Perioperative Medication

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

Whinney C. CCJM. Nov 2009; 76(Suppl 4): S126-S132.

 Perioperative Consult
• Complete H/P
- Understand perioperative risk
• Pharmacologic history:
- Prescription drugs
- OTC
- Multivitamins
- Nutritional supplements/herbs
- Alcohol; tobacco; drugs

Clay BJ. J Hosp Med. 2008 Nov-Dec;3(6):465-72.

 General Principles
• Stress response to surgery and hemodynamic
consequences of anesthesia:
- ↑ sympathetic tone
- ↑ vasopressin
- ↑ cortisol
- ↑ RAAS
- ↑ local vasodilatory prostaglandins
 General Principles
• ↓ GI absorption
- Changes in splacnic blood flow
- Transmural intestinal edema
- Villous atrophy
- Hypomotility
• Ileus, opioids, anticholinergic agents,
electrolyte disturbances

Whinney C. CCJM. Nov 2009; 76(Suppl 4): S126-S132.

Pass SE. Am J Health Syst Pharm. 2004 May 1;61(9):899-912.
 General Principles

• 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)

Pass SE. Am J Health Syst Pharm. 2004 May 1;61(9):899-912.

Kennedy JM. Br J Clin Pharmacol. 2000 Apr;49(4):353-62.
 General Principles

• Abrupt discontinuation can cause withdrawal:

- SSRI
- Beta-blockers
- Clonidine
- Benzodiazepines
- Statins
- Corticosteroids.
Papadopoulos S. Orthopedics 2006; 29:413-17.
Marik PE. Arch Surg. 2008;143(12):1222-1226.
General Principles

Arch Intern Med. 2006;166:2525-2531.

 General Principles
• Continue medications with rebound or
withdrawal potential
• Discontinue:
- Increase surgical risk
- Non-essential for quality of life
• Use clinical reasoning

Whinney C. CCJM. Nov 2009; 76(Suppl 4): S126-S132.

Geriatric patient

Muravchick S. Anesthesiol Clin NA. 2000;18:74

 Geriatric patient
↓ Vascular
distensibility ↑ preload
+ sensitivity
Ventricular
hypertrophy

↓ baroreflexes ↓ response to
hypovolemia

↓ FEV1
Atelectasis
Physiologic
+ shunt
Hypoxemia
Pneumonia
↓ closing capacity

Singh A. Current Opinion in Anaesthesiology 2010; 23:449–454

Geriatric patient

Rivera R. Anesthesiology 2009; 110:1176–81.

 Morbid obese patients

↑ cardiac output
↑ lean body weight
↑ adipose mass
↑ extracellular volume

Lemmens HJM. Current Opinion in Anaesthesiology 2010, 23:485–491.

Janmahasatian S, Clin Pharmacokinet 2005; 44:1051–1065.
 Morbid obese patients

Lemmens HJM. Current Opinion in Anaesthesiology 2010, 23:485–491.

Janmahasatian S, Clin Pharmacokinet 2005; 44:1051–1065.
 Evidence of recommendations
• There are no randomized studies
• Expert consensus
• Pharmacology knowledge
- Pharmacokinetics
- Therapeutic effect
- Interaction with anesthetic agents
• Theoretical considerations (MVI)
• Case reports

Whinney C. CCJM. Nov 2009; 76(Suppl 4): S126-S132.

 General Principles
• Continue medications with rebound or
withdrawal potential
• Discontinue:
- Increase surgical risk
- Non-essential for quality of life
• Use clinical reasoning

Whinney C. CCJM. Nov 2009; 76(Suppl 4): S126-S132.

 Case 1
75 y/o man with renal mass. PMH HTN, CAD s/p BMS 3 mo ago.
On Atenolol 25 mg/d; Clopidogrel 70 mg/d and ASA 81 mg/d.
Scheduled for robotic heminephrectomy.
What is your recommendation for perioperative management of
antiplatelets?

