Microsoft word - pph preoperative medication procedure 2010-02-10.doc

Lucidoc Form #36332, revision 0, 2/10/2010 Also found at http://www.pph.org/media/file/Pharmacy/PreopMeds(2).pdf See also Lucidoc Procedure #15076 – “Preoperative Patient Screening for Pre-Admission” for details on how this form will be used. Adapted from UpToDate.com topic on “Perioperative Medication Management”1 and other sources2,3,4,5,6 MEDICATION
CLINICAL CONCERN
DAY BEFORE SURGERY
MORNING OF SURGERY
APPLIES TO
CARDIOVASCULAR MEDICATIONS
Quality indicator: patients on a beta-blocker at home must take a dose within 24 hours pre-op or post-op. Do not take.7,8
Can cause hypovolemia Take regularly scheduled doses. Do not take.
Hyperkalemia if diuretic Do not take if K+-wasting diuretic held Do not take if K+-wasting
torsemide, budesonide, chlorthalidone, indapamide, ethacrynate). Interoperative floppy iris Ophthalmic surgery: Surgeon should be notified. Holding drug
Other surgery: Take regularly scheduled doses through morning of
ANTIHYPERLIPIDEMIC
MEDICATIONS
Statins, ezetemibe
Do not take.
Do not take.
Do not take.
Do not take.
ENDOCRINE AGENTS
Do not take.
Lucidoc Form #36332, revision 0, 2/10/2010 MEDICATION
CLINICAL CONCERN
DAY BEFORE SURGERY
MORNING OF SURGERY
APPLIES TO
Do not take.
Take ½ of AM dose
PAIN MEDICATIONS
abdominal cramps, nausea, vomiting, diarrhea, insomnia, anxiety and salivation. Do not take.
Lucidoc Form #36332, revision 0, 2/10/2010 MEDICATION
CLINICAL CONCERN
DAY BEFORE SURGERY
MORNING OF SURGERY
APPLIES TO
Hold for at least 3 half lives prior to surgery.12,13
Surgeon may allow NSAID use up through morning of surgery. If surgeon has not advised the patient to continue taking the medication, then proceed to the following: If surgery is planned to take place before the minimum time to hold, the surgeon should be notified and the patient should be If patient reports that holding the medication will be problematic, the surgeon should be called for alternative pain management. Alternatives include either a short acting NSAID (e.g. ibuprofen) or an NSAID with limited to no platelet activity (see first column on Brand name
Half-life Hold for at least
NEUROLOGIC MEDICATIONS
Lucidoc Form #36332, revision 0, 2/10/2010 MEDICATION
CLINICAL CONCERN
DAY BEFORE SURGERY
MORNING OF SURGERY
APPLIES TO
doses. Close monitoring of
volume and electrolyte
status.
Preop BMP required within
30 days.
Can cause arrhythmias, Take regularly scheduled doses. Do not take.
Can cause arrhythmias, Take AM dose, but not evening dose Do not take.
Monamine Oxidase Inhibitors (MAOI’s) Drug interactions with Take through morning of surgery. Anesthesiologist must be
anesthesia medications informed of the need to use MAOI safe anesthesia or to
discontinue the medication for 2 weeks prior to surgery. MAOI safe anesthesia = avoid ephedrine, meperidine, and
dextromethorphan. Phenylephrine is OK.
Selegeline (Eldepryl oral or Emsam patch) Preadmission RN to leave note on
chart to remind surgeon to resume
ASAP post-op and consult
neurologist if oral doses will not be Parenteral substitutions are
feasible post-op.
available. For IM substitution give 1/10th the usual oral dose and for IV substitution give 1/30th the usual dose. RHEUMATOLOGIC AGENTS
Probenecid interacts with Take regularly scheduled doses. Do not take.
Do not take.
Do not take on day before surgery.
