perioperative medication management

Perioperative Medication Management

Perioperative Medication Management

Moises Auron MD, FAAP, FACPMoises Auron MD, FAAP, FACP

Staff, Department of Hospital MedicineStaff, Department of Hospital Medicine

DisclaimerDisclaimer

• None

ObjectivesObjectives

• Reviews the general principles to determine continuation or discontinuation of medications in the perioperative setting.

• Discuss evidence and controversies around perioperative medication management.

• Outline a practical guide for perioperative medication management.

• Will discuss the most commonly used medications as well as the ones with increased controversy.

JustificationJustification

• Steady increase in surgical complexity- Increased elderly population

• Lack of formal training in perioperative medicine• Involuntarily stopping of initiating new medications• Federal requirement (Joint Commission on

Accreditation of Healthcare Organizations - JCAHO) - #3: Increase safety in medication management- #8: Medication reconciliation – precise and complete

http://www.jointcommission.org/patientsafety/nationalpatientsafetygoals

http://www.jointcommission.org/

Evidence of recommendationsEvidence of recommendations

• There are no randomized studies• Expert consensus• Pharmacology knowledge

- Pharmacokinetics- Therapeutic effect - Interaction with anesthetic agents

• Theoretical considerations (MVI)• Case reports

Whinney C. CCJM. Nov 2009; 76(Suppl 4): S126-S132.

Perioperative ConsultPerioperative Consult

• Complete H/P- Understand perioperative risk

• Pharmacologic history:- Prescription drugs- OTC- Multivitamins - Nutritional supplements/herbs- Alcohol; tobacco; drugs

Clay BJ. J Hosp Med. 2008 Nov-Dec;3(6):465-72.

General PrinciplesGeneral Principles

• Stress response to surgery and hemodynamic consequences of anesthesia:

- ↑ sympathetic tone

- ↑ vasopressin

- ↑ cortisol

- ↑ RAAS

- ↑ local vasodilatory prostaglandins

• ↓ GI absorption

- Changes in splacnic blood flow

- Transmural intestinal edema

- Villous atrophy

- Hypomotility

• Ileus, opioids, anticholinergic agents, electrolyte disturbances


Pass SE. Am J Health Syst Pharm. 2004 May 1;61(9):899-912.


• Discontinuation - Rebound effects- Withdrawal- Worsening intraoperative

clinical status

• Continuation- Hemorrhage- Hypoglycemia- Interaction with anesthetics- Postoperative complications

• O.R. 2.7 (95% CI, 1.76–4.04)

Pass SE. Am J Health Syst Pharm. 2004 May 1;61(9):899-912.

Kennedy JM. Br J Clin Pharmacol. 2000 Apr;49(4):353-62.


• Abrupt discontinuation can cause withdrawal:

- SSRI

- Beta-blockers

- Clonidine

- Benzodiazepines

- Statins

- Corticosteroids.

Papadopoulos S. Orthopedics 2006; 29:413-17.

Marik PE. Arch Surg. 2008;143(12):1222-1226.


Arch Intern Med. 2006;166:2525-2531.


• Continue medications with rebound or withdrawal potential

• Discontinue:

- Increase surgical risk

- Non-essential for quality of life

• Use clinical reasoning



Geriatric patientGeriatric patient

Muravchick S. Anesthesiol Clin NA. 2000;18:74

Singh A. Current Opinion in Anaesthesiology 2010; 23:449–454

↓ Vascular distensibility

Ventricular hypertrophy

↑ preload sensitivity+

↓ baroreflexes ↓ response to hypovolemia

↓ FEV1

↓ closing capacity

Physiologic shunt

+AtelectasisHypoxemiaPneumonia


Rivera R. Anesthesiology 2009; 110:1176–81.


Morbid obese patientsMorbid obese patients

↑ cardiac output

↑ lean body weight

↑ adipose mass

↑ extracellular volume

Lemmens HJM. Current Opinion in Anaesthesiology 2010, 23:485–491.Janmahasatian S, Clin Pharmacokinet 2005; 44:1051–1065.

Lemmens HJM. Current Opinion in Anaesthesiology 2010, 23:485–491.Janmahasatian S, Clin Pharmacokinet 2005; 44:1051–1065.

