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![Use of bridging
preoperatively
We generally reserve bridging for individuals
considered at very high or high risk of
thromboembolism , EXAMPLES
• recent [within the prior three months] stroke,
• mechanical heart valve,
• CHA2DS2-VASc score of 7 or 8
• if they require interruption of warfarin
45
7/19/2023](https://image.slidesharecdn.com/preoperativemedicationmanagementseminar-230719135103-4f3a8400/85/Preoperative-medication-management-seminar-pptx-45-320.jpg)
![Cont…
• In these cases, the bridging agent (e.g.,
therapeutic-dose subcutaneous low molecular
weight [LMW] heparin) is started three days
before surgery
46
7/19/2023](https://image.slidesharecdn.com/preoperativemedicationmanagementseminar-230719135103-4f3a8400/85/Preoperative-medication-management-seminar-pptx-46-320.jpg)
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Similar to Preoperative medication management seminar.pptx
Preoperative medication management seminar.pptx
- 1. Preoperative medication management Dr. Abdulkadir Ahmed(ACCPMR1) Moderator; Dr.Endale(consultant anesthesiologist) 1 7/19/2023
- 2. Outline • objective • introduction •Principles of medication management • Cardiovascular medications • Gastrointestinal agents • Pulmonary agents • Medications affecting hemostasis • Oral contraceptives • Antipsychotics • Herbal medications 2 7/19/2023
- 3. objective • To knowpreoperative medications management and to reduce perioperative complications 7/19/2023 3
- 4. introduction • At least50 percent of patients undergoing surgery take medications on a regular basis • It is the responsibility of the anesthesiologist to instruct patients regarding which medications to take or not take preoperatively 4 7/19/2023
- 5. PRINCIPLES OF MEDICATION MANAGEMENT • Acomplete medication history should be obtained, and all clinicians involved in patient management • Medications associated with known medical morbidity if withdrawn abruptly should be continued in the perioperative period or tapered if feasible 5 7/19/2023
- 6. Cont… • The metabolismand elimination of medications and their metabolites may be altered during the perioperative period. • The majority of medications can be resumed once the patient is able to tolerate oral intake. 6 7/19/2023
- 7. CARDIOVASCULAR MEDICATIONS Beta blockers • Reduceischemia by decreasing myocardial oxygen demand due to increased catecholamine release • Prevent or control arrhythmias • Acute withdrawal of a beta blocker pre or postoperatively can lead to substantial morbidity (withdrawal issues are less concern when B B are used for hypertension or migraine) • Preoperatively initiate at least 5-7days prior to operation and not < 3 days Contraindicated in acute congestion (increases risk of Stroke and Death ) 7 7/19/2023
- 8. Cont… • Potential adverseeffects of perioperative beta blockade include bradycardia and hypotension. • Nonselective beta blockers can interact with epinephrine, used for infiltration anesthesia or management of intraoperative anaphylaxis 8 7/19/2023
- 9. Cont… In light of •the potential benefits of perioperative beta blockade • Minimal adverse effects, • And consequences of acute withdrawal, it is recommended that beta blockers be continued in the perioperative period and continue throughout the hospital stay. 7/19/2023 9
- 10. Cont… • The doseof the beta blocker should be closely regulated throughout the perioperative period to maintain the blood pressure and heart rate 7/19/2023 10
- 11. Alpha blockers • Giventhe possible negative consequences of withdrawal, we recommend that alpha 2 agonist drugs be continued in the perioperative period but not to be initiated • Abrupt discontinuation will result in rebound Hypotension and Tachycardia 11 7/19/2023
- 12. CCB • Despite littledata regarding calcium channel blockers during the perioperative period, these agents appear safe and have theoretic benefit • Data regarding bleeding risk are contradictory. Thus, it is recommended that calcium channel blockers be continued in patients who are already taking them preoperatively. • There are no serious interactions between calcium channel blockers and anesthetic agents 12 7/19/2023