Do not take.
stroke, hemodynamic instability, and drug-drug interactions with some psychiatric medications Lucidoc Form #36332, revision 0, 2/10/2010 MEDICATION
CLINICAL CONCERN
DAY BEFORE SURGERY
MORNING OF SURGERY
APPLIES TO
sedation and potentiation Do not take on day before surgery.
Do not take.
medications, and its use is associated with concerns about withdrawal, tolerance, and addiction Interoperative floppy iris Ophthalmic surgery: Surgeon should be notified.
Other surgery: Take regularly scheduled doses through day before
MEDICATION
CLINICAL
BEFORE SURGERY
APPLIES TO
ANTIPLATELETS
Surgeon must decide.
PPH guidelines available below. “Platelet function aspirin” test available. Platelet function should be normal 72 hours after last dose. Prescriber and surgeon should collaborate to decide whether to give or hold.
Aspirin: “Platelet function aspirin” test available. Platelet function should be normal 72 Dipyridamole: Should wear off by about 36-48 hours after last dose. “Platelet function epinephrine” test may be useful if there is a need to ensure normal platelet function. Bleeding16,17,18 Surgeon must decide. Probably mild bleeding potential. Consider stopping for 48h
preop. “Platelet function epinephrine” test may be useful if there is a need to ensure normal platelet function. Prescriber and surgeon should collaborate to decide whether to give or hold.
PPH guidelines are available below. If drug held, guidelines recommend holding for 5-10 days. Full platelet recovery will occur in 3 days for 50% of patients, and in 5 days for 80% Interventional radiology.
of patients. Full recovery will take longer than 5 days in 20% of patients.
P2Y12 platelet testing is advised if there is a need to ensure normal platelet function.
Surgeon must decide.
Should wear off by about 36 hours after last dose. “Platelet function epinephrine” test may be useful if there is a need to ensure normal platelet function. Prescriber and surgeon should collaborate to decide whether to give or hold.
PPH guidelines are available below for clopidogrel, but ticlopidine has a much longer half- life. Full recovery of platelets may take 11-13 days on average. P2Y12 platelet testing is advised if there is a need to ensure normal platelet function. Prescriber and surgeon should collaborate to decide whether to give or hold.
PPH guidelines are available below. Prasugrel has the same recommendations as CLOP. Endoscopy,
If drug held, guidelines recommend holding for 5-10 days. Full platelet recovery may occur Interventional radiology.
in as early as 3-5 days for some patients, but may take longer than 5 days in other patients.
P2Y12 platelet testing is advised if there is a need to ensure normal platelet function.
Lucidoc Form #36332, revision 0, 2/10/2010 Lucidoc Form #36332, revision 0, 2/10/2010 MEDICATION
CLINICAL CONCERN
BEFORE SURGERY
APPLIES TO
ANTICOAGULANTS
Prescriber and surgeon should collaborate to decide whether to Endo, I.R & All surgeries
give or hold.
Surgeon must advise patient on when last dose should be
administered.
PPH recommends 12-24h, depending on renal function. Surgeon must advise patient on when last dose should be
administered.
PPH recommends 24-48h, depending on renal function. Lucidoc Form #36332, revision 0, 2/10/2010 MEDICATION
CLINICAL CONCERN
BEFORE SURGERY
APPLIES TO
ESTROGEN / PROGESTERONE
Surgeon must decide. PPH Guidelines:
Procedures with low risk of VTE: Take regularly scheduled doses.
Procedures with moderate to high risk of VTE. Consider holding for
4-6 weeks prior to surgery and for two weeks after regaining full
mobility.
Selective estrogen receptor modulator Increased risk of VTE. When used for PREVENTION of cancer or treatment of osteoporosis Inpatient surgery
Surgeon must decide. PPH Guidelines:
Procedures with low risk of VTE: Take regularly scheduled doses. Procedures with moderate to high risk of VTE. Consider
holding for 4-6 weeks prior to surgery and for two weeks after
regaining full mobility.
When used for TREATMENT of cancer prescriber and surgeon
should collaborate to decide whether to give or hold.
