Perioperative medication management — structured SAQ (15 marks)

(a) Pre-operative medication plan for each medication (7 marks)

One mark per drug with withhold timing and rationale, maximum seven.

• Anticoagulant for AF (name it: warfarin versus a DOAC). If warfarin: stop 5 days pre-op (BRIDGE methods); do not routinely heparin-bridge — arterial TE 0.4 vs 0.3 percent, major bleed 1.3 vs 3.2 percent; ACCP 2022 strong recommendation against bridging in AF. If a DOAC: PAUSE — omit 2 days before a high-bleeding-risk intra-abdominal cancer hysterectomy; resume 2 to 3 days after; no heparin bridge.^[1][2][7]
• Metformin: withhold around major surgery / iodinated contrast because of lactic-acidosis risk if renal perfusion falls; restart when eating and renal function is confirmed. Exact 24/48-hour recipes are not in the abstracts used for this topic — say so rather than invent them.^[5]
• Empagliflozin: hold before elective surgery (euglycaemic DKA, especially with insulin and prolonged fasting). International guidelines quoted in Haziri 2026 recommend 3 to 4 days. Resume when eating. Mention the 2026 cardiac-complication signal with longer holds so the answer is not cartoon-simple.^[6]
• Enalapril: withhold the morning of non-cardiac surgery (Hollmann 2018: less intraoperative hypotension, OR 0.63; no mortality/MACE difference). Not an unsourced 24-hour rule.^[4]
• Naproxen: stop before a procedure with bleeding risk; paracetamol is the safer default. Do not invent a 24-hour NSAID half-life unless you can name a source.
• Diabetes overall: HbA1c 7.8 percent is below the AAGBI optimisation threshold of 69 mmol/mol. Major surgery that will miss more than one meal is a VRIII setting, not sliding-scale-only.^[5]

(b) VTE prophylaxis plan for major gynaecological cancer surgery (3 marks)

• Cancer hysterectomy is high VTE-risk abdominal/pelvic cancer surgery. ACCP 9th edition: 4 weeks of postoperative LMWH.^[8]
• ENOXACAN-II: enoxaparin 40 mg subcutaneously daily; four weeks vs one week; venographic VTE 4.8 vs 12.0 percent (P=0.02), persisting at three months 5.5 vs 13.8 percent. Quote those numbers — not “15–40 percent without prophylaxis” and not “symptomatic VTE halved”.^[3]
• Mechanical prophylaxis (IPC) as an adjunct is ACCP-consistent for high-risk patients not at high bleed risk; start pharmacologic prophylaxis once haemostasis allows.

(c) Neuraxial timing (3 marks)

• Tell the anaesthetist the exact agent, last dose time, renal function, and whether any LMWH has been given. PAUSE/Douketis do not publish a spinal-catheter hour table in the abstracts used here.^[2]
• If she is not receiving a pre-operative LMWH bridge (correct for AF), there is no prophylactic LMWH in the pre-op window to time against the needle.
• Do not recite an unsourced “12 h prophylactic / 24 h therapeutic” table as if it were PAUSE. Regional-anaesthesia guidelines exist; this SAQ scores the candidate who knows the limit of their numbers.

(d) Discharge plan (2 marks)

• Resume the DOAC 2 to 3 days after high-bleed-risk surgery once haemostasis is secure (PAUSE); if warfarin, BRIDGE resumed within 24 hours — only if the wound is dry.^[1][2]
• Continue enoxaparin 40 mg daily to complete four weeks after abdominal/pelvic cancer surgery (ENOXACAN-II / ACCP). Restart empagliflozin and metformin when eating and renal function is confirmed. Restart enalapril when oral intake and blood pressure are stable. Write dates on the discharge summary.^[3][8]

Common errors that lose marks

• Routine LMWH bridging for atrial fibrillation — BRIDGE and ACCP 2022.
• Teaching Marik as a 25 / 50 / 100 mg hydrocortisone ladder.
• Quoting ENOXACAN-II as 15–40 percent untreated VTE.
• Inventing ASRA hour tables or a 72-hour dabigatran row that is not in PAUSE.
• Starting a beta-blocker 2 to 4 hours pre-op (POISE-1) if the stem had invited it.

Full marks need sourced intervals (PAUSE 1/2 days, BRIDGE 5-day warfarin stop, ENOXACAN 40 mg for four weeks, Hollmann morning-of ACE inhibitor, SGLT2 3–4 day guideline hold) plus the humility to omit milligrams you cannot quote.