Download Preoperative Testing and Medication Management

1
Preoperative Testing and Medication Management
I.
Preoperative Testing and Workup for Non-Cardiac Procedures
a. Preoperative Management
II.
Preoperative Medication Management
a. Medication Specific Recommendations by Class
i. Anticoagulants/Antithrombotics Medications
ii. Antidepressants
iii. Cancer Medications
iv. Cardiovascular and Antihypertensives
v. Corticosteroids and Glucocorticoids
vi. Diabetes Medications
vii. Disease Modifying Antirheumatic Drugs (DMARD)
viii. Gastrointestinal Medications
ix. Genitourinary Medications
x. Herbal Agents
xi. Hormonal Medications
xii. Investigational Medications
xiii. Pulmonary Medications
xiv. Substance Abuse
xv. TNF alpha Inhibitors
xvi. Miscellaneous Other Medications
III.
Additional Perioperative Recommendations, Considerations, and Guidelines
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
Indications for Electrocardiography Based on Cardiac Risk
OSU Preoperative Assessment Center/Preadmission Test (OPAC/PAT) Carotid Bruit Algorithm
Preoperative Testing Grid
Management of Obstructive Sleep Apnea (OSA)
Management of Antiplatelet Therapy in Patients with Arterial Stents
Perioperative / Periprocedure Glucose Management
Blood Type and Cross with appropriate allocation per Surgical Blood Order Schedule (SBOS)
Prevention of Surgical Site Infections (SSIs) with Antimicrobial Prophylaxis
Antibiotic Prophylaxis for Infective Endocarditis
Deep Venous Thrombosis (DVT) - Prevention
Anticoagulation Reversal
i. Dabigatran (Pradaxa) Reversal Treatment for Bleeding Events
ii. Rivaroxaban, Apixaban: Factor Xa Inhibitors - Reversal Treatment for Bleeding
iii. Warfarin - Management of Elevated INR and Reversal
l. Inpatient Tobacco Cessation Clinical Protocol
m. Contrast Induced Neuropathy
Disclaimer
Clinical practice guidelines and algorithms at The Ohio State University Wexner Medical Center
(OSUWMC) are standards that are intended to provide general guidance to clinicians. Patient
choice and clinician judgment must remain central to the selection of diagnostic tests and
therapy. OSUWMC’s guidelines and algorithms are reviewed periodically for consistency with
new evidence; however, new developments may not be represented.
Copyright © 2017. The Ohio State University Wexner Medical Center. All rights reserved. No
part of this document may be reproduced, displayed, modified, or distributed in any form without
the express written permission of The Ohio State University Wexner Medical Center.
2
Preoperative Testing and Medication Management for Non-Cardiac Surgical Procedures
Preoperative Evaluation
•
•
•
A preoperative evaluation must be done within
30 days before a surgical procedure.
History and physical examination information
must be reviewed and updated within 24 hours
of admission or registration and prior to the
planned surgical procedure.
The preoperative evaluation is not a substitute
for preventive health care but may be used as
an opportunity to address preventive services.
Medical History
•
Indication(s) for the surgical procedure
o Allergies and adverse medication
reactions
o It is most helpful to specify the
approximate date, the type of reaction,
the treatment, the response, and if the
agent was subsequently taken.
•
Current medications including prescriptions,
over-the-counter, and herbal and dietary
supplements
o Specify the generic and brand name,
specific preparation (tablet, capsule,
liquid), dose in each unit, route by which
the agent is taken (oral, feeding tube,
transdermal), number of units taken,
and time(s) of day taken.
o Pay special attention to high-risk
medications including opioids, diabetes
medications, antihypertensives,
anticoagulants (warfarin, heparins,
antiplatelet medications), and oral
cancer/chemotherapy medications.
•
•
•
Medical problems, including current status
o Use the IHIS Problem List
o Pay special attention to sleep apnea
risk, abnormal airway, recent stroke or
heart attack and intravascular stents
Factors that increase infection risk
o Skin disease (e.g., open lesions)
o Diabetes mellitus
o Malnutrition
o Smoking
Thorough evaluation of issues relevant to the
planned procedure and anesthesia:
o History of anesthesia complication,
personal and family (e.g., obstructive
sleep apnea, malignant hyperthermia)
o Cardiac and pulmonary function
o
o
o
Functional capacity
History of clotting or bleeding
abnormality, personal and family
History of tobacco, alcohol, drug use
Physical Examination
•
•
•
•
•
•
•
Height, weight, and body mass index (BMI)
Vital signs:
o Blood pressure
o Pulse (rate and rhythm)
o Respiratory rate
Airway assessment
Pulmonary
Cardiovascular
Neurologic
Other findings pertinent to the patient and the
procedure
Preoperative Risk Assessment
•
The American Society of Anesthesiology (ASA)
classification is a global impression of the
clinical state of a patient based upon all
available history, physical examination findings,
and laboratory data (Table 1 on page 3).
•
Document ASA class, as it is a robust predictor
of perioperative complications.
•
Determine the perioperative cardiac risk based on
the type of procedure planned (Table 2 on
page 3).
•
See page 4 for a more detailed algorithm on
cardiac risk. (The algorithm addresses ordering
electrocardiography and scoring cardiac risk.)
Preoperative Testing
•
Laboratory and diagnostic tests are not routinely
necessary unless there is a specific patient or
procedural indication.
Nothing by Mouth (NPO)*
Type
Clear Liquid
Light Meal
Full Meal
Infant Formula/Non-Human Milk
Breast Milk
Tube Feeds
Duration
2 hours
6 hours
(A light meal consists of
dry toast and clear liquids)
8 hours
6 hours
4 hours
6 hours
*Recommendations for generally healthy patients who undergo
elective procedures. Not recommended for women in labor.
Reference: Anesthesiology 3 2011, Vol.114, 495-511.
doi:10.1097/ALN.0b013e3181fcbfd9
3
Preoperative Testing and Medication Management for Non-Cardiac Surgical Procedures
Table 1: American Society of Anesthesiologists' (ASA) Physical
Status Classification
ASA
ASA I
Definition
A normal
healthy patient
Table 2: Cardiac Risk by Surgical Procedure
Examples, including, but not
limited to:
HIGH RISK >5%
Healthy, non-smoking, no or
minimal alcohol use
Aortic and other major vascular surgical procedures
Emergent major operations, particularly in older adults
(especially those >75 years of age)
Peripheral vascular surgical procedures
ASA II
A patient with
mild systemic
disease
Mild diseases only without
substantive functional limitations.
Examples include (but not limited
to): current smoker, social alcohol
drinker, pregnancy, obesity (30 <
BMI < 40), well-controlled
DM/HTN, mild lung disease
Major cardiac and thoracic surgical procedures
Anticipated prolonged surgical procedures associated
with large fluid shift and/or blood loss
INTERMEDIATE RISK 1-5%
Carotid endarterectomy
Non-major head and neck surgery / procedures
ASA III
A patient with
severe systemic
disease
Substantive functional limitations;
One or more moderate to severe
diseases. Examples include (but
not limited to): poorly controlled
DM or HTN, COPD, morbid obesity
(BMI ≥40), active hepatitis, alcohol
dependence or abuse, implanted
pacemaker, moderate reduction of
ejection fraction, ESRD undergoing
regularly scheduled dialysis,
premature infant PCA < 60 weeks,
history (>3 months) of MI, CVA,
TIA, or CAD/stents.