Morbid obese patientsMorbid obese patients

Evidence of recommendationsEvidence of recommendations

• There are no randomized studies• Expert consensus• Pharmacology knowledge

- Pharmacokinetics- Therapeutic effect - Interaction with anesthetic agents

• Theoretical considerations (MVI)• Case reports


• Continue medications with rebound or withdrawal potential

• Discontinue:

- Increase surgical risk

- Non-essential for quality of life

• Use clinical reasoning



Case 1Case 175 y/o man with renal mass. PMH HTN, CAD s/p BMS 3 mo ago. On Atenolol 25 mg/d; Clopidogrel 70 mg/d and ASA 81 mg/d.Scheduled for robotic heminephrectomy. What is your recommendation for perioperative management of antiplatelets?

a) Continue clopidogrel and ASAb) Hold both clopidogrel and ASA on day of surgery c) Stop clopidogrel 5 days before surgery and continue ASAd) Stop both clopidogrel and ASA 7 days before surgerye) Stop ASA 7 days before surgery and continue clopidogrel

ASAASA

• Irreversible cyclooxygenase (COX) inhibition• 7-10 days for platelet regeneration• Perioperative use associated with ↓ CV morbidity• Stop for > 5 days ↑ stroke and ACS risk• Decision of continue vs. hold related to

hemorrhagic risk vs. perioperative CV morbidity.- E.g. Neurosurgery; prostate; etc. - Resume 24h after surgery (ACCP 2008)

Oscarsson A. Br J Anaesth. 2010 Mar;104(3):305-12.

O’Riordan JM. Arch Surg. 2009;144(1):69-76.

2008 ACCP Guidelines on Antithrombotic Therapy. Chest. 2008 Jun;133(6 Suppl):299S-339S.

Coronary StentsCoronary Stents

2007 ACC/AHA Perioperative Task Force. Circulation. 2009;120:e169-e276.2008 ACCP Guidelines on Antithrombotic Therapy. Chest. 2008 Jun;133(6 Suppl):299S-339S.

Other antiplateletsOther antiplatelets

• Thienopyridines - irreversible inhibition of ADP-induced platelet aggregation

• Discontinue:- Clopidogrel – 5 days - Prasugrel – 7 days- Ticlopidine – 10-14 days

• Resume ASAP.• Continue ASA in patients with stents• Unclear data on perioperative safety of dipyridamole

Cohn S. Perioperative Medicine. Mc Graw Hill. 2007. Pp 36-49. Jaffer A. CCJM. 2009; 76(Suppl 4): S37-S44.

NSAIDSNSAIDS• Reversible inhibition of COX-1 ↓ TXA2 ↓ platelet

adhesion- Nephrotoxicity- ↑ bleeding risk x 1.5-2

• COX-2 (celecoxib) – minimal effect of platelet fx- Nephrotoxicity- Adverse cardiovascular effects- ↓ postoperative opioid requirements

• Non-acetylated NSAIDS (salsalate) –no antiplatelet effect

Straube S. Acta Anaesthesiol Scand. 2005;49:601-613.O’Riordan JM. Arch Surg. 2009;144(1):69-76.

• Suggest to hold them pre-operatively due to both nephrotoxicity and GI bleeding risk.

• Antiplatelet effect depends on its half life

- Platelet function analysis (PFA-100) –in-vitro normalization 24h after stopping ibuprofen.

• Discontinue 3 days before surgery

- Ibuprofen can be used up to 24h before

Goldenberg NA. Ann Intern Med 2005 Apr 5;142(7):506-9.

NSAIDSNSAIDS

2008 ACCP Guidelines2008 ACCP Guidelines

2008 ACCP Guidelines on Antithrombotic Therapy. Chest. 2008 Jun;133(6 Suppl):299S-339S.Jaffer A. CCJM. 2009; 76(Suppl 4): S37-S44.

CHADS2 ScoreCHADS2 Score

Snow V. Ann Intern Med 2003; 139:1009–1017.Jaffer A. CCJM. 2009; 76(Suppl 4): S37-S44.

