EXPERT
Dr. Ayman Tarabishy, MD
Physiatrist (Physical Medicine)
Dr. Ayman Tarabishy is an anesthesiologist practicing in Taylor, MI. Dr. Tarabishy ensures the safety of patients who are about to undergo surgery. Anestesiologists specialize in general anesthesia, which will (put the patient to sleep), sedation, which will calm the patient or make him or her unaware of the situation, and regional anesthesia, which just numbs a specific part of the body. As an anesthesiologist, Dr. Tarabishy also might help manage pain after an operation.
Dr. Ayman Tarabishy, MD
- Livonia, MI
- ordan University of Science and Technology
- Accepting new patients
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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 READ MORE
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]
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]
What treatment should I get for nerve root compression?
Treatment options of nerve root compression depends on the cause and the severity. Most small disc bulges burnout and resolve spontaneously with time or with some physical therapy, READ MORE
Treatment options of nerve root compression depends on the cause and the severity. Most small disc bulges burnout and resolve spontaneously with time or with some physical therapy, sometimes injections help. On the other hand, significant mechanical compression of the nerve root, especially when it involves elements other than a disc bulge like thickened ligament, bone spurs, spine bones malalignment may never get better without surgical decompression.
The standard of care for most nerve root compressions without alarming neurological deficits like marked weakness of major muscle groups, balance difficulties, or changes in bowel or bladder habits is to start with physical therapy or chiropractic care along with some anti-inflammatory medications, weight loss, back and core muscle strengthening, smoking cessation and sometimes work/lifestyle modifications as a first line. If things don’t improve, then consider injections. If things still don’t improve, then surgical consultation is necessary.
The standard of care for most nerve root compressions without alarming neurological deficits like marked weakness of major muscle groups, balance difficulties, or changes in bowel or bladder habits is to start with physical therapy or chiropractic care along with some anti-inflammatory medications, weight loss, back and core muscle strengthening, smoking cessation and sometimes work/lifestyle modifications as a first line. If things don’t improve, then consider injections. If things still don’t improve, then surgical consultation is necessary.
Pain in the back. Is it due to epidural?
There are no clinical studies that suggest that epidural injections during delivery or cesarean section causes chronic back pain. Many times pregnancy itself whether from the weight READ MORE
There are no clinical studies that suggest that epidural injections during delivery or cesarean section causes chronic back pain.
Many times pregnancy itself whether from the weight of the baby, or the hormones that relax for back and pelvic muscles, or poor posture because of the full uterus is the cause of back pain after delivery. Pregnancy hormones sometimes mask this pain while pregnant and as their levels go down after delivery the pain becomes more apparent. Especially for the caring mother that is now carrying the baby.
If the epidural injection was complicated, like many attempts were done, and some of them landed where they’re not supposed to be, it may cause some postprocedural pain, although unlikely to become chronic.
Many times pregnancy itself whether from the weight of the baby, or the hormones that relax for back and pelvic muscles, or poor posture because of the full uterus is the cause of back pain after delivery. Pregnancy hormones sometimes mask this pain while pregnant and as their levels go down after delivery the pain becomes more apparent. Especially for the caring mother that is now carrying the baby.
If the epidural injection was complicated, like many attempts were done, and some of them landed where they’re not supposed to be, it may cause some postprocedural pain, although unlikely to become chronic.
