ISAKanyakumari - Anaesthesia Practice in Kanyakumari District

ANAESTHESIA PEARLS

Obsteric Anaesthesia
Post LSCS Analgesia
Medication in the perioperative period

Practice Guidelines for Obstetric Anesthesia

An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia

Aspiration Prophylaxis

	Oral intake of modest amounts of clear liquids may be allowed for uncomplicated laboring patients.
	The uncomplicated patient undergoing elective cesarean delivery may have modest amounts of clear liquids up to 2 h before induction of anesthesia.
	The volume of liquid ingested is less important than the presence of particulate matter in the liquid ingested.
	Patients with additional risk factors for aspiration (e.g., morbid obesity, diabetes, difficult airway) or patients at increased risk for operative delivery (e.g., nonreassuring fetal heart rate pattern) may have further restrictions of oral intake, determined on a case-by-case basis.
	Solid foods should be avoided in laboring patients.
	Patients undergoing elective surgery (e.g., scheduled cesarean delivery or postpartum tubal ligation) should undergo a fasting period for solids of 6–8 h depending on the type of food ingested (e.g., fat content).
	Before surgical procedures (i.e., cesarean delivery, postpartum tubal ligation), practitioners should consider timely administration of nonparticulate antacids, H2 receptor antagonists, and/or metoclopramide for aspiration prophylaxis.

Anesthetic Care for Labor and Delivery

Neuraxial Techniques: Availability of Resources

	When neuraxial techniques that include local anesthetics are chosen, appropriate resources for the treatment of complications (e.g., hypotension, systemic toxicity, high spinal anesthesia) should be available.
	If an opioid is added, treatments for related complications (e.g., pruritus, nausea, respiratory depression) should be available.
	An intravenous infusion should be established before the initiation of neuraxial analgesia or anesthesia and maintained throughout the duration of the neuraxial analgesic or anesthetic.
	Administration of a fixed volume of intravenous fluid is not required before neuraxial analgesia is initiated.

Timing of Neuraxial Analgesia and Outcome of Labor

	Neuraxial analgesia should not be withheld on the basis of achieving an arbitrary cervical dilation, and should be offered on an individualized basis when this service is available.
	Patients may be reassured that the use of neuraxial analgesia does not increase the incidence of cesarean delivery .

Neuraxial Analgesia and Trial of Labor after Previous Cesarean Delivery

	Neuraxial techniques should be offered to patients attempting vaginal birth after previous cesarean delivery.
	For these patients, it is also appropriate to consider early placement of a neuraxial catheter that can be used later for labor analgesia or for anesthesia in the event of operative delivery.

Early Insertion of Spinal or Epidural Catheter for Complicated Parturients

	Early insertion of a spinal or epidural catheter for obstetric (e.g., twin gestation or preeclampsia) or anesthetic indications (e.g., anticipated difficult airway or obesity) should be considered to reduce the need for general anesthesia if an emergent procedure becomes necessary.
	For these patients, it is also appropriate to consider early placement of a neuraxial catheter that can be used later for labor analgesia or for anesthesia in the event of operative delivery.

In these cases, the insertion of a spinal or epidural catheter may precede the onset of labor or a patient’s request for labor analgesia.

Continuous Infusion Epidural (CIE) Analgesia

	The selected analgesic/anesthetic technique should reflect patient needs and preferences, practitioner preferences or skills, and available resources.
	CIE may be used for effective analgesia for labor and delivery.
	When a continuous epidural infusion of local anesthetic is selected, an opioid may be added to reduce the concentration of local anesthetic, improve the quality of analgesia, and minimize motor block.
	Adequate analgesia for uncomplicated labor and delivery should be administered with the secondary goal of producing as little motor block as possible by using dilute concentrations of local anesthetics with opioids.
	The lowest concentration of local anesthetic infusion that provides adequate maternal analgesia and satisfaction should be administered .