ASA IV
A patient with
severe systemic
disease that is
a constant
threat to life
Examples include (but not limited
to): recent ( < 3 months) MI, CVA,
TIA, or CAD/stents, ongoing
cardiac ischemia or severe valve
dysfunction, severe reduction of
ejection fraction, sepsis, DIC, ARD
or ESRD not undergoing regularly
scheduled dialysis
ASA V
A moribund
patient who is
not expected to
survive without
the operation
Examples include (but not limited
to): ruptured abdominal/thoracic
aneurysm, massive trauma,
intracranial bleed with mass effect,
ischemic bowel in the face of
significant cardiac pathology or
multiple organ/system dysfunction
ASA VI
A declared
brain-dead
patient whose
organs are
being removed
for donor
purposes
Reference: American Society of Anesthesiologists' (ASA) Physical Status
Classification/1991 is reprinted with permission of the American Society of
Anesthesiologists, 1061 American Lane, Schaumburg, Illinois 60173-4973
Non-major intraperitoneal and intrathoracic surgery /
procedures
Orthopedic surgical procedures
Prostate surgical procedures
Urologic surgical procedures
LOW RISK <1%
Biopsies and superficial procedures (e.g., breast biopsy)
Endoscopic procedures
Cataract surgery / ophthalmologic procedures
Breast surgery
Minor prostate procedures (e.g., cystoscopy)
4
Indications for Electrocardiography Based on Cardiac Risk
Preoperative history
and physical examination
Note: If the past medical history shows
the patient has a medical issue which
would indicate the appropriateness of
an EKG (and this can be seen on the
chart review before the provider does
their own history and physical) consider
obtaining an EKG
Signs or symptoms of
cardiovascular disease?
Electrocardiography*
YES
NO
Low risk surgery**
(risk < 1%)
Electrocardiography
NOT Indicated
Intermediate risk surgery**
(risk 1-5%)
At least one RCRI***
clinical risk factor?
NO
High-risk surgery**
(risk > 5%)
Electrocardiography*
YES
*ECG is valid for 6 months if patient is clinically stable
**Please refer to Table 2 on page 3 for cardiac risk by procedure
***RCRI = Revised Cardiac Risk Index (see below)
Risk Factor
Points
History of stroke or transient ischemic attack (TIA)
1
History of MI, CABG, or PTCA
1
Heart failure
1
Serum creatinine level > 2.0mg/dL
1
Diabetes mellitus requiring insulin
Major vascular, intrathoracic, intra-abdominal, or
intracranial procedure
1
1
Revised Cardiac Risk Index (RCRI)***
Points
Risk %
0
0.4
1
0.9
2
6.6
>3
>11
RCRI Source: Lee, T.H. Lee, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major
noncardiac surgery Circulation, 100 (1999), pp. 1043–1049
5
OPAC/PAT Carotid Bruit Algorithm

This algorithm is for patients who have a carotid bruit discovered during preoperative examination.

First, determine if the patient has had stroke/TIA symptoms in the previous 9 months. Examples of stoke/TIA symptoms
include, but are not limited to:
○ Shade coming down over the eye or other sudden vision change
○ Sudden confusion or difficulty talking
○ Sudden loss of balance or difficulty walking
○ Sudden focal weakness or loss of dexterity

If the patient has had stroke/TIA symptoms in the previous 9 months, and, if there is no contraindication, then ensure they
are taking aspirin 81mg PO daily.

Next, obtain carotid duplex ultrasound within the previous 6 months.
○ OSUWMC order “vasc duplex carotid bilateral”
Result of carotid duplex ultrasound
< 50% internal carotid stenosis
70-99% internal carotid stenosis
(both sides)
(either side)
Asymptomatic
OK for
surgery/procedure
Symptomatic
Refer to
Endovascular
Neurosurgery OR
Vascular Surgery at
the preference of the
referring physician.
Consider atrial fibrillation as well as
other causes and consult Cardiology,
Stroke Neurology, or “Neurovascular/
Stroke Neurosurgery” as indicated.
50-69% internal carotid stenosis
(one or both sides, but no more than 69% either side)
Asymptomatic
OK for
surgery/procedure
Refer to
Endovascular
Neurosurgery OR
Vascular Surgery at
the preference of
the referring
physician.
Symptomatic
Refer to
Endovascular
Neurosurgery OR
Vascular Surgery at
the preference of
the referring
physician.
Preoperative Testing Grid
Timing Prior to Procedure
OPAC/
PAT¹
ECG
30 days
6 mos
2
CXR
1 yr
CBC
Ediff Plt
6 wks
Coagulation Tests
6
4
T&C
INR/PT
PTT
30 days
DOS
DOS
X
Hgb A1c Chem 6
4 wks
6 wks
K+
LFTs
DOS²
6 wks
UA Total
MRSA/
TSH,
with
MSSA
Free T4 Reflex to
Screen7
Culture
6 wks
6 wks
6 wks
HCG
UCG
DOS 3
Medical Condition or Current Treatment
Anemia
Anesthesia complications (history)
Atrial fibrillation (current or paroxysmal)
Bleeding dis order
Chemotherapy ( recent < 6 months )
CNS disease
Acute or symptomatic heart failure
Coronary artery disease and planned intermediate- or highrisk surgery (see page 3 of guideline)
Diabetes mellitus (DM) or DM risk
ESRD (on dialysis)
Factor deficiency
Functional capacity (poor, < 4 mets )
Hepatic (liver) disease
Hypertension (poorly controlled)
Hyperthermia (malignant)
Immigrant (recent, < 2 years)
Intubation difficulty in the past or at high ris k for difficulty
Cachexia (Malabsorption and/or malnutrition)
Malignancy (current)
Muscular dystrophy
Nausea and vomiting (severe or active)
Neck mobility poor or unable to open mouth (trismus)
Obesity (morbid, BMI > 40 kg/m 2)
Pacer/ICD
Premenopausal unless S/P TAH and/or BSO
Pulmonary disease-symptomatic
Radiation therapy to chest (history)
Radiation therapy to neck (history) and not taking thyroid
replacement
Renal Ins ufficiency (not on dialysis)
Rheumatoid arthritis (receiving treatment)
Scoliosis/Kyphosis (moderate to severe)
Sickle cell anemia
Sleep apnea or risk for sleep apnea 5
Stroke (CVA/TIA), History of
Thrombocytopenia
Upper airway or mediastinal les ion
Venous thromboembolism (DVT, PE) (recent < 6 months)
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
DOS
DOS
X
X
DOS
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
DOS
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
¹ Appropriate for OPAC/PAT visit if also has ASA score of 3-4
² PA & Lateral CXR or equivalent radiologic examination
3
DOS = Day of Surgery
4
See Surgical Blood Order Schedule (SBOS) for maximum recommended blood volume per procedure
5
See OSUWMC Obstructive Sleep Apnea guideline
6
Also refer to surgeon’s preference list
7
If MRSA/MSSA Screen positive, order mupirocin/bactroban
Preoperative screening and laboratory testing is unwarranted and may be harmful unless the patient has a specific clinical indication.
DOS
X
7
Preoperative Testing Grid
OPAC/
PAT¹
Timing Prior to Procedure
2
ECG
CXR
30 days 6 mos
1 yr
CBC
Coagulation Tests
Ediff Plt
T&C
6 wks
INR/PT
30 days
X
DOS
PTT
4
Hgb A1c Chem 6
4 wks
6 wks
K+
LFTs
DOS² 6 wks
UA Total
MRSA/
HCG
TSH,
with
MSSA
Free T4 Reflex to
7 UCG
Screen
Culture
6 wks
6 wks
6 wks
X
X
X
X
X
X
X
Medication History
Coumadin/ Warfarin
Digoxin
Diuretic
X
X
X
X
X
Dabigatran
X
Rivaroxaban
Apixaban/edoxaban
Anticipated IV contrast for procedure
X
X
DOS
DOS
PTT/TT
DOS
DOS
X
6
Types of Procedures
Major vascular, peripheral vascular-including carotid
Craniotomy
Head/Neck surgery-major
Major cerebral vascular
Open abdominal cases
Orthopedic surgery-major
Procedures with anticipated EBL > 500 mL
Prolonged procedures with major fluid shifts and/or blood
loss
Spine surgery-major
Thoractomy/lung resection/VATS
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
¹ Appropriate for OPAC/PAT visit if also has ASA score of 3-4
² PA & Lateral CXR or equivalent radiologic examination
3
DOS = Day of Surgery
4
See Surgical Blood Order Schedule (SBOS) for maximum recommended blood volume per procedure
5
See OSUWMC Obstructive Sleep Apnea guideline
6
Also refer to surgeon’s preference list
7
If MRSA/MSSA Screen positive, order mupirocin/bactroban
Preoperative screening and laboratory testing is unwarranted and may be harmful unless the
patient has a specific clinical indication.
