“What decides the medication before my surgery?”

Here are the guidelines for medication classes before surgery according to the ASA (American Society of anesthesiologists)



III. Protocol: Medications to still take on morning of surgery
A. All Cardiovascular medications
1. See Perioperative Beta Blocker
2. Continued medications include
a. Clonidine (use patch if NPO)
b. Antiarrythmics
3. Exceptions - cardiovascular medications to stop
a. See antihypertensives below (Diuretics, ACE Inhibitors, ARBs, Calcium Channel Blockers)
B. Anti-reflux medications (e.g. Omeprazole, Ranitidine)
C. Seizure and anti-parkinson medications
D. Psychiatric medications
1. Benzodiazepines
a. Risk of withdrawal when abruptly stopped perioperatively
b. May reduce anesthetic need
2. Antipsychotics
a. Decreased Seizure threshold
b. Risk of Neuroleptic Malignant Syndrome
3. Antidepressants
a. May be continued (risk of Antidepressant Withdrawal symptoms)
E. Bronchodilators
1. Bring asthma Inhalers to hospital on day of surgery
F. CPAP machine
1. Bring to hospital on day of surgery
G. Oral Contraceptives (unless stoped for prevention of DVT)
H. Corticosteroids or immunosuppressants
1. Consider Stress Dose Steroids if on equivalent of >5 mg/day in 6 months prior to surgery
I. Rheumatologic agents
1. Despite case reports of infection and delayed healing risks
J. Levothyroxine (Synthroid)
K. HIV Medications
L. Pain medications
1. Acetaminophen or Opiates
2. Not Aspirin or NSAIDS
IV. Protocol: Medications to not take on morning of surgery
A. Diuretics or weight loss medications
B. Potassium supplements or Vitamins
C. Diabetes medications
1. See Perioperative Diabetes Management
2. Oral diabetes medications are typically held on the day of surgery (see below)
3. Basal Insulin (e.g. Lantus) is taken at half dose (on night before or AM of surgery)
4. Bolus Insulin (e.g. Lispro) is held at home while NPO
V. Protocol: Medications to avoid in the perioperative period
A. Medications associated with bleeding risk
1. See Perioperative Anticoagulation
2. NSAIDs
a. Short-acting agents: Stop 1 day before surgery
i. Diclofenac (Voltaren)
ii. Ibuprofen (Motrin)
iii. Indomethacin (Indocin)
iv. Ketoprofen (Orudis)
b. Mid-acting agents: Stop 3 days before surgery
i. Diflunisal (Dolobid)
ii. Naproxen (Naprosyn)
iii. Sulindac (Clinoril)
c. Long-acting agents: Stop 10 days before surgery
i. Meloxicam (Mobic)
ii. Nabumetone (Relafen)
iii. Piroxicam (Feldene)
3. COX2 Inhibitors (e.g. Celebrex)
a. Stop at least 2 days before surgery (Nephrotoxicity Risk)
4. Antiplatelet Agents: P2Y agents - Clopidogrel (Plavix), Brillanta (Ticagrelor), Effient (Prasugrel)
a. See Perioperative Antiplatelet Therapy
b. Do not stop antiplatelet agents without carefully reviewing indications and minimum duration from stenting
i. See Antiplatelet Therapy for Vascular Disease
ii. Cardiology should be consulted before stopping P2Y agents in post-stenting patients
iii. Consider continuing Aspirin while holding the second antiplatelet agent
c. Clopidogrel (Plavix), Brillanta (Ticagrelor)
i. Stop at least 5 days before surgery if no contraindication to stopping
d. Effient (Prasugrel)
i. Stop at least 7 days before surgery if no contraindication to stopping
e. Restart 24 hours after procedure or per surgeons discretion
5. Aspirin
a. Stop at least 5 days before surgery if no contraindication to stopping
b. Consider continuing Aspirin
i. Patients with high thrombosis risk (e.g. recent Myocardial Infarction)
ii. Minor procedures: Dental, dermatologic and Cataract surgery
iii. Consider stopping before Colonoscopy (especially if polypectomy is performed)
6. Other antiplatelet agents
a. Cilostazol (Pletal)
i. Stop at least 3 days before surgery
b. Ticlopidine (Ticlid)
i. Stop at least 5 days before surgery
c. Aspirin and Extended-Release Dipyridamole (Aggrenox)
i. Stop at least 7 days before surgery
7. Warfarin (Coumadin)
a. Stop 5 days before surgery
b. See Warfarin Protocol for the Perioperative Period (includes Bridging Indications)
c. Restart 12 hours after procedure or per surgeons discretion
8. Dabigatran (Pradaxa)
a. Consider doubling days of cessation prior to surgeries with high risk of bleeding
b. Creatinine Clearance >50 ml/min: Stop 2 days before surgery
c. Creatinine Clearance <50 ml/min: Stop 5 days before surgery
d. Restart 24 hours after surgery (72 hours after surgery if high bleeding risk)
9. Rivaroxaban (Xarelto)
a. Stop at least 1-2 days before procedure (longer if Chronic Kidney Disease or very high risk of bleeding)
b. Restart 24 hours after surgery (72 hours after surgery if high bleeding risk)
B. Thromboembolism risk
1. Estrogen Replacement, Birth Control Pills
a. Ideal to stop at least 1 month before surgery
b. Weigh risk versus benefit
c. If agent continued, consider DVT Prophylaxis measures
2. SERMs (Tamoxifen, Raloxifene)
a. Stop at least 1 week before procedures at high risk for Thromboembolism
b. Tamoxifen should only be stopped on Consultation with patient's oncologist
C. Diabetes Mellitus
1. See Perioperative Diabetes Management (includes Insulin management)
2. Oral Hypoglycemics
a. Hold for NPO period as well as the AM of surgery
3. SGLT2 Inhibitors (e.g. Jardiance)
a. Hold for at least 24 hours prior to surgery (risk of ketoacidosis)
4. Metformin (Glucophage)
a. Hold at least 24 hours prior to surgery (due to theoretical Lactic Acidosis risk)
D. Antihypertensives
1. Diuretics
2. Consider holding Calcium Channel Blockers while NPO
3. ACE Inhibitors and Angiotensin Receptor Blockers (hold one dose before surgery)
a. Avoiding within 11 hours, reduces risk of immediate post-induction Hypotension
b. Comfere (2005) Anesth Analg 100:636-44 [PubMed]
E. Ophthamologic surgery: Cataract
1. Notify surgeon of Flomax use in the perioperative period (due to risk of Floppy Iris Syndrome)
a. Ophthalmologists can take preventive measures at surgery if they know of Flomax use
b. As a long-acting medication, stopping the medication immediately before the procedure will not alter the risk
F. Parkinsonism Agents
1. MAO inhibitors should be tapered off 2-3 weeks before the procedure
a. Includes Selegiline and Rasagiline
b. Risk of interaction with perioperative Meperidine, Dextromethorphan, Ephedrine, Opioids
2. Avoid stopping Sinemet in perioperative procedure (risk of Parkinsonian hyperpyrexia syndrome)
3. Stay moving in the post-operative period (within 2-3 days of procedure - incorporate PT/OT)
G. Miscellaneous agents
1. Alendronate (Fosamax)
a. Stop at time of surgery due to instructions that are difficult to follow perioperatively (e.g. NPO)
H. DMARDs and TNF Agents
1. Stopping before orthopedic procedures (esp. TNF agents) lowers the risk of Surgical Site Infections
2. Agents are stopped 1-2 weeks before procedure and resumed 1-2 weeks after surgery
a. Consult with orthopedics and rheumatology regarding specific medications and patient risk factors
3. den Broeder (2007) J Rheumatol 34(4):689-95 [PubMed]
I. Herbal preparations
1. Stop all Herbals and supplements at least one week before surgery
a. Safest overall strategy due to numerous combination products
2. Specific agents with known risk in the perioperative period
a. Echinacea
b. Ephedra (should be avoided in general)
c. Garlic (discontinue at least 7 days before surgery)
d. Gingko (discontinue at least 36 hours before surgery)
e. Ginseng (discontinue at least 7 days before surgery)
f. Kava (discontinue at least 24 hours before surgery)
g. St. John's Wort (stop at least 5 days before surgery)
h. Valerian (slowly taper off before surgery)
i. Ang-Lee (2001) JAMA 286:208-16 [PubMed]