- 13. ACE inhibitors and angiotensinII receptor blockers • ACE inhibitors and ARBs can theoretically blunt the compensatory activation of the renin-angiotensin system during surgery and result in prolonged hypotension • The decision to continue or discontinue is individualized based on ; the indications for the drug, the patient's blood pressure, and the type of surgery and anesthesia planned 13 7/19/2023
- 14. Cont… • For mostpatients, we usually withhold them on the morning of surgery. • However, when the indication is for heart failure or poorly controlled hypertension, we continue them to avoid further exacerbation of these conditions 14 7/19/2023
- 15. DIURETICS Two major physiologiceffects of diuretics are hypokalemia and hypovolemia. Hypokalemia 1.Can theoretically increase the risk of perioperative arrhythmia 2.Potentiate the effect of muscle relaxant used during anesthesia as well as provoke paralytic ileus 15 7/19/2023
- 16. Cont… hypotension • Systemic vasodilatationinduced by anesthetic agents may cause hypotension in patients who are intravascular depleted from diuretics. 16 7/19/2023
- 17. Diuretics for treatmentof HF Continue based on the assessment of volume status For patients with well controlled HF and stable volume status Hold the morning dose on the day of surgery Patients with HF whom fluid balance historically been more difficult to control continue the diuretic without interruption 17 7/19/2023
- 18. Cont… • If diureticsare held the morning of surgery and volume overload develops, a quick diuresis can be initiated by intravenous administration preoperatively • thiazide diuretics taken for hypertension, which should be continued on the day of surgery 18 7/19/2023
- 19. digoxin • It isrecommended continuing digoxin preoperatively. (Decreases the incidence of postoperative supraventricular arrhythmias) • Obtaining a drug level preoperatively is not usually recommended . 19 7/19/2023
- 20. statins There is growingevidence in the literature to suggest that perioperative statin therapy is safe and beneficial in reducing morbidity and mortality in the perioperative period. 20 7/19/2023
- 21. Statins work viaseveral mechanisms • lowering lipids, • enhancing nitric oxide–mediated pathways, • reducing expression of cytokines and adhesion molecules, • and lowering C-reactive protein levels with associated vasodilatory, anti-inflammatory, and antithrombotic effects 7/19/2023 21
- 22. Cont… • The greatestbenefit occurs in patients at higher risk for cardiovascular complications. • The ESC also recommends that statins be started in high-risk surgery patients, optimally between 30 days and at least 1 week before surgery. 7/19/2023 22
- 23. Cont… • Guidelines fromthe ACC/AHA state that statin use is reasonable for patients undergoing vascular surgery with or without clinical risk factors, and statins may be considered for patients with at least one clinical risk factor who are undergoing intermediate-risk procedures 7/19/2023 23
- 24. GASTROINTESTINAL AGENTS • H2 blockersand proton pump inhibitors Based on the potential benefits stress related mucosal damage gastric aspiration during anesthesia they reduce gastric fluid ph,there by reducing the risk of chemical pneumonitis from aspiration can be minimized by administration of these drugs 24 7/19/2023
- 25. Inhaled beta agonists andanticholinergics • inhaled medications used to control obstructive pulmonary disease, such as beta agonists (albuterol, salmeterol, formoterol) and anticholinergic (ipratropium, tiotropium), should be continued perioperatively 25 7/19/2023
- 26. ENDOCRINE AGENTS Glucocorticoids • Inhaledand systemic glucocorticoids should be continued during the perioperative period • Patients on glucocorticoids (corticosteroids) are at risk of adrenal insufficiency if steroids are abruptly withdrawn • an anesthetic agent, etomidate, should be avoided in patients at risk for adrenal suppression and adrenal crisis 26 7/19/2023
- 27. 1.Nonsuppressed HPA axis. In general,patients who have taken glucocorticoid : • less than 3 wks. any dose & any patient. • Chronic alternative day therapy <10mg prednisone. • < 5mg/day morning prednisone or its equivalent of any duration are unlikely to have HPA axis suppression. • Should continue usual doses of glucocorticoids perioperatively. 7/19/2023 27