Single-injection Spinal Opioids with or without Local Anesthetics

	Single-injection spinal opioids with or without local anesthetics may be used to provide effective, although time-limited, analgesia for labor when spontaneous vaginal delivery is anticipated.
	If labor is expected to last longer than the analgesic effects of the spinal drugs chosen or if there is a good possibility of operative delivery, a catheter technique instead of a single injection technique should be considered.
	A local anesthetic may be added to a spinal opioid to increase duration and improve quality of analgesia.

Single-injection Spinal Opioids with or without Local Anesthetics

	Single-injection spinal opioids with or without local anesthetics may be used to provide effective, although time-limited, analgesia for labor when spontaneous vaginal delivery is anticipated.
	If labor is expected to last longer than the analgesic effects of the spinal drugs chosen or if there is a good possibility of operative delivery, a catheter technique instead of a single injection technique should be considered.
	A local anesthetic may be added to a spinal opioid to increase duration and improve quality of analgesia.

Pencil-point Spinal Needles

Pencil-point spinal needles should be used instead of cutting-bevel spinal needles to minimize the risk of post– dural puncture headache.

Combined Spinal–Epidural (CSE) Anesthetics

CSE techniques may be used to provide effective and rapid analgesia for labor.

Patient-controlled Epidural Analgesia (PCEA)

	PCEA may be used to provide an effective and flexible approach for the maintenance of labor analgesia.
	PCEA may be preferable to CIE for providing fewer anesthetic interventions, reduced dosages of local anesthetics, and less motor blockade than fixed-rate continuous epidural infusions.
	PCEA may be used with or without a background infusion.

Removal of Retained Placenta

In general, there is no preferred anesthetic technique for removal of retained placenta.

If an epidural catheter is in place and the patient is hemodynamically stable, epidural anesthesia is preferable.

	Hemodynamic status should be assessed before administering neuraxial anesthesia.
	Aspiration prophylaxis should be considered.
	Sedation/analgesia should be titrated carefully due to the potential risks of respiratory depression and pulmonary aspiration during the immediate postpartum period.
	In cases involving major maternal hemorrhage, general anesthesia with an endotracheal tube may be preferable to neuraxial anesthesia.
	Nitroglycerin may be used as an alternative to terbutaline sulfate or general endotracheal anesthesia with halogenated agents for uterine relaxation during removal of retained placental tissue.

Initiating treatment with incremental doses of intravenous or sublingual (i.e., metered dose spray) nitroglycerin may relax the uterus sufficiently while minimizing potential complications (e.g., hypotension).

Anesthetic Choices for Cesarean Delivery

Equipment, facilities, and support personnel available in the labor and delivery operating suite should be comparable to those available in the main operating suite.

Resources for the treatment of potential complications (e.g., failed intubation, inadequate analgesia, hypotension, respiratory depression, pruritus, vomiting) should be available in the labor and delivery operating suite.

Appropriate equipment and personnel should be available to care for obstetric patients recovering from major neuraxial or general anesthesia.

The decision to use a particular anesthetic technique should be individualized based on anesthetic, obstetric, or fetal risk factors (e.g., elective vs. emergency), the preferences of the patient, and the judgment of the anesthesiologist.

Neuraxial techniques are preferred to general anesthesia for most cesarean deliveries.

	An indwelling epidural catheter may provide equivalent onset of anesthesia compared with initiation of spinal anesthesia for urgent cesarean delivery.
	If spinal anesthesia is chosen, pencil-point spinal needles should be used instead of cutting-bevel spinal needles.
	General anesthesia may be the most appropriate choice in some circumstances (e.g., profound fetal bradycardia, ruptured uterus, severe hemorrhage, severe placental abruption).
	Uterine displacement (usually left displacement) should be maintained until delivery regardless of the anesthetic technique used.
	Intravenous fluid preloading may be used to reduce the frequency of maternal hypotension after spinal anesthesia for cesarean delivery.
	Initiation of spinal anesthesia should not be delayed to administer a fixed volume of intravenous fluid.
	Intravenous ephedrine and phenylephrine are both acceptable drugs for treating hypotension during neuraxial anesthesia.

In the absence of maternal bradycardia, phenylephrine may be preferable because of improved fetal acid– base status in uncomplicated pregnancies.

