drugs and anaesthesia-which one to continue which one not to

1. DR.PROF. RANJITA ACHARYA
M.B.B.S , M.D. ANAESTHESIOLOGY
PROFESSOR IN DEPARTMENT OF ANAESTHESIOLOGY ,CRITICAL CARE &
PALLIATIVE MEDICINE
IMS AND SUM HOSPITAL
BHUBANESWAR
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2. Outline
 Introduction
 Where the question arises?
 Systemic overview
 Summary
 Take home message
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3. Introduction
 Traditionally the focus of Anaesthesiology practice has mainly
been intraoperative management of patients undergoing
surgical procedures.
 But over the past few decades, Anaesthesiologists’ have been
acknowledged for the significant improvement in perioperative
safety and quality.
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4.  Appropriate perioperative medication management is essential
to ensure positive surgical outcomes and prevent medication
misadventures.
 To decrease perioperative risk , Identification of these
comorbid conditions might be an opportunity for the
anesthesiologist to intervene.
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5.  These conditions are best managed before the day of surgery,
thus allowing ample time for thoughtful evaluation,
consultation, and planning.
 The aim of this discussion is, to know ; which drug to
preferably stop and which one to continue.
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6.  Many medications can be continued during surgery with
several exception.
 However ; the decision to discontinue medication may
exacerbate the underlying medical condition or may cause
withdrawal ,Therefore; the decision must be taken on
individual patient basis.
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7. Where the question arises??
Not in regular healthy patients
But , In patients with underlying comorbid
conditions
In whom , A more comprehensive
evaluation is required
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8. CARDIO-VASCULAR SYSTEM
 Which drugs to continue?
 Which drugs to stop ?
 Evidence in literature.
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9. To continue in CVS
 Anti arrhythmic drugs to be continued although they
can prolong action of non depolarising neuromuscular blocking
agents.
 Anti anginal to be continued , worsening of angina if
stopped
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10.  Cardiac glycosides continued to decrease risk of
arrhythmias , cardiac failure ,embolism , poor tissue
healing .
 Thiazides and loop diuretics to be continued
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11.  Vasodilator antihypertensive and Centrally acting
Antihypertensive drugs continued ,as sudden
discontinuation may lead to sudden rebound hypertension.
 Alpha blockers to be continued except prior to
cataract surgery
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12.  Beta –blockers to be continued since abrupt
withdrawal may cause side effects which may manifest after 12
to 72 hours after discontinuation and may increase morbidity
and mortality.
 But to start beta blockers immediately prior to
operation may be fatal.
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13. 13

14. 14

15.  Nitrates to be continued since may increase risk of
acute coronary syndrome or worsening of angina if stopped.
 Lipid regulating drugs statin therapy should be
continued since it is beneficial in preventing peri-operative
myocardial infarction.
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16.  Calcium channel blockers to be continued
since withdrawal may cause rebound hypertension
and coronary vasospasm leading to an exacerbation of
angina.
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17. To Stop In CVS
 Potassium sparing diuretics to withhold on morning of
surgery due to risk of hyperkalemia in immediate postop period
 Alpha blockers recommended to discontinue before
one to two weeks of cataract surgery due to risk of intra-
operative floppy iris syndrome
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18.  ACE inhibitors to be continued if prescribed for
cardiac failure.
to be discontinued if prescribed for hypertension as it
may intensify hypotensive effects of anaesthetics and which may
be less responsive to vasopressors.
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19.  ARB’S(angiotensin receptor antagonist):
Omit on morning of surgery if taking for
hypertension
consider withholding postoperatively if patient is
dehydrated or hypotensive.
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20. What if we continue ARB’S and
ACE inhibitors??
PRE-
OPERATIVE
• ARB’S and
ACE
inhinitors
within 24
hours
INTRA-
OPERATIVE
• Elevated risk
for intra-
operative
hypotension
POST-
OPERATIVE
• Elevated
risk of post-
operative
myocardial
injury.
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21. 21

22.  Lipid regulating drugs all statins should be
continued
except cholestyramine since it is required to
be made with water and patient need to be nil per oral
on day of surgery.
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23. Anticoagulants In Patients With
Prosthetic Heart Valves :
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 Patients may need to discontinue anticoagulation before
surgery.
 However, this temporary discontinuation increase risk of
arterial or venous thromboembolism due to a rebound
hypercoagulable state and due to the prothrombotic effects of
surgery.
 The risk of thromboembolism is estimated to be about 5% to
8%.