- 28. 2.Suppressed HPA axis •Patients taking prednisone at dose > 20mg/day, >/= 3wks.(16mg methylpredisone,2mg dexa,80mg hydrocortisone /day) • Patients with a cushingoid appearance. • Should be assumed to have HPA axis suppression and needs increased dose of steroid perioperatively. 7/19/2023 28
- 29. Cont… • A) Forminor procedures or surgery under local anesthesia (eg, inguinal hernia repair) take usual morning steroid dose. No extra supplementation is necessary. • B) For moderate surgical stress (eg, lower extremity revascularization, total joint replacement) take usual morning steroid dose. Give 50 mg hydrocortisone intravenously just before the procedure and 25 mg of hydrocortisone every 8 hours for 24 hours. Resume usual dose thereafter. 7/19/2023 29
- 30. Cont… • C) Formajor surgical stress (e.g, esophagogastrectomy, total proctocolectomy, open heart surgery) take usual morning steroid dose. • Give 100 mg of intravenous hydrocortisone before induction of anesthesia, and 50 mg every 8 hours for 24 hours. Taper dose by half per day to maintenance level. 7/19/2023 30
- 31. Diabetic medications • Itis estimated 50% chance of requiring surgery in their lifetime • One key aspect of the perioperative management is glycemic control • the complex interplay of being nil per os (NPO) preoperatively, the operative procedure, anesthesia, and additional postoperative factors such as sepsis, disrupted meal schedules and altered nutritional intake, hyper alimentation, and emesis can lead to labile blood glucose levels 7/19/2023 31
- 32. insulin For allpatients, discontinue all short-acting (e.g., regular) insulin on the day of surgery Patients with type 2 diabetes should take none, or up to one half of their dose of long-acting or combination (e.g., 70/30 preparations) insulin, on the day of surgery. Patients with type 1 diabetes should take a small amount (usually one third) of their usual morning long-acting insulin dose on the day of surgery. Patients with an insulin pump should continue their basal rate only. 32 7/19/2023
- 33. Non-insulin anti diabetic medications •Discontinue on the day of surgery (exception: SGLT2 inhibitors should be discontinued 24 hours before elective surgery) 33 7/19/2023
- 34. Drugs used forthyroid disease • It is recommended perioperative continuation of therapy for both hyperthyroidism and hypothyroidism. • In the case that a patient cannot take oral medications for several days, the approach depends upon the thyroid medication: 34 7/19/2023
- 35. Cont… • Thyroxin (T4)has a long half-life If oral T4 cannot be resumed within five to seven days, it should then be administered parenterally (intravenously or intramuscularly). • The antithyroid thionamide medications (methimazole and propylthiouracil) have a very short half-life decision individualized 35 7/19/2023
- 36. Medications affecting hemostasis Aspirin • Theperioperative benefits and risks of aspirin depend on the patient's indication for aspirin and the planned surgery. 36 7/19/2023
- 37. Cont… • Continue aspirinin patients prior percutaneous coronary intervention high-grade IHD significant CVD and can be safely continued in most patients undergoing minor dental surgery or dermatologic procedures. Otherwise, discontinue aspirin 3 days before surgery. 37 7/19/2023
- 38. Oral contraceptives • Causeof thrombosis in young women • Must balance the risk of unwanted pregnancy against the risk of thromboembolism • OCs with higher estrogen content (≥35 mcg) have a greater risk of thromboembolism compared with those with lower estrogen content (≤30 mcg) 38 7/19/2023
- 39. Cont… • In general,it is recommended continuation of OCs and provision of appropriate perioperative thromboprophylaxis • In patients at higher risk for VTE who are undergoing high-risk surgery, discontinuation of OCs may be reasonable to mitigate the additional VTE risk 39 7/19/2023
- 40. Nonsteroidal Anti- inflammatory Drugs •NSAIDs have reversible antiplatelet effects; hence, once the drugs have been eliminated, platelet function returns to normal. • Concomitant NSAID use does not appear to increase the risk of spinal hematoma with neuraxial anesthesia • But Preoperative discontinuation of NSAIDs may be of value in patients at risk for perioperative AKI 40 7/19/2023