For postoperative analgesia after neuraxial anesthesia for cesarean delivery, neuraxial opioids are preferred over intermittent injections of parenteral opioids.

Postpartum Tubal Ligation

	For postpartum tubal ligation, the patient should have no oral intake of solid foods within 6–8 h of the surgery, depending on the type of food ingested (e.g., fat content).
	Aspiration prophylaxis should be considered.
	Both the timing of the procedure and the decision to use a particular anesthetic technique (i.e., neuraxial vs. general) should be individualized, based on anesthetic risk factors, obstetric risk factors (e.g., blood loss), and patient preferences.
	Neuraxial techniques are preferred to general anesthesia for most postpartum tubal ligations.

Be aware that gastric emptying will be delayed in patients who have received opioids during labor and that an epidural catheter placed for labor may be more likely to fail with longer post delivery time intervals.

If a postpartum tubal ligation is to be performed before the patient is discharged from the hospital, the procedure should not be attempted at a time when it might compromise other aspects of patient care on the labor and delivery unit.

Management of Obstetric and Anesthetic Emergencies

Institutions providing obstetric care should have resources available to manage hemorrhagic emergencies.

In an emergency, the use of type-specific or O negative blood is acceptable.

In cases of intractable hemorrhage when banked blood is not available or the patient refuses banked blood, intraoperative cell-salvage should be considered if available.

The decision to perform invasive hemodynamic monitoring should be individualized and based on clinical indications that include the patient’s medical history and cardiovascular risk factors.

Labor and delivery units should have personnel and equipment readily available to manage airway emergencies, to include a pulse oximeter and qualitative carbon dioxide detector, consistent with the ASA Practice Guidelines for Management of the Difficult Airway.

Basic airway management equipment should be immediately available during the provision of neuraxial analgesia.

Portable equipment for difficult airway management should be readily available in the operative area of labor and delivery units.

The anesthesiologist should have a preformulated strategy for intubation of the difficult airway.

When tracheal intubation has failed, ventilation with mask and cricoid pressure, or with a laryngeal mask airway or supraglottic airway device (e.g., Combitube®, Intubating LMA [Fastrach™]) should be considered for maintaining an airway and ventilating the lungs.

If it is not possible to ventilate or awaken the patient, an airway should be created surgically.

	Basic and advanced life-support equipment should be immediately available in the operative area of labor and delivery units.
	If cardiac arrest occurs during labor and delivery, standard resuscitative measures should be initiated.

Uterine displacement (usually left displacement) should be maintained.

If maternal circulation is not restored within 4 min, cesarean delivery should be performed by the obstetrics team.

Ref : Practice Guidelines for Obstetric Anesthesia: An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Anesthesiology 2007; 106:843–63.

