Preoperative Guidelines for Medications Prior to Surgery

Aka: Preoperative Guidelines for Medications Prior to Surgery, Preoperative Fasting Recommendation, Nothing by Mouth Prior to Surgery Guideline, Perioperative NPO Guidelines, Perioperative Medication Guidelines, Medication Management in the Perioperative Period, Medications to Avoid Prior to Surgery

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II. Protocol: Food and Liquids

  1. Rule: 2, 4, 6, 8 rule applies to all ages
  2. Clear liquid definition
    1. Water
    2. Fruit juice without pulp (e.g. apple juice)
    3. Gatorade
    4. Pedialyte
    5. Carbonated beverage
    6. Clear tea
    7. Black coffee
    8. Not allowed as clear liquid: Milk, milk products or Alcohol
  3. No clear liquids within 2 hours of surgery
    1. Includes no water or apple juice
  4. No Breast Milk within 4 hours of surgery
  5. No solid foods within 6 hours of surgery
    1. Includes orange juice, soda, infant formula and milk
  6. No fried foods, fatty foods or meats within 8 hours of surgery
    1. These foods are associated with Delayed Gastric Emptying
  7. References
    1. (2011) Anesthesiology 114: 495–511 [PubMed]

III. Protocol: Medications to still take on morning of surgery

  1. All Cardiovascular medications
    1. See Perioperative Beta Blocker
    2. Continued medications include
      1. Antiarrythmics
      2. Clonidine
        1. Consider Clonidine patch if NPO
          1. Wallace (2006) Curr Opin Anaesthesiol 19(4):411-7 +PMID:16829723 [PubMed]
        2. However Clonidine patch requires 3 days of cross-taper with oral dosing
          1. See Clonidine for transition from oral to transdermal
          2. Clonidine patch is also considerably more expensive than tablets
    3. Exceptions - cardiovascular medications to stop
      1. See Antihypertensives below (Diuretics, ACE Inhibitors, ARBs, Calcium Channel Blockers)
  2. Anti-reflux medications (e.g. Omeprazole, Ranitidine)
  3. Seizure and anti-parkinson medications
  4. Psychiatric medications
    1. Benzodiazepines
      1. Risk of withdrawal when abruptly stopped perioperatively
      2. May reduce Anesthetic need
    2. Antipsychotics
      1. Decreased Seizure threshold
      2. Risk of Neuroleptic Malignant Syndrome
    3. Antidepressants
      1. May be continued (risk of Antidepressant Withdrawal symptoms)
  5. Bronchodilators
    1. Bring asthma Inhalers to hospital on day of surgery
  6. CPAP machine
    1. Bring to hospital on day of surgery
  7. Oral Contraceptives (unless stoped for prevention of DVT)
  8. Corticosteroids or Immunosuppressants
    1. Consider Stress Dose Steroids if on equivalent of >5 mg/day in 6 months prior to surgery
  9. Rheumatologic agents
    1. Despite case reports of infection and delayed healing risks
  10. Levothyroxine (Synthroid)
  11. HIV Medications
  12. Pain Medications
    1. Acetaminophen or Opiates
    2. Not Aspirin or NSAIDS

IV. Protocol: Medications to not take on morning of surgery

  1. Diuretics or Weight Loss Medications
  2. Potassium supplements or Vitamins
  3. 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

