Sick-day rules for the peri-operative clinician

Abstract

It is recommended that people receiving treatment for diabetes, renal disease, cardiovascular conditions and glucocorticoid deficiency are advised on how to manage their condition should they develop acute illness in the community [1, 2]. For people receiving treatment for renal disease or cardiovascular conditions, this relates predominantly to new onset or worsening of diarrhoea and vomiting, whereas for people with diabetes or glucocorticoid deficiency, there is a broader application, including common cold and infections. These ‘sick-day rules’ aim to prevent complications that may otherwise lead to an unscheduled admission. The advice includes instructions such as: monitoring their blood sugars and ketones more frequently; drink more than usual; when to seek medical help; and how to modify their medicines (sick-day medication guidance). Certain classes of medicines should be omitted during concurrent illness, such as vomiting or diarrhoea, until patients are feeling better or are able to eat and drink for 24–48 h. Other medicines might require dose adjustment (Table 1).

Table 1. Examples of sick-day medication guidance for various medicines.

Medicine class	Risk with concurrent illness/dehydration	Sick-day medication guidance
Angiotensin-2 receptor antagonists	Acute kidney injury and dehydration	Stop and restart 24–48 h after eating and drinking and feeling better
Diuretics	Acute kidney injury and dehydration	Stop and restart 24–48 h after eating and drinking and feeling better
Non-steroidal anti-inflammatory drugs	Acute kidney injury	Stop and restart 24–48 h after eating and drinking and feeling better
Metformin	Lactic acidosis	Stop and restart 24–48 h after eating and drinking and feeling better
Sulfonylureas	Hypoglycaemia	Check glucose more frequently and dose adjust
Sodium-glucose co-transporter-2 inhibitors	Ketoacidosis	Stop and restart 24–48 h after eating and drinking and feeling better Check for ketones and seek medical advice if elevated
Insulins	Dysglycaemia Diabetic ketoacidosis	Check glucose and ketones regularly. Dose-adjust insulins. Maintain carbohydrate and fluid intake
Corticosteroids	Adrenal insufficiency crisis	Increase dose according to severity

In the surgical setting, accounting for sick-day rules is distinct from usual peri-operative medicine management. The latter refers predominantly to medicine considerations that may pose issues for surgery, anaesthesia or disease management. Sick-day rules, however, aim to avoid specific complications in the event of medicine continuation, such as acute kidney injury; dehydration; and lactic and ketoacidosis. Some medicines have sick-day rules that also apply in the peri-operative setting, such as angiotensin-converting enzyme inhibitors [3] corticosteroids [4]; and sodium-glucose co-transporter-2 inhibitors [5]. However, awareness of the concept of ‘sick-day rules’ appears to be limited in the peri-operative setting, as evidenced by poor adherence to sick-day rule recommendations for medicines such as corticosteroids [4].

Not considering sick-day rules in the peri-operative setting might pose risks to patients following surgery, particularly given the increased drive to perform day-case surgery in patients with multimorbidity. As such, it is imperative for anaesthetists, surgeons and nurses to integrate sick-day rules into their practices. Additionally, patients need to be informed to apply their sick-day rules, including sick-day medication guidance, to both surgical procedures and concurrent illnesses.