Post-cesarean section analgesia

Route		Drug	Pro’s	Con’s
NEURAXIAL	INTRATHECAL	Morphine Cost-effective	Gold standard	Dose-dependent pruritus. Dose-independent PONV. Urinary retention. Oral herpes reactivation. Respiratory depression (usually delayed due to rostral spread).
		Diamorphine	Quicker onset and increased duration of action compared to IT morphine.	Pruritus and vomiting at higher doses.
		Fentanyl/Sufentanil	Excellent intraoperative analgesia. Lower incidence of PONV and delayed respiratory depression.	Little postoperative analgesic benefit.
		Meperidine = Pethidine	Can be used in patients with contraindication to local anesthetics.	Undesirable motor blockade due to local anesthetic properties PONV.
		Nalbuphine	More favorable side effect profile compared to IT morphine.	Less pain control Few evidence in literature.
		Clonidine (adjunct)	Prolonged postoperative analgesia Postoperative antihyperalgesic properties.	Mildly increased intraoperative sedation.
		Dexmedetomidine (adjunct)	Encouraging results in lower abdominal surgery.	No studies in context of cesarean delivery.
		Neostigmine (adjunct)	Reduces postoperative morphine requirements	PONV
		Magnesium (adjunct)	Reduces postoperative morphine requirements.	More studies required.
	EPIDURAL	Morphine	Good postoperative analgesia.	Similar side effect profile as IT morphine, but more pruritus.
		Diamorphine	Good and prolonged postoperative analgesia. Nausea is uncommon. Less pruritus compared to IT diamorphine.
		Fentanyl/Sufentanil	Appropriate for PCEA
		Meperidine = Pethidine	Less maternal nausea and similar patient satisfaction compared to IT Morphine. Appropriate for PCEA.	Low risk of drug exposure in breastfed infants.
		Extended release epidural morphine	Prolonged postoperative analgesia. Increased patient mobility and decreased staff workload.	High cost-price. Possible interaction with local anesthetics.
		Clonidine (adjunct)	Prolonged postoperative analgesia. Postoperative antihyperalgesic properties.
		Dexmedetomidine (adjunct)	Encouraging results in lower abdominal surgery.	No studies in context of cesarean delivery
		Neostigmine (adjunct)	Reduces postoperative morphine requirements.	More research required
		Magnesium (adjunct)	Reduces postoperative morphine requirements.	More research required
SYSTEMIC	INTRAVENOUS	Morphine	Appropriate for IVPCA	Pruritus, PONV, respiratory depression
		Fentanyl	Appropriate for IVPCA.
		Meperidine = Pethidine		Neonatal neurobehavioral depression.
		Alfentanil	Fast onset of action. Interesting in combination with morphine.	High cost-price
	INTRAMUSCULAR and SUBCUTANEOUS		Ease of administration. Low cost-price. Long history of use in postpartum women.	Injection is uncomfortable for patients. Variable blood levels and interval required for absorption. High staff workload. Poorly reported in literature.
	ORAL	Oxycodone		Case reports of neonatal respiratory depression.
		Morphine		Poorly reported in literature. Pruritus, PONV, respiratory depression.
		Tramadol	Compatible with breastfeeding.	PONV
LOCAL ANESTHETIC TECHNIQUES TARGETING PERIPHERAL NERVE AFFERENTS	ILIOINGUINAL AND ILIOHYPOGASTRIC (IIIH) NERVE BLOCK WOUND INFILTRATION TAP BLOCK		Good postoperative analgesia. Appropriate for continuous technique. Prolonged postoperative analgesia. Prolonged postoperative analgesia (up to 2 days) Easy to perform. Few complications.	Relatively short duration of action. More research to evaluate continuous techniques required. Conflicting results in literature. Relatively high cost of disposable devices. Difficult in obese patients. Risk of peritoneal puncture (solution: ultrasound)
SYSTEMIC ADMINISTRATION OF NON- OPIOID ANALGESICS		Paracetamol	Little risk associated with paracetamol therapy. Compatible with breastfeeding.
		Nonsteroidal antiinflammatory drugs	Targets also the visceral component of post-cesarean section pain. Well-documented opioid-sparing effects. Compatible with breastfeeding.	Potential problems with bleeding, platelet dysfunction and renal insufficiency. Risk of uterine atony in postpartum period.
		COX2-inhibitors	Decrease NSAID-related adverse effects (on platelet and gastro-intestinal systems)	Poorly reported in literature
		Ketamine	Anti-hyperalgesic properties	Conflicting results in literature. No data on transfer in breast milk.
		Gabapentine		More research required

Ref:

Post-cesarean section analgesia;
Acta Anaesth. Belg., 2012, 63, 147-167

Medication in the perioperative period: stop or continue?

INTRODUCTION

Routinely used medications have many potential interactions with drugs used during surgery, but few situations prohibit concurrent administration. The half-life of routinely used medications and adjustment of the dose according to the perioperative schedule must be considered. Many medications must be continued through the perioperative period, with the last dose taken with a sip of clear liquid up to 2 hours prior to the procedure, and resumed during recovery.

Other drugs must be stopped, replaced, or temporarily administered by another route.

The perioperative period extends from the preoperative day through the operation and into the postoperative recovery.