• Bridging to LMWH or UH:

- Moderate-high thromboembolic risk

• Prophylactic dose of LMWH:

- Low thromboembolic risk

2008 ACCP Guidelines on Antithrombotic Therapy. Chest. 2008 Jun;133(6 Suppl):299S-339S.


Anticoagulant BridgingAnticoagulant Bridging

• Half life x 4 = discontinuation time- Warfarin ~ 5 days- Start UH or LMWH 36h after last warfarin dose- Last LMWH dose 24h before surgery- Stop UH 6h before surgery

2008 ACCP Guidelines on Antithrombotic Therapy. Chest. 2008 Jun;133(6 Suppl):299S-339S.Levy JH. Anesthesiology 2010; 113(3):726 – 45.

Case 2Case 290 y/o woman with PAD and AFib. Meds: warfarin 5 mg/d; ASA 325 mg/d; diltiazem ER 180 mg/d. Scheduled for cataract surgery.What is your recommendation for perioperative management of warfarin and ASA in cataract surgery?

a) Continue both warfarin and ASAb) Stop ASA 7d prior and warfarin 5 d priorc) Bridge warfarin to LMWHd) Cancel surgery given patient’s agee) Stop warfarin 5 d prior and continue ASA

Continue antiplatelets and anticoagulants in cataract surgery

Continue antiplatelets and anticoagulants in cataract surgery

• Prospective cohort study (N = 19,283) no significant difference in local (hemorrhage) or systemic (TIA, ACS) complications among patients that stopped vs. continued ASA and warfarin.

• Retrospective study (N = 48,862) – Review of national cataract surgery databank – warfarin and clopidogrel use not associated with significant increase of anesthetic or hemorrhagic complications that could jeopardize patient’s vision.

Katz J. Ophthalmology 2003 Sep;110(9):1784-8.Benzimra JD. Eye. 2009;23(1):10-16.

• Continue vitamin K antagonists- Dental procedures – use of local haemostatic

agents (epsilon-aminocaproic acid)• Dental hygiene, uncomplicated extractions,

prosthesis, restaurations, endodontics, periodontal therapy

- Minor dermatologic procedures• Mohs; simple excisions

- Cataract surgery; trabeculectomy- EGD, C-scope w/o biopsy; EUS

2008 ACCP Guidelines on Antithrombotic Therapy. Chest. 2008 Jun;133(6 Suppl):299S-339S.Jaffer A. CCJM. 2009; 76(Suppl 4): S37-S44.


New anticoagulantsNew anticoagulants

Levy JH. Anesthesiology 2010; 113(3):726 – 45.

Stop x 4 half lives = ~ 2 days

Levy JH. Anesthesiology 2010; 113(3):726 – 45.

New anticoagulantsNew anticoagulants

Case 3Case 3

65 y/o man, hyperlipidemia, HTN, diverticulosis. Meds: rosuvastatin, chlorthalidone. Scheduled for left hemicolectomy in 2 wk. Patient is able to climb 2 flight of stairs. What is your recommendation?

a) Stop chlorthalidone on day of surgeryb) Stop both medications on day of surgeryc) Continue both medicationsd) Start atenolol now – adjust dose to HR ~ 60-70x’

DiureticsDiuretics

• It is recommended to stop on day of surgery

- Hypovolemia

- Electrolyte derangement

• Hypokalemia

• Hyponatremia

• Hypo/Hypercalcemia

• Individualize in patients with CHF


RAAS InhibitorsRAAS Inhibitors

ACEI

ARB

Aldosterone antagonists• Eplerenone, spironolactone

Direct renin blocker• Aliskiren

Inhibition of Ang II vasoconstrictor effect

↓ Aldosterone

↑ Vasodilatory agents(Bradykinin, NO, prostacyclin)

ANESTHESIA

+

Fyhrquist F. J Intern Med. 2008 Sep;264(3):224-36. Comfere T. Anesth Analg. 2005;100:636-644.

↑ post-induction hypotension

↑ vasoconstrictor use (adrenergic agonists, vasopressin)

Venous blood “Pooling”

↓ Cardiac output

RR post-induction hypotension treated with vasopressor agents

Rosenman DJ. J Hosp Med. 2008 Jul;3(4):319-25.


Rosenman DJ. J Hosp Med. 2008 Jul;3(4):319-25.

