Perioperative medicine training resources: U2M2: Medication management in the perioperative period

PREFACE
This Standard references and relies upon the Society of Hospital Pharmacists of Australia (SHPA) Standards of Practice for Clinical Pharmacy Services1 as the foremost Standard. This Standard may overlap with others and depending on the area of specialty practice it may be advisable to refer to additional Standards of Practice.

The use of the word ‘specialisation’ in this standard is in line with the National Competency Standards Framework for Pharmacists in Australia2 where ‘specialisation’ refers to the scope of practice rather than the level of performance. ‘Specialisation’ of itself does not confer additional expertise.

This Standard is for professional practice and is not prepared or endorsed by Standards Australia. It is not legally binding.

Abstract
The widespread use of complementary products poses a challenge to clinicians in the perioperative period and may increase perioperative risk. Because dietary supplements are regulated differently from traditional pharmaceuticals and guidance is often lacking, the Society for Perioperative Assessment and Quality Improvement convened a group of experts to review available literature and create a set of consensus recommendations for the perioperative management of these supplements. Using a modified Delphi method, the authors developed recommendations for perioperative management of 83 dietary supplements. We have made our recommendations to discontinue or continue a dietary supplement based on the principle that without a demonstrated benefit, or with a demonstrated lack of harm, there is little downside in temporarily discontinuing an herbal supplement before surgery. Discussion with patients in the preoperative visit is a crucial time to educate patients as well as gather vital information. Patients should be specifically asked about use of dietary supplements and cannabinoids, as many will not volunteer this information. The preoperative clinic visit provides the best opportunity to educate patients about the perioperative management of various supplements as this visit is typically scheduled at least 2 weeks before the planned procedure.

Abstract
There is a lack of guidelines for preoperative dosing of opioid and nonopioid pain medications for surgical patients, which can lead to suboptimal preoperative pain control. The Society for Perioperative Assessment and Quality Improvement identified preoperative dosing of opioid and nonopioid analgesics as an area in which consensus could improve patient care. The aim of this guideline is to provide consensus that will allow perioperative physicians to make optimal recommendations regarding preoperative pain medication dosing. Six categories of pain medications were identified: opioid agonists, opioid antagonists, opioid agonist-antagonists, acetaminophen, muscle relaxants, and triptans/headache medications. We then used a Delphi survey technique to develop consensus recommendations for preoperative dosing of individual medications in each of these groups.

Abstract
Neurologic diseases are prevalent in patients undergoing invasive procedures; yet, no societal guidelines exist as to best practice in management of perioperative medications prescribed to treat these disorders. The Society for Perioperative Assessment and Quality Improvement tasked experts in internal medicine, anesthesiology, perioperative medicine, and neurology to provide evidence-based recommendations for preoperative management of these medications. The aim of this review is not only to provide consensus recommendations for preoperative management of patients on medications for neurologic disorders, but also to serve as an educational guide to perioperative clinicians. While, in general, medications for neurologic disorders should be continued preoperatively, an individualized approach may be needed in certain situations (eg, holding anticonvulsants on day of surgery if electroencephalographic mapping is planned during epilepsy surgery). Pertinent interactions with commonly used drugs in anesthesia practice, as well as considerations for targeted laboratory testing or perioperative drug substitutions, are addressed as well.

Abstract
Perioperative medical management is challenging due to the rising complexity of patients presenting for surgical procedures. A key part of preoperative optimization is appropriate management of long-term medications, yet guidelines and consensus statements for perioperative medication management are lacking. Available resources utilize the recommendations derived from individual studies and do not include a multidisciplinary focus or formal consensus. The Society for Perioperative Assessment and Quality Improvement (SPAQI) identified a lack of authoritative clinical guidance as an opportunity to utilize its multidisciplinary membership to improve evidence-based perioperative care. SPAQI seeks to provide guidance on perioperative medication management that synthesizes available literature with expert consensus. The aim of this Consensus Statement is to provide practical guidance on the preoperative management of endocrine, hormonal, and urologic medications. A panel of experts with anesthesiology, perioperative medicine, hospital medicine, general internal medicine, and medical specialty experience was drawn together and identified the common medications in each of these categories. The authors then utilized a modified Delphi approach to critically review the literature and generate consensus recommendations.

Abstract
Perioperative medication management is integral to preoperative optimization but remains challenging because of a paucity of literature guidance. Published recommendations are based on the expert opinion of a small number of authors without collaboration from multiple specialties. The Society for Perioperative Assessment and Quality Improvement (SPAQI) recognized the need for consensus recommendations in this area as well as the unique opportunity for its multidisciplinary membership to fill this void. In a series of articles within this journal, SPAQI provides preoperative medication management guidance based on available literature and expert multidisciplinary consensus. The aim of this consensus statement is to provide practical guidance on the preoperative management of gastrointestinal and pulmonary medications. A panel of experts with anesthesiology, perioperative medicine, hospital medicine, general internal medicine, and medical specialty experience was drawn together and identified the common medications in each of these categories. The authors then used a modified Delphi approach to review the literature and to generate consensus recommendations.

Abstract
Perioperative medical management is challenging because of the rising complexity of patients presenting for surgical procedures. A key part of preoperative optimization is appropriate management of long-term medications, yet guidelines and consensus statements for perioperative medication management are lacking. Available resources use recommendations derived from individual studies and do not include a multidisciplinary focus on formal consensus. The Society for Perioperative Assessment and Quality Improvement identified a lack of authoritative clinical guidance as an opportunity to use its multidisciplinary membership to improve evidence-based perioperative care. The Society for Perioperative Assessment and Quality Improvement seeks to provide guidance on perioperative medication management that synthesizes available literature with expert consensus. The aim of this consensus statement is to provide practical guidance on the preoperative management of immunosuppressive, biologic, antiretroviral, and anti-inflammatory medications. A panel of experts including hospitalists, anesthesiologists, internal medicine physicians, infectious disease specialists, and rheumatologists was appointed to identify the common medications in each of these categories. The authors then used a modified Delphi process to critically review the literature and to generate consensus recommendations.