X
DOS3
8
Perioperative Medication Management by Class
Limited clinical trials data are available to guide medication management in the perioperative period. Therefore,
perioperative medication management is largely based on estimating the risks and benefits of either continuing or
discontinuing the medication and the urgency of the surgery or procedure being performed. Management must be
tailored to the specific patient and procedure and should be based upon:
•
The patient’s medication allergies and prior adverse reactions
•
The patient’s medical problems/comorbidities
•
The specific procedure being performed including anesthesia/analgesia management (e.g. neuraxial
anesthesia).
•
For specific recommendations on antiplatelets and anticoagulants with regional anesthesia while the
catheter is in place and post-catheter removal see Appendix A.
Anticoagulant/Antithrombotics
Consider the procedure and need for neuraxial anesthesia when planning perioperative medication management.
Oral Anticoagulant/Antithrombotic Medications
•
Restart time depends on the procedure and risk for bleeding
Class
aspirin
Do not hold*
clopidogrel (Plavix®)1,2
5 - 7 days *
Prior to Procedure
Minimum recommended
time between last dose of
antithrombotic and
neuraxial catheter
placement
Patient- and procedurespecific decision should
be made with patient and
care team.
7 days
prasugrel (Effient®)1,3
7 days*
10 days
ticagrelor (Brilinta®)1,4
5 days*
5 days
vorapaxar (Zontivity®)
40 - 50 days
Elective procedures
with a low bleeding
risk
CrCl > 80 mL/min:
> 24 hours
Contraindicated
Examples
1
Antiplatelet
medications
Minimum
Recommended
Holding Time
Additional Considerations
Before holding any of these
medications see
OSUWMC Management of
Antiplatelet Therapy in
Patients with Arterial Stents
Around the Time of Surgeries
and Procedures guideline
CrCl 50 – 79 mL/min:
> 36 hours
CrCl 30 – 49 mL/min:
> 48 hours
CrCl 15 – 29 mL/min:
> 72 hours
Direct Thrombin
Inhibitor
® 5
dabigatran (Pradaxa )
CrCl <15 mL/min:
> 96 hours and normal
PTT and TT
Procedures at
moderate - high
bleeding risk
CrCl > 80 mL/min:
> 48 hours
CrCl > 15 mL/min: 5 days
CrCl < 15 mL/min: 6 days
Depending on indication for
anticoagulation, risk of
bleeding with the procedure
and renal function patient may
require longer holding time
and/or bridging.
Check PTT or TT to verify
CrCl 50 – 79 mL/min:
> 72 hours
CrCl 30 – 49 mL/min:
> 96 hours
CrCl 15 – 29 mL/min:
> 120 hours
CrCl <15 mL/min:
> 120 hours and normal
PTT and TT
*Patient- and procedure-specific decision should be made with patient and care team whether to hold medication.
A
Consider the procedure and need for neuraxial anesthesia prior to holding anticoagulation medications.
9
Oral Anticoagulant/Antithrombotic Medications (Continued)
•
Restart time depends on the procedure and risk for bleeding
Class
Minimum
Recommended
Holding Time
Examples
Elective procedures
with a low bleeding
risk
CrCl > 30 mL/min:
> 24 hours
apixaban (Eliquis®)5
Prior to Procedure
Minimum recommended time between
last dose of antithrombotic and
neuraxial catheter placement
CrCl > 30 mL/min: 3 days
CrCl < 30 mL/min: 5 days
CrCl 15 – 29 mL/min:
> 36 hours
Factor Xa Inhibitors
® 5
rivaroxaban (Xarelto )
5
edoxaban (Savaysa®)
CrCl <15 mL/min:
> 48 hours
Procedures at
moderate - high
bleeding risk
CrCl > 30 mL/min:
> 48 hours
Additional
Considerations
CrCl > 50 mL/min: 3 days
CrCl < 50 mL/min: 5 days
Depending on
indication for
anticoagulation,
risk of bleeding
with the
procedure and
renal function
patient may
require longer
holding time
and/or bridging.
CrCl < 30 mL/min:
> 72 hours
celecoxib (Celebrex®)
ibuprofen (Motrin®,
Advil®)
NSAIDs
®
meloxicam (Mobic )
No need to hold dose
If holding other
antiplatelets or
anticoagulants, hold
NSAID concurrently
naproxen (Aleve®,
Naproxyn®)
Phosphodiesterase
Inhibitors
Vitamin K Antagonist
If the decision is made to hold, the time
to hold should be based upon 5 halflives of specific NSAID. Contact
Pharmacy for assistance. See Appendix
A
cilostazol (Pletal®)
dipyridamole-aspirin
(Aggrenox®)
dipyridamole
(Persantine®)
Do not hold
48 hours*
Do not hold*
7 days
Do not hold
48 hours*
pentoxifylline (Trental®)
Do not hold
Do not hold
warfarin (Coumadin®,
Jantoven®)*5,6
0 - 5 days*
5 days, normalization of INR
Discontinue
NSAID 5 days
prior to surgical
procedure if not
on any other
antiplatelet or
anticoagulant.
Depending on
indication for
anticoagulation
and risk of
bleeding with
the procedure
the holding time
may vary and
bridging may be
required.
Check INR to
verify. Do not
use Point-ofcare.
*Patient- and procedure-specific decision should be made with patient and care team whether to hold medication.
A
Consider the procedure and need for neuraxial anesthesia prior to holding anticoagulation medications.
10
Intravenous or Subcutaneous Anticoagulant/Antithrombotic Medications
•
Restart time depends on the procedure and risk for bleeding
Class
Minimum
Recommended
Holding Time
Examples
unfractionated heparin
(UFH) - subcutaneous
5000 units q12h
3 - 4 hours
3 - 4 hours
3 - 4 hours
5000 units q8h
7500 units q8h
24 hours
®
dalteparin (Fragmin )
prophylaxis
12 hours
®
Heparin and related
medications6
enoxaparin (Lovenox )
therapeutic
24 hours
enoxaparin (Lovenox®)
prophylaxis
12 hours
Outpatients: 8 hours
CrCl ≤ 30mL/min: 48 hours
CrCl > 30mL/min: 12 hours
CrCl ≤ 30mL/min: 24 hours
CrCl > 30 mL/min: 24 hours
CrCl < 30 mL/min: 72 hours
CrCl > 30 mL/min: 12 hours
CrCl < 30 mL/min: 72 hours
CrCl > 50 mL/min: 4 days
®
fondaparinux (Arixtra )
therapeutic
3 days
fondaparinux (Arixtra®)
prophylaxis
48 hours
unfractionated heparin
(UFH) – infusion
Additional
Considerations
8 hours
8 hours
CrCl > 30mL/min: 24 hours
®
dalteparin (Fragmin )
therapeutic
Prior to Procedure
Minimum recommended time between
last dose of antithrombotic and
neuraxial catheter placement
Inpatients: No time restriction.
Consider the peak effect of
subcutaneous heparin at 2 hours when
placing catheter.
