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Should ASC’s Consider Valium A Safe “Take-At-Home” Pre-Operative Drug?

July 27, 2012 Leave a comment

I recently received an inquiry from one of our Clients regarding a practice the physicians wanted to initiate at their ASC.  The physicians believed that patients would be best served if given 0.5mg of Valium taken post-operatively at home the morning of surgery.  This would enable them to be nice and relaxed when they got to the pre-op area.

Consideradtion #1 Patient Age and Side Effects 

There are several issues going on here.  When considering what drugs to use with any patient, one has to consider the age of the patient and all possible side effects inherent to the age.  Obviously, the elderly and the very young have special considerations regarding their age whenever choosing a drug, but what is in consideration here is adult and geriatric patients.

Valium is a benzodiazeprine and is used widely to reduce tension and anxiety and, in surgery or certain medical treatments, to induce amnesia.  It is also used for seizures, restless leg syndrome, as a muscle relaxant, and for its sedative effects.

Adverse effects include anterograde amnesia.  Cognitive deficits can persist for up to 6 months or longer. Produces sedfation.  Paradoxicaol effects include excitement, rage, worsening of seizures in epileptic patients.  In patients suffering from, or prone to depression these symptoms can worsen.

The sedative effect of Valium may last longer in older patients.  There is also an increased incident of falls and accidents following the administration of Valium in the older patients.  It can lead to catastrophic side effects if mixed with alcohol. (Remember Karen Ann Quinlan?).  Valium is very addictive.  One physician discourages it use under any condition due to its degree of impairment in some patients.

Valium is detectable in the blood for up to 3 days.

If patients are given a sedative at home, doesn’t this increase their chances of falling at home?

Consideration #2 Falls Prevention Strategies at Home 

Falls in the elderly are a serious concern.  Within our ASCs, we initiate a “Falls Prevention Program.”  We inservice our staff in this area and measure their competency.  We track and trend falls and make changes in our Centers to decrease the possibility of falls.  We paint parking guards in the  parking lots and curbs.  We escort patients to their car.  We don’t leave patients alone to dress following surgery, but insist on staying with them to assist.  We identify patients at a high risk to fall with colored socks or wristbands.  We hold their arm when ambulating.  We recognize that the patient has received sedation, and are, thus, at a higher risk to fall.

BUT if these same patients are given a sedative at home doesn’t this increase their chances of falling at home?  I think of some of our elderly patients especially with their walkers, canes, and underlying health conditions that pre-dispose them to falling.  I know, too, how many times patients with underlying conditions get their feet “tangled up” and fall, and know that this risk has to increase when sedated.

Consideration #3 Alcohol Use by Patients

Valium can be lethal if taken with alcohol.  While alcohol use in the elderly is far below that of the 20 something age group, it is not uncommon.  Alcohol use in the elderly may, in fact, be under-reported.  Many retirees believe they can now sit back and do whatever they want.  Many believe they have earned the right to drink whenever and whatever they choose.  Many life-long habitual users may have increased their alcohol intake with all the golf games, card games, bingo matches, etc. to the extent that a “little nip” at breakfast is not uncommon.  This under reporting includes admitting to their physicians the extent of their use.  Valium and Alcohol do NOT mix…even that little nip can be dangerous.  It should be a concern that our patients fully understand this, discuss their use honestly with their physicians, and comply with instructions.

Consideration #4 Patient Depression and Dependence

Depression is increasingly common among our older population.  Their lives have changed, and are continuing to change, on an ongoing basis, in almost every aspect.  They retire from careers of 20-30 years that have demanded a large part of their lives and have helped to define them as individuals.  They become “stay at home” residents of the community.  This is where they might discover they have no hobbies, or they find that the hobbies they had before aren’t available to them now due to heath problems.  Their physical condition has changed.  They don’t have the stamina they once had.  They may be experiencing some underlying health conditions such as high blood pressure, cardio-vascular disease, coronary disease, diabetes.  Their mortality may be smacking them square in the face.   Husbands and wives are thrust together all day long, another adjustment.  Valium can increase this depression…but, the sedative properties may also provide an escape from all their problems and lead to dependence.

Consideration #5 Choosing Alternative Drugs 

The advantages of Valium under a controlled situation cannot be argued.  However, I would argue that there are other equally advantageous drugs that may be used to provide sedation and insomnia.  Cost may be a factor, as some of the alternative drugs are certainly more costly than Valium.

Consideration #6 Patient/Care Person’s Education 

Patients being given Valium should be reminded to not drive, make important decisions, or sign legal documents for up to 24 hours after taking the drug.

At the very least, the patient’s care person needs to be thoroughly educated about the drug during the pre-operative phone call, so as to be able to take the necessary precautions.

Consider #7 Risk Management and an Alternative Strategies

I am not pointing fingers at this drug and saying, “No! No! No!”  Valium is a staple in any health clinic’s inventory as recommended by WHO.  I am merely pointing out that it is not to be considered lightly, and we, as ambulatory surgery healthcare specialists, need to look at it seriously when prescribing it as a “take at home” med prior to surgery.

I recommend, as a licensed risk manager, that we not give the patients this drug at home prior to their admission to the center, but that we expedite the admission process such that their dosage could be given as soon as possible once they are admitted to the pre-op area.

We should always take great consideration in selecting any drug we prescribe to the patient to be taken at home with no medical supervision.

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