Surgical Principles: Perioperative Medication Management

Cardiovascular Medication

Continue

  • β-Blockers (Do Not Start < 24 Hours Before Surgery)

Hold the Day Of

  • Statins/Lipid Lowering Drugs
    • Continue if High Risk of CV Events
  • ACEI & ARB (Anesthesia Blunts Sympathetics, Relying on RAAS)

Stop Sooner

  • NSAIDs: 2 Days
  • Aspirin: 7-10 Days
    • Continue if High Risk of CV Events
  • Clopidogrel/Plavix: 7-10 Days
  • Estrogen: 4 Weeks (VTE Risk)

Blood Thinners

Hold Timing

Reversal

Dual-Antiplatelet Therapy (DAPT)

  • Low Bleeding Risk Procedure: Continue ASA, Hold Clopidogrel for 5 Days
  • High Bleeding Risk Procedure: Hold ASA & Clopidogrel for 5 Days

Hyperglycemic Medication

Target

  • Glucose Target: 140-180

Oral Hypoglycemics

  • Metformin & Oral Hypoglycemics: Hold the Morning Of (Risk for Lactic Acidosis)

Insulin Management

  • Rapid & Short Acting: Hold the Morning Of
    • Rapid Acting – Lispro (Humalog) & Aspart (Novolog)
    • Short Acting – Regular
  • Intermediate & Long Acting: Full Night Dose & Half the Morning Doses
    • Intermediate Acting – NPH (Novolin/Humulin)
    • Long Acting – Glargine (Lantus) & Detemir (Levemir)
  • Insulin Pump: Sleep Basal Rate

Steroids/Suppressed HPA (Hypothalamic-Pituitary-Adrenal) Axis

Stress Dose Indications

  • Stress Dose if Given Systemic Steroids in Last 6 Months
  • Not Suppressed/No Stress Dose Indicated:
    • Low Dose < 5 mg Daily
    • Low Dose < 10 mg Every Other Day
    • Any Dose for Short Duration < 3 Weeks

Stress Dosing

  • Minor Surgery: Usual Dose
    • Ex: Herniorrhaphy
  • Moderate Surgery: Usual Dose + 50 mg Before & 25 mg Every 8 Hours for 24 Hours
    • Ex: Lower Extremity Revascularization, Joint Replacement
  • Major Surgery: Usual Dose + 100 mg Before & 50 mg Every 8 Hours for 24 Hours
    • Ex: Esophagectomy, CABG, Proctocolectomy

Other Medications

Anti-Retroviral Medications

  • Continue Until Time of Surgery & Restart as Soon as Tolerating Oral Intake
    • No IV Antiretroviral Bridge Needed

Transplant Medications

  • In General Continue Steroids & Other Maintenance Therapies (Mycophenolate, Cyclosporin & Tacrolimus)
  • Consider Holding Sirolimus for 2 Weeks Postoperatively Due to Impaired Wound Healing – Will Need Tacrolimus Instead During that Time

Chronic Pain Medication

  • Oral Opioids – Take Normal Dose the Morning of
  • Fentanyl Patch – Continue Patch Preoperatively & In the Operating Room