- 41. Cont… • NSAIDs arediscontinued 24 to 72 hours preoperatively • Earlier discontinuation does not increase safety, and it may be burdensome to many patients with significant arthritis or chronic pain. 41 7/19/2023
- 42. Anticoagulants Warfarin (Coumadin) •Warfarin discontinuation is appropriate • Discontinue 5 days before surgery, except for patients having cataract surgery without a bulbar block • Check the PT/INR a day before and a day after surgery 42 7/19/2023
- 43. Cont… • There maybe circumstances when preoperative INR testing is warranted, such as in patients who have a <5 day warfarin interruption or a recent high INR (>4.5). In such cases we check the INR one to two days before the surgery 7/19/2023 43
- 44. Cont… • If theINR is >1.5, administer a low dose of oral vit K(e.g 1-2mg) to hasten the normalization of PT/INR and recheck INR in the following days. • Proceed with surgery if the INR is <1.4 • An INR in the normal (<1.3) or near-normal (1.3 to 1.4) range is important in patients undergoing surgery associated with a high bleeding risk (eg, intracranial, spinal, urologic) or if neuraxial anesthesia is to be used. 44 7/19/2023
- 45. Use of bridging preoperatively Wegenerally reserve bridging for individuals considered at very high or high risk of thromboembolism , EXAMPLES • recent [within the prior three months] stroke, • mechanical heart valve, • CHA2DS2-VASc score of 7 or 8 • if they require interruption of warfarin 45 7/19/2023
- 46. Cont… • In thesecases, the bridging agent (e.g., therapeutic-dose subcutaneous low molecular weight [LMW] heparin) is started three days before surgery 46 7/19/2023
- 47. medications for psychiatric and psychologicalproblems • Most medications for psychiatric and psychological problems should be continued into the preoperative period. • Thus, most antidepressants, antipsychotics, and benzodiazepines are best maintained to avoid exacerbations of symptoms. 47 7/19/2023
- 48. Cont… • Historically, monoamineoxidase inhibitor (MAOI) antidepressants were discontinued preoperatively; however, elimination of the risks associated with many of these drugs required drug discontinuation at least 3 weeks before surgery. • This long withdrawal period is specifically applied to MAOIs that cause irreversible inhibition of MAO. 48 7/19/2023
- 49. Cont… • Preoperative withdrawalof these drugs has potential risks. • Specifically, case reports of suicides or severe depression following discontinuation of MAOIs have been reported. • Thus, the safest approach may be to continue these drugs and adjust the anesthetic plan accordingly (e.g., avoid meperidine and indirect- acting vasopressors such as ephedrine). 49 7/19/2023
- 50. Cont… • Patients takinglithium require evaluation of electrolyte and creatinine concentrations. Discontinuation of lithium has also been associated with suicide. 7/19/2023 50
- 51. Cont… • Continued perioperativeSSRI are associated with increased surgical bleeding Abrupt discontinuation can cause dizziness,chills,muscle aches and anxiety Overall, it is still reasonable to continue SSRI perioperatively in most patients, (unless z patient has high bleeding risk) 7/19/2023 51
- 52. Cont… • Antipsychotics shouldbe used cautiously in patients at risk for exacerbation of psychoses • should be withheld in patients whose baseline or follow-up electrocardiogram (ECG) demonstrates prolongation of the QT interval. • Shorter-acting and low-dose antipsychotics should be considered, and complete discontinuation may be preferable after consultation with a psychiatrist 7/19/2023 52
- 53. HERBAL MEDICATIONS • Herbalmedications, used frequently, may have effects that could be deleterious in the perioperative period, including clotting abnormalities and interactions with anesthetics • It is recommend stopping herbal agents at least one week before surgery 7/19/2023 53
- 54. eight commonly used herbalremedies • Ephedra • Garlic • Ginkgo • Ginseng • Kava • St. John's wort • Valerian • Echinacea 7/19/2023 54
- 55. Reference’s • Miller’s anesthesia9th edition • Barash Clinical anesthesia 8th edition • up-to-date 55 7/19/2023
- 56.