Consider LMWH
anti-Xa level to
assess level of
anticoagulation
CrCl ≤ 50 mL/min: 5 days
CrCl > 50 mL/min: 3 - 4 days
CrCl < 50 mL/min: 4 days
Hold 4-6 hours prior to
procedures
4 hours if normal PTT
Verify PTT is
normal
Heparin should
be resumed at
the discretion of
the surgeon/
medical team
when
postoperative
hemostasis
deemed to be
adequate
Rate > 1.5 mcg/kg/min hold 6
hours and recheck PTT
Argatroban7
Rate 0.5 - 1.5
mcg/kg/min - hold 8
hours and recheck PTT
Rate < 0.5 mcg/kg/min hold for 12 hours and
recheck PTT
If neuroaxial anesthesia is needed,
decision should be based upon
discussion with the Anesthesiologist,
surgical team, and pharmacy specialist
*Hepatic and/or renal
insufficiency may need
to hold longer
CrCl >60 mL/min: Hold
for 2 - 4 hours and
recheck PTT
Direct Thrombin
Inhibitor
bivalirudin
(Angiomax®)8
CrCl 10 – 60 mL/min:
Hold for 4 - 6 hours and
recheck PTT
See Bivalirudin
Dosing and
Monitoring
Guide
See Argatroban
Dosing and
Monitoring
Verify PTT is
Normal
If neuroaxial anesthesia is needed,
decision should be based upon
discussion with the Anesthesiologist,
surgical team, and pharmacy specialist
Intermittent HD offdialysis: (May need to
hold longer)
desirudin (Iprivask®)
24 hours
24 hours if normal PTT
Depending on
indication may
require longer
holding time
and/or bridging.
11
Intravenous or Subcutaneous Anticoagulant/Antithrombotic Medications (Continued)
Class
12 hours
Prior to Procedure
Minimum recommended time between
last dose of antithrombotic and
neuraxial catheter placement
5 days
4 hours
24 hours
Minimum 48 hours for
emergency procedures
No need to hold dose
Minimum 48 hours for emergency
procedures
No need to hold dose
Minimum
Recommended
Holding Time
Examples
® 9
abciximab (Reopro )
eptifibatide
(Integrilin®)10
Antiplatelets
tirofiban (Aggrastat®)11
Therapeutic Alteplase
®
(TPA )
Catheter Clearance
Thrombolytic
Additional
Considerations
Platelet function
may remain
abnormal for up
to 7 days post
abciximab
infusion due to
irreversible
platelet
inhibition.
*Patient- and procedure-specific decision should be made with patient and care team whether to hold medication.
A
Consider the procedure and need for neuraxial anesthesia prior to holding anticoagulation mediations.
Antidepressants
Class
Monoamine
Oxidase
Inhibitors
(MAOIs)
Selective
Serotonin
Reuptake
Inhibitors
(SSRIs)
Selective
Serotonin and
Norepinephrine
Reuptake
Inhibitors
(SNRIs)
Class
Examples
phenelzine (Nardil®)
selegiline
(Emsam®)
sertraline (Zoloft®)
paroxetine (Paxil®)
citalopram
(Celexa®)
duloxetine
(Cymbalta®)
Milnacipran
(Savella®)
Venlafaxine
(Effexor®)
Examples
amitriptyline
(Elavil®)
Tricyclic
Antidepressants
doxepin
(Sinequan®)
imipramine
(Tolfranil®)
Lithium
Benefits of
Continuation
Maintain control of
psychiatric
symptoms
Risks of Continuation
Can cause hypertensive
crisis when used with
sympathomimetics.
Continue
Can cause neuroleptic
malignant syndrome when
used with meperidine.
Maintain control of
psychiatric
symptoms
Avoid withdrawal
syndrome
Increased bleeding risk due
to inhibition of platelet
aggregation
Maintain control of
psychiatric
symptoms
Avoid withdrawal
syndrome
Increased bleeding risk due
to inhibition of platelet
aggregation
Benefits of
Continuation
Risks of Continuation
Maintain control of
psychiatric
symptoms
Avoid withdrawal
syndrome
Maintain control of
psychiatric
symptoms
Avoid withdrawal
syndrome
Usual
Management
Continue
Continue
Additional Considerations
Clearly document to avoid
both drug and food
interactions during the
procedure and
hospitalization.
Requires low tyramine diet.
SSRI need to be
discontinued for up to 3
weeks to be out of the
system and clinical benefit
may not occur for several
weeks after reinitiating.
Use methylene blue with
caution because of risk of
serotonin syndrome
SNRI need to be
discontinued for up to 3
weeks to be out of the
system and clinical benefit
may not occur for several
weeks after reinitiating.
Use methylene blue with
caution because of risk of
serotonin syndrome
May increase risk of
arrhythmia in combination
with some volatile
anesthetics or
sympathomimetics.
May increase risk for
prolongation of muscle
relaxant effects. May
increase risk for
nephrogenic diabetes
insipidus and thyroid
dysfunction.
Usual
Management
Additional Considerations
Continue
Continue
Consider checking free T4
and TSH prior to the
procedure. Monitor fluid
balance and check
electrolytes frequently.
*Patient- and procedure-specific decision should be made with patient and care team whether to hold medication.
12
Cancer Medications *
Class
Examples
Minimum Recommended Holding Times
Additional Considerations
At least 4 weeks prior to the procedure per the package
insert, although based on pharmacokinetics, at least 6
weeks is desired in most cases
Wait at least 4 weeks
postoperatively or until wound
is healed to start
®
bevacizumab (Avastin )
ramucirumab (Cyramza®)
VEGF Inhibitor
ziv-Aflibercept (Zaltrap®)
regorafenib (Stivarga®)
2 weeks
®
axitinib (Inlyta )
24 hours
®
cabozantinib (Cometriq )
28 days
®
Tyrosine
Kinase
Inhibitors
ibrutinib (Imbruvica )
3 - 7 days
olaratumab (Lartruvo®)
No data Consult Clinical Pharmacy Specialist
®
pazopanib (Votrient )
7 days
Hold ibrutinib 3 - 7 days after
the procedure depending on
the risk of bleeding with the
procedure
®
ponatinib (Iclusig )
7 days
sorafenib (Nexavar®)
6 days
sunitinib (Sutent®)
Asparaginase
derivative
Consider holding these
medications based upon the
indication for the medication,
procedure, and risk for wound
healing.
2 - 3 weeks
Fibrinogen should be
checked preoperatively if
given within 4 weeks of the
procedure. For fibrinogen
< 100 mg/dL consider
cryoprecipitate.
pegaspargase (Oncaspar)
Cancer/Immunomodulation Medications *
Class
Minimum
Recommended
Holding Time
Minor Surgery: Stop
1 day before
Examples
Lenalidomide (Revlimid®)
Immunomodulator
(IMiDs)
Pomalidomide (Pomalyst®)
®
Thalidomide (Immunoprin )
Ortho, GI or GU
Surgery: Stop 1
week before
Risks of Continuation
Wound healing, bleeding to
secondary to
thrombocytopenia/concurrent
anticoagulation, increased risk
of thrombosis if
aspirin/anticoagulant
Additional
Considerations*
Minor Surgery: Resume at
least 7 days after surgery
Ortho, GI or GU Surgery:
Follow up with Multiple
Myeloma physician before
resuming
*Discontinuation/continuation or holding times for procedures must be determined by the attending physician for each case
13
Cardiovascular and Antihypertensives
Class
Benefits of
Continuation
Examples
Risks of Continuation
Usual
Management
Additional Considerations*
aliskiren
®
(Tekturna )
candesartan
cilexetil
(Atacand®)
enalapril
(Vasotec®)
irbesartan
(Avapro®)
ACE Inhibitors,
ARBs, Neprilysin
inhibitor/ARB, and
Renin Inhibitors12
lisinopril (Zestril®,
Prinivil®)
Blood pressure
control
Intraoperative hypotension
Hold 24 hours
prior to
surgical
procedure
Hypotension
Continue
Hypotension
Continue
losartan
(Cozaar®)
quinapril
(Accupril®)
ramipril (Altace®)
valsartan
(Diovan®)
sacubitrilvalsartan
®
(Entresto )
doxazosin
(Cardura®)
Alpha Blocker
®
Blood pressure
control
terazosin (Hytrin )
tamsulosin
(Flomax®)
Less postoperative
urinary retention
clonidine
®
(Catapress )
Blood pressure and
heart rate control
methyldopa
(Aldomet®)
Avoid withdrawal
syndrome
Alpha 2 Agonists
amiodarone
(Cordarone®)
dronedarone
(Multaq®)
Antiarrhythmics
dofetilide
(Tikosyn®)
Suppress
arrhythmia
Induce arrhythmia
Continue
QT prolongation
sotalol
(Betapace®,
Betapace AF®)
metoprolol
(Lopressor®,
Toprol XL®)
Beta-Blockers13
carvedilol
(Coreg®)
atenolol
(Tenormin®)
bisoprolol
(Zebeta®, Ziac®)
Consider obtaining baseline
preoperative 12-lead ECG in
patients with changes in renal
function (sotalol, dofetilide).