RR post-op MI


• Retrospective study (1996 - 2008)

• N = 10,023 (3,052 ACE vs. control –propension analysis)

• Preop ACEI postop complications- Mortality (OR: 2.83, 95% CI: 1.03 to 7.8; P = 0.04)- Nephrotoxicity (OR: 1.7, 95% CI: 1.22 to 2.38; P = 0.0002- Atrial fibrillation (OR: 1.33, 95% CI: 1.17 to 1.51; P = 0.0001)- Inotropic use (OR: 1.17, 95% CI: 1.07 to 1.29; P = 0.0001).

• Mortality: 1%. - ACEI : x 2 (1.3% vs. 0.7%; OR: 2.00, 95% CI: 1.17- 3.42; P = 0.013).

J Am Coll Cardiol 2009;54:1778–84.

• Stop ACEI – one dose

• Stop ARB – 24 h

• Aliskiren – half life ~ 24 h ~ 3 days?

• Spironolactone – one dose

• Eplerenone – one dose

Whinney C. CCJM. Nov 2009; 76(Suppl 4): S126-S132.Saber W. CCJM. Mar 2006;73(Suppl 1):S82-7.

RAAS Inhibitors - RecommendationsRAAS Inhibitors - Recommendations

Pathophysiology of perioperative ischemiaPathophysiology of perioperative ischemiaIncreased sympathetic toneIncreased sympathetic tone

Increased cathecolamine releaseIncreased cathecolamine release

Increased cortisol Increased cortisol

↑ ↑ Myocardial VOMyocardial VO22

Inflammatory stateInflammatory state

- TNFTNF

- CRPCRP

- IL-1 and IL-6IL-1 and IL-6

- FFAFFA

↑ ↑ Platelet functionPlatelet function

Endothelial dysfunctionEndothelial dysfunction

• AnesthesiaAnesthesia

• Fluid-shifts, anemiaFluid-shifts, anemia

• PainPain

• Increased metabolic demandsIncreased metabolic demands

++

++

Increased plaque shear stressIncreased plaque shear stress

Plaque rupturePlaque rupture

Tissue ↓OTissue ↓O22

Non – Q MINon – Q MI

Perioperative Betablockers Perioperative Betablockers

Chopra V. JAMA. Feb 10 2010; 303(6): 551-2.

Devereaux PJ, et al. Lancet 2008; 371: 1839 – 47.

CVA Death

1ry Outcome AMI

HR 0.84, 95%CI 0.70–0.99 HR 0.73, 95%CI 0.60–0.89

HR 2.17, 95%CI 1.26–3.74

HR 1.33, 95%CI 1.03-1.74

N = 8351 - Metoprolol 4174- Placebo 4177Primary outcome – composite of CV mortality, non-fatal AMI, non-fatal cardiac arrest

Metoprolol succinate 200 mg/d

Lindenauer PK. N Engl J Med 2005;353: 349-61.

RCRI

Diabetes

CAD

CVA

CHF

CKD (cre > 2); GFR < 30?

Perioperative Betablockers Perioperative Betablockers

• N = 940 vascular surgery patients• Cardiac events at 30 days:

- 1-4 wks - O.R. 0.46, 95% CI: 0.27 to 0.76- > 4 wks - O.R. 0.48, 95% CI: 0.29 to 0.79

• Long term mortality:- 1- 4 wks– H.R. 0.52, 95% CI: 0.21 to 0.67- > 4 wks – H.R. 0.50, 95% CI: 0.25 to 0.71

Flu WJ. J Am Coll Cardiol, 2010; 56:1922-1929,

BetabloqueadoresBetabloqueadoresBetabloqueadoresBetabloqueadores

• Class I - continue in patients actively using it• Class IIa

- Probably recommended in vascular surgery in high risk patients (CAD; positive stress test)

- Reasonable in patients with CAD and > 1 CV risk factor. • Class IIb

- Unknown in the absence of CAD- Unknown in the absence of risk factors

• Class III- Do not use in patients with contraindications. - Dangerous to start high doses without slow up-titration in

naïve patients.