a) Continue clopidogrel and ASA

b) Hold both clopidogrel and ASA on day of surgery
c) Stop clopidogrel 5 days before surgery and continue ASA
d) Stop both clopidogrel and ASA 7 days before surgery
e) Stop ASA 7 days before surgery and continue clopidogrel
 ASA
• Irreversible cyclooxygenase (COX) inhibition
• 7-10 days for platelet regeneration
• Perioperative use associated with ↓ CV morbidity
• Stop for > 5 days  ↑ stroke and ACS risk
• Decision of continue vs. hold  related to
hemorrhagic risk vs. perioperative CV morbidity.
- E.g. Neurosurgery; prostate; etc.
- Resume 24h after surgery (ACCP 2008)
Oscarsson A. Br J Anaesth. 2010 Mar;104(3):305-12.
O’Riordan JM. Arch Surg. 2009;144(1):69-76.
2008 ACCP Guidelines on Antithrombotic Therapy. Chest. 2008 Jun;133(6 Suppl):299S-339S.
 Coronary Stents

2007 ACC/AHA Perioperative Task Force. Circulation. 2009;120:e169-e276.

2008 ACCP Guidelines on Antithrombotic Therapy. Chest. 2008 Jun;133(6 Suppl):299S-339S.
 Other antiplatelets
• Thienopyridines - irreversible inhibition of ADP-induced
platelet aggregation
• Discontinue:
- Clopidogrel – 5 days
- Prasugrel – 7 days
- Ticlopidine – 10-14 days
• Resume ASAP.
• Continue ASA in patients with stents
• Unclear data on perioperative safety of dipyridamole

Cohn S. Perioperative Medicine. Mc Graw Hill. 2007. Pp 36-49.

Jaffer A. CCJM. 2009; 76(Suppl 4): S37-S44.
 NSAIDS
• Reversible inhibition of COX-1  ↓ TXA2  ↓ platelet
adhesion
- Nephrotoxicity
- ↑ bleeding risk x 1.5-2
• COX-2 (celecoxib) – minimal effect of platelet fx
- Nephrotoxicity
- Adverse cardiovascular effects
- ↓ postoperative opioid requirements
• Non-acetylated NSAIDS (salsalate) –no antiplatelet
effect

Straube S. Acta Anaesthesiol Scand. 2005;49:601-613.

O’Riordan JM. Arch Surg. 2009;144(1):69-76.
 NSAIDS
• Suggest to hold them pre-operatively due to
both nephrotoxicity and GI bleeding risk.
• Antiplatelet effect depends on its half life
- Platelet function analysis (PFA-100) –in-vitro
normalization 24h after stopping ibuprofen.
• Discontinue 3 days before surgery
- Ibuprofen can be used up to 24h before

Goldenberg NA. Ann Intern Med 2005 Apr 5;142(7):506-9.

 2008 ACCP Guidelines

2008 ACCP Guidelines on Antithrombotic Therapy. Chest. 2008 Jun;133(6 Suppl):299S-339S.

Jaffer A. CCJM. 2009; 76(Suppl 4): S37-S44.
CHADS22 Score

Snow V. Ann Intern Med 2003; 139:1009–1017.

Jaffer A. CCJM. 2009; 76(Suppl 4): S37-S44.
 2008 ACCP Guidelines

• Bridging to LMWH or UH:

- Moderate-high thromboembolic risk
• Prophylactic dose of LMWH:
- Low thromboembolic risk

2008 ACCP Guidelines on Antithrombotic Therapy. Chest. 2008 Jun;133(6 Suppl):299S-339S.

 Anticoagulant Bridging

• Half life x 4 = discontinuation time

- Warfarin ~ 5 days
- Start UH or LMWH 36h after last warfarin dose
- Last LMWH dose 24h before surgery
- Stop UH 6h before surgery

2008 ACCP Guidelines on Antithrombotic Therapy. Chest. 2008 Jun;133(6 Suppl):299S-

339S.
Levy JH. Anesthesiology 2010; 113(3):726 – 45.
 Case 2
90 y/o woman with PAD and AFib. Meds: warfarin 5 mg/d;
ASA 325 mg/d; diltiazem ER 180 mg/d. Scheduled for cataract
surgery.
What is your recommendation for perioperative management
of warfarin and ASA in cataract surgery?

a) Continue both warfarin and ASA

b) Stop ASA 7d prior and warfarin 5 d prior
c) Bridge warfarin to LMWH
d) Cancel surgery given patient’s age
e) Stop warfarin 5 d prior and continue ASA
Continue antiplatelets and anticoagulants
in cataract surgery
• Prospective cohort study (N = 19,283)  no
significant difference in local (hemorrhage) or
systemic (TIA, ACS) complications among patients
that stopped vs. continued ASA and warfarin.