Consider monitoring
potassium and magnesium
(sotalol and dofetilide).
Minimize medications that
prolong QT interval.
* All patients receiving IV
antiarrhythmic therapy must
be continuously monitored on
telemetry
If beta-blocker is combined
with thiazide diuretic, e.g.
atenolol-chlorthalidone, then
treat as a beta-blocker and
usually continue.
Less cardiac
ischemia
Blood pressure and
heart rate control
Avoid withdrawal
syndrome
Hypotension
Continue
Bradycardia
Ideally, initiation of betablocker therapy should be
long enough in advance to
assess safety and tolerability
before surgery.
14
Cardiovascular and Antihypertensives (continued)
Class
Benefits of
Continuation
Examples
Risks of Continuation
Usual
Management
Additional Considerations*
Dihydropyridine:
amlodipine
(Norvasc®)
Blood pressure
nifedipine
(Procardia®,
Adalat®)
Calcium Channel
Blockers
Heart rate control
®
felodipine (Plendil )
Nondihydropyridine:
diltiazem
(Cardizem®)
verapamil (Calan®,
Isoptin®)
Digoxin
Ivabradine
Hypotension – some of
these drugs have a long
half- life
digoxin (Lanoxin®)
ivabradine
(Corlanor®)
Blood pressure
Hypotension
Heart rate control
Bradycardia
Lower heart rate
Induce arrhythmia
Less heart failure
Toxicity
Lower heart rate
Induce arrhythmia
Continue
If blood pressure or heart rate
is too low, then hold 24 hours
prior to surgical procedure.
Continue
Consider obtaining digoxin
level prior to surgical
procedure.
Consider obtaining potassium
and magnesium prior to
surgical procedure.
Continue
chlorthalidone
(Thalitone®)
furosemide (Lasix®)
torsemide
(Demadex®)
Hypotension
bumetanide
(Bumex®)
Diuretics
hydrochlorothiazide
(Mircozide®)
Hypokalemia
Avoid fluid
overload
Hyperkalemia
Do not take on
day of
procedure
Hyponatremia
metolazone
(Zaroxolyn®)
Hypernatremia
Continue diuretics in diureticdependent heart failure
patients. If a thiazide diuretic
is combined with a betablocker, e.g. atenololchlorthalidone, then treat as a
beta-blocker and usually
continue.
spironolactone
(Aldactone®)
triamterene/hydroc
hlorothiazide
(Dyazide®,
Maxzide®)
isosorbide dinitrate
(Isordil®)
Nitric Oxide
Vasodilators
isosorbide
mononitrate
(Imdur®)
hydralazine
(Apresoline®)
Continue
Blood pressure
Hypotension
Angina control
Do not take on
day of
procedure
minoxidil (Loniten®)
Hyperkalemia
Potassium
potassium chloride
®
®
(K-Dur , Klor-con )
Avoid
hypokalemia
Irritation of esophagus or
stomach
Do not take on
day of
procedure
Consider risks of hypotension
versus hypertension when
making decisions to either
give or hold antihypertensives
If the patient will be receiving
a diuretic, then continue
potassium.
15
Cardiovascular and Antihypertensives (continued)
Class
Examples
Benefits of
Continuation
Risks of Continuation
Usual
Management
Additional Considerations*
atorvastatin
®
(Lipitor )
pravastatin
(Pravachol®)
Statin
rosuvastatin
(Crestor®)
Lower risk of
thrombotic stroke
and myocardial
infarction
Rhabdomyolysis
Continue
simvastatin
®
(Zocor )
Cholestyramine
®
(Questran )
ezetimibe (Zetia®)
Non-Statin LipidLowering
Medications
fenofibrate
(Tricor®)
gemfibrozil
(Lopid®)
Cholestyramine can
sequester other medications
Fibrate-induced
rhabdomyolysis
Niacin-induced vasodilation
and itching
Do not take on
day of
procedure
niacin (Niaspan®)
Fish oil (> 3
grams/day)
Increased risk of bleeding
Hold for 7 days
prior to
procedure
May consider continuing in
patients treated for very high
triglycerides.
*Patient- and procedure-specific decision should be made with patient and care team whether to hold medications
Corticosteroids and Glucocorticoids
•
For relative potencies of corticosteroids please see the OSUWMC Pharmacy Intranet site
®
®
®
•
Examples: prednisone (Deltasone ), methylprednisolone (Medrol , Medrol Dosepak ), dexamethasone
®
(Decadron )
o Plan for stress dose in patients who have been taking immunosuppressants or immunomodulators for
an extended period of time.
•
If receiving steroids for transplant immunosuppression, consider consulting transplant team for
specific recommendations
This table applies to patients with adrenal suppression caused by exogenous steroids. For patients with
endogenous adrenal failure consult the patient’s endocrinologist for steroid management. (Note: patients
with primary adrenal insufficiency will require mineralocorticoids perioperatively with oral fludrocortisones, higher
doses of hydrocortisone, or liberal use of saline solutions)
Dose/Duration of
Corticosteroid
Less than 3 weeks
duration
Adrenal Reserves
Usual Choice
Additional Considerations*
Likely has adequate
cortisol reserves in
adrenal glands
Continue usual dose of corticosteroid on the
morning of the procedure and afterwards
For hypotension unresponsive to
intravenous fluid boluses treat with
hydrocortisone sodium succinate
(Solu-Cortef®, A-Hydrocort®) 50-75 mg
IV Q8H x3 during postoperative period
or equivalent alternate corticosteroid
Dose equivalent to 5 - 20
mg/day prednisone for
more than 3 weeks
May or may not be
adequate reserve cortisol
in adrenal glands
Adrenal reserves testing is expensive, time
consuming and unreliable in this setting. Most
patients will not need “stress dose”
corticosteroids and should continue usual
doses of corticosteroids on the morning of the
procedure and afterwards. However, for major
procedures consider hydrocortisone sodium
succinate (Solu-Cortef®, A-Hydrocort®) 5075mg IV Q8H x3 during postoperative period or
equivalent alternate corticosteroid
If patient has not received stress dose
corticosteroids and develops
hypotension unresponsive to
intravenous fluid boluses treat with
hydrocortisone sodium succinate
(Solu-Cortef®, A-Hydrocort®) 50-75 mg
IV Q8H x3 during postoperative period
or equivalent alternate corticosteroid
Dose greater than or
equal to 20 mg/day
prednisone for three
weeks or more and
patients with Cushingoid
appearance
Likely has minimal
reserve cortisol available
in adrenal glands
Should usually receive “stress dose”
corticosteroids, e.g. hydrocortisone sodium
succinate (Solu-Cortef®, A-Hydrocort®) 50-75
mg IV Q8H x3 during postoperative period or
equivalent alternate corticosteroid
Dose equivalent to 5
mg/day or less or 10 mg
every other day of
prednisone
*Patient- and procedure-specific decision should be made with patient and care team whether to hold medication.