Overnight fasting reduces the risk for aspiration of stomach contents when the patient is placed under general anesthesia. However, liquids are cleared from the stomach within 2 hours of ingestion, and no differences in the volume or pH of gastric contents is noted in those patients taking clear fluids 2 hours before surgery compared to those taking clear fluids 9 hours before surgery. Therefore, patients can be given their routine medications with sips of water up to 2 hours before anesthesia.

I. Cardiovascular System Ischemic heart disease :

Drug	Day before Surgery	Day of Surgery	During Surgery	After Procedure
Nitroglycerine	Usual dose	Usual dose	IV infusion if frank ischemia	Continue IV dose if needed or until medication can be taken PO
Beta-blockers	Usual dose	Usual dose plus beta-blocker protocol	Usual dose plus beta-blocker protocol	Usual dose plus beta-blocker protocol
Calcium channel blockers	Usual dose	Usual dose morning of surgery	Usual dose morning of surgery	Continue IV dose until medication can be taken PO
Aspirin	Discontinue 1 week before surgery			Restart postoperatively at discretion of surgeon
Ticlopidine	Discontinue 1 week before surgery			Restart postoperatively at discretion of surgeon

II.Hypertension

Drug	Day before Surgery	Day of Surgery	During Surgery	After Procedure
Beta-blockers	Usual dose	Usual dose on morning of surgery with sip of water	IV infusion if frank ischemia	Continue IV dose if needed or until medication can be taken PO
Calcium channel blockers	Usual dose	Usual dose on morning of surgery with sip of water	IV bolus or infusion (usually not required)	Continue IV dose until medication can be taken PO
ACE inhibitors	Stop day before	Do not take day of surgery	IV formulations (usually not required)	Continue IV dose until medication can be taken PO
Diuretics	Stop day before		IV beta-blockers/IV calcium channel blockers	Restart when patient on oral liquids
Pottasium Supplements	Stop day before;consider checking potassium level			Restart when patient on oral liquids
Central-acting sympatholytics	Usual dose	Usual dose on morning of surgery with sip of water	Transdermal clonidine/IV methyldopa	Restart when patient on orals liquids
Peripheral sympatholytics	Usual dose	Usual dose on morning of surgery with sip of water	Any IV formulation (usually not required)	Restart when patient on orals liquids
Alpha-blockers	Usual dose	Usual dose on morning of surgery with sip of water	Any IV formulation (usually not required)	Restart when patient on orals liquids
Vasodilators	Usual dose	Usual dose on morning of surgery with sip of water	IV formulation (usually not required)	Continue IV dose until medication can

III. Antithrombotic medication:

Preoperative recommendations concerning antithrombotics and anticoagulants

Acetylsalicylic acid	continue / stop 5-7d before surgery
Thienopyridines :	Stop unless exception (see text)
clopidogrel (Plavix®)	Stop 7 days before surgery
ticlopidin (ticlid®)	Stop 10 days before surgery
Prasugrel (efient®)	Stop 10 days before surgery
dipyridamole	last intake evening before surgery
Vit k Antogonists :	continue / stop depending on surgery
Acenocoumarol (Sintrom®)	Stop 4 days before surgery
Warfarine (Marevan®)	Stop 5-7 days before surgery
fenprocoumarol (Marcoumar®)	Stop 7-10 days before surgery
LMWH :
Prophylactic dose	Stop 12 hours before surgery
Half or full therapeutic dose	Stop 24 hours before surgery
Unfractionated heparin Iv	Stop 4-6 hours before surgery / continue

Warfarin

Interruption of warfarin — After stopping warfarin, it usually takes two to three days for the INR to fall to below 2.0, and four to six days for the INR to normalize.

Once the INR is 1.5 or below, surgery can be performed with relative safety in most cases, although a normalized INR is typically required in patients undergoing surgery associated with a high bleeding risk (eg, intracranial, spinal, urologic) or if spinal anesthesia is to be used.

Following surgery and after warfarin is restarted, it takes approximately five days for the INR to rise above 2.0. It is therefore estimated that if warfarin is withheld for five days before surgery and is restarted as soon as possible afterwards, patients would have a subtherapeutic INR for approximately four days before surgery and four days after surgery.