Abstract
Cardiovascular conditions such as hypertension, arrhythmias, and heart failure are common in patients undergoing anesthesia for surgical or other procedures. Numerous guidelines from various specialty societies offer variable recommendations for the perioperative management of these medications. The Society for Perioperative Assessment and Quality Improvement identified a need to provide multidisciplinary evidence-based recommendations for preoperative medication management. The society convened a group of 13 members with expertise in perioperative medicine and training in anesthesiology or internal medicine. The aim of this consensus effort is to provide perioperative clinicians with guidance on the management of cardiovascular medications commonly encountered during the preoperative evaluation. We used a modified Delphi process to establish consensus. Twenty-one classes of medications were identified: α-adrenergic receptor antagonists, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, angiotensin receptor-neprilysin inhibitors, β-adrenoceptor blockers, calcium-channel blockers, centrally acting sympatholytic medications, direct-acting vasodilators, loop diuretics, thiazide diuretics, potassium-sparing diuretics, endothelin receptor antagonists, cardiac glycosides, nitrodilators, phosphodiesterase-5 inhibitors, class III antiarrhythmic agents, potassium-channel openers, renin inhibitors, class I antiarrhythmic agents, sodium-channel blockers, and sodium glucose cotransportor-2 inhibitors. We provide recommendations for the management of these medications preoperatively.

The mission of NCCIH is to determine, through rigorous scientific investigation, the fundamental science, usefulness, and safety of complementary and integrative health approaches and their roles in improving health and health care.

NCCIH’s vision is that scientific evidence informs decision making by the public, health care professionals, and health policymakers regarding the integrated use of complementary health approaches in a whole person health framework.

Voiced by ANZCA fellow Dr Peter Cook from The Tweed Hospital.

This is an audio recording of a chapter from the 2021 edition of Australasian Anaesthesia (commonly referred to as the Blue Book).

This episode covers the first 11 FAQ related to Clinical Care. The topics covered include intubation and hospital protocols for intubation in the operating room, intensive care unit, and emergency department. Check out the ASA Covid-19 Information for Health Care Providers.

Keywords: Anaesthesiology; Anti-thrombotic therapy; Arrhythmias; Beta-blockers; Cerebrovascular disease; Guidelines; Heart failure; Non-cardiac surgery; Perioperative cardiac management; Post-operative cardiac surveillance; Pre-operative cardiac risk assessment; Pre-operative cardiac testing; Pre-operative coronary artery revascularization; Pulmonary disease; Renal disease; Valvular disease.

Abstract
Aims: The aim of this study was to assess the effects of pre-operative statin therapy on cardiovascular events in the first 30-days after non-cardiac surgery.

Methods and results: We conducted an international, prospective, cohort study of patients who were ≥45 years having in-patient non-cardiac surgery. We estimated the probability of receiving statins pre-operatively using a multivariable logistic model and conducted a propensity score analysis to correct for confounding. A total of 15 478 patients were recruited at 12 centres in eight countries from August 2007 to January 2011. The matched population consisted of 2845 patients (18.4%) treated with a statin and 4492 (29.0%) controls. The pre-operative use of statins was associated with lower risk of the primary outcome, a composite of all-cause mortality, myocardial injury after non-cardiac surgery (MINS), or stroke at 30 days [relative risk (RR), 0.83; 95% confidence interval (CI), 0.73-0.95; P = 0.007]. Statins were also associated with a significant lower risk of all-cause mortality (RR, 0.58; 95% CI, 0.40-0.83; P = 0.003), cardiovascular mortality (RR, 0.42; 95% CI, 0.23-0.76; P = 0.004), and MINS (RR, 0.86; 95% CI, 0.73-0.98; P = 0.02). There were no statistically significant differences in the risk of myocardial infarction or stroke.

Conclusion: Among patients undergoing non-cardiac surgery, pre-operative statin therapy was independently associated with a lower risk of cardiovascular outcomes at 30 days. These results require confirmation in a large randomized trial.

Abstract
Preoperative fasting is universally accepted as a beneficial practice to reduce the risk of pulmonary aspiration of gastric contents during the induction of general anaesthesia. What is less clear for many junior doctors and nurses is the administration of oral medication during the fasting period. This study aims to highlight the subjective understanding of the statement, 'nil by mouth' with regard to drug administration.

Abstract
Background: Patients with Parkinson's disease (PD) may experience problems in hospital, with their medication being withheld or inappropriate medication being prescribed. Since surgical admissions present particular risks, the authors examined the management of patients with PD on surgical wards.

Methods: All patients with PD admitted to surgical departments in Aberdeen Royal Infirmary during an 18-month period were identified. Medical and nursing notes were reviewed retrospectively, and drug prescription and administration were studied in detail. All documented complications were recorded.

Results: 59 surgical admissions (51 receiving PD medication, median duration 6 days) were studied. 71% had missed doses of PD medication, with 34% missing over 10% of prescribed doses. Values were similar for levodopa and agonists. Overall, 12% of all prescribed PD medication was missed (mean 0.7 missed doses per patient per day). No reason for missed doses was recorded in 64% of cases, while inappropriate reasons included 'out of stock' (12%) and 'nil by mouth' (8%). Centrally acting antidopaminergic drugs (mainly antiemetics) were prescribed in 41% of cases, and administered in 22%. Complications, most commonly neuropsychiatric, were documented in 69% of non-day-case admissions.

