Preparing for Surgery & Procedure

Recommendation for Preop Medication Management

The follow medications SHOULD BE CONTINUED up to and including the day of surgery. (Instruct patient to take with a small sip of water)

1. Alzheimer’s medications
2. Anti-anxiety and psychiatric medications
3. Anti-depressants except MAO-inhibitors (See below)
4. Anti-hypertensive medication (anything ending in –olol).
5. 4A. Other anti-hypertensive medications and Cardiac medications (Hydralazine, nitrates, calcium channel blockers, digoxin, alpha antagonists)
6. Anti- seizure medications
7. Anti-viral and retroviral agents
8. Asthma medications (inhalers and nebulizers please USE on the morning prior to arrival)
9. Birth control pills
10. COX-2 inhibitors (check with surgeon if there is concern about new bone growth/healing)
11. Cardiac medications – See Other Anti-hypertensive Agents and Cardiac Medications above
12. Eye drops
13. Heartburn or anti-reflux medications
14. Immunosuppressants (eg Azathioprine, Cyclosporine, Rapamune, Methotrexate, Remicade, Humira, Enbrel)- do not stop any immunosuppressant medication without speaking with the prescribing physician. Patients with organ transplants should be continued on imunosuppresants.
15. Opioids (eg morphine, oxycodone or oxycontin, fentanyl patch)
16. Statins (e.g simvastatin, rosuvastatin)
17. Steroids (oral and inhaled)
18. Thyroid medications

The following medications should be DISCONTINUED prior to surgery:

1. ACE inhibitors (angiotensin converting enzyme inhibitors, anything ending in –pril)- hold on day of surgery.
2. ARBs (angiotensin II receptor blockers.anything ending in –artan) – hold on day of surgery
3. Antiplatelet agents (Plavix, clopidrogel, ticlopidine, Ticlid, prasugrel, Effient, ticagrelor, Brilinta. –please refer to FMLA Algorithm for Management of Perioperative Antiplatelet Therapy. Discuss with prescribing physician.
4. Biphosphonates – hold on day of surgery
5. Coumadin – if normal coagulation is required, discontinue 5 days before surgery- will need to check PT and INR preop. Discuss with prescribing physician and consider bridging therapy.
6. Dabigatran- Length to hold depends on renal function and risk of bleeding. Discontinue PRADAXA 1 to 2 days (CrCl >/=50mL/min) or 3 to 5 days (CrCl < 50mL/min). Consider longer times for patients undergoing major surgery, spinal puncture, or placement of spinal or epidural catheter. Discuss with prescribing physician and consider bridging therapy.
7. Diuretics- hold on day of surgery
8. Heparin –patients receiving either UFH or LMWH should have their doses held for 12 hours preop if taking prophylactic dosing and 24 hours if taking therapeutic dosing.
9. Herbal supplements and Vitamin E-containing multivitamins – discontinue 7 days prior to surgery
10. Insulin –please refer to FMLH protocol for insulin management (see below). Order finger stick on arrival on day of surgery.

    Patient with insulin pump should continue their basal rate ONLY.
    FMLH protocol for pre-procedure insulin management:

    1. Hold short acting insulin (eg Humalog, Novolog, Regular)
    2. NPH: give half of usual dose
    3. Pre-mixed insulin (eg Humulin or Novolog mix 70/30) give 1/3 of usual dose
    4. Insulin Glargine (Lantus): give usual dose
    5. Insulin Detemir (Levemir): give usual dose
11. Iron – Hold on day of surgery
12. MAO inhibitors – Patient may need special instructions- consider Anesthesiology Consultation preop
13. NSAIDS – discontinue 7 days before surgery
14. Oral diabetic agents – hold on day of surgery
15. Premarin – hold on day of surgery
16. Rivaroxaban – hold min 24 hours prior to surgery. Discuss with prescribing physician and consider bridging therapy
17. Direct Renin inhibitor (Aliskiren /Tekturna) – hold o day of surgery

Viagra or similar drugs- hold 24 hours preop

SPECIAL SITUATIONS – ASPIRIN:

Aspirin: Patients with cardiac stents or balloon angioplasty should continue aspirin throughout surgical period, with the exception of intracranial neurosurgeries and special exceptions requested by the attending surgeon.

Delay elective or non-urgent surgery for at least 90 days for bare metal stents and at least 180 days for drug-eluding stents. Patients with cardiac stents (bare metal and drug-eluding stents) should hold plavix for 7 days (or Prasugrel -7d, Ticagrelor – 5d) and proceed to OR with continued aspirin. Restart Plavix (clopidogrel) as soon as possible postop.

This is a summary of the June 2012 update by Ellinas, Lauer, Manley, Woehlck of the adapted article from JACC Vol 50, No 17, 2007, Slawski, Cinquegrani, Kersten, Marks, Pfeifer

Preparing for Procedure

If you are having Day Surgery, remember the following:

• Have someone available to take you home, you will not be able to drive for at least 24 hours
• Do not drink or eat anything in the car on the trip home
• The combination of anesthesia, food, and car motion can quite often cause nausea or vomiting. After arriving home, wait until you are hungry before trying to eat. Begin with a light meal and try to avoid greasy food for the first 24 hours
• If you had surgery on an extremity (leg, knee, hand or elbow), keep that extremity elevated and use ice as directed. This will help decrease swelling and pain
• Take your pain medicine as directed. Begin the pain medicine as you start getting uncomfortable, but before you are in severe pain. If you wait to take your pain medication until the pain is severe, you will have more difficulty in controlling the pain