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Chapter 9. Management of Chronic Medications in the Perioperative Period

Yakub Abrakhimov, MD

Of note, this chapter does not include the perioperative management of anticoagulants, antiplatelets, glucocorticoids, and anticonvulsants, which are treated in separate chapters.

  • Understand pathophysiology of patient’s various comorbidities and deduce if discontinuation of a particular drug would lead to disease progression
  • Consider the possibility of withdrawal with an abrupt cessation of a particular drug
  • Consider possible drug–drug interactions perioperatively
  • Understand anticipated type of surgery, anesthesia, as well as the postoperative course

See Table 9-1.

Table 9-1 Perioperative Management of Cardiovascular Agents
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Table 9-1 Perioperative Management of Cardiovascular Agents
MedicationTwo days prior to surgeryOne day prior to surgeryMorning of surgeryPerioperative considerations
Beta-blockersYes (do not stop)Yes (do not stop)Yes (do not stop)
  • Abrupt cessation may lead to hypertension, tachycardia, and myocardial ischemia
  • If needed (and enough time), adjust dose for HR 60–70 without hypotension
  • Shown to decrease perioperative risk of myocardial ischemia in patients with cardiac disease. Perioperative initiation not recommended (because of possible increased risk of CVA and mortality)
  • Can bridge patient to IV forms
Calcium channel blockersYesYesYes
  • Stop if patient hypotensive
  • Abrupt cessation will not result in withdrawal effects
  • Can bridge patient to IV forms
Angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEI/ARB)YesYes
  • Yes, if used to treat hypertension
  • No, if used for other indications
  • Continuation may lead to hypotension perioperatively
  • Abrupt cessation may lead to rebound postoperative hypertension
  • Intraoperative use of IV angiotensin to treat refractory hypotension has been reported
  • No clear evidence of adverse effects of continuation; it might be less confusing for patients to take all HTN medications; however, this is controversial
Alpha-blockersYesYesYes
  • Known to cause orthostatic hypotension and dizziness
ClonidineYesYesYes
  • Abrupt cessation may lead to severe rebound hypertension
  • If patient is anticipated to restart PO clonidine within 12 h of preoperative dose, then clonidine should be continued up to and including day of surgery
  • If patient will be unable to restart PO dose within 12 h of preoperative dose, then he or she should be bridged to patch form of clonidine 3 days prior to surgery
  • PO dose should be tapered while patch form is initiated
DiureticsYesYesNo
  • Continuation may lead to hypovolemia and electrolyte disturbances
StatinsYesYesYes
  • In combination with perioperative risk of muscle injury, may contribute to development of myopathy
  • Perioperative use as cardioprotective agent still under investigation
  • Administer postoperatively by NGT if unable to swallow
Non-statin cholesterol lowering agentsYesNoNo
  • Cholestyramine/colestipol binds bile acids in GI tract and hinders absorption of various medications
  • Niacin/folic acid may lead to myopathy and rhabdomyolysis
NitratesYesYesYes
  • Transdermal forms may have decreased efficacy if skin perfusion is compromised
DigoxinYesYesYes
  • Perioperative physiologic changes such as change in pH, hypoxia, electrolyte disturbances and use of other drugs may lead ...

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