BRIDGING ANTICOAGULATION

Bridging anticoagulation can be defined as the administration of a short-acting anticoagulant, typically a LMW heparin, during the perioperative interruption of warfarin.

In general, such bridging anticoagulation may be considered in patients with the following:

	Prior stroke or systemic embolic event
	Mechanical mitral valve
	Mechanical aortic valve and additional stroke risk factors
	Atrial fibrillation and multiple stroke risk factors (eg, CHADS2 ≥4, CHA2DS2-VASc ≥5)
	Recent (within three months) venous thromboembolism
	Active coronary or peripheral vascular disease
	Previous thromboembolism during interruption of warfarin therapy
	Major cardiac or vascular surgery

Risk Stratification for Perioperative Arterial and Venous Thromboembolism to Guide Whether Bridging Anticoagulation Is Needed

Thromboembolic Risk Category	Clinical Indication for Warfarin Therapy
Thromboembolic Risk Category	Atrial Fibrillation	Mechanical Heart Valve	Venous Thromboembolism
High risk (annual risk >10%)*	CHADS2 score 5 or 6	Any mechanical mitral valve	Recent (within 3 mo) VTE
	Recent (within 3 mo) stroke/TIA	Older aortic mechanical valve (caged-ball, tilting disk)	High-risk thrombophilia‡
	Rheumatic valvular heart disease	Recent (within 3 mo) stroke or TIA
Moderate risk (annual risk 5% to 10%)	CHADS2 score 3 or 4	Bileaflet aortic valve prosthesis with ≥1 risk factor†	VTE within 3–12 mo
			Moderate-risk thrombophilia§
			Recurrent VTE
			Active cancer‖
Low risk (annual risk <5%)	CHADS2 score 0–2 (no prior stroke or TIA)	Bileaflet aortic bileaflet without any risk factors†	VTE >12 mo ago

	CHADS2 indicates score based on cardiac failure-hypertension-age-diabetes-stroke; VTE, venous thromboembolism; and TIA, transient ischemic attack.
	* Additional patients who may be at high risk include those with prior thromboembolism during interruption of warfarin.
	† Age ≥75 years, atrial fibrillation, congestive heart failure, hypertension, diabetes mellitus, or stroke or TIA.
	‡ Deficiency of protein C, protein S, or antithrombin; antiphospholipid syndrome; homozygous factor V Leiden or prothrombin gene mutation.
	§ Heterozygous factor V Leiden or prothrombin gene mutation
	‖ Cancer that is metastatic or treated within the past 6 months.

After warfarin is stopped, 5 to 6 days before surgery (to allow sufficient time for its anticoagulant effect to wane), bridging anticoagulation is started 3 days before surgery, with the last dose given 24 hours before surgery. After surgery, bridging is resumed no earlier than 24 hours after surgery; at the same time, warfarin is restarted. Bridging is continued, typically for 4 to 6 days, until the anticoagulant effect of warfarin has resumed and the blood is sufficiently thinned again.

Enoxaparin (Lovenox) 1 mg/kg twice daily is often used.

Recommendations for anticoagulant substitution therapy:

Thromboembolic risk	Substitution
High risk in mitral valve surgery, multiple valve surgery, old mechanical valves, atrial fibrillation with a CHADS2 score 5-6, thromboembolic incident less than 3 months ago	Therapeutic dose of LMWHs until 24 hours before surgery. Start LMWH if INR less than 2. Continue LMWH postoperatively until 2 daysof therapeutic INR. Restart VKA (usual dose) the day after surgery if hemostasis is sufficient
Moderate risk in bileaflet aortic valve surgery with other risk factors, atrial fibrillation with a CHADS2 score 3-4, thromboembolic event 3-12 months ago.	HALF-THERAPEUTIC DOSE of LMWHs until 24 hours before surgery.
Low risk in atrial fibrillation with a CHADS2-VASC score equal or less than 2, thromboembolic event more than 1 year ago.	PROFYLACTIC DOSE of LMWHs until 12 hours before surgery.

