[0:00]Hey guys, welcome back to the channel. Today we're going to be finishing off the pre-operative management series and today I'm going to be talking about perioperative medication management.
[0:09]I'm going to try and make this as high yield and, you know, fast-paced as possible, just to get through all the main medications that you're going to be managing for patients going to surgery. So let's get started.
[0:18]So the first class of medications I'd like to talk about is going to be Aspirin or the antiplatelets.
[0:23]And in terms of these medications, you're often going to hold for 5 to 7 days before surgery.
[0:29]This is based on this POISE 2 trial that was published in 2014. And basically it stated that among patients with elevated operative risk, perioperative aspirin does not reduce rate of all-cause mortality or non-fatal MI.
[0:43]However, it is associated with an increased risk of major bleeding. So based on this trial, usually we are going to hold it before surgery and you can usually restart 24 hours after surgery.
[0:53]Now, if you go on to UpToDate or read some more articles about this, then there are some actual recommendations for continuing aspirin if somebody has like prior stents or a cabbage and they're really high risk for having thrombosis of that stent again, for example.
[1:06]Uh, but I'd say in 90% or more of cases, you're going to be holding aspirin 5 to 7 days before surgery.
[1:11]Next up, we've got beta blockers and this is going to be a very, very common question that you're going to get is what should we do with the patient's beta blockers before surgery?
[1:19]And the answer is to continue their beta blockers if they are already taking them.
[1:23]However, if the patient is not already taking a beta blocker, you don't want to start a new beta blocker in this scenario, unless you have at least like 2 to 4 weeks for it to really kick in.
[1:36]And that's because actually there's a couple of trials that showed that starting a new beta blocker was actually associated with increased rates of stroke and death.
[1:40]The studies which kind of led to these guidelines, if you're interested, is the POISE trial and the DECREASE trials.
[1:48]And so in the POISE trial, what they did was they started people on high dose Metoprolol succinate, 100 milligrams, right before surgery, like 2 to 4 hours, and then continued them on 200 milligrams daily thereafter.
[2:00]And so obviously that's a huge, huge dose. And those patients are the ones that had decreased risk of MI, but increased risk of death and stroke. And so it was bad to start beta blockers before surgery.
[2:09]The DECREASE trials, on the other hand, um, started bisoprolol like a median of 34 days before surgery and slowly titrated it to a heart rate of 50 to 70.
[2:18]And they realized that there is actually a big benefit to doing that, a slow titration over the course of several weeks.
[2:24]However, um, there has been a lot of criticism of the DECREASE trials because they've kind of had some falsified data and some misconduct and everything.
[2:32]But in general, continue beta blockers if patients are already taking them and don't start new beta blockers if it's pretty soon that they're going to be getting the surgery.
[2:39]All right, next up we have NSAIDs and this is going to be a very easy one. Um, so commonly patients are going to be on NSAIDs and you do not want to continue NSAIDs.
[2:49]You can continue them for lower risk procedures, but in general, you want to discontinue NSAIDs prior to surgery.
[2:57]Next, let's talk about anticoagulation and this is going to be a very, very important topic to know because this is probably a majority of where the questions are going to come regarding your patients.
[3:07]And, uh, two main categories that you're really going to see here is going to be patients on warfarin and then patients on DOACs.
[3:14]For warfarin, we typically are going to hold 5 days prior to surgery.
[3:20]And the next topic to cover is, does this patient need bridging? And this is going to be kind of a whole topic in and of itself.
[3:30]But just to touch upon it very briefly, when you have a patient on warfarin, then say they have a procedure, um, let's say post-op day 0.
[3:40]And so we're going to hold their warfarin on post-op day -5, basically, 5 days before surgery.
[3:47]And so this whole time period right here, they're not on any anticoagulation at all.
[3:52]And so there is a subset of patients in which we would want to do what's called a bridge, which is to continue some form of anticoagulation for them so that they don't develop a clot in that 5-day period where they're not really on anticoagulation.
[4:06]And typically what we do this with is going to be with heparin products.
[4:10]Heparin is a lot quicker to, you know, come out of the system, so it's a lot easier for the surgeons, you know, the day before surgery.
[4:18]You're just going to hold the heparin and then it's going to be all out of their system by the time that they go to surgery, but they're still going to be therapeutically anti-coagulated that whole time.
[4:25]After the surgery, you're going to restart the warfarin. So restart warfarin, but it takes several days for the warfarin to get back up to a therapeutic INR of greater than 2.
[4:36]So while this is happening, you're also going to do a bridge as well until you get that, um, therapeutic INR again on that warfarin.
[4:44]So question is, does the patient really need the bridge that we see, uh, before and after? And this was answered in a really seminal landmark trial called the BRIDGE trial.
[4:55]And I'll show a picture of that in just a little bit, but basically what this trial found is that the risk of them actually having a thromboembolic event in that interim period of 5 days is actually very, very low.
[5:07]And basically what the guidelines are showing us now is that you should really only bridge if their CHADS2 score, and not the CHADS-VASc score, is, um, 5 or more, 5 or 6.