Conclusion: Poor prescribing and incomplete drug administration are common in patients with PD on surgical wards. Measures to improve management are identified.

Abstract
Background: The American College of Chest Physicians Clinical Practice Guideline on the Perioperative Management of Antithrombotic Therapy addresses 43 Patients-Interventions-Comparators-Outcomes (PICO) questions related to the perioperative management of patients who are receiving long-term oral anticoagulant or antiplatelet therapy and require an elective surgery/procedure. This guideline is separated into four broad categories, encompassing the management of patients who are receiving: (1) a vitamin K antagonist (VKA), mainly warfarin; (2) if receiving a VKA, the use of perioperative heparin bridging, typically with a low-molecular-weight heparin; (3) a direct oral anticoagulant (DOAC); and (4) an antiplatelet drug.

Methods: Strong or conditional practice recommendations are generated based on high, moderate, low, and very low certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology for clinical practice guidelines.

Results: A multidisciplinary panel generated 44 guideline recommendations for the perioperative management of VKAs, heparin bridging, DOACs, and antiplatelet drugs, of which two are strong recommendations: (1) against the use of heparin bridging in patients with atrial fibrillation; and (2) continuation of VKA therapy in patients having a pacemaker or internal cardiac defibrillator implantation. There are separate recommendations on the perioperative management of patients who are undergoing minor procedures, comprising dental, dermatologic, ophthalmologic, pacemaker/internal cardiac defibrillator implantation, and GI (endoscopic) procedures.

Conclusions: Substantial new evidence has emerged since the 2012 iteration of these guidelines, especially to inform best practices for the perioperative management of patients who are receiving a VKA and may require heparin bridging, for the perioperative management of patients who are receiving a DOAC, and for patients who are receiving one or more antiplatelet drugs. Despite this new knowledge, uncertainty remains as to best practices for the majority of perioperative management questions.

Keywords: antithrombotic therapy; bleeding; perioperative care; surgery; thrombosis.

Abstract
Background: Current guidelines on perioperative care recommend the prophylactic use of β blockers in high-risk patients undergoing noncardiac surgery. However, recent studies show that, in some instances, perioperative β blockade can cause harm. Furthermore, chronic β blockade, titrated to effect before surgery, may be superior to acute perioperative β blockade. The primary objective of this study was to compare major acute cardiac outcomes in patients who underwent surgery with chronic β blocker therapy with those in patients with acute β-blocker therapy.

Methods: Data were collected for 10,691 consecutive patients undergoing elective noncardiac surgery between April 1, 2008, and April 30, 2010. Propensity scores, estimating the probability of receiving a preoperative β blocker, were calculated to match (1:1) the patients with acute and chronic β-blocker therapy. The primary outcome was a composite of myocardial infarction, nonfatal cardiac arrest, and perioperative mortality. The rate of cardiac events was compared in the matched cohorts.

Results: A total of 962 patients were chronically treated with a β blocker before surgery; in 436 patients, the β blocker was administrated acutely. Propensity score matching created 301 patient pairs who were well-balanced for major comorbidities, concomitant drug use, and type of surgery. The primary outcome was observed in 9 (3.0%) chronic versus 24 (8.0%) acute β-blocked patients (relative risk, 2.67; 95% CI, 1.27-5.60; P = 0.011).

Conclusions: Acute β blockade, initiated within the first 2 days after surgery, was associated with worse cardiac outcome compared with a matched cohort of patients who underwent surgery on chronic β blockade. These results should be validated in a larger prospective trial.

Abstract
Prescribing errors are a recognised problem on admission to acute medical wards which may be detrimental to patient care. The authors had anecdotal evidence that prescribed medicines do not always reach patients and the aim of this audit was to quantify this problem. Admission prescription charts on two separate occasions were studied in detail and all drugs prescribed but not given in the first 48 hours were recorded along with the reason given for omission. In total, 271 patient charts were analysed. Of these, 20% of prescriptions affecting 17% of patients did not reach patients. The two dominant reasons for medications not being given to patients were that the medication was not available on the ward (38% of omissions) or that the patient was nil by mouth (32% of omissions). In 10% of cases the patient refused the medication, in 19% no reason for omission was given and in only a minority (0.3%) was the patient off the ward. This audit demonstrates that even when medications are prescribed they are not always given. This may lead to increased morbidity and length of stay. Strategies need to be put in place to reduce this problem. The current system that permits omission of medications with inadequate justification must be revised.

Abstract
Objective: To provide clinicians with information about avoiding adverse drug withdrawal events (ADWEs) when discontinuing unnecessary medications as per the STOPPFrail criteria.

Data sources: Searches of MEDLINE (1970-June 2020), the Cochrane Database of Systematic Reviews (through June 2020), Google Scholar (through June 2020).

Study selection: Reviews and original studies of ADWEs.

Data extraction: Tapering protocols for specific drugs/ classes from randomized controlled deprescribing trials.

Data synthesis: Six drug classes were identified as being high risk for physiological ADWEs.

Conclusion: The occurrence of ADWEs is rare in comparison to adverse drug reactions in older adults. Few drugs/classes have been reported to have physiological ADWEs with abrupt discontinuation. For these we provide information about tapering protocols and symptom monitoring to avoid ADWEs.

