General Medications
This covers perioperative management of medications, with the exception of:
- Anticoagulants, covered under Anticoagulants
- Antiplatelets, covered under Antiplatelet Agents
- Insulin and oral hypoglycaemics, covered under Perioperative Management
Respiratory Medications
Inhaled bronchodilators:
- Continue
↓ risk of post-operative respiratory complications.
Theophylline:
- Withhold from day prior to surgery
Multiple potential pharmacokinetic interactions.
Cardiac Medications
Alpha 2 agonists:
- Continue if already taking
Give parentally if will be NBM.
ACE-Is/A2RBs:
- Generally withhold, however:
- Favour continuing if for cardiac failure or poorly controlled hypertension to avoid exacerbation
- Favour withholding if intraoperative hypotension likely or problematic
If withheld, restart as soon as possible.
Beta-blockade:
* Continue if already taking * Consider starting: * If indicated and therapy can be initiated 2-4 weeks prior to surgery * In patients with known ischaemic heart disease or myocardial risk factors
* In patients with RCRI ⩾3 * If initiating, it is ideal to begin long enough in advance to evaluate safety and tolerability
* At least 2-7 days * ⩽1 day harmful
Calcium Channel Blockers:
- Continue if already taking
Non-statin lipid-lowering agents:
- Discontinue if taking
May interfere with oral absorption of other medications, and contribute to myopathy.
Statins:
- Should be continued
- Consider initiation in patients:
- Undergoing vascular surgery
- Who have an indication and are undergoing elevated risk procedures
Diuretics:
- Depends on indication:
- For hypertension
Withhold on morning of surgery. - For cardiac failure
- Well controlled with stable volume state
Withhold on morning of surgery. - Poorly controlled or previous problems with fluid overload
Continue.
- Well controlled with stable volume state
- For hypertension
CNS Agents
Antidepressants:
- SSRIs/SNRIs
Generally continue, however:- May be ceased if substantial concern about bleeding
Should be weaned off:- Over several weeks
- With psychiatrist involvement
- And consideration of starting an alternative anaesthetic regimen
- May be ceased if substantial concern about bleeding
- MAO-Is
Generally cease 2 weeks prior.- Risk of profound hypertension with indirect acting sympathomimetics
Directly acting agents (noradrenaline, adrenaline, phenyephrine, isoprenaline) are safe when used judiciously. - May be continued if:
- Anaesthetist comfortable with MAO-safe anaesthesia
- Psychiatrist concerned about exacerbation of psychiatric disease with drug cessation
- Risk of profound hypertension with indirect acting sympathomimetics
- Lithium/Valproate
Generally continue perioperatively due to concerns about exacerbating underlying disease. Ensure regular monitoring of:- Fluids
- Electrolytes
- Serum lithium levels
- TCAs
May be continued but:- Preoperative 12-lead ECG and intraoperative 5-lead ECG should be performed
If ceased due to concerns about arrhythmia, should be tapered off 7-14 days prior to surgery. - Tramadol and meperidine should be avoided
- Atropine or scopolamine may ↑ perioperative confusion
- Preoperative 12-lead ECG and intraoperative 5-lead ECG should be performed
Endocrine Medications
OCP: * Consider ceasing 4 weeks prior if high VTE risk.
Thyroxine:
- Should be continued perioperatively
- Requires parental administration if cannot be resumed within 5-7 days perioperatively
Glucocorticoids:
- Chronic glucocorticoid therapy may suppress the HPA axis and prevent an appropriate adrenal response to physiological stress
In absence of glucocorticoids, endogenous cortisol release:- ↑ even with minor surgery or illness
↑ may be 5 to 50 times normal, depending on degree of insult. - May persist for days
Normalise within 24 hours for small insults, and 5 days for larger insults.
- ↑ even with minor surgery or illness
- Addition of “stress dose” steroids perioperatively is common practice, although lacks a strong evidence base
- In general, patients:
- Do not have HPA suppression with:
- Prednisolone doses <5mg/day
- Any dose of glucocorticoid for <3 weeks
- Do have HPA suppression with:
- Prednisolone doses >20mg/day
- Evidence of Cushing’s syndrome
- Do not have HPA suppression with:
- Stress-dosing varies on degree of surgical stress:
- Minor stress
Take usual steroid dose. - Moderate stress
Take usual steroid dose, and supplement with:- 50mg Hydrocortisone IV pre-procedure
- 25mg Hydrocortisone Q8H for 24/24
- Severe stress
Take usual steroid dose, and supplement with:- 100mg Hydrocortisone IV pre-procedure
- 50mg Hydrocortisone Q8H for 24/24
- Taper hydrocortisone dose by half each day until maintenance steroid dose reached
- Minor stress
Complementary and Alternative Medicines
In general, ceasing all herbal/complimentary medicine 2 weeks prior is a safe approach.
Specific medications:
- Ephedra
Cease 24 hours prior; ↑ cardiac risk. - Garlic
Cease 7 days prior; ↑ bleeding risk. - Ginkgo balboa
Cease 36 hours prior; ↑ bleeding risk. - Ginseng
Cease 7 days prior; ↑ hypoglycaemia. - Kava
Cease 24 hours prior; pharmacokinetic interactions with anaesthetic agents. - St. John’s Wort
Cease 5 days prior; multiple pharmacokinetic interactions. - Valerian root
Tapered weeks pre-operatively; ↑ sedation with anaesthesia. - Echinacea
↑ Hypersensitivity.
References
- De Hert S, Imberger G, Carlisle J, et al. Preoperative evaluation of the adult patient undergoing non-cardiac surgery. Eur J Anaesthesiol. 2011;28(10):684-722.
- Duceppe E, Parlow J, MacDonald P, Lyons K, McMullen M, Srinathan S, et al. Canadian Cardiovascular Society Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Noncardiac Surgery. Canadian Journal of Cardiology. 2017 Jan 1;33(1):17–32.