24.  Anticoagulation in minor surgery with minimal expected
blood loss may be continued in patients with
prosthetic heart valves.
 When possible, elective surgery should be avoided in the first
month after an acute episode of arterial or venous
thromboembolism.
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25.  Anticoagulation in major surgery warfarin is
discontinued 3 to 5 days preoperatively.
Unfractionated heparin or subcutaneous low-
molecular-weight heparin is administered
continued until the day before or the day of
surgery.
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26. Anticoagulants in pregnancy
 In parturients with prosthetic heart valves anticoagulants are
very important, because the incidence of arterial embolization
is greatly increased during pregnancy.
 warfarin administration in first trimester can be associated
with fetal defects and fetal death. So , it is discontinued during
pregnancy
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27.  Instead of warfarin subcutaneous standard or low-molecular-
weight heparin is administered until delivery.
 Low-dose aspirin therapy is safe for the mother and fetus and
can be used in conjunction with the heparin therapy.
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28. Antiplatelet Recommendations
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29. Antiplatelet And Neuroaxial
Puncture Recommendation
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30. Endocrine system
 Which drugs to continue?
 Which drugs to stop?
 And its anaesthetic
implication?
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31.  Thyroid hormones to be continued
 Anti thyroid drugs to be continued
 Oestrogens and hormone replacement therapy (HRT)
to be continued in minor surgery and also to be
continued in major surgery with thromboprophylaxis since
increse risk of VTE (venous thromboembolism)
 Corticosteroids continue since drop in steroid levels
may worsen situation.
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32. Pheochromocytoma
 Preoperative α-block is standard practice and aims to provide
preoperative arterial pressure control with subsequent
restoration of blood volume
 Phenoxybenzamine implicated in postoperative refractory
(catecholamine-resistant) hypotension. It should therefore be
stopped 24–48 h before surgery due to its long half-life.
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33.  Doxazosin is a competitive, selective α1-blocker, studies
suggest a reduced incidence of postoperative hypotension,
making it a good alternative to phenoxybenzamine.
 Calcium channel blockers additional drug class to further
improve control in those already α-blocked. monotherapy not
recommended
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34.  Oral hypoglycaemic discontinued on day of surgery
since patient is fasting
 Those patients on insulin should get insulin as per blood sugar
charting on day of surgery as per sliding scale.
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35. Recommendations for insulin
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36. CENTRAL NERVOUS SYSTEM
 Which drugs to continue?
 Which drugs to stop?
 And its anaesthetic
implication?
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37.  Antiepileptic continued , cardiology monitoring if
patient is on phenytoin.
 Opioid and non opioid analgesics continued
 Anti migraine drugs continue.
 Patients on dopaminergic drugs (LEVODOPA)
continued as in parkinsonism, should be first in OT list
 Pyridostigmine, Neostigmine continue
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38.  Antipsychotic, anxiolytics, Hypnotics to be continued.
 Tricyclic anti depressants(TCA) to be continued but increase
risk of arrhythmia and for intraoperative hypotension noradrenaline
is recommended.
 SSRI(selective serotonine reuptake inhibitors) continue.
Reported prolonged bleeding time nd rarely cause serotonin
syndrome
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39. MAO(monoamine oxidase) inhibitors
 if continued have to use safe anaesthetic technique since this may
lead to serotonine syndrome or hypertensive crises
 Avoid indirect acting sympathomimetic, suxamethonium, pethidine,
tramadol, ketamine.
If unable use safe technique – discontinue irreversible MAO
inhibitor two wks before surgery nd start with reversible MAO
inbitor.
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40.  Serotonin and noradrenaline reuptake inhibitors(SNRI)
continue, keep in mind to use serotonin free anaesthetic
technique.
 Drugs for mania and hypo mania- Lithium