Editor's Notes
- #4 To know preoperative medication management To anticipate and prepare for perioperative incidents And reduce perioperative complication
- #5 It is the responsibility of the anesthesiologist to instruct patients regarding which medications to take or not take preoperatively.
- #6 2.Abrupt cessation of medication for known morbidity is not advisable It should be continued or tapered if feasible bc it might exacerbate the condition during the perioperative period
- #8 Beta blockers have a number of potential beneficial effects when taken perioperatively. Beta blockers reduce ischemia by decreasing myocardial oxygen demand due to increased catecholamine release. They may also help prevent or control arrhythmias. Patients who take beta blockers chronically for management of angina are at risk of ischemia with withdrawal of beta blockade. Acute withdrawal of a beta blocker pre- or postoperatively can lead to substantial morbidity and even mortality [7-9]. Withdrawal issues are of less concern when beta blockers are used for hypertension or migraine prophylaxis. Acute discontinuation of b b can cause angina pectoris, MI or sudden death since adequate beta blockade can take weeks to achieve safely in patients with systolic heart failure, it is preferred to initiate beta blockade in the preoperative period only if acute decompensated heart failure is not present and surgery can be substantially delayed. If surgery is urgent, we prefer postponing beta blockade until a later date
- #9 B blockers work by blocking the effect of hormone epinephrine
- #11 The dose of the beta blocker should be closely regulated throughout the perioperative period to maintain the blood pressure and heart rate (rate-pressure produc ince adequate beta blockade can take weeks to achieve safely in patients with systolic heart failure, we prefer initiation of beta blockade in the preoperative period only if acute decompensated heart failure is not present and surgery can be substantially delayed. If surgery is urgent, we prefer postponing beta blockade until a later date
- #12 For patients already taking clonidine, abrupt withdrawal of clonidine can precipitate rebound hypertension Given the possible negative consequences of withdrawal, we recommend that alpha 2 agonist drugs be continued in the perioperative period, but not initiated.
- #13 Data are limited regarding the risks and benefits of calcium channel blockers in the perioperative setting. Small trials have shown a more stable intraoperative hemodynamic profile in patients treated with continuous diltiazem, compared with placebo, during coronary bypass surgery [30
- #18 there is no consensus on whether diuretics should be discontinued prior to elective surgery [2]. Our approach depends upon the reason for diuretic use and on an individual patient's history.
- #20 the two indications for digoxin are to prevent hospitalization and readmission in patients with reduced left ventricular function and to control ventricular response in atrial fibrillation
- #21 Guidelines from the ACC/AHA state that statin use is reasonable for patients undergoing vascular surgery with or without clinical risk factors, and statins may be considered for patients with at least one clinical risk factor who are undergoing intermediate-risk procedures.98
- #24 For those who undergo vascular surgery statin use is reasonable with or with out clinical rf For those who undergo intermediate risk procedure stain use is reasonable with at least one rf
- #25 There are several potential advantages of continuing H2 blockers or proton pump inhibitors perioperatively. The stress of surgery and other conditions (eg, intensive care unit [ICU] stay and mechanical ventilation) can increase the risk of stress-related mucosal damage, which may be minimized by administration of these drugs
- #26 Inhaled medications used to control obstructive pulmonary disease, such as beta agonists (albuterol, salmeterol, formoterol) and anticholinergics (ipratropium, tiotropium), have been found to reduce the incidence of postoperative pulmonary complications in patients with asthma and chronic obstructive pulmonary disease and should be continued perioperatively. e recommend continuing beta agonists in the perioperative period, including the day of surgery.
