Withold meds in periop period
Anticoagulants
Aspirin
Increased blood loss reported, but no increase in bleeding complications/mortality (non cardiac surgery)
Does not appear to increase risk of neuraxial technique
Should not be routinely stopped (except for intracranial, prostatectomy - balance bleeding vs CVS risk
In cardiac surgery
Increased blood loss but no increase in mortality
Improved saphenous vein bypass graft patency
Should give aspirin (either continue or administer within 48hrs and continue indefinitely)
Clopidogrel
Risk benefits of stopping
At least 7 days if stopping
If emergency surgery, some recommended platelet transfusion for haemorrhage that continues despite haemostatic techniques
No data to confirm that Plt tx reverses clopidogrel effect
Consider Txa
Dual antiplatelt
Asp + Clop
Increased absolute risk of major blled (cf Aspirin alone)
Warfarin
Cessation of warfarin not recommended for minor surgery
Bridging anticoag not req for
Pts on Warfarin for AF
When index event (DVT, PE) occurred over 3/12 ago
Patients with tissue valves
Pts with mechanical aortic valve in sinus rhythm, requiring non-cardiac surgery
Bridging
Cease Warfarin 5/7 prior
Commence LMWH/heparin when INR< therapeutic
Recommence post op (usually to usual preop dose) cover until therapeutic
Antihypertensives
Beta Blockers
Should be continued throughout periop period (risk rebound HTN, benefit from CVS protection
Consider in pts undergoing vascular surgery who are at high cardiac risk
ACC/AHA guidelines
POISE showed increased risk of stroke and mortality - some groups of patients may have benefited (underpowered to measure)
Should not be given if have absolute contraindications
ACEi-ARB2s
Controversial: Blunt RAAS and cause prolonged hypotension but haven't been linked to adverse CVS outcomes
Withold the morning of surgery (unless taking ACEi for heart failure, is not hypotensive and has normal renal fx
Only start post op when euvolaemic
Alpha 2 agonists
If currently on therapy, should continue (risk of rebound if withdraw)
Consider in high risk patient
Awaiting POISE II
CCBs
Little data
Appear safe and have theoretic benefit
Continue throughout periop period
Statins
Patient currently taking statins should continue therapy
Unclear dose, targets and indications
May improve endothelial function, reduce inflammation, stabilise plaque in setting of surgical stress
NNT varies with risk group 186 to 30
Oral hypoglycaemics
OHG: Omit morning dose. If long acting omit from night before
Monitoring: 2hrly BSL from when the patient is admitted (If BSL<5 give 5% Dex at 100ml/hr, If BSL>10 give novorapid)
Insulin
Usual basal Lantus and Levemir the night before
Halve morning dose of NPH, protophane
Omit prandial bolus of short acting insulin in the morning if there is no meal
Herbal meds
Echinacea - improves immune system. Potentially hepatotoxic - cease 2 weeks prior
Ephedra - CNS stimulant, weight loss. Sympathomimetic. Discontinue 24hrs before
Garlic - Treats HTN, atherosclerosis, anti platelet effect (bleed risk ) - cease 7 days prior
Ginger - antiinflammatory, antiemetic (serotinergic inhibitor - risk bleed - cease 2 weeks preop
Gingko biloba - Neuroprotective, free radical scavenger, anti-platelet, risk of bleed - discontinue 36 hours
Ginseng - mood enhancer, aphrodisiac - risk of bleeding, hypocalcaemia - discontinue 7 days prior
Kava - sedative, anxiolytic - potentiates GABA - reduces anaesthetic requirements - discontinue 24 hours preop
St Johns Wort - antidepressant - inhibits MAOI, induce p450 - serotonin crisis - discontinue 5 days preop