• Retrospective study (N = 48,862) – Review of

national cataract surgery databank – warfarin and
clopidogrel use not associated with significant
increase of anesthetic or hemorrhagic
complications that could jeopardize patient’s vision.
Katz J. Ophthalmology 2003 Sep;110(9):1784-8.
Benzimra JD. Eye. 2009;23(1):10-16.
 2008 ACCP Guidelines
• Continue vitamin K antagonists
- Dental procedures – use of local haemostatic agents
(epsilon-aminocaproic acid)
• Dental hygiene, uncomplicated extractions,
prosthesis, restaurations, endodontics,
periodontal therapy
- Minor dermatologic procedures
• Mohs; simple excisions
- Cataract surgery; trabeculectomy
- EGD, C-scope w/o biopsy; EUS

2008 ACCP Guidelines on Antithrombotic Therapy. Chest. 2008 Jun;133(6 Suppl):299S-339S.

Jaffer A. CCJM. 2009; 76(Suppl 4): S37-S44.
New anticoagulants

Levy JH. Anesthesiology 2010; 113(3):726 – 45.

 New anticoagulants

Stop x 4 half lives = ~ 2 days

Levy JH. Anesthesiology 2010; 113(3):726 – 45.

 Case 3
65 y/o man, hyperlipidemia, HTN, diverticulosis.
Meds: rosuvastatin, chlorthalidone. Scheduled for left
hemicolectomy in 2 wk. Patient is able to climb 2 flight of
stairs.
What is your recommendation?

a) Stop chlorthalidone on day of surgery

b) Stop both medications on day of surgery
c) Continue both medications
d) Start atenolol now – adjust dose to HR ~ 60-70x’
 Diuretics
• It is recommended to stop on day of surgery
- Hypovolemia
- Electrolyte derangement
• Hypokalemia
• Hyponatremia
• Hypo/Hypercalcemia
• Individualize in patients with CHF

Whinney C. CCJM. Nov 2009; 76(Suppl 4): S126-S132.

 RAAS Inhibitors
Inhibition of Ang II vasoconstrictor
effect
ACEI
↓ Aldosterone
ARB
Aldosterone antagonists ↑ Vasodilatory agents
• Eplerenone, spironolactone (Bradykinin, NO, prostacyclin)
Direct renin blocker
• Aliskiren
Venous blood “Pooling”
+ ↓ Cardiac output
ANESTHESIA

↑ 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-induction hypotension treated with vasopressor agents

Rosenman DJ. J Hosp Med. 2008 Jul;3(4):319-25.

 RAAS Inhibitors

RR post-op MI

Rosenman DJ. J Hosp Med. 2008 Jul;3(4):319-25.

• Retrospective study (1996 - 2008)

• N = 10,023 (3,052 ACE vs. control –propension analysis)

• Preop ACEI  postop complications

- Mortality (OR: 2.83, 95% CI: 1.03 to 7.8; P = 0.04)
- Nephrotoxicity (OR: 1.7, 95% CI: 1.22 to 2.38; P = 0.0002
- Atrial fibrillation (OR: 1.33, 95% CI: 1.17 to 1.51; P = 0.0001)
- Inotropic use (OR: 1.17, 95% CI: 1.07 to 1.29; P = 0.0001).

• Mortality: 1%.
- ACEI : x 2 (1.3% vs. 0.7%; OR: 2.00, 95% CI: 1.17- 3.42; P = 0.013).

J Am Coll Cardiol 2009;54:1778–84.

RAAS Inhibitors - Recommendations

• Stop ACEI – one dose

• Stop ARB – 24 h
• Aliskiren – half life ~ 24 h  ~ 3 days?
• Spironolactone – one dose
• Eplerenone – one dose

Whinney C. CCJM. Nov 2009; 76(Suppl 4): S126-S132.

Saber W. CCJM. Mar 2006;73(Suppl 1):S82-7.
 Pathophysiology of perioperative ischemia
• Anesthesia Increased sympathetic tone
• Fluid-shifts, anemia
• Pain Increased cathecolamine release
• Increased metabolic demands

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

Chopra V. JAMA. Feb 10 2010; 303(6): 551-2.

