Medications and Surgery...

 

There are more than 52 million inpatient and outpatient surgical procedures performed in the United States each year. While every effort is made by the surgeon, anesthesiologist, nursing staff and the operating room team to minimize any risks to you during and after your surgery, these efforts can be undermined by taking certain medications and or supplements which unknowingly can have a deleterious effect.

The stress of surgery to the body may also cause an unpredictable release of stimulating hormones, resulting in an elevation of your blood pressure, as well as effects on the kidneys. Surgery can lead to unpredictable GI absorption of medications. The use of narcotics for post operative pain can also affect drug absorption as well.

 

Medications that should be continued

 

Take your scheduled am dose.

  • Anti-epileptics / Anti-Seizure medications: Tegretol (Carbamazepine), Dilantin (Phenytoin) etc.
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  • Thyroid medications
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  • Mood stabilizers
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    • SSRI's (Lexapro, Paxil, Prozac, Zoloft)
      • Potential for withdrawl- should continue
      • Serotonin depletion from platelets increases risk of bleeding, especially with NSAIDS
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    • Tri-cyclic Antidepressants (Imipramine)
      • Side effects of drop in blood pressure
      • Continue meds
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    • Benzodiazepines (Valium)
      • Safe to continue
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    • Antipsychotics (Haldol)
      • Risk of hypotension and extra-pyramidal actions
      • Safe to continue
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    • MAO inhibitors (Tx of anxiety, depression, Parkinson's and Alzheimers)
      • Ensure that your anesthesiologist is aware that you are taking these medications
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  • Diabetic medications
    • General reduction of insulin dose in the evening prior to surgery and decreased or omitted dose in the morning of surgery
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    • Metformin (peaks in 2-3 hours, half life of 6 hours and duration of 12-18 hours)
      • Discontinue for 48 hours prior to surgery
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    • NPH
      • 2/3 of evening/ bedtime dose and 2/3 of evening regular dose
      • Morning of surgery- half of NPH- hold all regular insulin

 

Herbal / Dietary supplements

 

Used by more than 40% of the population, though often thought of as natural and harmless.

 

Stop at least 7 days prior due to uncertainty of their contents

  • Echinacea - if used for > 8 weeks, can actually be immunosuppressive (infection and delayed wound healing) as well as liver toxicity
  • Ephedra - can elevate blood pressure and cause irregular heart rhythms
  • Garlic - increased bleeding risk
  • Ginko - increased bleeding risk
  • Ginseng - increased bleeding risk. Lowers after meal blood glucose
  • St. John's Wart - decreases metabolism of medications
  • Kava, Valerian - potentiates sedative effects of medications

 

Stop for 2-3 weeks prior to surgery- all can increase risk of bleeding

  • Fish oil
  • Glucosamine
  • Saw Palmetto
  • Chondroitin
  • Milk thistle

 

Common over the counter medications

 

  • Non Steroidal Anti-Inflammatory drugs: NSAID's (Ibuprofen)
    • Risk of bleeding and kidney damage
    • Stop at least 3 days prior to surgery (platelet function returns to normal in 24 hours)
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  • Aspirin
    • Risk of bleeding
    • Hold for at least 1 week prior to surgery
    • Should not be stopped for patients who have cardiac stents placed
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  • Acetaminophen (Tylenol)
    • No need to stop this medication

 

Prescription medications and surgery

 

  • Phenterimine (adipex-P) fat absorption blocker/ weight loss aid
    • Need to stop at least 14 days prior to surgery. Uncontrollable hypo or hypertension unresponsive to normal measure
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  • Hormone therapy
    • Consider stopping 4 weeks prior to major surgery IF you have a history of a blood clot
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  • Evista
    • Should be stopped 1 week prior to surgery for risk of DVT

 

Blood pressure medications/ Anti-hypertensives

 

  • Water pills /Diuretics (lasix, thiazide)
    • Hold on the day of surgery because potential for dehydration and electrolyte depletion
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  • Angiotensin Receptor blockers (Avapro, Benicar, Corgard, Diovan)
    • If become hypotensive, they are less responsive to vasopressors
    • Long half life- therefore hold for 24 hours prior to surgery
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  • ACE inhibitors- (Accupril/ quinapril, Captopril, Lotensin/ Benazapril)
    • Stop your medication on the morning of your surgery (if the only indication is for hypertension). If you also have congestive heart failure or you are also a diabetic- consult your physician before stopping the morning dose.
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  • Calcium Channel Blockers (Adalat/ Nifedipine, Cardizem)
    • Continue meds unless severe left ventricular dysfunction
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  • Beta Blockers (Atenolol, Bystolic, Inderal/propranolol, Lopressor/ metoprolol
    • Continue meds, especially for positive stress test or high risk of cardiac problems
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  • Alpha 2 agonist (Clonidine)
    • Continue in the peri-operative period to avoid severe withdrawal reactions
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  • Digoxin
    • Tx of CHF and atrial tachy-arrythmias
    • Continue medication
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  • High cholesterol medications- Statins
    • Hold your morning dose but it should be continued in the perioperative period
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Antiplatelet medications

All need to be stopped to limit risk of bleeding.

  • Clopidogrel- (Plavix) stop for 5 to 7 days
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  • Ticlipodine- (Ticlid) stop for 14 days prior to surgery
    • For patients with established atherosclerotic disease
    • Shown to increase postoperative bleeding
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  • Coumadin (Warfarin) held for 4 5 days and PT/ INR checked on day of surgery (PTT 1.5 2 x upper normal)
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  • Lovenox (enoxaparin) held for 24 hours if taking treatment dose, and 12 hours for "prophylactic dose" 1 mg/Kg q 12 hours or 1.5 mg/ Kg/D- bridge with warfarin
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  • (Pletal) Cilostazol should be held for 7 days prior to surgery
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  • (Effient) Prasugrel should be held for 10 days prior to surgery

 

Anti-coagulation medications

 

  • Coumadin (warfarin)
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    • Intermediate risk thrombo-embolism- GYN surgery
      • Stop warfarin 4 -5 days prior to surgery
      • Consider LMWH 2-3 days prior to surgery or no bridging
      • Start Heparin and LMWH after surgery
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    • High risk thromboembolism
      • Bridge protocol
      • Await hemostasis before restarting LMWH
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    • Patients with Drug Eluting Stents
      • 12 months of dual antiplatelet therapy and postpone elective surgery for 1 year
      • No peri-operative modification of anti-platelet regimen
      • No discontinuation of low dose aspirin (<300 mg/D)
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  • Corticosteroids
    • As little as 5 mg/d of prednisone for more than 5 days can cause HPA hormonal axis suppression