3 Issues to Watch When Using Valium as a Preoperative Drug in an ASC

This article is written by Ann Dean, founder of ADA Group.

I recently received an inquiry from one of our clients regarding a practice the physicians want to initiate in their center. Specifically, the physicians believe that the patient would be best served by receiving 0.5mg of Valium to take at home the morning of surgery.  This would relax them before they arrived in the pre-op area.

There are several issues going on here. When considering which 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 those to consider in this situation are 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 to treat 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 six months or longer. Paradoxical effects include excitement, rage, worsening of seizures in epileptic patients. In patients suffering from or prone to depression, these symptoms can worsen.

Here are four issues that affect patients taking valium for surgery:

1. Sedation and increased chance of falls. 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 older patients, and the drug can have catastrophic side effects if mixed with alcohol. Valium is also very addictive, and some physicians discourage its use under any condition due to the degree of impairment it manifests in some patients.

Patients being given valium should be reminded not to drive, make important decisions, or sign legal documents for up to 24 hours after taking the drug. Valium is detectable in the blood for up to 3 days.

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 World Health Organization. I am merely pointing out that it is not to be considered lightly, and we, as ambulatory surgery healthcare specialists, need to take it seriously when prescribing it as a "take at home" medication prior to surgery.

Falls in the elderly are a serious concern. We take the following measures to prevent falls in our surgery centers:

• Initiate a falls prevention program
• Inservice staff on falls prevention and measure their competency
• Track and trend falls and make changes to decrease the possibility of falls
• Paint parking guards in parking lots and curbs
• Supervise patients while they dress following surgery
• Escort patients to their cars
• Identify high-risk fall patients with colored socks or wristbands
• Hold patients' arms while ambulating
• Recognize patients who have received sedation and are therefore at higher risk of falls

However, if these same patients are given a sedative at home, the drug will still increase their chances of falling at home. This issue is most pressing with some of our elderly patients — especially those with walkers, canes, and underlying health conditions that pre-dispose them to falling. I know how often patients with underlying conditions get their feet "tangled up" and fall, and I know that this risk has to increase when sedated.

2. Alcohol use. Valium can be lethal if taken with alcohol. While the rate of alcohol use in the elderly is far below that of the 20-year-old 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 and bingo matches, to the extent that drinking early in the day is not uncommon. This under-reporting includes admitting to their physicians the extent of their use. Valium and alcohol do not mix, and even a small amount can be dangerous. It should be a concern that our patients fully understand this, discuss their alcohol use honestly with their physicians, and comply with instructions.

3. Depression. Depression is increasingly common among our older population. Their lives have changed, and are continuing to change in almost every aspect. They retire from careers of 20 to 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, cardiovascular disease, coronary disease and 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.

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. Consequently, I would 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.

In closing, we should take great consideration in selecting any drug we prescribe to the patient to be taken at home with no medical supervision. At the very least, the patient's care person needs to be thoroughly educated about the drug during the preoperative phone call, so as to be able to recommend the necessary precautions.

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