AbstractThe average age of surgical candidates is increasing with the ageing population worldwide. Major surgery in older patients is associated with a significant risk of complications due to physiologic changes occurring with ageing and individual patient factors such as frailty, polypharmacy, and multimorbidity. Periodic medication review should be part of the routine management of all older patients, with the perioperative period presenting an opportune time for this review. Regular medications may need short-term modification during the surgical period. Medications implicated in increasing risk of inducing or worsening delirium should be identified and withdrawal considered ahead of time. Perioperative commencement of medication aimed at reducing risk of other complications, including cardiovascular events, should be considered on an individual basis, analysing risks and benefits. Comprehensive medication review and careful planning through the perioperative period may enhance the prospects of recovery and reduce morbidity and mortality for older surgical patients.

Abstract
Parkinson's disease is the second most common neurodegenerative disease worldwide, leading to a wide range of disability and medical complications. Managing patients with Parkinson's disease in the perioperative hospital setting can be particularly challenging. Suboptimal management can lead to medical complications, prolonged hospital stays, and delayed recovery. This review aims to address the most important issues related to caring for patients with Parkinson's disease perioperatively who are undergoing emergent or planned general surgery. It also intends to help hospitalists, internists, and other health care providers mitigate potential in-hospital morbidity and prevent prolonged recovery. Challenges in managing patients with Parkinson's disease in the perioperative hospital setting include disruption of medication schedules, "nothing by mouth" status, reduced mobility, and medication interactions and their side effects. Patients with Parkinson's disease are more prone to immobility and developing dysphagia, respiratory dysfunction, urinary retention, and psychiatric symptoms. These issues lead to higher rates of pneumonia, urinary tract infections, deconditioning, and falls compared with patients without Parkinson's disease, as well as prolonged hospital stays and a greater need for post-hospitalization rehabilitation. Steps can be taken to decrease these complications, including minimizing nothing by mouth status duration, using alternative routes of drugs administration when unable to give medications orally, avoiding drug interactions and medications that can worsen parkinsonism, assessing swallowing ability frequently, encouraging incentive spirometry, performing bladder scans, avoiding Foley catheters, and providing aggressive physical therapy. Knowing and anticipating these potential complications allow hospital physicians to mitigate nosocomial morbidity and shorten recovery times and hospital stays.

Abstract
Aims: To identify drug usage/withdrawal in surgical patients and the relative risk this imposes on postoperative surgical complications.

Methods: A prospective survey of patients' medicines, oral intake (food/fluids/ medicines) and postoperative complications was carried out in the General Surgical Unit, Dunedin Hospital, Dunedin, New Zealand.

Results: One thousand and twenty-five general surgical patients aged >/= 16 years, were entered into the study. Half of the patients were taking medicines unrelated to surgery. On average these patients received 9 different drugs (range 1-47) from a selection of 251, of which 21% were released in the last 10 years. The mean number of these drugs taken increased with age, vascular surgery and other major procedures. The majority of patients (53%) were taking drugs for cardiovascular problems. Only 8% of admissions were on the drugs more traditionally recognized to be of importance to the surgery, i.e. steroids and diabetic therapy. With respect to risk, taking a drug unrelated to surgery was associated with an increased relative risk of a postoperative complication by 2.7 (95% C.I. 1.76-4.04) compared with those who were not taking any drug. Cardiovascular drugs contributed significantly to this risk; when they were excluded from analysis, the risk dropped to 1.8 (95% C.I. 1.14-2.93). Death may be more common in those taking ACE inhibitors. Drug withdrawal and complications were analysed and as the time without medicines increased (range 1-42 days) so did the complication rate (chi2 = 14.7, DF = 2, P = 0.007). Of those patients who were taking a cardiovascular medicine and were without their normal medicines for a period of time postoperatively, 12% suffered a cardiac complication.

Conclusions: Many patients admitted to a general surgical ward, are taking medicines unrelated to surgery. Drug therapy unrelated to surgery is a useful predictor for increased postoperative complications and one for which preventive action can be taken. This study provides evidence that withdrawal of regular medicines may add significant risk to the surgery and further complicate outcome. The longer patients were without their regular medicines the more nonsurgical complications they suffered. Reintroduction of patients' regular medicines early in their postoperative course may decrease morbidity and mortality in-patients.

Abstract
As the population ages, the use of multiple medications also increases. Polypharmacy (taking multiple drugs at a time) presents concerns to the perianesthesia nurse who is caring for the geriatric patient. The pharmacokinetics and pharmacodynamics of drugs are often altered in older adult patients. Adverse drug reactions and drug interactions occur more often in geriatric patients than in younger patients. For these reasons, the benefits and risks of multiple medications and the administration of certain types of drugs must be carefully considered in the elderly patient. The selection of any medication should be individually based on the benefits and risks. Adverse drug reactions play a significant role in hospitalization for the general population, and the elderly are more susceptible to these. These drug reactions often contribute to significant morbidity as well as mortality. Medications need to be considered carefully in the older adult patient, but perhaps more so in the perioperative/perianesthesia period. Drug interactions are diverse. The type of anesthesia may influence the patient's outcome, depending on the medications the patient is currently taking. The patient's response to the stress of surgery is also affected by individual medical conditions as well as medications the patient is currently receiving Polypharmacy, inappropriate medications, adverse drug reactions, drug-disease issues, and drug interactions in the geriatric population are concerns in the perioperative/perianesthesia setting.

Abstract
Purpose of review: The implications for perioperative management of new oral antihyperglycemic medications and new insulin treatment technologies are reviewed.