- #27 An anesthetic agent, etomidate, should be avoided in patients at risk for adrenal suppression and adrenal crisis. This is a commonly used anesthetic induction agent known to have properties of inhibiting steroid synthesis and precipitating acute adrenal insufficiency
- #28 Chronic glucocorticoid therapy can suppress the hypothalamic-pituitary-adrenal (HPA) axis and, during times of stress such as surgery, the adrenal glands may not respond appropriately. APPROACH BASED UPON HPA AXIS SUPPRESSION
- #29 cushingoid appearance Moon face Buffalo hump Acne Obese torso Easily bruised skin
- #32 the complex interplay of being nil per os (NPO) preoperatively, the operative procedure, anesthesia, and additional postoperative factors such as sepsis, disrupted meal schedules and altered nutritional intake, hyperalimentation, and emesis can lead to labile blood glucose levels. A rational approach to diabetes mellitus management allows the clinician to anticipate alterations in glucose and improve glycemic control perioperatively [4
- #33 For all patients, discontinue all short-acting (e.g., regular) insulin on the day of surgery (unless insulin is administered by continuous pump). Patients with type 2 diabetes should take none, or up to one half of their dose of long-acting or combination (e.g., 70/30 preparations) insulin, on the day of surgery. Patients with type 1 diabetes should take a small amount (usually one third) of their usual morning long-acting insulin dose on the day of surgery. Patients with an insulin pump should continue their basal rate only.
- #34 SGLT2 should be discontinued 24hrs before elective surgery To minimize the risk of postoperative ketoacidosis and uti.
- #36 •Thyroxine (T4) has a long half-life, and patients on chronic T4 therapy who are unable to take oral medication for several days do not need parenteral T4. If oral T4 cannot be resumed within five to seven days, it should then be administered parenterally (intravenously or intramuscularly). •The antithyroid thionamide medications (methimazole and propylthiouracil) have a very short half-life. The decision on how long to hold antithyroid medications for a patient who is unable to take oral medications must be individualized based upon several factors, including the patient's history of thyroid disease and length of previous treatment with antithyroid medications.
- #37 Aspirin irreversibly inhibits platelet cyclooxygenase, which may increase intraoperative blood loss and hemorrhagic complications [87-92]. However, the same effect can help to prevent perioperative vascular complications, in particular cardiac and thromboembolic complications. The perioperative benefits and risks of aspirin depend on the patient's indication for aspirin and the planned surgery.
- #38 All patients with cardiovascular disease (CVD) should receive lifelong aspirin to prevent ischemic cardiovascular events. Thus, most patients referred for CABG take aspirin daily and we continue aspirin until surgery. For patients with a new diagnosis of CVD (and not taking aspirin) and who need CABG, the decision to start aspirin preoperatively should be individualized, taking into account the duration of the delay to surgery (ie, risk of an ischemic event in the interval between diagnosis and CABG), the bleeding risk at the time of surgery, and potential problems associated with starting a new medication shortly before surgery. If the delay is more than five days, we start aspirin in most cases. If the delay is less than five days, most of our experts start aspirin in patients not at high bleeding risk.
- #39 oral contraceptives (OCs) are statistically the most frequent cause of thrombosis in young women due to their widespread use. The risk of thrombosis increases within four months of initiation and decreases to previous levels within three months of stopping treatment. Surgery itself is a risk factor for thrombosis and compounds the risk associated with oral contraceptive use.
