1. Full Medication Recommendations – Delegation Protocol
2. Diabetes Management for Procedures on Patients coming from home - Adult & Pediatric: Go to section on “Preoperative Instructions for Ambulatory Procedures” in document.
3. Consult Preop PASS Service if any patient has a drug-eluting (DES) cardiac or carotid stent or is on Plavix or aspirin for other vascular stent.
- If antiplatelet or anticoagulant medication is not associated with vascular stents, or a patient at risk of TIAs/CVAs, the decision to hold or continue anticoagulants/antiplatelet drugs is a conversation between the surgeon and the PCP or specialist managing these drugs.
- AGGRENOX is a combination antiplatelet agent. Each capsule contains 200 mg dipyridamole and 25 mg aspirin. Since it is often given to prevent CVAs or TIAs, of course we'd prefer that the patient stay on this, but the process should be a discussion between the surgeon and the PCP or specialist managing this drug.
4. Consult with Preop PASS Service if patient is taking Suboxone, buprenorphine, pentazocine, or naltrexone due to potentially difficult period pain management issues.
5. Guidelines for anticoagulant “HOLD” when Regional/Neuraxial Anesthesia is planned:
Management of Antithrombotic Therapy in the Setting of Periprocedural, Regional Anesthesia and/or Pain
Procedures – Adult – Inpatient/Ambulatory - Clinical Practice Guideline
6. Condensed Summary of Preop Medication Instructions: It is impossible to list EVERY medication that patients might be taking. Below is a summary of the most important preoperative medication issues. Medications (unless noted below) may be taken at their usual schedule on the day of anesthesia/surgery. If there is a medication NOT mentioned here, and that medication has cardiovascular or pulmonary affects, please check with the anesthesiologist supervising the Preoperative PASS Clinic
- Always take regular use antireflux/heartburn meds
- Always take regular use pulmonary inhalers
- Always take beta blockers (unless instructed otherwise by Cardiology Electrophysiology Lab)
- Always take an anti-arrhythmic meds (unless instructed otherwise by Cardiology Electrophysiology Lab)
- Always take clonidine (PO or patch)
- Always take baclofen
- Always take anti-seizure meds
- Always take anti-Parkinson meds
- Always take regular use nitrates (for heart pain angina)
- Always take ranolazine (Ranexa)
- Always take medications treating pulmonary hypertension
- Always take insulin or oral hypoglycemics according to the uConnect Diabetes “Preoperative Instructions for Ambulatory Procedures” protocol.
- Don’t take ACE Inhibitors, ARBs, or Direct Renin inhibitors, if for stable HTN. Consult Preop Clinic if used for heart failure or unstable or extreme hypertension.
- Don’t take PDE5s (ED drugs) unless used for pulmonary HTN – in which case ALWAYS take. Consult preop PASS Clinic if PDE5 drug being used to treat urinary frequency.
- Don’t take most oral hypoglycemic meds (see diabetes drugs above)
- STOP herbals and fish oil 1 week before anesthesia
- STOP diet pills 1 week before anesthesia
- STOP "Exelon" (rivastigmine) patch 3 days before anesthesia
7. Is propofol contraindicated for use in adults allergic to egg, soy or peanut?
- Soy-allergic and Egg-allergic Patients Can Safely Receive Anesthesia
- No evidence for contraindications to the use of propofol in adults allergic to egg, soy or peanut
8. Danger with Intraop Methylene Blue use and preop use of SSRIs
Methylene Blue Danger
Co-administration of selective serotonin reuptake inhibitors (SSRIs) with methylene blue during surgery may increase the risk of systemic toxicity, including serotonin syndrome (a potentially life-threatening condition). The coadministration of these agents is contraindicated according to prescribing information.
Mechanism: Administration of methylene blue (a potent monoamine oxidase inhibitor) with a serotonergic agent may result in excessive serotonin levels in the CNS and produce toxicity. Features of toxicity include confusion, disorientation, agitation, expressive aphasia, altered muscle tone in limbs, hypoxia, ocular symptoms, and depressed level of consciousness.