Recent findings: The preoperative period represents an opportunity to optimize glycemic control and potentially to reduce adverse outcomes. There is now general consensus that the optimal blood glucose target for hospitalized patients is approximately 106-180 mg/dl (6-10 mmol/l). Recommendations for the management of antihyperglycemic medications vary among national guidelines. It may not be necessary to cease all antihyperglycemic agents prior to surgery. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are associated with higher rates of ketoacidosis especially in acutely unwell and postsurgical patients. The clinical practice implications of new insulin formulations, and new systems for insulin delivery, are not clear. The optimal perioperative management of these will vary depending on local institutional factors such as staff skills and existing clinical practices. Improved hospital care delivery standards, quality assurance, process improvements, consistency in clinical practice, and coordinated multidisciplinary teamwork should be a major focus for improving outcomes of perioperative patients with diabetes.

Summary: Sulfonylureas and SGLT2i should be ceased before moderate or major surgery. Other oral antihyperglycemic therapies may be continued or ceased. Complex patients and/or new therapies require specialized multidisciplinary management.

Abstract
Objective: To develop process-based quality indicators to improve perioperative care for elderly surgical patients.

Background: The population is aging and expanding, and physicians must continue to optimize elderly surgical care to meet the anticipated increase in surgical services. We sought to develop process-based quality indicators applicable to virtually all disciplines of surgery to identify necessary and meaningful ways to improve surgical care and outcomes in the elderly.

Methods: We identified candidate perioperative quality indicators for elderly patients undergoing ambulatory, or major elective or nonelective inpatient surgery through structured interviews with thought leaders and systematic reviews of the literature. An expert panel of physicians in surgery, geriatrics, anesthesia, critical care, internal, and rehabilitation medicine formally rated the indicators using a modification of the RAND/UCLA Appropriateness Methodology.

Results: Ninety-one of 96 candidate indicators were rated as valid. They were categorized into 8 domains: comorbidity assessment, elderly issues, medication use, patient-provider discussions, intraoperative care, postoperative management, discharge planning, and ambulatory surgery. Of note, 71 (78%) of the indicators rated as valid address processes of care not routinely performed in younger surgical populations.

Conclusions: Attention to the quality of care in elderly patients is of great importance due to the increasing numbers of elderly undergoing surgery. This project used a validated methodology to identify and rate process measures to achieve high quality perioperative care for elderly surgical patients.

Abstract
Introduction: Ageing--along with its associated physiological and pathological changes--places individuals at a higher risk of multimorbidity and treatment-related complications. Today, polypharmacy, a common and important problem related to drug use, occurs subsequent to this multimorbidity in the elderly in all populations. In recent decades, several scientific investigations have studied polypharmacy and its correlates, using different approaches and definitions, and their results have been inconclusive. Differences in definitions and approaches in these studies form a barrier against reaching a conclusion regarding the risk factors and consequences of polypharmacy. It is therefore imperative to establish an appropriate definition of polypharmacy.

Methods and analysis: A systematic review will be conducted using PubMed, Scopus, Web of Science, EMBASE, PsycINFO and AgeLine bibliographic databases, as well as the grey literature on polypharmacy in older adults to answer these two questions: What definitions in the literature are being used for polypharmacy in older people?, and Which definitions are more comprehensive and applicable? 2 independent reviewers will conduct the primary screening of the articles and data extraction, and eligible sources will be selected after discussing non-conformities. All extracted data from selected articles will be categorised based on the type of study participants, study design and setting, the methodological quality of primary studies and any other potential source of heterogeneity, and results will be summarised in a table, which will contain the levels of evidence and methodological quality of the included studies. The most comprehensive definition of polypharmacy will be selected from the final list of definitions through an international expert webinar.

Ethics and dissemination: This research is exempt from ethics approval because the work is carried out on published documents. We will disseminate this protocol in a related peer-reviewed journal.

Abstract
Study objective: To quantify the impact of preoperative medication adherence on recovery length of stays and complication rates.

Design: Cross-sectional analytical study.

Setting: Postanesthetic care unit (PACU) of a single-center tertiary hospital.

Patients: Surgical patients admitted for surgery at our institution over a 4-month period.

Intervention: A data collection tool was used to collect demographic data, length of stay in recovery, prespecified conditions likely to impact on PACU recovery (chronic pain, insulin-dependent diabetes, epilepsy, hypertension, on a methadone program, and Parkinson disease), medication compliance, and complications in PACU.

Measurements: Differences among categorical variables were assessed for significance using the χ2 test; continuous parametric data were compared using a time to survival analysis via Kaplan-Meier estimates and Cox proportional hazard regressions to account for possible confounders.

Main results: Preoperative medication compliance for the prespecified conditions was 65.1%. Patients with a preoperative condition spent more time in the PACU compared to patients without a preoperative condition. Time in PACU was not significantly longer for patients who took their medications compared to those who failed to take their medications. Patients with multiple prespecified conditions were more likely to incur a postoperative complication compared to patients without a prespecified condition. Patients with preoperative hypertension and insulin-dependent diabetes incurred higher complication rates in PACU for medication nonadherence compared to medication adherence.

Conclusion: This study taken together with accruing evidence suggests that preoperative medication omission remains an ongoing issue that can influence complication rates in the PACU. Patients with preoperative conditions stay longer in PACU, and medication omission was associated with higher rates of certain postoperative complications in PACU. This identifies patients likely to require more interventions and greater recovery resources. Further research into the impact of medication omission on recovery parameters after discharge from the PACU is warranted.

Abstract
Purpose
STOPP/START is a physiological systems-based explicit set of criteria that attempts to define the clinically important prescribing problems relating to potentially inappropriate medications (PIMs–STOPP criteria) and potential prescribing omissions (PPOs–START criteria). The previous two versions of STOPP/START criteria were published in 2008 and 2015. The present study describes the revised and updated third version of the criteria.

