QuestionMultiA
QuestionChoice
33781
d
Paracetamol;1g;oral (PO);4-hourly
QuestionChoice
33785
h
Senna;7.5mg;oral (PO);Daily
QuestionChoice
33787
j
Morphine sulphate;10mg;intravenous (IV);4-hourly
QuestionChoice
33778
a
Bisoprolol fumarate;10mg;oral (PO);Daily
QuestionChoice
33783
f
Tramadol;100mg;oral (PO);6-hourly
QuestionChoice
33782
e
Ibuprofen;400mg;oral (PO);8-hourly
QuestionChoice
33780
c
Amlodipine;5mg;oral (PO);Daily
QuestionChoice
33786
i
Warfarin;5mg;oral (PO);Daily
QuestionChoice
33784
g
Ondansetron;4mg;oral (PO);PRN
QuestionChoice
33779
b
Ramipril;2.5mg;oral (PO);Daily
Concept
Chapter
#### Monitoring

The BNF advises to monitor lung function (in patients with a history of obstructive airway disease).

#### Overdoses

Overdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).
Non-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.

Management
 - Airway protection 
 - Activated charcoal within 1 hour
 - IV Fluids
 
IV glucagon is the first-line management.
 
For symptomatic bradycardia, IV atropine may be used.

2618
2711
Post-operative drug induced constipation & drugs that causes fluid retention
Topic
13
Neurosurgery
1. Common drugs that are stopped prior to surgeries include NSAIDs, diuretics, ACEi and ARBs. ACEi and ARBs are stopped due to the increased risk of peri- and postoperative hypotension. Bisoprolol and calcium channel blockers (amlodipine) are safe and have potential benefits when taken preoperatively. Anticoagulants are also stopped when the surgical bleeding risk outweighs the individual’s thromboembolic risk . Bisoprolol is also generally continued due to the additional risk of ischemia following acute withdrawal. The use of beta blockers cause a sympathetic blockade, which lead to an upregulation of beta receptors and an increase in its responsiveness to circulating catecholamines. Catecholamine levels are elevated during surgery, this results in an increase in myocardial oxygen demand and an exacerbation of ischaemic events. NSAIDs are generally stopped due to its antiplatelet effects (via the inhibition of COX-1 and decreased production of thromboxane A2, preventing platelet aggregation). This increases the bleeding risk perioperatively. Diuretics are stopped due to concerns of hypokalaemia, which increases the risk of perioperative arrhythmia and hypovolaemia, which, in addition to the vasodilating effect of anaesthetic agents can lead to hypotension. Analgesia apart from NSAIDs are generally continued pre-operatively.
b) Paracetamol is the first step in the WHO analgesic ladder and is commonly used for pain relief. Paracetamol tablets are available in 500mg and 1g tablets but the maximum dose per day is 4g spread evenly over 6 hours or four times a day. The dose prescribed for this patient is likely to represent a transcription error of 6-hrly to 4-hrly.
6778
b e i
d
Case presentation: A 65-year-old gentleman on the gastroenterology ward is recovering from an abdominal peritoneal resection for anal cancer. PH. Hypertension, Type 2 Diabetes, Heart failure, AF. DH. His current regular medications are listed (below).


Question 1: Select the THREE prescriptions that should be stopped prior to his surgery. (mark them with a tick in column A)
Question 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B).