 1ry Outcome AMI

HR 0.84, 95%CI 0.70–0.99 HR 0.73, 95%CI 0.60–0.89

N = 8351
- Metoprolol 4174
- Placebo 4177
Primary outcome –
composite of CV mortality,
non-fatal AMI, non-fatal
CVA Death
cardiac arrest
HR 2.17, 95%CI 1.26–3.74
Metoprolol succinate
200 mg/d

HR 1.33, 95%CI 1.03-1.74

Devereaux PJ, et al. Lancet 2008; 371: 1839 – 47.

Perioperative Betablockers
RCRI
Diabetes
CAD
CVA
CHF
CKD (cre > 2); GFR < 30?

Lindenauer PK. N Engl J Med 2005;353: 349-61.

• N = 940 vascular surgery patients
• Cardiac events at 30 days:
- 1-4 wks - O.R. 0.46, 95% CI: 0.27 to 0.76
- > 4 wks - O.R. 0.48, 95% CI: 0.29 to 0.79
• Long term mortality:
- 1- 4 wks– H.R. 0.52, 95% CI: 0.21 to 0.67
- > 4 wks – H.R. 0.50, 95% CI: 0.25 to 0.71

Flu WJ. J Am Coll Cardiol, 2010; 56:1922-1929,

 Betabloqueadores
Betabloqueadores
• Class I - continue in patients actively using it
• Class IIa
- Probably recommended in vascular surgery in high risk
patients (CAD; positive stress test)
- Reasonable in patients with CAD and > 1 CV risk factor.
• Class IIb
- Unknown in the absence of CAD
- Unknown in the absence of risk factors
• Class III
- Do not use in patients with contraindications.
- Dangerous to start high doses without slow up-titration in
naïve patients.

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

2007 ACC/AHA Perioperative Task Force. Circulation. 2009;120:e169-e276.

Dunkelgrun M. Ann Surg. 2009;249:921-926.
Glynn RJ. N Engl J Med. 2009;360:1851-1861.
 Other cardiovascular medications
• Clonidine
- Anxiolytic properties
- Rebound HTN
- Continue.

• α-blockers
- BPH
- Tamsulosine – discontinue before cataract surgery
• Intraoperative floppy iris syndrome
- Discontinue

• Calcium channel blockers

- Continue

• 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?

a) Stop pump and convert to long acting insulin

b) Continue basal infusion of insulin
c) Start iv insulin and glucose (glucose clamp)
d) Stop pump and start ISS
 Objectives of glycemic control

• Avoid hypo- and hyperglycemia

• Maintain stable electrolyte balance
• Prevent ketoacidosis
• Maintain strict glycemic control
- ICU: > 110 mg/dL < 180 mg/dL
- Non-ICU: > 100 mg/dL < 140 mg/dL

Meneghini LF. CCJM. Nov 2009; 76 (Suppl 4): S53-S59

Diabetes Care. Jun 2009; 32(6):1119-1131.
Pre-operative DM management
• Stop OHA in AM of surgery
- Chlorpropamide (~2 days before)
- Metformin  continue the previous day
- Thiazolidinediones (pioglitazone)
- GLP-1 agonists (exenatide)
- DPP-4 inhibitors (sitagliptine)

Meneghini LF. CCJM. Nov 2009; 76 (Suppl 4): S53-S59

Duncan AI. Anesth Analg. 2007;104:42-50.
Salpeter S. Cochrane Database Syst Rev. 2002:CD002967.
 Pre-operative DM management

• Insulin
- Day before  same regime
- Day of surgery:
• Do not use short acting insulin
• Long acting insulin: 50% dose
• Insulin pump  continue basal rate

Meneghini LF. CCJM. Nov 2009; 76 (Suppl 4): S53-S59

Duncan AI. Anesth Analg. 2007;104:42-50.
Salpeter S. Cochrane Database Syst Rev. 2002:CD002967.
 Pre-operative DM management

• 70/30 Insulin
- Long acting insulin (NPH): 50%
- 50 u  70% = 35 u
 Administer 50% ~ 17 u

Meneghini LF. CCJM. Nov 2009; 76 (Suppl 4): S53-S59

Duncan AI. Anesth Analg. 2007;104:42-50.
Salpeter S. Cochrane Database Syst Rev. 2002:CD002967.
 Case 5
80 y/o woman with PMR admitted for cholecystectomy.
Meds: Prednisone 5 mg/d.
What is your recommendation for perioperative
management of steroids?