  1. Medications associated with bleeding risk
    1. See Perioperative Anticoagulation
    2. NSAIDs
      1. Short-acting agents: Stop 1 day before surgery
        1. Diclofenac (Voltaren)
        2. Ibuprofen (Motrin)
        3. Indomethacin (Indocin)
        4. Ketoprofen (Orudis)
      2. Mid-acting agents: Stop 3 days before surgery
        1. Diflunisal (Dolobid)
        2. Naproxen (Naprosyn)
        3. Sulindac (Clinoril)
      3. Long-acting agents: Stop 10 days before surgery
        1. Meloxicam (Mobic)
        2. Nabumetone (Relafen)
        3. Piroxicam (Feldene)
    3. COX2 Inhibitors (e.g. Celebrex)
      1. Stop at least 2 days before surgery (Nephrotoxicity Risk)
    4. Antiplatelet Agents: P2Y agents - Clopidogrel (Plavix), Brillanta (Ticagrelor), Effient (Prasugrel)
      1. See Perioperative Antiplatelet Therapy
      2. Do not stop antiplatelet agents without carefully reviewing indications and minimum duration from stenting
        1. See Antiplatelet Therapy for Vascular Disease
        2. Cardiology should be consulted before stopping P2Y agents in post-stenting patients
        3. Consider continuing Aspirin while holding the second antiplatelet agent
      3. Clopidogrel (Plavix), Brillanta (Ticagrelor)
        1. Stop at least 5 days before surgery if no contraindication to stopping
      4. Effient (Prasugrel)
        1. Stop at least 7 days before surgery if no contraindication to stopping
      5. Restart 24 hours after procedure or per surgeons discretion
    5. Aspirin
      1. Stop at least 5 days before surgery if no contraindication to stopping
      2. Consider continuing Aspirin
        1. Patients with high thrombosis risk (e.g. recent Myocardial Infarction)
        2. Minor procedures: Dental, dermatologic and Cataract surgery
        3. Consider stopping before Colonoscopy (especially if polypectomy is performed)
    6. Other antiplatelet agents
      1. Cilostazol (Pletal)
        1. Stop at least 3 days before surgery
      2. Ticlopidine (Ticlid)
        1. Stop at least 5 days before surgery
      3. Aspirin and Extended-Release Dipyridamole (Aggrenox)
        1. Stop at least 7 days before surgery
    7. Warfarin (Coumadin)
      1. Stop 5 days before surgery
      2. See Warfarin Protocol for the Perioperative Period (includes Bridging Indications)
      3. Restart 12 hours after procedure or per surgeons discretion
    8. Dabigatran (Pradaxa)
      1. Consider doubling days of cessation prior to surgeries with high risk of bleeding
      2. Creatinine Clearance >50 ml/min: Stop 2 days before surgery
      3. Creatinine Clearance <50 ml/min: Stop 5 days before surgery
      4. Restart 24 hours after surgery (72 hours after surgery if high bleeding risk)
    9. Rivaroxaban (Xarelto)
      1. Stop at least 1-2 days before procedure (longer if Chronic Kidney Disease or very high risk of bleeding)
      2. Restart 24 hours after surgery (72 hours after surgery if high bleeding risk)
  2. Thromboembolism risk
    1. Estrogen Replacement, Birth Control Pills
      1. Ideal to stop at least 1 month before surgery
      2. Weigh risk versus benefit
      3. If agent continued, consider DVT Prophylaxis measures
    2. SERMs (Tamoxifen, Raloxifene)
      1. Stop at least 1 week before procedures at high risk for Thromboembolism
      2. Tamoxifen should only be stopped on Consultation with patient's oncologist
  3. Diabetes Mellitus
    1. See Perioperative Diabetes Management (includes Insulin management)
    2. Oral Hypoglycemics
      1. Hold for NPO period as well as the AM of surgery
    3. SGLT2 Inhibitors (e.g. Jardiance)
      1. Hold for 3 days prior to surgery (risk of Ketoacidosis)
      2. Resume when oral intake returns to normal
    4. Metformin (Glucophage)
      1. Hold at least 24 hours prior to surgery (due to theoretical Lactic Acidosis risk)
  4. Antihypertensives
    1. Diuretics
    2. Consider holding Calcium Channel Blockers while NPO
    3. ACE Inhibitors and Angiotensin Receptor Blockers (hold one dose before surgery)
      1. Avoiding within 11 hours, reduces risk of immediate post-induction Hypotension
      2. Comfere (2005) Anesth Analg 100:636-44 [PubMed]
  5. Ophthamologic surgery: Cataract
    1. Notify surgeon of Flomax use in the perioperative period (due to risk of Floppy Iris Syndrome)
      1. Ophthalmologists can take preventive measures at surgery if they know of Flomax use
      2. As a long-acting medication, stopping the medication immediately before the procedure will not alter the risk
  6. Parkinsonism Agents
    1. MAO Inhibitors should be tapered off 2-3 weeks before the procedure
      1. Includes Selegiline and Rasagiline
      2. 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)
  7. Miscellaneous agents
    1. Alendronate (Fosamax)
      1. Stop at time of surgery due to instructions that are difficult to follow perioperatively (e.g. NPO)
  8. DMARDs and Biologic 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 2-4 weeks after surgery
      1. Consult with orthopedics and rheumatology regarding specific medications and patient risk factors
    3. den Broeder (2007) J Rheumatol 34(4):689-95 [PubMed]
  9. Herbal preparations
    1. Stop all Herbals and supplements at least one week before surgery
      1. Safest overall strategy due to numerous combination products
    2. Specific agents with known risk in the perioperative period
      1. Echinacea
      2. Ephedra (should be avoided in general)
      3. Garlic (discontinue at least 7 days before surgery)
      4. Gingko (discontinue at least 36 hours before surgery)
      5. Ginseng (discontinue at least 7 days before surgery)
      6. Kava (discontinue at least 24 hours before surgery)
      7. St. John's Wort (stop at least 5 days before surgery)
      8. Valerian (slowly taper off before surgery)
      9. Ang-Lee (2001) JAMA 286:208-16 [PubMed]

VI. References

  1. Danielson (2012) ICSI: Preoperative Evaluation
    1. http://bit.ly.Preop0712
  2. (2012) Anesthesiology 116:522-38 [PubMed]

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