Methods
A detailed system-by-system review of the published literature from April 2014 to March 2022 was undertaken with the aim of including clinically important new explicit PIM and PPO criteria and removing any criteria considered to be no longer correct or outdated. A panel of 11 academic physicians with recognized expertise in geriatric pharmacotherapy from 8 European countries participated in a Delphi panel with the task of validating the draft criteria. The panel was presented with the draft new criteria using the SurveyMonkey® on-line platform in which panelists were asked to indicate their level of agreement on a five-point Likert scale.

Results
Two hundred and four evidence-based draft criteria (one hundred and forty-five STOPP criteria, fifty-nine START criteria) were presented to panelists for assessment using the Delphi validation method. Over the course of four rounds of Delphi validation, the panel achieved consensus on 133 STOPP criteria and 57 START criteria, i.e., 190 STOPP/START criteria in total representing a 66.7% increase in the number of criteria compared to STOPP/START version 2 published in 2015.

Conclusion
A fully revised and updated version of STOPP/START criteria has been validated by a European expert panel using the Delphi consensus process.

Supplementary Information
The online version contains supplementary material available at 10.1007/s41999-023-00777-y.

Abstract
Purpose: The issues regarding the discontinuation and reinstitution of long-term therapies, including cardiovascular agents, anticoagulants and antiplatelet agents, central nervous system agents, and herbal medicines, in the perioperative period are discussed.

Summary: It is estimated that one fourth of all patients undergoing a surgical procedure are taking long-term medications. The issues surrounding the decision to discontinue such medications before surgery and when to reinstitute them are complex. In the preoperative period, it is important to avoid the use of medications that may negatively interact with anesthetic agents. Postoperatively, the concern shifts toward avoiding withdrawal symptoms that may develop and possible progression of the underlying disease if the medications are not restarted in a timely fashion. The potential for decreased gastrointestinal motility in the postoperative patient, which may reduce the efficacy of oral medications, must also be considered. Antihypertensive medications may cause cardiovascular complications, such as hypotension or myocardial ischemia. Psychoactive medications may cause prolonged sedation and withdrawal symptoms may develop. Antithrombotic agents may increase the risks of bleeding during surgery. Several herbal medicines may cause a combination of these effects.

Conclusion: The decision to withhold and restart medications should be based on available clinical data and expert opinion. Health care professionals should exercise diligence in obtaining an accurate medication history on all preoperative patients and in reviewing the medications in the postoperative orders.

Abstract
Background: Missing doses of antibiotics in hospitalized patients is a well-described but inadequately recognized issue. We hypothesized that missing doses of antibiotics decreases quality of care.

Methods: Retrospective study on patients admitted to the Shock Trauma ICU from February to June 2015. Patients prescribed a multidose course of antibiotics were evaluated. A missed antibiotic dose was one ordered but never given (a completely missed dose) or a dose that was not given within an hour before or after the planned time (an off-schedule missed dose). Patient outcomes included a positive culture, ventilator, ICU and hospital length of stay (LOS), and mortality. Multiple statistical methods were used as appropriate; significance was set as P < 0.05.

Results: For the 5-mo study period, 280 patients were admitted and 200 met inclusion criteria. Eight percent of patients (16/200) did not miss any antibiotic doses, 39% (77/200) had only off-schedule doses, 2% (4/200) had only completely missed doses, and 51% (103/200) had both off-schedule and completely missed doses. For the 200 patients, 8167 doses were ordered and 2096 (26%) were missed. Adjusting for age, gender, BMI, injury severity score, and doses of antibiotics showed that those who miss doses off-schedule had longer LOS than those who do not miss doses of antibiotics. There was a significant nonlinear relationship between LOS and frequency of early (P-value = 0.02) and late (P-value = 0.01) doses.

Conclusions: To reduce length of hospital stay and optimize quality, methods to improve compliance with antibiotic dosing schedules should be investigated.

Abstract
Several studies have demonstrated that pre-operative fasting may be as short as 2 h for clear fluids and 6 h for solids with no adverse effect on volume or pH of gastric contents. Other studies suggest that many patients do not receive pre-operative prescribed medications. One hundred and fifty-three adults presenting for elective surgery (mean age 51 years) were studied to assess fasting practice. Fasting times far in excess of the recommended safe minimum were found. Mean length of fast for solids was 15 h 24 min (95% confidence intervals +/- 49 min) and for fluids 12 h 30 min (95% confidence intervals +/- 30 min). Of the 53 patients taking regular medications, 23 did not receive one or more drugs pre-operatively; most notably 45% of cardiac prescriptions were not administered. Despite strong evidence to support a change, actual practice continues to fall below accepted standards.

Abstract
Most reviews of drug withdrawal effects focus on drugs of potential abuse such as opioids, benzodiazepines, etc. Abrupt discontinuation of many other drugs used in medicine cause withdrawal syndromes, some of which can be fatal. Discontinuation of a number of cardiovascular drugs can increase risk of cardiovascular events above that of people not taking these drugs. These include β-adrenergic receptor antagonists, aspirin, HMG-CoA reductase inhibitors (statins), and heparin. Rebound hypertension occurs after abrupt cessation of many antihypertensive drugs. The possibility of discontinuation syndromes has usually been neglected until adverse clinical events force them to be noticed. Attention to the possibility of drug discontinuation effects is an important part of drug safety evaluation.