IV. Perioperative Medication Management for Patients With Diabetes and Hypothyroidism:

Drug	Day before Surgery	Day of Surgery	During Surgery	After Procedure
Oral hypoglycemics	Usual dose	Omit dose	Insulin (SC or IV)	Insulin until patient is no longer NPO
Insulin	Usual dose	Omit dose	Insulin (SC or IV)	Usual dose
Thyroxine	Usual dose	Usual dose on morning of surgery with sip of water		Restart the dose when patient is no longer NPO

V. Perioperative Medication Management in Patients With Epilepsy

Drug	Day before Surgery	Day of Surgery	During Surgery	After Procedure	Substitute Drug if Needed
NSAIDs with long half-life	Discontinue 1 week before surgery			IM preparation until patient is on oral liquids
NSAIDs with short half-life	Discontinue 2-3 days before surgery			IM preparation until patient is on oral liquids
NSAIDs in patients with arthritis					Low-dose steroids

VI. Perioperative Management of NSAIDs

Drug	Day before Surgery	Day of Surgery	During Surgery	After Procedure	Substitute Drug if Needed
NSAIDs with long half-life	Discontinue 1 week before surgery			IM preparation until patient is on oral liquids
NSAIDs with short half-life	Discontinue 2-3 days before surgery			IM preparation until patient is on oral liquids
NSAIDs in patients with arthritis					Low-dose steroids

VII. Perioperative management of psychotropic agents:

Name or class of drug	Clinical considerations	Recommended strategy for surgery with brief NPO state	Recommended strategy for surgery with prolonged NPO state
Tricyclic antidepressants	Continuation may increase the potential for arrythmias. Abrupt withdrawal can lead to insomnia, nausea, headache, increased salivation and increased sweating.	Continue therapy up to and including day of surgery for patients on high doses. Patients on low doses and in whom perioperative arrythmia is likely should discontinue for 7 days prior to surgery.	Resume with oral intake. No parenteral substitution available.
Serotonin reuptake inhibitors	Increased risk of bleeding.	Discontinue therapy 3 weeks prior to surgery in patients undergoing high risk procedures (such as certain CNS procedures).	Resume with oral intake. No parenteral substitution available.
Monoamine oxidase inhibitors	If continued, and direct acting sympathomimetic agents like ephedrine are used during anesthesia, can result in severe HTN. If agents like meperidine or dextromethorphan are used can result in "serotonin syndrome".	For emergency procedures a MAO safe anesthetic technique should be used. For other surgeries, anesthesiologist and psychiatrist should collaborate and decide either to use MAO-safe anesthetic technique or discontinue the medication. If discontinued should be stopped for 2 weeks prior to surgery.	Resume with oral intake. No parenteral substitution available.
Lithium	Continuation may prolong the effect of muscle relaxants and due to impaired renal concentrating ability can cause hypovolemia and hypernatremia.	Continue therapy up to and including day of surgery with close monitoring of electrolytes and volume status.	Resume with oral intake. No parenteral substitution available.
Valproic acid	No known adverse effects.	Continue therapy up to and including day of surgery.	Continue therapy up to and including day of surgery. Resume with oral intake. A parenteral Formulation (valproate sodium) is available.

