Several medications are reviewed for use & disuse perioperatively.
Anticoagulant & antiplatelet agents risk perioperative bleeding. Management has always had great complexity, now compounded by numerous agents and situations. As editor, I have decided that the best thing I can do with this material is direct users to good external sources until a single unified and authoritative source of guidance emerges which I could adapt here (if you know of one, let me know).
External links to web & *app resources
MAQI2 Anticoag Toolkit U-Mich
iPRO's MAPPP
ACC's Manage Anticoag
ASRA's Coags (reg-neuraxial)
Univ.
Michigan's MAQI2 Anticoagulation Toolkit and iPRO's MAPPP (managing
anticoag in the periprocedure period) give guidance on all of the
medications in all situations (VTE, A-fib, heart valve, CAD, DAPT) in
which these meds are used; note VTE is covered only by extending PAUSE
trial's a-fib DOAC guidance. ACC's app only covers A-fib. ASRA Coags
(American Society Regional Anesthesia) covers the unique risks involved
in neuraxial and regional anesthesia, and ASRA has no web version.
* directly launching each app above would be desirable, but this is no longer technically possible, sorry.
General principles of periop mgmnt
General principles (students, residents)
My summaries (some old!)
Warfarin & bridging Heparins (2012-2015)
Aspirin (2015)
Clopidogrel/P2Y12-inhibitors (appx. 2015)
DOAC guidance from PAUSE trial
The ICSI guideline offers the following recommendations for the management of insulins and diabetic medications around surgery:
- individualized diabetes mgmt plans should be formulated prior to surgery so as to avoid glycemic extremes (strong, low)
- long-acting insulins (glargine, NPH, etc.) may be decreased by up to 50% preoperatively (strong, low)
- do not administer oral hypoglycemics or short-acting insulins preoperatively (strong, low)
-
Short-acting, sliding scale insulin should be used to treat high blood
glucose values in patients holding their normal diabetic medications
(strong, low)
- GLP-1 agonists (exenatide, liraglutide) should be
held perioperatively (strong, low) as these agents slow GI motility and
may further delay GI recovery after surgery
- DPP-4 inhibitors
(sitagliptin) can be continued perioperatively, if patient desires
(strong, low). But ICSI adds that since they work on glucose for
absorption in the GI tract, the agents are safe but unnecessary since
surgical patients are NPO
- SGLT-2 inhibitors (not addressed by
ICSI) are the subject of case reports regarding euglycemic DKA. No
guideline yet offers advice, including ADA Diabetes Standards 2020.
Experts and case series reviewers suggest withholding SGLT-2’s 24, 48,
even 72 hours before surgery, and not resuming until patient is
tolerating full diet. Pay attention for stronger evidence and guidance.
-
Glycemic control should be directed at achieving blood glucose levels
between 140-180 mg/dL and not be directed at more intensive goal targets
(80-110 mg/dL) (strong, high)
Further ICSI pointers:
- mild hyperglycemia is preferable to hypoglycemia
- long-acting or intermediate insulin may be used to cover basal insulin needs; 50-100% of usual dose is reasonable
- insulin pumps should be continued but only to provide basal insulin coverage
-
details of insulin recommendations influenced by insulin sensitivity of
patient, timing of procedure, length of procedure, and how long patient
will need to be NPO following procedure
ACC
reviews the evidence that ACE's and ARB's can cause transient
hypotension but then notes that the same large study showed no actual
adverse outcomes. Thus ACC says:
- continuation of ACE inhibitors or ARBs perioperatively is reasonable (IIa, B)
- if ACE inhibitors or ARBs are held before surgery, it is reasonable to restart as soon as clinically feasible
ICSI
points out the same issue of hypotension at induction of anesthesia and
acknowledges the question as controversial, without making a
recommendation.
Be aware that new evidence may prompt
reconsideration. The VISION trial was a large 4,802 patient
international cohort study of 45+ yr. olds. 1,245 patients had their
ACE/ARB held 24+ hrs before surg vs. 3,557 with med uninterrupted. The
all-bad-outcomes composite of death-stroke-MI occurred in 12.0% with
ACE/ARB held vs. 12.9% when continued, p 0.01, and clinically meaningful
intraoperative hypotension occurred for 23.3% off ACE/ARB vs. 28.6%
when continued p<0.001 (Roshanov Anesth 2017).
The accompanying
editorial recommends that the VISION study findings should prompt a
large RCT to settle the issue rather than itself change practice. Pay
attention to how this finding is interpreted locally.
Guidance
on handling buprenorphine (and buprenorphine/naloxone a.k.a Suboxone)
peri- and post-operatively is evolving. Guidelines suggest several
options:
1) Continue buprenorphine at the patient's maintenance
dose, but break the total daily dose into 3-4 smaller more frequent
doses. Although used mainly for its craving/withdrawal-suppression
effect of 24+ hours duration, Buprenorphine also has a shorter
pain-relieving effect on the order of 6-8 hours duration. Thus for
mild-to-moderate pain, buprenorphine itself can be used when dosed more
frequently.
2) Continue use of buprenorphine but at doses elevated
above the patient's maintenance dose, divided every 6 hours, and then
tapered post-operatively in both frequency and quantity back down to the
original maintenance dose.
3) Continue buprenorphine at the
patient's maintenance dose but add strong full opioid agonists
(fentanyl, morphine, hydromorphone) at higher than usual doses to
overcome buprenorphine binding and provide necessary post-op pain
relief. Patients treated with high dose opioids should have closer
monitoring and narcan available. Post-operative doses should be tapered
until discontinued, leaving the patient once again on just the
buprenorphine maintenance dose.