continue in minor surgery.
discontinue after discussing with psychiatrist before 24
to 72 hours in major surgery
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41. RESPIRATORY SYSTEM
 Which drugs to continue?
 Which drugs to stop?
 And its anaesthetic
implication?
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42.  Anticholinergic Agents (inhaled)
 Corticosteroids continue all
 Leukotriene Inhibitors
 Theophylline to be continued
but consider Aminophylline in patients who are nil by
mouth as theophylline has narrow therapeutic range
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43.  Suggested perioperative steroid regimen- Patients whose have
received a regular daily dose of >10 mg prednisolone or equivalent
in the last 3 months
 Minor surgery (hernias, hand surgery)- morning daily dose
 Moderate surgery (hysterectomy)- Usual preoperative steroids +
50 mg hydrocortisone at induction + 25mg hydrocortisone 8 hrly for
24h
 Major surgery (surgery where there is delayed oral intake,
major trauma, prolonged surgery)- Usual preoperative steroids +
100 mg at induction + 50mg hydrocortisone every 8hrly for 24hr
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44. GASTROINTESTINAL SYSTEM
 Which drugs to continue?
 Which drugs to stop?
 And its anaesthetic
implication?
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45.  Anti spasmodics
 Proton pump inhibitors
 H2 receptor antogonist
 Aminosalicylates
 Antacids to be avoided since it may cause aspiration in
nil per oral patient if given immediately prior to surgery.
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46.  Adsorbant and bulk forming drugs
continue in diarrhea and watch for contipation
Avoid in bowel surgery
 Chelates and complexes (sucralfate) withhold
 Laxatives withhold
 Bile acid sequestrants withhold
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47. CHEMOTHERAPUTIC DRUGS
 Which drugs to continue?
 Which drugs to stop?
 And its anaesthetic
implication?
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48.  Cytotoxic drugs patient specific management after
consult with oncologist and hematologist.
 Immunosuppressant drugs to be continued,
stopped only if infection sets in post operatively.
 Monoclonal antibody (Rituximab) delay surgery upto
3months after last dose
 Immunomodulating drugs continue with
thromboprophylaxis
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49. Drugs in infections
 Anti fungal
 Anti bacterial
 Anti viral (specifically anti HIV)
 In antivirals protease inhibitors interact with
midazolam so avoid
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50. Musculoskeleton system
 Gout and hyperuricemia continue
 Rheumatic disease progress supressants (azathiopine and
hydroxychloroquine) continue
 Non steroidal anti inflamatory drugs (NSAID)
NSAIDs long acting(naproxen, celecoxib) stop 3 days before surgery
NSAIDs short acting(indomethacin, diclofenac) stop 1 day before
surgery
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51. SUMMARY:FOCUS ON WHAT TO STOP?
 ACE inhibitors
 Angiotensin 2 antagonists causes intra-op hypotension
 All Diuretics--- this will be on an individual patient and drug
basis.
 Diabetic treatment (alternative treatment must be arranged).
 Antiplatelet And Anticoagulant drugs as per
recommendations.
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52.  Not essential drugs eg. Vitamins, iron, laxatives,
osteoporosis treatment, liquid antacid medicines, herbal
remedies or homeopathic medicines.
 Lithium should be omitted.
 Non steroidal anti inflammatory drugs (eg. Diclofenac,
indomethacin, ibuprofen), unless prescribed.
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53. To Continue for Surgery
 All “cardiac” or blood pressure drugs
 All Epilepsy or Parkinsons drugs
 All Asthma drugs or inhalers
 All medications which reduce gastric acid secretion/production
(eg: - omeprazole, lansoprazole, ranitidine)
 All Thyroid drugs
 All major and minor tranquilisers, which are taken regularly at
home. Also anti-depressants and nicotine patches.
 All steroids taken regularly, including inhalers
 All immunosuppressants and cancer drugs (eg. azathioprine,
tamoxifen)
 All analgesics can be given before surgery - EXCEPT NSAID’S
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54. REFERENCES
 Millers anaesthesia 9th edition
 Stoeltings and co-existing diseases 7th edition
 Recent online articles
 Images from internet
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55. Thank you !!
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