Circulation 2009;120;e169-e276;

Hypolipemic agentsHypolipemic agents• Statins

- Favorable evidence (↓ cardiovascular complications) • DECREASE IV

- Decreased venous thromboembolism- Continue

• Cholestiramine- Decrease absorption of other drugs

• Fibrates and Niacine- Rhabdomyolisis- Do not offer perioperative benefits

2007 ACC/AHA Perioperative Task Force. Circulation. 2009;120:e169-e276.Dunkelgrun M. Ann Surg. 2009;249:921-926.Glynn RJ. N Engl J Med. 2009;360:1851-1861.

Discontinue

Other cardiovascular medicationsOther cardiovascular medications

• Clonidine- Anxiolytic properties- Rebound HTN- Continue.

• α-blockers - BPH- Tamsulosine – discontinue before cataract surgery

• Intraoperative floppy iris syndrome- Discontinue

• Calcium channel blockers

- Continue

• Anti-angina; anti-arrhytmics - Continue Abdel-Aziz S. Curr Opin Ophthalm. 2009; 20:37–41

Wallace AW. Anesthesiology. 2004;101:284-293.Bell CM. JAMA. 2009;301:1991-1996.Wijeysundera DN. Anesth Analg. 2003;97:634-641.

Case 4Case 425 y/o man with DM1, CHF (EF 30%), ESRD. Scheduled for renal transplant. Meds: insulin pump, atorvastatin, carvedilol, lisinopril.How would you manage his insulin preoperatively?

a) Stop pump and convert to long acting insulinb) Continue basal infusion of insulinc) Start iv insulin and glucose (glucose clamp)d) Stop pump and start ISS

Objectives of glycemic controlObjectives of glycemic control

• Avoid hypo- and hyperglycemia

• Maintain stable electrolyte balance

• Prevent ketoacidosis

• Maintain strict glycemic control

- ICU: > 110 mg/dL < 180 mg/dL

- Non-ICU: > 100 mg/dL < 140 mg/dL

Meneghini LF. CCJM. Nov 2009; 76 (Suppl 4): S53-S59

Diabetes Care. Jun 2009; 32(6):1119-1131.

Pre-operative DM managementPre-operative DM management

• Stop OHA in AM of surgery

- Chlorpropamide (~2 days before)

- Metformin continue the previous day

- Thiazolidinediones (pioglitazone)

- GLP-1 agonists (exenatide)

- DPP-4 inhibitors (sitagliptine)

Meneghini LF. CCJM. Nov 2009; 76 (Suppl 4): S53-S59Duncan AI. Anesth Analg. 2007;104:42-50.Salpeter S. Cochrane Database Syst Rev. 2002:CD002967.

• Insulin

- Day before same regime

- Day of surgery:

• Do not use short acting insulin

• Long acting insulin: 50% dose

• Insulin pump continue basal rate



• 70/30 Insulin

- Long acting insulin (NPH): 50%

- 50 u 70% = 35 u Administer 50% ~ 17 u



Case 5Case 580 y/o woman with PMR admitted for cholecystectomy. Meds: Prednisone 5 mg/d.

What is your recommendation for perioperative management of steroids?

a) Continue same dose of prednisone

b) Administer 15 mg of prednisone

c) Stop prednisone on day of surgery

d) Administer hydrocortisone 100 mg i.v. upon induction

• Normal adrenal gland ~ 5.7 mg (15.7 μmol) / m2BSA cortisol- Male 1.80 m; 75 kg produces ~ 30 μmol/d of cortisol

• Oral supplementation in a patient without any endogenous cortisol production x2 endogenous production. - overcome biological availability and the first-pass metabolism of

the liver. • Stress endogenous cortisol ↑ 5-6x

• Rationale for perioperative steroid supplementation:- Exogenous glucocorticosteroids suppress the HPAA- Max. stim. adrenal produces ~ 200–300 mg of cortisol- Pts w/ suppressed HPAA need extreme doses of steroids

Perioperative SteroidsPerioperative Steroids


• 2 randomized placebo-controlled studies• Patients on basal steroid dose

Yong SL. Cochrane Database Syst Rev. 2009 Oct 7;(4):CD005367.