a) Continue same dose of prednisone

b) Administer 15 mg of prednisone
c) Stop prednisone on day of surgery
d) Administer hydrocortisone 100 mg i.v. upon induction
 Perioperative Steroids
• Normal adrenal gland ~ 5.7 mg (15.7 μmol) / m2BSA cortisol
- Male 1.80 m; 75 kg produces ~ 30 μmol/d of cortisol

• Oral supplementation in a patient without any endogenous cortisol

production  x2 endogenous production.
- overcome biological availability and the first-pass metabolism of the
liver.
• Stress  endogenous cortisol ↑ 5-6x

• Rationale for perioperative steroid supplementation:

- Exogenous glucocorticosteroids suppress the HPAA
- Max. stim. adrenal produces ~ 200–300 mg of cortisol
- Pts w/ suppressed HPAA need extreme doses of steroids
 Perioperative Steroids
• 2 randomized placebo-controlled studies
• Patients on basal steroid dose

It is not possible to refute or support perioperative steroid

supplementation
Yong SL. Cochrane Database Syst Rev. 2009 Oct 7;(4):CD005367.
Marik PE. Arch Surg. 2008;143(12):1222-1226
de Lange DW. Eur J Int Med. 2008; 19: 461–467
 Perioperative Steroids
Axis suppression Minor surgical Moderate surgical Major surgical stress
stress (hernia) stress (articular (CABG)
replacement)
No Daily dose Daily dose Daily dose
PDN < 5 mg/d No supplementation No supplementation No supplementation
Steroids < 3wk
-ve Cosyntropin
Documented or Daily dose Hydrocortisone Hydrocortisone
suspicion No supplementation 50 mg iv (induction) 100 mg iv (induction)
PDN > 20 mg/d > 25 mg iv q8h x 24h- 50 mg iv q8h x 24h
3wk 48h 25 mg iv q8h x 24-48h
Cushingoid
+ve Cosyntropin
Unknown Daily dose Cosyntropin +ve Hydrocortisone
PDN 5-10 mg > No supplementation Hydrocortisone 100 mg iv (induction)
3wk 50 mg iv (induction) 50 mg iv q8h x 24h
25 mg iv q8h x 24h- 25 mg iv q8h x 24-48h
48h
Shaw M. CCJM. 2002;69(1):9-11
Schiff RL. Med Clin North Am. 2003 Jan;87(1):175-92.
Cohn SL. Perioperative Medicine. McGraw Hill. 2006. Pp 158-163.
 Case 6
70 y/o man with COPD; never intubated. Hospitalized 1 y ago. Meds:
salmeterol/fluticasone, tiotropium, albuterol prn, montelukast. He is
asymptomatic. Scheduled for THA.
How will you manage his COPD medications in preparation for surgery?

a) Stop inhalers. Administer hydrocortisone i.v.

b) Administer prednisone 60 mg/d starting 48 h before surgery
c) Continue all inhalers
d) Perform PFT’s and adjust inhalers accordingly
e) Stop montelukast and start theophylline
COPD / Asthma

Yamakage M. J Anesth. 2008; 22:412–428

 COPD / Asthma
• Continue:
- Bronchodilators
- Inhaled steroids
- Montelukast
• Optimize symptoms
- Antibiotics (thick sputum)
- Oral steroids (5 days before)
• Stop theophylline (disrhythmias)
Woods BD. Br J Anaesth 2009; 103 (Suppl. 1): i57–i65.
Yamakage M. J Anesth. 2008; 22:412–428
Silvanus MT. Anesthesiology 2004; 100: 1052–7
 Case 7
50 y/o woman with bipolar disorder and paranoid schizophrenia. Meds:
Lithium carbonate, valproic acid, olanzapine and escitalopram.
Scheduled for mastectomy secondary to breast cancer.

What are your recommendations for management of psychiatric drugs?

a) Stop all of them on day of surgery
b) Continue valproic acid and Lithium only
c) Continue olanzapine and escitalopram only
d) Stop olanzapine
e) Continue all of them
 Neuropsychiatric drugs

• 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.

Huyse FJ. Psychosomatics 2006; 47:8–22

Weinrieb RM. Expert Opin Drug Saf. 2005;4:337-344.
Movig KL. Arch Intern Med. 2003;163:2354-2358.
Michelson D. Br J Psychiatry. 2000;176:363-368.
 Neuropsychiatric drugs

• Tricyclic antidepressants:
- inhibit recapture of norepinephrine and
serotonin
• Theoretical  risk of disrhythmias
• Abrupt discontinuation  cholinergic effect
• Continue in perioperative period.