16
Diabetes Medications
•
See OSUMC Perioperative / Periprocedure Glucose Management guideline
Disease Modifying Antirheumatic Drugs (DMARD)
Class
Benefits of
Continuation
Examples
Risks of Continuation
methotrexate
®
(Trexall )
DMARD
hydroxychloroquine
®
(Plaquenil )
sulfasalazine
®
(Azulfidine )
azathioprine
®
(Imuran )
Usual
Management
If normal
renal function
ok to
continue in
perioperative
period
Additional
Considerations*
Continue
Avoid disease
flares
Myelo/ immunosuppression
Continue
Continue
Stop 2 weeks
prior to
procedures,
resume when
wound fully
healed
®
leflunomide (Arava )
*Patient- and procedure-specific decision should be made with patient and care team whether to hold medication.
Gastrointestinal Medications
Class
Examples
Benefits of
Continuation
Risks of Continuation
Usual
Management
Additional
Considerations*
calcium carbonate
Antacids
Anti-inflammatory
aluminum
hydroxide
(AlternaGEL®, AluCap®, Alu-Tab®,
Amphojel®)
mesalamine
(Pentasa®,
Asacol®)
balsalazide
®
(Colazal )
cimetidine
(Tagamet®)
H2 Blockers
famotidine
(Pepcid®)
ranitidine (Zantac®)
esomeprazole
(Nexium®)
Proton Pump
Inhibitors
lansoprazole
(Prevacid®)
omeprazole
(Prilosec®)
Temporary
neutralization of
stomach acid
Avoid flare of
irritable bowel
disease
Reduction in
stomach acid and
GERD symptoms
Additional matter in the
stomach
Do not take on day
of procedure
Continue
Continue
Avoid rebound
hyperacidity
Reduction in
stomach acid and
reflux symptoms
May substitute H 2
blocker or PPI
If on cimetidine,
consider replacing
with other H 2
blocker due to
multiple drug
interactions.
Continue
Avoid rebound
hyperacidity
pantoprazole
(Protonix®)
*Patient- and procedure-specific decision should be made with patient and care team whether to hold medication.
17
Genitourinary Medications
Class
Recommended
Holding Time
Examples
Risk of Continuation
Usual Management
Additional
Considerations*
®
alfuzosin (Uroxatral )
®
doxazosin (Cardura )
dutasteride (Avodart®)
BPH
®
finasteride (Proscar )
Less postoperative
urinary retention
Hypotension
Continue
®
tamsulosin (Flomax )
®
terazosin (Hytrin )
*Patient- and procedure-specific decision should be made with patient and care team whether to hold medication
Herbal Agents
• There is no evidence herbal medications improve surgical outcomes and there are theoretical reasons these
agents may increase perioperative morbidity and the exact purity of some herbal medications is unclear
• Stop the following agents 7 days prior to procedures because of the potential increased risk of bleeding
o Aloe, Burdock root, Chamomile, Chondroitin, Dong quai, Evening primrose, Flaxseed, Fish oil, Garlic,
Ginger, Ginkgo, Ginseng, Glucosamine, Green tea, Hu zhang, Melatonin, Saw palmetto, Tumeric,
Vitamin A and E
• The above list in not all inclusive - Consult pharmacy if there are any concerns with additional herbal agent
Hormonal Medications
Class
Benefits of
Continuation
Examples
oral contraceptives
Avoid unplanned
pregnancy
hormone
replacement therapy
Decrease
postmenopausal
symptoms
Hormonal
medications
Risks of Continuation
Additional
Considerations*
Advise the patient
to use other forms
of birth control if
oral
contraceptives
are held
Increased risk of Venous
Thromboembolism
anastrozole
(Arimidex®)
Usual
Management
Continue
exemestane
(Aromasin®)
®
letrozole (Femara )
For specific very
high DVT risk
patients/
procedures it may
be appropriate to
discontinue their
estrogen
containing
medications 4 – 6
weeks prior to the
procedure.
raloxifene (Evista®)
Selective
estrogen receptor
modulator
tamoxifen
(Nolvadex®)
toremifene
(Fareston®)
Stop 4 weeks
prior to
procedures for
patients at
moderate/high
risk of VTE
Investigational Medications
1. Summary protocol procedures are on the “Pharmacy Intranet”
a. Provides study name and #, location of investigational medication, and protocol link.
b. Procedures include drug preparation, dose, storage/stability parameters, randomization process,
and more.
2. For Non-Oncology studies:
a. A “Drug Order Form,” (customized paper Rx) will be faxed to the pharmacy executing the study.
b. For additional protocol information such as inclusion/exclusion criteria the Investigational Drug
Services (IDS) can provide this during business hours or the study coordinator can after IDS hours
of operation. The study team is responsible for ensuring the patient meets all criteria before and
during their enrollment.
3. For Oncology studies:
a. Treatment plans including the pertinent investigational medications are available in Beacon (IHIS).
b. The protocol can be found in OnCore
18
Pulmonary Medications
Class
Benefits of
Continuation
Examples
ipratropium
®
(Atrovent HFA)
Beta-Agonists
formoterol
(Foradil®,
Perforomist®)
Usual
Management
Additional
Considerations*
Anti-cholinergic side
effects
Anti-Cholinergics
tiotropium (Spiriva
HandiHaler®)
albuterol
®
(Proventil or
Ventolin® HFA)
Risks of Continuation
Reduced risk of
postoperative
pulmonary
complications in
patients with reactive
airway disease
Continue
Tachycardia
salmeterol
(Serevent®)
bosentan
®
(Tracleer )
Endothelin receptor
antagonists
macitentan
(Opsumit®)
Avoid withdrawal,
rebound pulmonary
hypertension
Hypotension
Continue
Improved control of
reactive airway
disease
Thrush
Continue
Improved control of
asthma
No known perioperative
adverse effects
Continue
ambrisentan
(Letairis®)
Inhaled
Glucucorticoids
fluticasone
(Flovent®)
montelukast
(Singulair®)
Leukotriene
Inhibitors
zafirlukast
(Accolate®)
®
Intravenous Prosta
cyclin/ analogues
Inhaled Prostacycli
n/ analogues
Oral Prostacyclin/ a
nalogues
zileuton (Zyflo )
epoprostenol
(Flolan®, Veletri®)
Consult to
cardiovascular
anesthesia is required.
Hypotension
treprostinil
(Remodulin®)
iloprost (Ventavis®)
Hypotension
treprostinil
(Tyvaso®)
treprostinil
(Orenitram®)
Hypotension
Interruption for ≥ 3
days, will need to retitrate
Hypotension
Oral prostacyclin
receptor (IP)
agonist
Phosphodiesterase
(PDE5) inhibitors15
Selexipag
(Uptravi®)14
sildenafil (Revatio®)
Avoid withdrawal,
rebound pulmonary
hypertension
Anemia
Continue
Concomitant use of
riociguat or nitrates is
contraindicated
Hypotension
®
Hemoglobin drops were
seen in selexipag in
clinical trials
tadalafil (Adcirca )
Risk of anemia,
hemorrhage, and
hemoptysis
Hypotension
Soluble guanylate
cyclase stimulator
Interruption for ≥ 3
days, will need to retitrate
Riociguat
(Adempas®)16
Anemia
Subcutaneous Pros
tacyclin/ analogues
treprostinil
(Remodulin®)
Theophylline
theophylline
(Theodur®)
Contraindicated with
nitrates, nitric oxide
donors, or PDE5
inhibitors
Hypotension
No known
perioperative benefits
Arrhythmia
Neurotoxicity
Hold 24 hours
before
procedures
*Patient- and procedure-specific decision should be made with patient and care team whether to hold medication.
