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
Heme
Anticoagulation
Antiplatelets
Endocrine
Glucocorticoids
Continue, but consider stress dosing for patients on high-dose steroids or surgeries of long duration:
- Greater than 20mg/day prednisone, 16mg/day methylprednisolone, 2mg/day dexamethasone, 80mg/day hydrocortisone for >3 weeks: stress dose indicated
- Less than 5mg/day prednisone, 4mg/day methylprednisolone, 0.5mg/day dexamethasone, 20mg/day hydrocortisone, or any amount of steroid for <3 weeks: no stress dose indicated
- For intermediate range, defer to patient history and HPA evaluation
- Decision should be highly personalized to patient and level of HPA axis suppression (e.g. based on AM cortisol)
- If stress dose indicated, hydrocortisone 300mg/day or equivalent for several days is common practice
- Avoid etomidate as induction agent due to risk of adrenal crisis
Levothyroxine
Continue
- To maintain euthyroid state
- Can be given IM/IV at 80% dose if necessary
Methimazole/Propylthiouracil (PTU)
Continue
- To maintain euthryoid state
Oral contraceptives (OCP)
Continue unless patient is has high risk of venous thromboembolism (VTE), in which case stop 4 weeks before surgery
- If continued, requires perioperative VTE prophylaxis
Pulmonary
Beta agonists
Continue
- Significant reduction in COPD/asthma complications
Anticholinergics
Continue
- Significant reduction in COPD/asthma complications
Glucocorticoids (inhaled)
Continue
- Avoids risk of adrenal insufficiency, particularly during stress of surgery
- Inhaled dosage relatively low and unlikely to cause adverse events
Gastrointestinal (GI)
H2 blockers/Proton pump inhibitors (PPI)
Continue
- Very safe intraoperatively
- Prevents stress ulcers
- Prevents gastric aspiration/chemical pneumonitis