Abstract
The discontinuation of statin therapy in patients with acute coronary syndromes has been associated with an increase of adverse coronary events. Patients who undergo major surgery frequently are not able to take oral medication shortly after surgery. Because there is no intravenous formula for statins, the interruption of statins in the postoperative period is a serious concern. The objective of this study was to assess the effect of perioperative statin withdrawal on postoperative cardiac outcome. Also, the association between outcome and type of statin was studied. In 298 consecutive statin users who underwent major vascular surgery, detailed cardiac histories were obtained, and medication use was noted. Postoperatively, troponin levels were measured on days 1, 3, 7, and 30 and whenever clinically indicated by electrocardiographic changes. End points were postoperative troponin release, myocardial infarction, and a combination of nonfatal myocardial infarction and cardiovascular death. Multivariate analyses and propensity score analyses were performed to assess the influence of type of statin and the discontinuation of statins for these end points. Statin discontinuation was associated with an increased risk for postoperative troponin release (hazard ratio 4.6, 95% confidence interval 2.2 to 9.6) and the combination of myocardial infarction and cardiovascular death (hazard ratio 7.5, 95% confidence interval 2.8 to 20.1). Extended-release fluvastatin was associated with fewer perioperative cardiac events compared with atorvastatin, simvastatin, and pravastatin. In conclusion, the present study showed that statin withdrawal in the perioperative period is associated with an increased risk for perioperative adverse cardiac events. Furthermore, there seemed to be better outcomes in patients who received statins with extended-release formulas.

Abstract
The objectives for the provision of a safe anaesthetic include rendering the patient analgesic for the procedure (amnesic if appropriate), with control of adverse haemodynamic perturbations, and muscle relaxation to facilitate surgery as necessary. This must be done with an understanding of the patient's pre-existing pathophysiology and drug therapy. This article focuses on the management of medications in the perioperative period from the practitioner's perspective. Areas of drug therapy examined include drugs affecting the cardiovascular, central nervous, haemostatic and endocrine systems. Review of the limited data available suggests that the safest course of action for the preoperative management of the vast majority of drug therapy is to continue such therapy until the time of surgery, particularly agents in which a withdrawal syndrome has been described, e.g. beta-adrenoceptor blocking agents, alpha 2-adrenoceptor agonists. Exceptions to this generalisation might include discontinuing ACE inhibitors prior to surgery as these agents may be associated with adverse haemodynamic changes during surgery. The management of drug therapy for patients receiving monoamine oxidase inhibitors (MAOIs) continues to be challenging due to the potential for drug interactions, e.g. severe hypertension with use of indirect-acting vasopressors and excitatory/depressive reactions with administration of pethidine (meperidine) or dextromethorphan. However, recent clinical experience has demonstrated the relative safety of continuing MAOIs prior to surgery by use of specific 'MAOI safe' anaesthetic techniques and/or substitution of short-acting MAOIs which do not irreversibly inhibit the enzyme. For drugs affecting the coagulation system, such as heparin and warfarin, prudence dictates discontinuing these agents whenever possible prior to surgery where it can be anticipated that haemorrhage will occur, e.g. vascular surgery, or where the consequences of even minor bleeding could be catastrophic, e.g. eye surgery. Controversy exists as to the management of patients receiving prophylactic low dose heparin for deep vein thrombosis prophylaxis or in whom intraoperative or postoperative anticoagulation is planned, e.g. aortic surgery, and in whom a regional anaesthetic technique is planned as part of the anaesthetic management. The data available suggest that, where prophylactic use of heparin is concerned, and provided the administration of the last dose of heparin and the institution of a regional anaesthetic nerve block does not occur at the same time, use of regional anaesthesia is not contraindicated in such circumstances. Where therapeutic anticoagulation is planned as part of the surgical management, there is a very small risk of the development of epidural or spinal haematoma when major central conduction nerve block is employed for anaesthesia, with resultant spinal cord compression and paralysis. These precautions do not apply to patients receiving aspirin or other nonsteroidal anti-inflammatory agents as there is a large clinical and published experience of the safety of regional anaesthesia in this group of patients. Patients treated with fibrinolytic agents are at increased risk for bleeding should surgery be required. For these patients, pre- and intraoperative use of agents with antifibrinolytic activity, e.g. aprotinin, has been demonstrated in case reports to be beneficial. Finally, recommendations for the management of patients who have received or are receiving glucocorticoids are given. Throughout the review, areas of uncertainty where further research is required are identified.

Abstract
We conducted a prospective study of non-cardiac surgical patients aged 70 years or more in 23 hospitals in Australia and New Zealand. We studied 4158 consecutive patients of whom 2845 (68%) had pre-existing comorbidities. By day 30, 216 (5%) patients had died, and 835 (20%) suffered complications; 390 (9.4%) patients were admitted to the Intensive Care Unit. Pre-operative factors associated with mortality included: increasing age (80-89 years: OR 2.1 (95% CI 1.6-2.8), p < 0.001; 90+ years: OR 4.0 (95% CI 2.6-6.2), p < 0.001); worsening ASA physical status (ASA 3: OR 3.1 (95% CI 1.8-5.5), p < 0.001; ASA 4: OR 12.4 (95% CI 6.9-22.2), p < 0.001); a pre-operative plasma albumin < 30 g.l⁻¹ (OR: 2.5 (95% CI 1.8-3.5), p < 0.001); and non-scheduled surgery (OR 1.8 (95% CI 1.3-2.5), p < 0.001). Complications associated with mortality included: acute renal impairment (OR 3.3 (95% CI 2.1-5.0), p < 0.001); unplanned Intensive Care Unit admission (OR 3.1 (95% CI 1.9-4.9), p < 0.001); and systemic inflammation (OR 2.5 (95% CI 1.7-3.7), p < 0.001). Patient factors often had a stronger association with mortality than the type of surgery. Strategies are needed to reduce complications and mortality in older surgical patients.