Huyse FJ. Psychosomatics 2006; 47:8–22

Cohn SL. Perioperative Medicine. McGraw Hill. 2006. Pp 36-49.
Wolfe RM. Am Fam Physician. 1997;56:455-462.
Kroenke K. South Med J. 1998;91:358-364.
 Neuropsychiatric drugs
• Benzodiazepines  continue
• Antipsychotics  continue
- Document ECG (QTc)
• MAOI  stop 2 weeks before
- Risk of HTN with sympathetic agents
- Serotoninergic syndrome
- Avoid meperidine, thyramine
- Use direct sympathomimetics (phenylefrine)

Huyse FJ. Psychosomatics 2006; 47:8–22

Cohn SL. Perioperative Medicine. McGraw Hill. 2006. Pp 36-49.
Noble WH. Can J Anaesth. 1992;39:1061-1066.
 Neuropsychiatric drugs
• Lithium  continue
- Monitor electrolytes (Nephrogenic Diabetes insipidus)
• Antiepileptics  continue
- Monitor selum levels
- Consider i.v. use
• Antiparkinson agents  continue
- Abrupt discontinuation  Malignant neuroleptic Sx
- Neurology consult
Huyse FJ. Psychosomatics 2006; 47:8–22.
Cohn SL. Perioperative Medicine. McGraw Hill. 2006. Pp 36-49.
Fujii T. Surg Today. 2009;39(9):807-810.
Gálvez-Jiménez N. Neurol Clin. 2004;22(2):367-377.
Gray EJ. J Oral Maxillofac Surg. 1996;54:909-912.
 Case 8
50 y/o woman with glioblastoma multiforme.
Meds: Dexamethasone, Levetiracetam, Ginseng, Garlic Ginkgo-
biloba. Scheduled for brain tumor removal in 2 weeks.
What is your recommendation for medication management?

a) Continue all her medications

b) Stop all medications on day of surgery
c) Stop Levetiracetam on day of surgery
d) Stop Ginseng and Ginkgo-biloba on day of surgery
e) Stop now the Garlic, Ginseng y Ginkgo-biloba
 Supplements and herbs
• Used by 33% of surgical patients
• Its complications include:
- AMI, stroke, hemorrhage
- Potentiating anesthetic agents
- Refractoriness to anesthetic agents
- Pharmacologic interactions

Ang-Lee MK. JAMA. 2001;286:208-216.

Kaye AD. Anesthesiology Clin N Am 2004; 22:125–139.
Rowe DJ. Aesthetic Surg J 2009;29:150–157.
 Supplements and herbs
Hypoglycemia
Inhibit platelet aggregation (irreversible)
Ginseng  PT-PTT in animals
 Anticoagulant effect of warfarin

AMI, stroke
Deplete endogenous catecholamine deposits
Ephedra (ma huang) Intraoperative hemodynamic instability
Fatal interaction with MAOIs

Inhibit platelet aggregation (irreversible)

Garlic  fibrinolysis   hemorrhagic risk
Erratic hypotensive activity

Ginkgo-biloba Inhibit PAF   hemorrhage risk

Ang-Lee MK. JAMA. 2001;286:208-216.

Kaye AD. Anesthesiology Clin N Am 2004; 22:125–139
Rowe DJ. Aesthetic Surg J 2009;29:150–157.
 Supplements and herbs
Sedation, anxiolysis
Kava kava  Sedative effect of anesthetic agents
Addictive potential  suppression

Multiples pharmacologic interactions  P450

St. John’s Wort
induction

Activate cellular immunity

Echinacea Allergic reactions; immunosuppression
Potentiates barbiturates

 Sedative effect of anesthesia

Valerian
Suppression; refractoriness to anesthesia

Ang-Lee MK. JAMA. 2001;286:208-216.

Kaye AD. Anesthesiology Clin N Am 2004; 22:125–139
Rowe DJ. Aesthetic Surg J 2009;29:150–157.
 Supplements and herbs

• Others: Chamomile – anticoagulant effect

• Other resources:
- www.nccam.nih.gov
- www.fda.gov/consumer
- www.herbmed.org

Kaye AD. Anesthesiology Clin N Am 2004; 22:125–139.

Rowe DJ. Aesthetic Surg J 2009;29:150–157.
Thank
Thank you!
you!