VIII. Perioperative management of endocrine agents:

Name or class of drug	Clinical considerations	Recommended strategy for surgery with brief NPO state	Recommended strategy for surgery with prolonged NPO state
Oral contraceptives	Continuation may increase risk of venous thromboembolism. Stopping can result in unwanted pregnancies.	Continue up to and including the day of surgery for procedures with low to moderate risk of venous thromboembolism. Stop 4-6 weeks before surgery for procedures with high risk for thromboembolism. Instruct on alternate forms of contraception and obtain serum pregnancy test immediately before surgery.	Continue up to and including the day of surgery for procedures with low to moderate risk of venous thromboembolism. Stop 4-6 weeks before surgery for procedures with high risk for thromboembolism. Instruct on alternate forms of contraception and obtain serum pregnancy test immediately before surgery.
Hormone replacement therapy	Continuation may increase risk of venous thromboembolism.	Continue up to and including the day of surgery for procedures with low to moderate risk of venous thromboembolism. Stop 4-6 weeks before surgery for procedures with high risk for thromboembolism.	Continue up to and including the day of surgery for procedures with low to moderate risk of venous thromboembolism. Stop 4-6 weeks before surgery for procedures with high risk for thromboembolism. Resume when tolerating oral medications.
Selective estrogen receptor modulators	Continuation may increase risk of venous thromboembolism.	Continue for surgeries with low risk of venous thromboembolism, and discontinue for surgeries with moderate to high risk for venous thromboembolism. When stopped should be stopped at least 4-6 weeks prior to surgery. When SERMs are used for breast cancer treatment consult oncologist.	Continue up to and including the day of surgery for procedures with low risk of venous thromboembolism. Stop 4-6 weeks before surgery for procedures with moderate to high risk for thromboembolism. Resume when tolerating oral medications. When SERMs are used for breast cancer treatment consult oncologist.

IX. Perioperative management of gastrointestinal and pulmonary agents:

Name or class of drug	Clinical considerations	Recommended strategy for surgery with brief NPO state	Recommended strategy for surgery with prolonged NPO state
H2 blockers	No known adverse effects	Continue therapy up to and including day of surgery.	Continue therapy up to and including day of surgery. Substitute IV forms available for prolonged postoperative NPO state.
Proton pump inhibitors	No known adverse effects.	Continue therapy up to and including day of surgery.	Continue therapy up to and including day of surgery. Substitute IV H2 blockers for prolonged postoperative NPO state.
Inhaled bronchodilators (beta agonists And anticholinergics)	No known adverse effects.	Continue therapy up to and including day of surgery.	Continue therapy up to and including day of surgery. Use nebulized forms if patient unable to comply with inhalation maneuver.
Theophylline	No known adverse effects but very narrow range between therapeutic and toxic level.	Continue up to day before surgery. Discontinue the evening before surgery	Continue up to day before surgery. Discontinue the evening before surgery. Resume with PO intake. Use nebulized or inhaled beta agonist or anticholinergics.
Leukotriene inhibitors	No known adverse effects.	Continue therapy up to and including day of surgery.	Continue therapy up to and including day of surgery and resume when patient able to take oral medications.

Potential perioperative effects of common herbals

Ginseng	Hypoglycemia Inhibits platelet aggregation (may be irreversible) Inhibits PT/PTT in animals Increases anticoagulation effect of warfarin
Ephedra	Myocardial infarction, cerebrovascular accident Depletes endogenous catecholamine stores, which can cause intraoperative hemodynamic instability Life-threatening interaction with MAO inhibitors
Garlic	Inhibits platelet aggregation (may be irreversible) Increases fi brinolysis Increases risk of bleeding Equivocal blood pressure lowering
Ginkgo	Inhibits platelet-activating factor, leading to biloba increased bleeding risk
Kava	Sedation, anxiolysis Increases sedative effect of anesthetics Potential for addiction, tolerance, withdrawal
St. John’s wort	Many drug–drug interactions via induction of CYP 450 enzymes
Echinacea	Activates cell-mediated immunity Allergic reactions Immunosuppression
Valerian	Increases sedative effect of anesthesia Withdrawal May increase anesthesia requirements.

Ref :

1. Perioperative Medication Management: Author: Nafisa K Kuwajerwala, MD; Chief Editor: William A Schwer, MD. Medscape.

2. Medication in the perioperative period : stop or continue ? A review. Acta Anaesth. Belg., 2011, 62, 193-201.

3. National Guidelines. Steps to reduce Surgical Risk – Guidelines for Perioperative evaluation. NGC-8596.

4. Perioperative medication management. Authors: Visala Muluk, MD., David S Macpherson, MD, MPH.

5. Perioperative medication management: General principles and practical applications. Cleveland Clinic Journal of Medicine - volume 76 • supplement 4 November 2009

ISA KANYAKUMARI

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