Lucidoc Form #36332, revision 0, 2/10/2010 MEDICATION
CLINICAL CONCERN
BEFORE SURGERY
APPLIES TO
Spinal or neurosurgical procedures: Surgeon must decide. PPH Spinal or neurosurgical
Guidelines are to consider discontinuing therapy 3 weeks prior to Other procedures: Take through morning of procedure Bleeding risk from SSRIs1
SSRIs can decrease intraplatelet serotonin concentrations and this may affect platelet aggregation [23]. Anecdotal reports have indicated a relationship between SSRI use and mostly minor bleeding complications, including easy bruising, petechiae and purpura, epistaxis and hematomas [24,25]. Studies have also suggested that selective serotonin reuptake inhibitors (SSRIs) are associated with an increased risk of upper gastrointestinal (UGI) bleeding, particularly in patients taking NSAIDs. This association was illustrated in two case control trials in which the risk of UGI bleeding was increased among patients who used SSRIs compared to those without exposure to these drugs (OR 3.0 and 1.6, for the two studies) [26,27]. The risk was substantially increased in those concurrently taking NSAIDS with SSRIs (OR 15.6 and 4.8), suggesting a potential synergistic effect. Acid suppressing medications may limit the increased risk [27] (See "NSAIDs (including aspirin): Pathogenesis of gastroduodenal toxicity"). A case control study of patients hospitalized for major bleeding while taking coumarin found that the risk for nongastrointestinal bleeding was significantly greater in people taking an SSRI (OR 1.7, 95% CI1.1-2.5), but that the risk for gastrointestinal bleeding was not increased [28]. Data on the intensity of anticoagulation was not available for this study, but it would be reasonable to use extra care in monitoring patients who are concurrently treated with an SSRI and an anticoagulant, SSRIs may also increase the need for transfusions with surgery. A retrospective study of 520 patients undergoing orthopedic surgery found that the risk for transfusion was increased in patients on serotonergic antidepressants (most of which were SSRIs) (OR 3.71, 95% CI 1.35-10.18) but not in patients on nonserotonergic antidepressants (OR 0.74, 95% CI 0.10-5.95) [29]. REFERENCES FOR SSRI BLEEDING RISK: 37. Li, N, Wallen, NH, Ladjevardi, M, Hjemdahl, P. Effects of serotonin on platelet activation in whole blood. Blood Coagul Fibrinolysis 1997; 8:517. 38. Serebruany, VL. Selective serotonin reuptake inhibitors and increased bleeding risk: are we missing something?. Am J Med 2006; 119:113. 39. Krasowska, D, Szymanek, M, Schwartz, RA, Myslinski, W. Cutaneous effects of the most commonly used antidepressant medication, the selective serotonin reuptake inhibitors. J Am Acad 40. de Abajo, FJ, Garcia Rodriguez, LA, Montero, D. Association between selective serotonin reuptake inhibitors and upper gastrointestinal bleeding: Population-based case-control study. BMJ 41. de Abajo, FJ, Garcia-Rodriguez, LA. Risk of upper gastrointestinal tract bleeding associated with selective serotonin reuptake inhibitors and venlafaxine therapy: interaction with nonsteroidal anti-inflammatory drugs and effect of acid-suppressing agents. Arch Gen Psychiatry 2008; 65:795. 42. Schalekamp, T, Klungel, OH, Souverein, PC, de Boer, A. Increased bleeding risk with concurrent use of selective serotonin reuptake inhibitors and coumarins. Arch Intern Med 2008; 168:180. 43. Movig, KL, Janssen, MW, de Waal, Malefijt J, et al. Relationship of serotonergic antidepressants and need for blood transfusion in orthopedic surgical patients. Arch Intern Med 2003; 163:2354. Lucidoc Form #36332, revision 0, 2/10/2010 Cardiac Cath Lab is not included within the scope of this procedure.
