or with use of the narcotic analgesia, anti-emetic (anti-nausea) medication is provided including Ondansetron (Zofran) and/or Metoclopramide (Maxalon). Following some surgeries that result in a degree of bleeding such as knee replacement or knee osteotomies, an iron and folic acid supplement – Fefol – is provided to help with the regeneration of normal levels of the red blood cells and haemoglobin, which may help reduce the time taken to overcome any post operative anaemia and help with wound healing. Fefol is likely to result in your bowel motions becoming quite dark or black, but will usually be quite firm rather than the runny black bowel motion associated with gastrointestinal bleeding, BUT if there are any concerns about the latter, especially if you have significant abdominal pain, then all NSAID medications must be stopped and the situation is best assessed promptly by your local emergency department.  Use of narcotic analgesia (Targin, Endone, Tramadol, Panadeine Forte, Mersyndol Forte) and an iron supplement (Fefol) increases the likelihood of developing constipation, and whilst this can be managed by using natural preparations (pears, prunes, lemons including fruit and/or juice, increased fluids, yoghurt, castor oil etc) a laxative – Coloxyl & Senna – is usually provided to be taken on a regular basis to help avoid this problem, if your bowel motions are excessively soft or loose you may discontinue this medication. Some knee operations (knee replacements, knee reconstruction, knee osteotomy, lateral retinacular release, microfracture, knee realignments and stabilisations etc) have an elevated risk of developing a clot in the lower limb veins known as a deep vein thrombosis or DVT and some patients are more at risk than others for this as well, as such, some patients will be discharged with blood thinning agents for up to 6 weeks, which may include 10 – 20 days of self administered injections of Enoxaparin (Clexane) under the skin, usually into the abdomen, and/or a low dose Aspirin (Astrix) depending upon their procedure and risk factors. A combination of these medications appropriate for your surgery and individual needs will usually be dispensed prior to your discharge from hospital with written instructions on what each medication is for, and when to take and what some of the possible side effects may be.

 

POST-INJURY

Depending upon the recentness and severity of your injury, you will usually benefit from a short course of moderately strong analgesia with Panadeine Forte or Mersyndol Forte and occasionally it may be necessary for very strong analgesia with Endone or Tramadol.  As a result of the injury there will usually be a degree of swelling and this can be managed with physical modalities (see below) but will usually resolve more rapidly with some Non Steroidal Anti Inflammatory Drugs (NSAID’s) such as Indomethacin (Arthrexin, Indocid) or Ibuprofen (Brufen). Anti-inflammatory medications are not advised if there are medical contra-indications such as previous gastrointestinal ulcers, renal impairment, high blood pressure or asthma with aspirin or non steroidal hypersensitivity or other allergies to such medication as they can promote or exacerbate these conditions. To minimise your risk of developing excessive stomach acid production and possible gastritis, gastro-oesophageal reflux or an ulcer, an acid inhibitor known as a Proton Pump Inhibitor (PPI) medication – Esomeprazole (Nexium) is prescribed as well for gastrointestinal protection. Other physical modalities for pain and swelling management (rest, ice, compression, elevation, crutches, heat & physiotherapy) where appropriate will be adopted as well to assist in decreased volume and  duration of need for these medications.