- #40 In patients at higher risk for VTE who are undergoing high-risk surgery (table 4), discontinuation of OCs may be reasonable to mitigate the additional VTE risk; if the decision is made to discontinue, OCs should be stopped four weeks prior to surgery. Women who discontinue OCs that are used for contraceptive purposes should use an alternative method of birth control, which should be continued for the first week after resuming OCs postoperatively;
- #42 NSAIDs have reversible antiplatelet effects; hence, once the drugs have been eliminated, platelet function returns to normal. Concomitant NSAID use does not appear to increase the risk of spinal hematoma with neuraxial anesthesia. 196 Preoperative discontinuation of NSAIDs may be of value in patients at risk for perioperative AKI. Typically, NSAIDs are discontinued 24 to 72 hours preoperatively. Earlier discontinuation does not increase safety, and it may be burdensome to many patients with significant arthritis or chronic pain.
- #45 There may be circumstances when preoperative INR testing is warranted, such as in patients who have a <5 day warfarin interruption or a recent high INR (>4.5). In such cases, we check the INR one to two days before the surgery, and, if the INR is >1.5, a low dose of oral vitamin K (eg, 1 to 2 mg) can be given for selected patients and/or procedures in which a normalized INR is required; this can be followed by re-checking an INR the following day. There may be circumstances when preoperative INR testing is warranted, such as in patients who have a <5 day warfarin interruption or a recent high INR (>4.5). In such cases, we check the INR one to two days before the surgery, and, if the INR is >1.5, a low dose of oral vitamin K (eg, 1 to 2 mg) can be given for selected patients and/or procedures in which a normalized INR is required; this can be followed by re-checking an INR the following day. An INR in the normal (<1.3) or near-normal (1.3 to 1.4) range is important in patients undergoing surgery associated with a high bleeding risk (eg, intracranial, spinal, urologic) or if neuraxial anesthesia is to be used
- #46 Bridging anticoagulation refers to giving a short-acting blood thinner, usually low-molecular-weight heparin given by subcutaneous injection for 10 to 12 days around the time of the surgery/procedure, when warfarin is interrupted and its anticoagulant effect is outside a therapeutic range
- #52 Continued perioperative use of selective serotonin reuptake inhibitors (SSRIs) are associated with increased surgical bleeding,457,458 whereas abrupt discontinuation of SSRIs can also cause dizziness, chills, muscle aches, and anxiety. Overall, it is still reasonable to continue SSRI perioperatively in most patients, aside from those undergoing procedures where bleeding could have significant postoperative sequalae (e.g., intracranial surgery
- #53 Antipsychotics should be used cautiously in patients at risk for exacerbation of psychoses. should be used cautiously in patients at risk for exacerbation of psychose. Shorter-acting and low-dose antipsychotics should be considered, and complete discontinuation may be preferable after consultation with a psychiatrist.
- #54 Herbal medications, used frequently, may have effects that could be deleterious in the perioperative period, including clotting abnormalities and interactions with anesthetics [142]. Clinicians should specifically inquire about herbal medication use in presurgical patients, as patients often do not readily disclose use.
- #55 1.Garlic may increase bleeding risk and should be discontinued at least seven days prior to surgery. 2. ginseng and ginger are not the same. Ginseng is a type of plant that grows slowly and has thick roots, and is part of the Panax genus. On the other hand, ginger is a flowering plant that produces stems beneath the ground known as rhizome Ginseng lowers blood sugar and may increase bleeding risk and should be discontinued at least seven days prior to surge 3. Kava may increase the sedative effect of anesthetics and should be discontinued at least 24 hours prior to surgery 4. St John's wort is a herbal medicine used to treat mental health problems t. John's wort may diminish the effects of several drugs by induction of cytochrome P450 enzymes and should be discontinued at least five days prior to surgery. 5. Valerian may increase the sedative effect of anesthetics and is associated with benzodiazepine-like withdrawal. There are no data on preoperative discontinuation. Ideally it is tapered weeks before surgery; if not, withdrawal is treated with benzodiazepines. 6. ginger;This result may warrant the discontinuation of ginger at least 2 weeks before surgery, resulted in an increased INR and epistaxis