Most medications should be taken on the patient’s usual schedule the day before the scheduled procedure. We recommend that patients not take most oral medications within 8 hours of their scheduled arrival time, because many medications can cause stomach irritation or nausea if taken without food. Many medications are available in IV form, and can be given during or after anesthesia when necessary.
This question becomes more complicated for antihypertensive medications, anticoagulants, antiplatelet therapy, and pain medications.
Nearly all the medications commonly used for general anesthesia and sedation have the effect of lowering blood pressure and reducing sympathetic tone; some of them depress cardiac function as well. Common medications include propofol, fentanyl, midazolam, and the inhaled fluorinated ethers such as sevoflurane and desflurane. For this reason, caution should be used in telling patients to take all antihypertensive medications on the morning of surgery, as significant hypotension may result during anesthesia.
- Beta blockers: Consensus opinion from the ACC/AHA in 2014 advises that patients who are already on beta blockers should continue to take them during the perioperative period. However, initiating beta blockade shortly before noncardiac surgery was associated with fewer nonfatal MIs but a higher rate of stroke, death, hypotension, and bradycardia. We advise patients to take their usual dose of a beta blocker on the morning of surgery with a sip of water.
- ARBs and ACE inhibitors: A recent large prospective cohort study found that patients who did not take ARBs or ACE inhibitors in the 24 hours before noncardiac surgery were less likely to suffer intraoperative hypotension and the primary composite outcome of all-cause death, stroke, or myocardial injury. Unless a patient’s hypertension is very difficult to control, it may be best to withhold ARBs and ACE inhibitors within 12-24 hours of a procedure under anesthesia.
- Diuretics: If the patient is taking a diuretic for treatment of hypertension, consider holding the diuretic on the morning of surgery in order to avoid dehydration while the patient is NPO. However, if the patient has severe liver disease or congestive heart failure, it may be best to continue diuretic therapy.
Anticoagulants and antiplatelet therapy
The surgeon or the physician performing the procedure often requests that anticoagulants or antiplatelet therapy be discontinued for several days to a week in advance of surgery. If you feel that it is not in your patient’s best interest to hold these medications, it is best to discuss this with the surgeon in advance.
Often, low-dose aspirin can be continued throughout the perioperative period without increasing the risk of bleeding for many routine procedures, and it may protect the patency of drug-eluting coronary stents. However, in some circumstances such as intracranial surgery, the risk of bleeding may be unacceptable.
In a 2016 update on dual antiplatelet therapy, ACC/AHA guidelines advise: “Decisions about the timing of surgery and whether to discontinue DAPT after coronary stent implantation are best individualized. Such decisions involve weighing the particular surgical procedure and the risks of delaying the procedure, the risks of ischemia and stent thrombosis, and the risk and consequences of bleeding. Given the complexity of these considerations, decisions are best determined by a consensus of the surgeon, anesthesiologist, cardiologist, and patient.”
Patients who are on opioid treatment for acute or chronic pain may be advised to take their medications with a sip of water up to two hours before the time of surgery. Fentanyl patches may be used per the patient's routine; it is helpful for the patient or family to make a note of the time and date of placement, and inform the anesthesia team. Patients with severe opioid dependence, especially those who are taking Suboxone (buprenorphine and naloxone) or methadone as maintenance therapy, should be referred for a Pre-surgical Pain Medicine consultation, as postoperative pain management in these patients presents special challenges.