Professional Documents
Culture Documents
Management
Moises Auron MD, FAAP, FACP
Staff, Department of Hospital Medicine
Disclaimer
• None
Objectives
• Reviews the general principles to determine
continuation or discontinuation of medications in
the perioperative setting.
• Discuss evidence and controversies around
perioperative medication management.
• Outline a practical guide for perioperative
medication management.
• Will discuss the most commonly used medications
as well as the ones with increased controversy.
Justification
• Steady increase in surgical complexity
- Increased elderly population
• Lack of formal training in perioperative medicine
• Involuntarily stopping of initiating new medications
• Federal requirement (Joint Commission on
Accreditation of Healthcare Organizations -
JCAHO)
- #3: Increase safety in medication management
- #8: Medication reconciliation – precise and complete
http://www.jointcommission.org/patientsafety/nationalpatientsafetygoals
Evidence of recommendations
• There are no randomized studies
• Expert consensus
• Pharmacology knowledge
- Pharmacokinetics
- Therapeutic effect
- Interaction with anesthetic agents
• Theoretical considerations (MVI)
• Case reports
• Discontinuation • Continuation
- Rebound effects - Hemorrhage
- Withdrawal - Hypoglycemia
- Worsening intraoperative - Interaction with anesthetics
clinical status
- Postoperative complications
• O.R. 2.7 (95% CI, 1.76–4.04)
↓ baroreflexes ↓ response to
hypovolemia
↓ FEV1
Atelectasis
Physiologic
+ shunt
Hypoxemia
Pneumonia
↓ closing capacity
↑ cardiac output
↑ lean body weight
↑ adipose mass
↑ extracellular volume
↑ post-induction hypotension
Fyhrquist F. J Intern Med. 2008 Sep;264(3):224-36. ↑ vasoconstrictor use (adrenergic
Comfere T. Anesth Analg. 2005;100:636-644.
agonists, vasopressin)
RAAS Inhibitors
RR post-op MI
• Mortality: 1%.
- ACEI : x 2 (1.3% vs. 0.7%; OR: 2.00, 95% CI: 1.17- 3.42; P = 0.013).
Increased cortisol
Inflammatory state +
- TNF ↑ Myocardial VO2
- CRP
- IL-1 and IL-6
- FFA Increased plaque shear stress Tissue ↓O2
↑ Platelet function
+
Endothelial dysfunction Plaque rupture Non – Q MI
Perioperative Betablockers
Circulation 2009;120;e169-e276;
Hypolipemic agents
• Statins
- Favorable evidence (↓ cardiovascular complications)
• DECREASE IV
- Decreased venous thromboembolism
- Continue
• Cholestiramine
- Decrease absorption of other drugs
• Fibrates and Niacine
- Rhabdomyolisis Discontinue
- Do not offer perioperative benefits
• α-blockers
- BPH
- Tamsulosine – discontinue before cataract surgery
• Intraoperative floppy iris syndrome
- Discontinue
• Anti-angina; anti-arrhytmics
- Continue Abdel-Aziz S. Curr Opin Ophthalm. 2009; 20:37–41
Wallace AW. Anesthesiology. 2004;101:284-293.
Bell CM. JAMA. 2009;301:1991-1996.
Wijeysundera DN. Anesth Analg. 2003;97:634-641.
Case 4
25 y/o man with DM1, CHF (EF 30%), ESRD. Scheduled for
renal transplant. Meds: insulin pump, atorvastatin, carvedilol,
lisinopril.
How would you manage his insulin preoperatively?
• Insulin
- Day before same regime
- Day of surgery:
• Do not use short acting insulin
• Long acting insulin: 50% dose
• Insulin pump continue basal rate
• 70/30 Insulin
- Long acting insulin (NPH): 50%
- 50 u 70% = 35 u
Administer 50% ~ 17 u
• SSRI:
- Potential antiplatelet effect
- Abrupt withdrawal symptoms
• Continue in perioperative period.
- In certain procedures (neurosurgery) its
discontinuation can be considered – discuss
with Psychiatry and stop gradually.
• Tricyclic antidepressants:
- inhibit recapture of norepinephrine and
serotonin
• Theoretical risk of disrhythmias
• Abrupt discontinuation cholinergic effect
• Continue in perioperative period.
AMI, stroke
Deplete endogenous catecholamine deposits
Ephedra (ma huang) Intraoperative hemodynamic instability
Fatal interaction with MAOIs