Perioperative medication management — structured oral station (12 minutes)

Opening prompt — "Construct the perioperative medication plan."

Model response — say it in this order:

• Procedure first: laparoscopic hysterectomy is intra-abdominal; treat anticoagulation as high bleeding risk.
• Indication: atrial fibrillation, no mechanical valve in the stem — BRIDGE population, not a valve-bridge question.
• Warfarin: stop 5 days pre-op; resume within 24 hours if haemostasis allows. Do not bridge. BRIDGE: arterial TE 0.4 percent no-bridge vs 0.3 percent bridge; major bleeding 1.3 vs 3.2 percent (RR 0.41 favouring no bridge). ACCP 2022: strong recommendation against heparin bridging in AF.^[1]
• Metformin: hold around major surgery/contrast; restart when eating and creatinine is checked. Do not invent a 24/48-hour pair if you cannot source it.
• Empagliflozin: hold before elective surgery; guidelines quote 3 to 4 days (euglycaemic DKA).
• Enalapril: withhold the morning of surgery (Hollmann) to reduce intraoperative hypotension.
• Naproxen: stop before a bleeding-risk procedure; paracetamol default.
• Fasting: name ASA 2017 / local ANZCA document; do not recite a 2-4-6 table unless you have the guideline in front of you.
• VTE: enoxaparin 40 mg daily to complete four weeks after abdominal/pelvic cancer surgery (ENOXACAN-II 12.0 vs 4.8 percent venographic VTE).^[6]

Probe 1 — "The anaesthetist wants a combined spinal-epidural. What is the LMWH timing?"

• We are not giving a pre-operative LMWH bridge, so there is no prophylactic LMWH in the pre-op window.
• Postoperative prophylactic LMWH still needs a documented gap against catheter insertion and removal. Quote the regional-anaesthesia guideline your hospital uses; do not invent 12-hour/24-hour numbers from PAUSE — they are not in that abstract.^[5]

Probe 2 — "She has been on prednisolone 10 mg daily for polymyalgia for two years. Does she need stress-dose cover?"

• 10 mg daily for two years meets Woodcock's "5 mg or greater for 1 month or more" exposure that may suppress the axis.^[3]
• Marik 2008: extra stress doses are not routinely required if the usual daily therapeutic dose is continued; two RCTs showed no haemodynamic difference.^[2]
• Woodcock: if you judge this as tertiary adrenal insufficiency, extra hydrocortisone is in addition to usual prednisolone. Do not recite a 25/50/100 mg ladder as "Marik 2008" — that ladder is not in the abstract.
• Known primary adrenal failure would be a mandatory stress-dose situation (Woodcock: delays may prove fatal).

Probe 3 — "The morning of surgery her fasting glucose is 14 mmol/L. What do you do?"

• This is a patient expected not to return to a normal diet immediately after an intra-abdominal operation — AAGBI 2015 is a VRIII setting, not sliding-scale-only.^[4]
• Inform anaesthesia and the diabetes team; do not invent a 1–2 unit/hour start rate if you cannot source it. Target is local protocol; AAGBI optimisation threshold pre-op was HbA1c under 69 mmol/mol.

Probe 4 — "The patient is anxious. Explain the warfarin plan."

• Eye level, name, plain language: we stop warfarin five days before so it wears off; we will not use the injection blood thinner to cover the gap because a large trial (BRIDGE) showed more bleeding and no stroke benefit in atrial fibrillation; we restart warfarin when the operation site is dry; she will have a different injection (enoxaparin 40 mg) for four weeks because this is cancer surgery.

Probe 5 — "Discharge plan?"

• Warfarin restart when haemostasis allows (BRIDGE resumed within 24 hours in the trial — only if dry). Four-week enoxaparin 40 mg. Restart empagliflozin/metformin when eating. Restart enalapril when blood pressure and oral intake are stable. Dates on the discharge summary.