[5:20]And so this basically means the patient had to have had a history of a stroke, or if their CHADS-VASc score is 7 to 9.
[5:28]Uh, other common, other common causes that you're going to need to bridge is a mechanical mitral valve, or a recent stroke or VTE in the last 3 months.
[5:40]If your patient does not have any of these criteria right here, then you should not bridge them.
[5:46]You should just hold their warfarin 5 days before surgery and then restart it on post-op day 1. And so just to go over a quick graphic of this, so here you see, uh, kind of a chart.
[5:54]This is from UpToDate of the, uh, high thrombotic risks and moderate and low thrombotic risk.
[6:03]And, you know, high thrombotic risk is people you should bridge.
[6:07]And then these ones are no bridging. And so when you take a look at this, you'll see any mitral valve prosthesis is going to be an indication for bridging.
[6:14]A CHADS2 score of 5 to 6, CHADS-VASc score of 7 to 9, or a recent stroke or TIA within 3 months, or a recent, uh, VTE within 3 months.
[6:26]Also you have those severe thrombophilias as well. These are all going to be patients that you do want to bridge, but otherwise all these patients here who are low and moderate thrombotic risk do not need to go, um, undergo a bridge.
[6:38]And it actually increases the risk of bleeding if you do decide to bridge these patients with heparin. All right, so that, that was a quick little bit about bridging in terms of warfarin.
[6:47]And then the other thing that we really need to discuss, and sorry, this is going to take me a little bit to erase, but uh, reversing INR.
[6:53]Because a lot of patients may come in with super therapeutic INR. And the quick answer to that is if there's any serious bleeding, then they should receive IV vitamin K as well as prothrombin complex concentrate.
[7:03]If INR is greater than 1.5 or greater than 2 or so and they have an urgent surgery, then you can give them, um, basically oral vitamin K.
[7:15]Usually you would do 2.5 to 5 milligrams and you would give them PCC if urgent, if the surgery needs to be urgently done in less than 24 hours.
[7:27]Otherwise you can just give the oral vitamin K. Keep in mind that when you give these doses of vitamin K, it may suppress the INR for a very prolonged time period.
[7:35]And so, um, sometimes we tend to, you know, lean more towards the conservative side when dosing this, especially when I talk with pharmacy, uh, we'll usually go on the lower side because sometimes you're just going to be stuck trying to get their INR therapeutic again after you reverse it.
[7:49]And it's going to take many, many days. All right, so now let's go back and talk about DOACs.
[7:52]And DOACs are a lot simpler because you don't have to think about bridging at all for these, um, conditions.
[7:58]So DOACs you're basically just going to hold 1 to 2 days prior to surgery. And so one day if it's a low risk procedure and 2 days if it's a higher risk procedure.
[8:07]If they're on dabigatran, um, then there's some renal impairment criteria where you may hold for an additional 2 days before that.
[8:14]And then again, you're going to restart 1 to 2 days after surgery as well.
[8:20]And a lot of times we defer to the surgeons about when the bleeding risk is appropriately low enough to restart.
[8:24]So here's, uh, just a little graphic from UpToDate and this is basically showing how for a high bleeding risk procedure, they're basically going to hold the DOAC for 2 days.
[8:32]They're going to hold it the day of the surgery and then maybe one more day and then resume the regular DOAC dose. And then for low bleeding risk procedures, they may just hold it one day before surgery.
[8:42]The day of the surgery and then they'll restart it right away after that. And then if you go online, you'll find some more guidelines just kind of going through the same kind of thought process.
[8:50]So you'll see that apixaban and rivaroxaban, uh, for a high bleeding risk procedure, we are going to hold it for 2 days prior to surgery, and then we're going to start it a day or 2 after surgery.
[9:02]Uh for dabigatran, you know, if they have renal impairment, then you're actually going to hold it for 4 days prior to surgery, and then you're going to restart it 1 to 2 days after surgery if the bleeding risk is appropriate.
[9:11]All right, and that's it for anticoagulation. So next let's move on to ACE inhibitors and ARBs. So this is going to be another huge cost that a lot of your patients are going to be on.
[9:21]And typically, you're just going to hold it 24 hours before surgery. The reason that we hold ACE inhibitors is because they are associated with intraoperative and post-operative hypertension.
[9:33]And so holding it that 24 hours before surgery is typically the practice you're going to do in 90% of cases.
[9:37]The one thing that you do want to do is make sure you do restart it after surgery because there has been found to have an increase in mortality, uh, 30-day mortality if they are not restarted within 48 hours after surgery.
[9:47]For calcium channel blockers, these are safe to continue. For diuretics, such as Lasix or thiazides, like hydrochlorothiazide, we're typically going to hold this on the morning of the surgery as well.
[10:00]Again, this is because, uh, it's going to increase the risk of hypertension, and so it's pretty easy, it's a lot easier for anesthesiologist to treat hypertension.
