Preoperative medication management

Patients often have a long list of medications they take, and decisions must be made about whether to continue or hold them prior to surgery.

Cardiovascular

Beta blockers

Continue if taking chronically

• Reduces coronary ischemia
• Acute withdrawal of chronic beta blocker associated with increased morbidity/mortality

ACE inhibitors/Angiotensin receptor blockers (ARB)

Discontinue morning of surgery. However, could consider continuing for certain cardiac procedures on patient-by-patient basis

• Inhibition of RAAS leads to refractory intraoperative hypotension
• For most surgeries, appears to be no increase in mortality or cardiovascular events from holding ACE/ARB
  • However, some studies suggest myocardial protection in CABG

Diuretics

Discontinue morning of surgery if taking for hypertension and euvolemic

Continue if unstable volume status or history of poorly controlled heart failure

• Theoretical risk of worsened hypotension due to intravascular depletion, though limited studies showing this in practice
• Theoretical risk of hypokalemia, though this has not been observed in practice

Calcium channel blockers

Continue

• Limited data showing neither benefit nor harm with continuation

Alpha 2 agonists (e.g. clonidine)

Continue if taking chronically

• Prevent rebound hypertension

Digoxin

Continue

• Limited data, though no evidence of adverse effects from continuation

Statins

Continue

• Shown to prevent vascular events perioperatively

Gastrointestinal (GI)

H2 blockers/Proton pump inhibitors (PPI)

Continue

• Very safe intraoperatively
• Prevents stress ulcers
• Prevents gastric aspiration/chemical pneumonitis