Abstract
Many patients presenting for a procedure/surgery take long-term oral medications. Many of these medications are omitted inappropriately during the fasting period, which can put patients at risk of undesirable complications. The PhD took a qualitative-quantitative approach to explore potential causes, solutions, implementation considerations and impact of strategies to improve medication management in patients with oral intake restrictions, such as when fasting before a procedure/surgery.

Four studies were conducted: The first identified barriers to managing medications appropriately, while the second investigated barriers and enablers to implementation of improvement initiatives. The third was a focus group exploring the perceptions and experiences of surgical nurses operating the initiatives. This was followed by a retrospective interrupted time series analyses of medications omitted inappropriately and overall omissions in patients fasting before a procedure/surgery, pre- and post-implementation of improvement strategies in Medical and Surgical areas of one hospital.

The barriers analysis indicated confusion about how to manage medications when patients have oral intake restrictions. This was exacerbated by lack of a standardised approach, leadership and using fasting and nil by mouth interchangeably. These findings supported development of improvement strategies that provide clarity and guidance for staff; specifically, clear definitions for fasting and nil by mouth in relation to medication administration and decision aids to highlight these instructions at the frontline. This was the basis of the Medications and Oral Restrictions Policy (the Policy).

Resource and infrastructure, staff interpretation of their roles and the perceived applicability and credibility of the Policy were common themes for both barriers and enablers to policy implementation. Challenging barriers included variability in the communication structure, differing interpretation of responsibility and staff movement and turnover. Despite a considered implementation approach, the enablers and strategies employed were insufficient to manage the barriers.

The focus group findings corroborated those from the medication management barriers analysis and barriers and enablers to policy implementation. Surgical nurses concurred about the confusion and lack of guidance pre-policy introduction; however, although the Policy offered clarity, guidance and context for managing medications for some, limitations in the Policy’s reach and individual staff interpretation of its messages and inherent decision-making process meant it was unhelpful for others.

The interrupted time series study suggested a moderate but statistically significant reduction in inappropriate and overall medication omissions in patients fasting before a procedure/surgery following policy implementation, especially in Medical areas. Surgical baseline omissions were lower than Medical’s, which contrasted evidence from the literature and requires exploration.

In summary, a pragmatic approach to medication management was associated with a moderate reduction in inappropriate and overall dose omissions in patients fasting before a procedure/surgery. The Policy provided clarity and guidance for some: Those who understood the context found the Policy helpful to their practice. Nonetheless, insufficient resources to provide context, ensure adequate uptake and sustainability affected wider policy impact. Existing systems that do not require ongoing staff effort to sustain, that are relatively impervious to staff movement, such as the electronic prescribing platform, should be capitalised on to improve the reach and uptake of the Policy.

Abstract
Background: Anesthesiologists are responsible for optimizing patients' preoperative medications, including maximizing their compliance with preoperative medication instructions. The authors hypothesized that a standardized, simplified instruction sheet presented and verbally reinforced during the preanesthesia clinic visit would improve patient medication compliance on the day of surgery.

Methods: An unmatched case-control design was applied, with nonrandomized, preintervention (controls) and postintervention (cases) data collected. In the preintervention group, patient education/instruction regarding taking medications on the day of surgery continued in the existing, unstandardized manner. In the postintervention group, patients were given a simplified, multicolored Preoperative Patient Medication Instruction Sheet, which was consistently verbally reviewed with patients. Group differences and independent variable associations were analyzed with conventional inferential biostatistics.

Results: A total of 521 and 531 patients were enrolled in the preintervention group and postintervention group, respectively. Of this, 309 patients (60%) of preintervention group versus 391 patients (74%) of postintervention group (P < 0.001) were compliant with their preoperative medication instructions on the day of surgery. Use of the Preoperative Medication Instruction Sheet (adjusted odds ratio [aOR] = 1.83; P < 0.001), Caucasian race (aOR = 1.74; P = 0.007), and recalling receiving both verbal/written preoperative medication instructions (aOR = 1.51; P = 0.006) were associated with greater patient medication compliance. Older age (aOR = 0.67; P = 0.014) and higher American Society of Anesthesiologists status (aOR = 0.60; P = 0.004) were associated with lesser patient medication compliance.

Conclusions: A standardized, multicolored, pictorial Preoperative Patient Medication Instruction Sheet, with patient communication in both verbal/written forms, seems to improve patient medication compliance on the day of surgery. African-Americans, older patients, and those with greater comorbidities may require a more concerted effort to achieve an adequate preoperative medication compliance.

Abstract
Periods of fasting perioperatively make normal drug treatment difficult to maintain. One hundred and seventy patients admitted consecutively for operations (excluding those having cardiac, neurosurgical, and orthopaedic operations) were studied to identify whether they received their prescribed drugs. Seventy two were receiving drugs unrelated to their operation or anaesthesia. One thousand seven hundred and forty six single prescriptions (that is, single doses) were recorded as to be given on the day of surgery and the next day, of which 256 (15%) were not administered. All prescriptions of analgesics and premedicants were given; when these were excluded the proportion of prescriptions that were not given rose to 29%. The prescriptions omitted included 38 out of 95 for drugs for cardiovascular disease, 34 out of 103 for drugs for respiratory disease, and 10 out of 61 for drugs for endocrine disorders. The omission of drugs was not known to the medical staff and may introduce variability in the response of patients perioperatively.