This document discusses guidelines for preoperative medication management. It provides guidance on cardiovascular, gastrointestinal, pulmonary, endocrine, diabetic, anticoagulant, psychiatric and other medications. The key principles are to continue most chronic medications to avoid complications from withdrawal, taper long-term steroids, hold certain medications like insulin on the day of surgery, and check coagulation status if anticoagulants are held preoperatively. The goal is to minimize perioperative risks while continuing necessary treatments.

1. Preoperative
medication
management
Dr. Abdulkadir Ahmed(ACCPM R1)
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
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3. objective
• To know preoperative medications management
and to reduce perioperative complications
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4. introduction
• At least 50 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
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5. PRINCIPLES OF
MEDICATION
MANAGEMENT
• A complete 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morbidity if withdrawn abruptly should be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
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6. Cont…
• The metabolism and 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.
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7. CARDIOVASCULAR
MEDICATIONS
Beta blockers
• Reduce ischemia 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
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8. Cont…
• Potential adverse effects of perioperative beta
blockade include bradycardia and
hypotension.
• Nonselective beta blockers can interact with
epinephrine, used for infiltration anesthesia or
management of intraoperative anaphylaxis
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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.
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10. Cont…
• The dose of the beta blocker should be closely
regulated throughout the perioperative period to
maintain the blood pressure and heart rate
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11. Alpha blockers
• Given the 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
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12. CCB
• Despite little data 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
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13. ACE inhibitors and
angiotensin II 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
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14. Cont…
• For most patients, 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
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15. DIURETICS
Two major physiologic effects 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
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16. Cont…
hypotension
• Systemic vasodilatation induced by anesthetic
agents may cause hypotension in patients who
are intravascular depleted from diuretics.
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17. Diuretics for treatment of
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
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18. Cont…
• If diuretics are 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
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19. digoxin
• It is recommended continuing digoxin
preoperatively.
(Decreases the incidence of postoperative
supraventricular arrhythmias)
• Obtaining a drug level preoperatively is not
usually recommended
.
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20. statins
There is growing evidence in the literature to
suggest that perioperative statin therapy is safe
and beneficial in reducing morbidity and mortality
in the perioperative period.
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21. Statins work via several
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
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22. Cont…
• The greatest benefit 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.
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23. Cont…
• 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
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24. GASTROINTESTINAL
AGENTS
• H2 blockers and 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
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25. Inhaled beta agonists
and anticholinergics
• inhaled medications used to control obstructive
pulmonary disease, such as beta agonists
(albuterol, salmeterol, formoterol) and
anticholinergic (ipratropium, tiotropium), should
be continued perioperatively
25
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26. ENDOCRINE AGENTS
Glucocorticoids
• Inhaled and 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
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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.
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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.
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29. Cont…
• A) For minor 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.
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30. Cont…
• C) For major 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.
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31. Diabetic medications
• It is 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
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32. insulin
 For all patients, 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.
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33. Non-insulin anti diabetic
medications
• Discontinue on the day of surgery
(exception: SGLT2 inhibitors should be discontinued 24
hours before elective surgery)
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34. Drugs used for thyroid
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:
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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
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36. Medications affecting
hemostasis
Aspirin
• The perioperative benefits and risks
of aspirin depend on the patient's
indication for aspirin and the planned
surgery.
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37. Cont…
• Continue aspirin in 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.
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38. Oral contraceptives
• Cause of 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
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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
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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
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41. Cont…
• 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.
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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
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43. Cont…
• 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
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44. Cont…
• If the INR 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.
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45. 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
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46. Cont…
• In these cases, the bridging agent (e.g.,
therapeutic-dose subcutaneous low molecular
weight [LMW] heparin) is started three days
before surgery
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47. medications for
psychiatric and
psychological problems
• 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.
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48. Cont…
• Historically, monoamine oxidase 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
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49. Cont…
• Preoperative withdrawal of 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
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50. Cont…
• Patients taking lithium
require evaluation of electrolyte and
creatinine concentrations. Discontinuation of
lithium has also been associated with
suicide.
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51. Cont…
• Continued perioperative SSRI 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)
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52. Cont…
• Antipsychotics should be 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
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53. HERBAL MEDICATIONS
• Herbal medications, 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
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54. eight commonly used
herbal remedies
• Ephedra
• Garlic
• Ginkgo
• Ginseng
• Kava
• St. John's wort
• Valerian
• Echinacea
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55. Reference’s
• Miller’s anesthesia 9th edition
• Barash Clinical anesthesia 8th edition
• up-to-date
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56. Thank you
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