[10:08]And so we want to hold all these medications that may cause hypertension during the surgery. Um, but if a patient is, you know, frequently volume overloaded and it's very difficult to control, or they're going into the surgery with a little bit of extra volume, then definitely feel free to continue.
[10:22]Then let's talk about insulin. So, insulin, if the patient is taking like a long-acting glargine the night before, then you're just going to want to decrease that by 10 to 25%, um, if taking a bedtime dose.
[10:35]And if they take a morning dose of a long-acting insulin, then decrease by 33 to 50% if taking morning dose.
[10:45]Again, this is to decrease the rates of intraoperative hypoglycemia or post-operative hypoglycemia, especially since the patients are going to be NPO before the surgery.
[10:53]Uh, alpha 2 agonists like clonidine, you want to continue because there is a risk of withdrawal if you stop them.
[11:00]This is a commonly asked one, but SSRIs are also one that you want to continue.
[11:04]Uh, the risk that there is, um, regarding these medications is that they slightly do increase the bleeding risk.
[11:10]Because obviously SSRIs interact with serotonin, and your platelets actually use serotonin in part of their, um, aggregation process.
[11:19]And so you have a slightly increased risk of bleeding, but stopping the SSRI has a much higher risk of leading to a severe mood disorder episode or something like that, uh, which is higher than the slightly increased risk of bleeding, so you should continue these perioperatively.
[11:35]Let's talk about SGLT2 inhibitors. You should hold these 3 to 4 days before surgery due to the risk of euglycemic DKA and UTIs and things like that.
[11:47]And other oral diabetes meds, like metformin and sulfonylureas, uh, you really just need to hold those the morning of, um, because, uh, it's just basically that risk of hypoglycemia that day of and then they continue that they can continue them afterwards.
[12:00]Statins should be continued as there is very low risk to these. And then just some kind of random other ones, H2 blockers or PPIs should be continued.
[12:10]And, uh, digoxin should be continued. Uh, if you have niacin or ezetimibe, you should actually hold these because there is a slightly increased risk of rhabdomyolysis.
[12:19]OCPs should generally be continued unless there is a significantly higher risk of a thromboembolism. And, um, we went over this in my previous video, but if a patient is on prednisone, if it is greater than 5 milligrams a day, then you should evaluate if they have any adrenal suppression and if they need any stress dose steroids.
[12:40]Otherwise, if it's just less than 5 milligrams, 5 milligrams or less, then they can just continue on that dose without any stress dose steroids.
[12:47]That's pretty much my big list of medications that you're most commonly going to encounter in the perioperative setting.
[12:53]Uh, but we also have a lot of new biologics and, uh, monoclonal antibodies, which you may have questions about, uh, because they're becoming more and more popular.
[13:01]And for that, I would highly recommend looking up this 2022 ACR AHKS guideline for perioperative medication management.
[13:10]And you'll see a whole list of medications that are recommended to continue through surgery, such as methotrexate, hydroxychloroquine, mycophenolate.
[13:20]I actually had a question about this one time, a surgeon was asking if this was going to affect wound healing, uh, tacrolimus, all these immunosuppressive medications, uh, should be continued.
[13:29]But a lot of these biologics and monoclonal antibodies, uh, they should actually be held, uh, because of the significant increase in, uh, infection, uh, after surgery.
[13:40]So this is a very helpful list to, uh, reference when you have patients on these medications. And that's pretty much it for my, uh, guide to medication management in the perioperative setting.
[13:52]Definitely the most important and most common ones you're going to encounter are going to be aspirin, beta blockers, anticoagulation, and then, uh, blood pressure medications like ACE inhibitors, calcium channel blockers, and diuretics.
[14:02]But hopefully this really helped you determine, uh, you know, the most common things that we're going to do before surgery for our patients.
[14:09]And because it is very hard to find a very comprehensive list of what you should do with all of these medications. And so if you want to do more reading on this and basically kind of confirm all of this stuff that we went over in this video, what I highly recommend is going to, um,
[14:21]is going to UpToDate. And my favorite articles are this, are going to be the one on perioperative medication management.
[14:30]And for this one, uh, you can very clearly look at each medication class, for example, beta blockers, alpha 2 agonists, calcium channel blockers, and you can really easily see the evidence behind their recommendations.
[14:43]Uh, in addition to that, then you have this management of cardiac risk for non-cardiac, uh, surgery and this talks a little bit more about aspirin and beta blockers in the perioperative setting.
[14:52]Uh, perioperative management of patients receiving anticoagulants. This is another really, really important article that is going to help you when you're trying to figure out when to bridge somebody or how many days they should hold their DOAC.
[15:04]And then you also have this perioperative management of blood glucose in adults with diabetes mellitus. So, uh, very, very helpful and useful articles are out there online.
[15:13]I think this is all deeper reading that you can do that will really help you understand this topic a little bit better. And I hope you enjoyed this video.
[15:20]Please let me know down in the comments what you thought and if you have any questions. And I'm happy to hear what you guys think. Thank you guys so much for watching as always. I hope to see you in the next video and I'll see you next time. Peace.