REFERENCES:
1 Muluk V, Macpherson DS. Perioperative Medication Management. UpToDate.com (v17.2) – last updated May 28, 2009 (accessed 10/8/2009)
2 Kuwajerwala NK, Reddy RC, Kanthimathinathan VS, Siddiqui RA. Perioperative Medication Management. Emedicine.medscape.com updated Aug 19, 2008 (accessed 7/24/2009)
3 Douketis JD, Berger PB, Dunn AS, Jaffer AK, Spyropoulos AC, Becker RC, Ansell J; American College of Chest Physicians. The perioperative management of antithrombotic therapy: American College
of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008 Jun;133(6 Suppl):299S-339S. 4 Saber W. Perioperative medication management: a case-based review of general principles. Cleve Clin J Med. 2006 Mar;73 Suppl 1:S82-7. 5 Schwartz A. Should I continue or discontinue that medication? AANA J. 2009 Jun;77(3):170. 6 Howe CR, Gardner GC, Kadel NJ. Perioperative medication management for the patient with rheumatoid arthritis. J Am Acad Orthop Surg. 2006 Sep;14(9):544-51. 7 Schirmer U, Schürmann W. Preoperative administration of angiotensin-converting enzyme inhibitors. Anaesthesist. 2007 Jun;56(6):557-61. 8 Comfere T, Sprung J, Kumar MM, et al. Angiotensin system inhibitors in a general surgical population. Anesth Analg. 2005 Mar;100(3):636-44. 9 Chang DF, Braga-Mele R, Mamalis N, Masket S, Miller KM, Nichamin LD, Packard RB, Packer M; ASCRS Cataract Clinical Committee. ASCRS White Paper: clinical review of intraoperative floppy-iris syndrome. J Cataract Refract Surg. 2008 Dec;34(12):2153-62. 10 Issa SA, Hadid OH, Baylis O, Dayan M. Alpha antagonists and intraoperative floppy iris syndrome: A spectrum. Clin Ophthalmol. 2008 Dec;2(4):735-41. 11 Neff KD, Sandoval HP, Fernández de Castro LE, Nowacki AS, Vroman DT, Solomon KD. Factors associated with intraoperative floppy iris syndrome. Ophthalmology. 2009 Apr;116(4):658-63. 12 Hong Y, Gengo FM, Rainka MM, Bates VE, Mager DE. Population pharmacodynamic modelling of aspirin- and Ibuprofen-induced inhibition of platelet aggregation in healthy subjects. Clin Pharmacokinet. 2008;47(2):129-37. 13 Gengo FM, Rubin L, Robson M, et al. Clinical Consequences in Stroke Prophylaxis Effects of Ibuprofen on the Magnitude and Duration of Aspirin's Inhibition of Platelet Aggregation. J. Clin. Pharmacol. 2008; 48; 117 14 Beckert BW, Concannon MJ, Henry SL, Smith DS, Puckett CL. The effect of herbal medicines on platelet function: an in vivo experiment and review of the literature. Plast Reconstr Surg. 2007 Dec;120(7):2044-50 15 Scharbert G, Kalb ML, Duris M, Marschalek C, Kozek-Langenecker SA. Garlic at dietary doses does not impair platelet function. Anesth Analg. 2007 Nov;105(5):1214-8 16 Yasunaga K, Mase K. Antiaggregatory effect of oral cilostazol and recovery of platelet aggregability in patients with cerebrovascular disease. Arzneimittelforschung. 1985;35(7A):1189-92. 17 Kaneda T, Urimoto G, Suzuki T. Spinal epidural hematoma following epidural catheter removal during antiplatelet therapy with cilostazol. J Anesth. 2008;22(3):290-3. 18 Kasanuki H. Guidelines for management of anticoagulant and antiplatelet therapy in cardiovascular disease (JCS2004). Circ J. 2004;68(Suppl IV):1221–1230.

Source: http://www.palomarhealth.org/media/File/Pharmacy/PreopMeds(2).pdf