Earlier guidelines offered
additional options of discontinuing buprenorphine altogether in favor of
peri & post-op exclusive use of strong opiate agonists. The latest
guideline (Kohan, 2021) recommends against such options due to evidence
on risks of withdrawal and precipitated withdrawal.
Ideally,
management would be coordinated with the patient’s opiate use disorder
prescriber and/or hospital pain management experts.
ACC says:
- patients chronically on beta-blockers should stay on beta-blockers perioperatively (I, B)
-
after surgery use of beta-blocker should be guided by clinical
circumstances, regardless of when beta-blocker was started (IIa, B)
-
for patients with intermediate- or high-risk myocardial ischemia noted
on preop stress testing, it may be reasonable to begin perioperative
beta-blockers (IIb, C)
- for patients with 3 or more RCRI risk
factors (diabetes, HF, CAD, CKD, CVA), it may be reasonable to begin
beta-blockers before surgery (IIb, B)
- for patients with a
compelling long-term indication for beta-blocker therapy but no other
RCRI risk factors, initiating beta-blockers in the perioperative setting
as an approach to reduce perioperative risk is of uncertain benefit
(IIb, B)
- for patients in whom beta-blocker therapy is initiated,
it may be reasonable to begin perioperative beta-blockers long enough
in advance to assess safety and tolerability, preferably more than 1 day
before surgery (IIb, B)
- beta-blocker therapy should not be started on the day of surgery (III:H, B)
There is no longer a recommended heart rate titration goal, as evidence is insufficient to guide on this topic.
What
happened to the enthusiasm for perioperative beta-blockade? Several
RCT's initially created excitement that periop beta-blockade could
protect patients from the risk of myocardial ischemia. But the POISE
trial gave untitrated fairly high-dose beta-blockade on the day of
surgery, yielding cardiac benefit but stroke harm, which dampened
overall enthusiasm. Furthermore, the scientific integrity of some work
in this field has been called into question. Thus the ACC
recommendations above which were once strong are now more tempered. .
ESA offers the following guidance:
– Patients chronically treated with TCAs should undergo cardiac eval [details unstated] (D).
– Antidepressant for chronically depressed patients should not be discontinued (B).
– Discontinuation of SSRI perioperatively is not recommended (D).
–
Irreversible MAOIs should be discontinued at least 2 weeks prior to
anesthesia. In order to avoid relapse of underlying disease, medication
should be changed to reversible MAOIs (D).
– The incidence of
postoperative confusion is significantly higher in schizophrenic
patients if medication was discontinued prior to surgery. Thus,
antipsychotic medication should be continued in patients with chronic
schizophrenia perioperatively (B).
– Lithium should be
discontinued 72 h prior to surgery. It can be restarted if the patient
has normal ranges of electrolytes, is hemodynamically stable and able to
eat and drink. Blood levels of lithium should be controlled within 1
week (B).
– For minor surgery under local anesthesia, continuation of lithium therapy can be considered (D).
When to stop (per ICSI 2014):
Non-COX selective, shorter half-life agents (ibuprofen, indomethacin, etc.): stop 1 day before surgery
Non-COX selective, longer half-life agents (naproxen, sulindac, etc.) stop 3 days before surgery
COX-2 selective agents (celecoxib) stop 2 days before surgery, mainly due to concern for renal effects
With
NSAIDs primarily cleared by the kidneys, recommendations above might be
adjusted (lengthened) in CKD patients. But CKD patients should not be
taking NSAIDs, so perhaps this proviso won’t arise often.
It is
commonly advised that NSAIDs be stopped 7-14 days before surgery. But
this is due to the misconception that NSAIDs inhibit platelets like
aspirin. Aspirin irreversibly inhibits platelets, thus aspirin needs to
be stopped long enough prior to surgery for the lifecycle of platelet
production to replace old inhibited platelets with new ones. However,
NSAIDs reversibly inhibit platelet function, and thus they only need to
be discontinued long enough for roughly 5 half-lives of the agent so
that it and it’s platelet inhibitory impact are cleared. It may not be
worth arguing with physicians who demand a lengthy discontinuation
period for NSAIDs, but patients should rest assured that inadvertent
NSAID use closer to surgery is not an indication to postpone their
procedure.
ACC says:
– patients on statins should continue (I,B)
– perioperative initiation of statin reasonable for all patients having vascular surgery (IIa B)
–
perioperative initiation of statin may be considered in patients with
clinical indications according to guideline directed medical therapy who
are undergoing elevated-risk procedures (IIb, C)
ICSI essentially recommends the same as above.
Systemic
a1-antagonists are typically used for BPH and HTN. However, they can
complicate cataract surgery by causing intraoperative floppy iris
syndrome (IFIS), characterized by sudden intraoperative iris prolapse
and pupil constriction. IFIS increases both the difficulty and the risk
of cataract surgery. Tamsulosin is associated with higher rates of IFIS
than other a-blockers. Few outside of ophthalmology know of this
condition.
Stopping the a-blocker does not reduce the risk of
IFIS. But having cataract surgery before starting an a-blocker, avoiding
Tamsulosin, and certainly alerting eye surgeons to a-blocker use before
surgery are all recommended (ASCRS & AAO).
ACC reviews the evidence and concludes that perioperative alpha-2 agonists for prevention of cardiac events are not recommended (III:NB, B)
Several studies done, Diltiazem seems more promising than other agents, but ACC recommends that large scale trials are necessary to define the value of calcium channel blockers perioperative before they can be recommended for use.