Yes and no. Perception and expectation. Kind of surgery is always an issue.

It depends on the procedure you are having, the length of the procedure, the ability of the facility to monitor use of sedative medication and physician preference. It is not uncommon to give either oral or IV medication prior to a procedure, but again dependent upon the items previously mentioned.

In general every person is a bit apprehensive ahead of surgical procedures. That is the reason why ahead of general anesthesia most of the anesthesiologists will give some Midazolam. If the procedure is very short your provider may opt out to avoid that you are sleepy to long.

Actually it is based a lot on doctor preference, as well as patient
needs.If a patient seems anxious then we may give them relaxing
medications. Every medication we give have some sort of side effect, so we
attempt to minimize things that are not needed. We don’t give relaxing
medications to elderly (most of the time) because it makes them hard to
wake up from surgery. Other deciding factors is the type of surgery you are
having, the anesthestic plan, and of course your o

Sometimes it is physician preference, but most often it has do with mental clarity after the procedure. Benzodiazapines are the commonly used premeds for relaxation and their effects can last up to 24hrs, so depending on the type of case some physicians may choose not give them.

Yes, that is the doctor's decision based on their review of your chart and the type of surgery you are having.

No

Premedication is very important in anesthesia. In the past, all patients were premedicated before arriving. I believe because of cost, this changed. But a well premedicated patient is more cooperative and have less complications.

Yes, to some degree. It also depends on patient's status and if procedure or surgery is going to be long or short and amount of stress it will inflict on the body.

Your anesthesiologist decides what premedication, if any, to give you prior
to general anesthesia for your surgery. This decision may be based on your
state of health, level of alertness, degree of disability, time of day,
concomitant use of medications (drug interactions) and other factors. Of
course, communicating your concerns, apprehensions, anxiety and nervousness
to your anesthesiologist and requesting a calming medication before surgery
are good ways to insure receiving that medication if you so desire.

Anesthesia is not cook book. It is an art form. Each physician has their own formula. So the short answer is yes Doctor preference.

Each anaesthetic is different and each doctor has a preference as well. We certainly give relaxing medication if the patient looks anxious, but also we give it to augment the effect of anesthetic drugs we use. In some cases, giving relaxing medication allows us to use less anaesthetic drugs yet get the same effect, thereby reducing the amount of drugs given to a patient.

Hi,

Giving premedication depends on circumstances, medical conditions, patient's level of anxiety and type of surgery. There are no rigid guidelines and sometimes, it depends on the provider preference.

I hope that helps.

Dr Ketch

It could be physician preference, age related contraindication, or short outpatient procedure.