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Perioperative Medication Management

Overview

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. Obtain advice on selecting alternative treatments from clinical or drug information pharmacists. Additional monitoring of the patient or plasma drug concentrations may be required when different treatments or formulations are used perioperatively. Heightened awareness and diligent documentation of patient medications from admission to discharge can reduce serious problems in the perioperative management of society’s increasingly elderly and frail population.

The perioperative period extends from the preoperative day through the operation and into the postoperative recovery. Proper perioperative management helps to prevent or minimize complications, to reduce postoperative pain, and to accelerate recovery. The components of perioperative medication management are as follows:

Accurate documentation of preoperative medication

Established decisions on stopping medications prior to surgery

Monitoring of appropriate chemistry study results to determine dosages and the occurrence of adverse effects

Appropriate management of pain

Administration of adjunctive medications

Use of appropriate formulations and alternative products when needed

Review of discharge medications to ensure discontinuation of surgery-specific drugs (eg, anticoagulants, analgesics) to avoid polypharmacy

Some drugs (eg, beta-blockers) have potential adverse effects when discontinued abruptly and should be given parenterally in the perioperative period. Switching to an alternative formulation of the same drug may involve a change in dose due to differing bioavailability of the active drug.

Kluger et al showed that 44% of surgical patients took medications prior to surgery, with an average of 2.1 drugs per patient.
Cardiac medications accounted for the largest proportion of prescriptions (41%). Almost 50% of the drugs were omitted on the day of surgery, while on the first day after the operation, 33% of the medications were withheld. The reasons for this pattern included the following:

Fasting (49%)

Failure of the admitting doctor to prescribe (29%)

Drug withheld on order of medical staff (10%)

Drug unavailable in pharmacy or not delivered to the ward (1%)

Gastrointestinal tract operation with prolonged ileus (3%)

Unknown (8%)

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.

For excellent patient education resources, see eMedicineHealth’s patient education article Pain After Surgery.

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