19
Substance Abuse
Class
Examples
Nicotine
replacement
products (gum,
lozenge, patch,
nasal spray,
inhaler, etc.)17
Benefits of
Continuation
Maintain abstinence
from smoking to
reduce smokingrelated complications
Risks of Continuation
Vasospams
Usual
Management
Per surgeon’s
preference
Additional
Considerations*
Likely safe for
continuation: lack of
evidence from human
studies that NRT
increases risk of post-op
complications (healing or
cardiovascular).
NRT may yield positive
cotinine test
Smoking Cessation
Varenicline
(Chantix®)18,19
Maintain abstinence
from smoking to
reduce smokingrelated complications
Bupropion
(Zyban®)20
Maintain abstinence
from smoking to
reduce smokingrelated complications
Decreased seizure
threshold (doses > 450
mg/day)
Continue
Acamprosate
(Campral®)21
Maintain abstinence
from alcohol intake
None
Continue
Naltrexone
(Revia®,
Vivitrol®)22,23
Maintain abstinence
from alcohol intake or
opioid use
Continue
Inadequate perioperative
pain control with opioid
analgesics (ex.
Hydromorphone,
fentanyl, remifentanil)
Induction of opioid
withdrawal upon
administration of opioids
Opioid/Alcohol Use
Deterrents
Buprenorphine
(Subutex®)
Buprenorphine/na
loxone
(Suboxone®)
Buprenorphine
patch
(Butrans®)24-26
Maintain abstinence
from opioid use;
Control chronic pain
Inadequate perioperative
pain control with opioid
analgesics (ex.
Hydromorphone,
fentanyl, remifentanil)
Use methylene blue with
caution because of risk
of hypertensive reactions
Consider regional
analgesia or the use of
non-opioid analgesics if
clinically appropriate
Oral: Hold 5
days
IM: Contact
prescribing
physician
Continue
unless patient
was otherwise
instructed by the
prescribing
physician
IM formulation may take
at least 4 weeks to be
eliminated from body
Naltrexone should be
restarted at the
discretion of the
prescribing chronic
pain
management/substanc
e use physician
Consider regional
analgesia or the use of
non-opioid analgesics if
clinically appropriate
If held, restarting may be
deemed “re-initiation”
depending on length of
hold
Recommend to alert
surgeon
For other products which contain any of the above ingredients but are not listed in the table, recommend following the
perioperative management guidance for the agent which is most restrictive.
20
TNF alpha inhibitors
Class
Recommended
Holding Time
Examples
Risk of Continuation
Usual
Management
Additional
Considerations*
®
abatacept (Orencia )
adalimumab (Humira®)
anakinra (Kineret®)
certolizumab (Cimzia®)
etanercept (Enbrel®)
Stop 2 weeks prior to
procedures
Myelo/immunosuppression
Resume when the wound
is fully healed
golimumab (Simponi®)
infliximab (Remicade®)
rituximab (Rituxan®)
tocilizumab (Actemra®)
Other medications to continue BEFORE and ON the MORNING of the procedure:
•
Alzheimer and dementia medications
•
Anti-psychotics
•
Anti-seizure medications
•
Anti-Parkinson's medications
•
Antibiotics*
•
Anxiolytics benzodiazepines
•
Gout medications
®
o Allopurinol (Zyloprim )
®
®
o Colchicine (Colcrys , Mitigare )
•
HIV medications
®
•
Mupirocin (Bactroban ) nasal ointment
•
Myasthenia Gravis medications
o Notify Anesthesia pre-operatively
•
Thyroid medications**
•
Transplant immunosuppression***
* Unless otherwise directed by Surgeon or Proceduralist
** Can be held up for 5 - 7 days postoperatively if patient is NPO
*** Sirolimus (Rapamune®), everolimus (Zortress®, Afinitor®), Temsirolimus (Torisel®) may be associated with
impaired wound healing, but there are no formal recommendations for holding suggest consulting with the
prescriber.
21
References:
1. OSUWMC Clinical Practice Guideline. Management of Antiplatelet Therapy in Patients with Arterial Stents
Around the Time of Surgeries and Procedures. 2014.
®
2. Plavix (clopidogrel bisulfate) [package insert]. Bridgewater, NJ; Bristol-Myers Squibb/Sanofi
Pharmaceuticals Partnership; Revised May 2009.
®
3. Effient (prasugrel hydrochloride) [package insert]. Indianapolis, IN; Eli Lilly and Company; Revised January
2011.
®
4. Brilinta (ticagrelor) [package insert]. Wilmington, DE; AstraZeneca; Revised September 2016.
5. Doherty JU, Gluckman TJ, Hucker WJ, et al. 2017 ACC Expert Consensus Decision Pathway for
Periprocedural Management of Anticoagulation in Patients With Nonvalvular Atrial Fibrillation. J Am Coll
Cardiol. 2017 Feb 21; 69 (7): 871-898.
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®
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®
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®
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•
•
Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, et al. 2014 ACC/AHA
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A Clinical Practice Guideline From the AABB. Annals of Internal Medicine (2014), doi:10.7326/M14-1589
Guideline Authors
•
•
•
•
•
•
•
•
•
•
Erica Stein, MD
Barbara Rogers, MD
Carl Schmidt, MD
Michael Guertin, MD
Kristin Brower, PharmD BCPS
Danielle Blais, PharmD, BCPS
Sarah Dickey, PharmD, BCPS
Donna Heavener, RN
Dawn Bachert, RN
Joyce Porginski, RN
Guideline Approved
_June 28, 2017.
Second Edition
Disclaimer: Clinical practice guidelines and algorithms at The Ohio State University Wexner Medical Center (OSUWMC) are standards
that are intended to provide general guidance to clinicians. Patient choice and clinician judgment must remain central to the selection of
diagnostic tests and therapy. OSUWMC’s guidelines and algorithms are reviewed periodically for consistency with new evidence;
however, new developments may not be represented.
Copyright © 2017. The Ohio State University Wexner Medical Center. All rights reserved. No part of this document may be reproduced,
displayed, modified, or distributed in any form without the express written permission of The Ohio State University Wexner Medical
Center.
Appendix A: Guideline for Antiplatelet and Anticoagulant Therapy Management Surrounding Regional Anesthesia
•
•
•
•
1
Neuraxial complications are extremely rare. Epidural hematomas are one possible complication of neuraxial anesthesia.
2
Antiplatelet or anticoagulant medications may increase the incidence of a neuraxial bleed.
Contact the Department of Anesthesiology Acute Pain Team with questions about resuming antiplatelet or anticoagulant medications in relation to
neuraxial anesthesia.
These recommendations do not apply to patients with perineural catheter placement.
Table 1:
Medication
Aspirin*
3
Aspirin/
Dipyridamole*
® 3
(Aggrenox )
Antiplatelet Agents
Prior to Procedure
While Catheter in Place
Post Procedure
Minimum recommended time between
Restrictions while neuraxial catheter in
Minimum recommended time between
Dose
last dose of antithrombotic agent and
place
neuraxial catheter removal or neuraxial
neuraxial catheter placement or
procedure and next dose of antithrombotic
neuraxial procedure
agent
Refer to OSUWMC Clinical Practice Guideline: Management of Antiplatelet Therapy in Patients with Arterial Stents Around the Time of Surgeries and
Procedures
Patient- and procedure-specific decision should be made with patient and care team.