It is not possible to refute or support perioperative steroid supplementation

Marik PE. Arch Surg. 2008;143(12):1222-1226de Lange DW. Eur J Int Med. 2008; 19: 461–467

Axis suppression Minor surgical stress (hernia)

Moderate surgical stress (articular replacement)

Major surgical stress

(CABG)

No

PDN < 5 mg/dPDN < 5 mg/d

Steroids < 3wkSteroids < 3wk

-ve Cosyntropin-ve Cosyntropin

Daily doseDaily dose

No supplementationNo supplementation





Documented or suspicion

PDN > 20 mg/d > 3wk

Cushingoid

+ve Cosyntropin

Daily dose

No supplementation

Hydrocortisone

50 mg iv (induction)

25 mg iv q8h x 24h-48h

Hydrocortisone

100 mg iv (induction)

50 mg iv q8h x 24h

25 mg iv q8h x 24-48h

Unknown

PDN 5-10 mg PDN 5-10 mg >> 3wk3wk



Cosyntropin +veCosyntropin +ve

Hydrocortisone Hydrocortisone

50 mg iv (induction)50 mg iv (induction)

25 mg iv q8h x 24h-25 mg iv q8h x 24h-48h48h

HydrocortisoneHydrocortisone

100 mg iv (induction)100 mg iv (induction)

50 mg iv q8h x 24h50 mg iv q8h x 24h

25 mg iv q8h x 24-48h25 mg iv q8h x 24-48h

Shaw M. CCJM. 2002;69(1):9-11Schiff RL. Med Clin North Am. 2003 Jan;87(1):175-92. Cohn SL. Perioperative Medicine. McGraw Hill. 2006. Pp 158-163.


Case 6Case 670 y/o man with COPD; never intubated. Hospitalized 1 y ago. Meds: salmeterol/fluticasone, tiotropium, albuterol prn, montelukast. He is asymptomatic. Scheduled for THA.

How will you manage his COPD medications in preparation for surgery?

a) Stop inhalers. Administer hydrocortisone i.v.

b) Administer prednisone 60 mg/d starting 48 h before surgery

c) Continue all inhalers

d) Perform PFT’s and adjust inhalers accordingly

e) Stop montelukast and start theophylline

COPD / AsthmaCOPD / Asthma

Yamakage M. J Anesth. 2008; 22:412–428

• Continue:- Bronchodilators- Inhaled steroids- Montelukast

• Optimize symptoms- Antibiotics (thick sputum)- Oral steroids (5 days before)

• Stop theophylline (disrhythmias)

Woods BD. Br J Anaesth 2009; 103 (Suppl. 1): i57–i65.Yamakage M. J Anesth. 2008; 22:412–428Silvanus MT. Anesthesiology 2004; 100: 1052–7

COPD / AsthmaCOPD / Asthma

Case 7Case 750 y/o woman with bipolar disorder and paranoid schizophrenia. Meds: Lithium carbonate, valproic acid, olanzapine and escitalopram.Scheduled for mastectomy secondary to breast cancer.

What are your recommendations for management of psychiatric drugs?a) Stop all of them on day of surgery b) Continue valproic acid and Lithium onlyc) Continue olanzapine and escitalopram onlyd) Stop olanzapinee) Continue all of them

http://2.bp.blogspot.com/_bE7Mw-gkKG4/TGcIGvChF2I/AAAAAAAAD3w/SND6xqtWfBA/s1600/theatre-mask1.gif

Neuropsychiatric drugsNeuropsychiatric drugs

• SSRI:

- Potential antiplatelet effect

- Abrupt withdrawal symptoms

• Continue in perioperative period.

- In certain procedures (neurosurgery) its discontinuation can be considered – discuss with Psychiatry and stop gradually.

Huyse FJ. Psychosomatics 2006; 47:8–22Weinrieb RM. Expert Opin Drug Saf. 2005;4:337-344.Movig KL. Arch Intern Med. 2003;163:2354-2358.Michelson D. Br J Psychiatry. 2000;176:363-368.

• Tricyclic antidepressants:

- inhibit recapture of norepinephrine and serotonin

• Theoretical risk of disrhythmias

• Abrupt discontinuation cholinergic effect

• Continue in perioperative period.

