Medications management perioperatively

Anticoagulants & Antiplatelets - Bleed Risk Balancing Act

• Goal: Minimize both thrombosis & bleeding. Decision hinges on patient's thromboembolic risk vs. surgery's bleeding risk.
• Warfarin: Stop 5 days pre-op. Bridge with heparin if high-risk (e.g., mechanical mitral valve, CHADS-VASc >5). Target INR < 1.5.
• DOACs (e.g., Apixaban): Stop 24-48h pre-op. No bridging needed.
• Antiplatelets:
  • Aspirin (secondary prevention): Often continued for most surgeries.
  • Clopidogrel (Plavix): Stop 5-7 days pre-op. Critical for recent coronary stents-always consult cardiology.

⭐ Neuraxial Anesthesia Warning: For patients on LMWH, wait at least 24 hours after the prophylactic dose before placing an epidural or spinal catheter to minimize spinal hematoma risk.

Cardio & BP Meds - Pump & Pipes Prep

• CONTINUE:
  • β-blockers: Prevents rebound tachycardia/ischemia. Do not start acutely pre-op.
  • Statins: Plaque stabilization benefits.
  • Clonidine/α2-agonists: Avoids rebound HTN crisis.
• HOLD Day of Surgery:
  • ACE Inhibitors / ARBs: Risk of refractory hypotension.
  • Diuretics (most): Prevents hypovolemia & electrolyte imbalance.
• BRIDGE/STOP (case-by-case):
  • Antiplatelets (Aspirin, Clopidogrel): Stop 5-7 days pre-op unless high thrombosis risk (e.g., recent stent).

⭐ Beta-blockers are the only BP med class proven to reduce perioperative cardiac events. Abrupt withdrawal can precipitate acute coronary syndromes.

Endocrine Meds - Sugar & Steroid Strategy

• Diabetes Mellitus (DM):

  • Hold most oral hypoglycemics on day of surgery.
  • Insulin: Give 50-75% of long-acting/basal dose; hold short-acting/bolus.
  • Maintain intra-operative glucose at 140-180 mg/dL, often with an insulin drip.

• Chronic Steroid Use: (e.g., >5 mg prednisone for >3 weeks)

  • Risk of HPA axis suppression; requires perioperative stress-dose steroids to prevent adrenal crisis.

⭐ Withhold Metformin for 24-48 hours pre-operatively, especially with renal dysfunction or IV contrast, to mitigate lactic acidosis risk.

CNS, Pain & Other Meds - Neuro & Nephro Notes

• Antiepileptics (AEDs): Continue dose to prevent breakthrough seizures; use IV/IM forms if NPO.
• Parkinson's Meds: Continue Levodopa/Carbidopa. Abrupt cessation risks neuroleptic malignant-like syndrome.
• Antidepressants: Generally continue SSRIs/TCAs. Stop MAOIs 2 weeks pre-op to prevent hypertensive crisis.
• NSAIDs: Stop 5-7 days before surgery due to bleeding risk from platelet inhibition.
• Diuretics: Hold on the day of surgery to avoid hypovolemia.

⭐ Lithium should be held 24-48 hours pre-op; fluid shifts can precipitate toxicity, prolonging neuromuscular blockade.

High‑Yield Points - ⚡ Biggest Takeaways

• Metformin is held on the day of surgery to prevent lactic acidosis.
• SGLT-2 inhibitors are stopped 3-4 days prior to prevent euglycemic DKA.
• ACE inhibitors/ARBs are held on the morning of surgery to avoid refractory hypotension.
• DOACs are typically stopped 24-48 hours before, based on bleeding risk.
• Warfarin is stopped 5 days pre-op; bridging with heparin may be required for high-risk patients.
• Statins and beta-blockers should be continued throughout the perioperative period.