All doses
7 days*
24 hours
Clopidogrel*
® 3
(Plavix )
Refer to OSUWMC Clinical Practice Guideline: Management of Antiplatelet Therapy in Patients with Arterial Stents Around the Time of Surgeries and
Procedures
12 hours;
75mg daily
7 days
Avoid while catheter is in place
24 hours if administering a loading dose
Dipyridamole
® 5
(Persantine )
All doses
Prasugrel *
® 3
(Effient )
Ticagrelor*
® 3
(Brilinta )
Cilostazol
® 4
(Pletal )
48 hours*
24 hours
Refer to OSUWMC Clinical Practice Guideline: Management of Antiplatelet Therapy in Patients with Arterial Stents Around the Time of Surgeries and
Procedures
All doses
10 days**
Avoid while catheter is in place
24 hours
Refer to OSUWMC Clinical Practice Guideline: Management of Antiplatelet Therapy in Patients with Arterial Stents Around the Time of Surgeries and
Procedures
All doses
5 days
Avoid while catheter is in place
24 hours
All doses
48 hours*
24 hours
No need to hold dose
Non-Aspirin
5
NSAIDs
Voraxapar
®
(Zontivity )
Non-Selective
If the decision is made to hold, the
duration to hold should be based upon
5 half-lives of specific NSAID. Contact
Pharmacy for assistance. See Table 3
COX-2
Selective
No need to hold dose
All doses
Contraindicated
4 hours
Avoid while catheter is in place
Medication
Dose
Prior to Procedure
Minimum recommended time between
last dose of antithrombotic agent and
neuraxial catheter placement or neuraxial
procedure
While Catheter in Place
Restrictions while neuraxial catheter in
place
Post Procedure
Minimum recommended time between
neuraxial catheter removal or neuraxial
procedure and next dose of antithrombotic
agent
GP IIb/IIIa inhibitors
Abciximab
® 5
(Reopro )
Eptifibatide
® 5
(Integrilin )
Tirofiban
® 5
(Aggrastat )
Argatroban
Bivalirudin
®
(Angiomax )
Desirudin
®
(Iprivask )
Alteplase
® 5
(TPA )
Alteplase
(TPA®)
5 days
All doses
Avoid while catheter is in place
12 hours**
24 hours
Continuous
Infusion
All doses
Therapeutic
dose for
stroke, etc.
1mg – 2mg
(catheter
clearance)
5000 units SQ
Q12H
Heparin
unfractionated
2,5
5000 units SQ
Q8H
7500 units SQ
Q8H
IV Infusion
Direct Thrombin Inhibitors (Injectable)
If neuraxial anesthesia is needed,
decision should be discussed with
Avoid while catheter is in place
Anesthesiologist, surgical team, and
pharmacy specialist
24 hours
Avoid while catheter is in place
Thrombolytic Agents
Not recommended, but maintain
catheter if emergency thrombolytic
Minimum 48 hours for emergency
therapy is required and notify
procedures
Department of Anesthesiology
Acute Pain Team.
24 hours
48 hours or normalization of fibrinogen
No need to hold dose
Injectable Anticoagulants
Inpatients: No time restriction.
5000 units Q12H may be given
Consider the peak effect of
while indwelling catheter in place
subcutaneous heparin at 2 hours
with concurrent SCDs
when placing catheter.
Can be restarted a minimum of 2
Outpatients: 8 hours
hours post-neuraxial anesthesia
catheter placement.
ASRA guidelines prefer the use of
Q12H dosing, however risk of
8 hours
bleed vs clot must be considered
when using TID dosing
8 hours
Avoid while catheter is in place
4 hours if normal PTT
Avoid while catheter is in place
2 hours- Consider PTT if concern for
bleeding risk
Medication
Dose
Prior to Procedure
Minimum recommended time between
last dose of antithrombotic agent and
neuraxial catheter placement or neuraxial
procedure
While Catheter in Place
Restrictions while neuraxial catheter in
place
Post Procedure
Minimum recommended time between
neuraxial catheter removal or neuraxial
procedure and next dose of antithrombotic
agent
CrCl > 30mL/min: 12 hours
5000 units SQ
QDay
Dalteparin
® 6
(Fragmin )
200 units/kg
SQ QDay
100 units/kg
SQ Q12H
40mg SQ
QDay
Enoxaparin
® 5,7,8
(Lovenox )
30mg SQ
Q12H
40mg SQ
Q12H
CrCl ≤ 30mL/min: 24 hours (consider
anti-Xa level to assess level of
anticoagulation)***
CrCl > 30mL/min: 24 hours
CrCl ≤ 30 mL/min: 48 hours
(consider anti-Xa level to assess
level of anticoagulation)***
CrCl > 30 mL/min: 12 hours
2.5mg SQ
QDay
Fondaparinux
® 5
(Arixtra )
5 – 10mg SQ
QDay
24 hours **
Avoid while catheter is in place
24 hours
Must wait 12 hours post-catheter
placement to re-initiate dosing
CrCl ≤ 30mL/min: 72 hours (consider
anti-Xa level to assess level of
anticoagulation )***
CrCl > 30 mL/min: 24 hours
1mg/kg Q12H
1 – 1.5mg/kg
SQ QDay
Must wait 8 hours post-catheter
placement to re-initiate dosing
24 hours**
Avoid while catheter is in place
CrCl ≤ 30 mL/min: 72 hours
(consider anti-Xa level to assess
level of anticoagulation)***
CrCl > 50 mL/min: 3 – 4 days
24 hours
CrCl ≤ 50 mL/min: 4 days (consider
anti-Xa level to assess level of
anticoagulation)***
CrCl > 50 mL/min: 4 days
24 hours
CrCl ≤ 50 mL/min: 5 days (consider
anti-Xa level to assess level of
anticoagulation)***
Avoid while catheter is in place
24 hours
Oral Anticoagulants
Medication
Dose
Apixaban
® 5
(Eliquis )
All doses
Dabigatran
® 5
(Pradaxa )
All doses
Edoxaban
® 5
(Savaysa )
All doses
Prior to Procedure
Minimum recommended time between
last dose of antithrombotic agent and
neuraxial catheter placement or neuraxial
procedure
While Catheter in Place
Restrictions while neuraxial catheter in
place
Post Procedure
Minimum recommended time between
neuraxial catheter removal or neuraxial
procedure and next dose of antithrombotic
agent
CrCl > 30 mL/min: 3 days
Rivaroxaban
® 5
(Xarelto )
All doses
Warfarin
®,
(Jantoven
® 5
Coumadin )
All doses
24 hours
CrCl ≤ 30mL/min: 5 days
CrCl > 15 mL/min: 5 days
24 hours
CrCl ≤ 15mL/min: 6 days
CrCl > 50mL/min: 3 days
Avoid while catheter is in place
CrCl ≤ 50mL/min: 5 days
CrCl > 50mL/min: 3 days
24 hours
24 hours
CrCl ≤ 50mL/min: 5 days
5 days, normalization of INR
24 hours
Hemorrheologic Agents
Pentoxifylline (Trental®)
No need to hold dose
Herbal Agents
Herbal Agents
Including (but not limited to):
Aloe, burdock root, chamomile,
chondroitin, dong quai, evening
primrose, flaxseed, fish oil, garlic,
ginger, ginko, ginseng,
glucosamine, green tea, hu zhang,
saw palmetto, turmeric, vitamin a
and e
7 days
Avoid while catheter is in place
Preferred hold time 24 hours. Contact
Pharmacy Specialist for
recommendation for specific medication
recommendation.
*Patient- and procedure-specific decision should be made with patient and care team whether to hold medication.
** For medications wherein ASRA guidelines recommend a range of holding, we have elected to recommend the more conservative holding time due to renal
elimination of medications and lack of reversal agents.
*** Order anti-Xa level specific to Low Molecular Weight Heparins (anti-Xa LMW Heparin). For other agents that effect Factor Xa, the presence of an elevated Xa
indicates presence of the medication and does not necessarily reflect the degree of anticoagulation.
Table 3: Half-Lives of Commonly Administered Non-Aspirin NSAIDs
NSAID
Diclofenac
Etodolac
Ibuprofen
Indomethacin
Ketorolac
Meloxicam
Nabumetone
Naproxen
Oxaprozin
Piroxicam
Half- life, h
1-2
6-8
2-4
5-10
5-6
15-20
22-30
12-17
40-60
45-50
5, 9-18
Discontinuation Time, 5 Half-lives, h
5-10
30-40
10-20
25-50
25-30
75-100
110-150
60-85
200-240
225-250
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®
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