Huyse FJ. Psychosomatics 2006; 47:8–22Cohn SL. Perioperative Medicine. McGraw Hill. 2006. Pp 36-49.Wolfe RM. Am Fam Physician. 1997;56:455-462.Kroenke K. South Med J. 1998;91:358-364.


• Benzodiazepines continue

• Antipsychotics continue

- Document ECG (QTc)

• MAOI stop 2 weeks before

- Risk of HTN with sympathetic agents

- Serotoninergic syndrome

- Avoid meperidine, thyramine

- Use direct sympathomimetics (phenylefrine)

Huyse FJ. Psychosomatics 2006; 47:8–22Cohn SL. Perioperative Medicine. McGraw Hill. 2006. Pp 36-49.Noble WH. Can J Anaesth. 1992;39:1061-1066.


• Lithium continue

- Monitor electrolytes (Nephrogenic Diabetes insipidus)

• Antiepileptics continue

- Monitor selum levels

- Consider i.v. use

• Antiparkinson agents continue

- Abrupt discontinuation Malignant neuroleptic Sx

- Neurology consult

Huyse FJ. Psychosomatics 2006; 47:8–22.Cohn SL. Perioperative Medicine. McGraw Hill. 2006. Pp 36-49.Fujii T. Surg Today. 2009;39(9):807-810. Gálvez-Jiménez N. Neurol Clin. 2004;22(2):367-377.Gray EJ. J Oral Maxillofac Surg. 1996;54:909-912.


Case 8Case 8

50 y/o woman with glioblastoma multiforme.

Meds: Dexamethasone, Levetiracetam, Ginseng, Garlic Ginkgo-biloba. Scheduled for brain tumor removal in 2 weeks.

What is your recommendation for medication management?

a) Continue all her medications

b) Stop all medications on day of surgery

c) Stop Levetiracetam on day of surgery

d) Stop Ginseng and Ginkgo-biloba on day of surgery

e) Stop now the Garlic, Ginseng y Ginkgo-biloba

Supplements and herbsSupplements and herbs

• Used by 33% of surgical patients

• Its complications include:

- AMI, stroke, hemorrhage

- Potentiating anesthetic agents

- Refractoriness to anesthetic agents

- Pharmacologic interactions

Ang-Lee MK. JAMA. 2001;286:208-216.Kaye AD. Anesthesiology Clin N Am 2004; 22:125–139.Rowe DJ. Aesthetic Surg J 2009;29:150–157.

Ginseng

Hypoglycemia Inhibit platelet aggregation (irreversible) PT-PTT in animals Anticoagulant effect of warfarin

Ephedra (ma huang)

AMI, stroke

Deplete endogenous catecholamine depositsIntraoperative hemodynamic instabilityFatal interaction with MAOIs

Garlic

Inhibit platelet aggregation (irreversible) fibrinolysis hemorrhagic risk

Erratic hypotensive activity

Ginkgo-biloba Inhibit PAF hemorrhage risk

Ang-Lee MK. JAMA. 2001;286:208-216.Kaye AD. Anesthesiology Clin N Am 2004; 22:125–139Rowe DJ. Aesthetic Surg J 2009;29:150–157.


Kava kava

Sedation, anxiolysis

Sedative effect of anesthetic agents

Addictive potential suppression

St. John’s WortMultiples pharmacologic interactions P450 induction

Echinacea

Activate cellular immunity

Allergic reactions; immunosuppression

Potentiates barbiturates

Valerian Sedative effect of anesthesia

Suppression; refractoriness to anesthesia

Ang-Lee MK. JAMA. 2001;286:208-216.Kaye AD. Anesthesiology Clin N Am 2004; 22:125–139Rowe DJ. Aesthetic Surg J 2009;29:150–157.


• Others: Chamomile – anticoagulant effect

• Other resources:

- www.nccam.nih.gov

- www.fda.gov/consumer

- www.herbmed.org

Kaye AD. Anesthesiology Clin N Am 2004; 22:125–139.Rowe DJ. Aesthetic Surg J 2009;29:150–157.


http://www.nccam.nih.gov/

http://www.fda.gov/consumer

http://www.herbmed.org/

Thank you!Thank you!Thank you!Thank you!

perioperative medication management

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