Chronic medications in the perioperative period

While most chronic medications can be safely continued in the perioperative period, decisions regarding certain medications remain controversial.

We mailed a questionnaire to all 150 anesthesiology program directors in the United States, with 113 (75%) responding. Opinions regarding preoperative discontinuance or modification of selected medications were assessed.

Antiplatelet agents are typically discontinued preoperatively, although the number of days varies widely. Few respondents discontinue tricyclic antidepressants, oral contraceptives, diuretics, or oral hypoglycemic agents. For a patient on insulin, the most popular regimen is half the patient's usual dose of neutral protamine Hagedorn insulin (50%) or no preoperative insulin (37%), whereas an insulin infusion for tight control was rarely advised. Respondents varied widely in their approach to steroid coverage, their cancellation of elective operations in patients with inadvertent aspirin ingestion, and the length of time before surgery they would discontinue warfarin. In patients with chronic atrial fibrillation, 72% of respondents favored use of a heparin window preoperatively.

Practice variations regarding insulin regimens, steroid coverage, aspirin, and anticoagulants reflect a lack of firm evidence favoring one approach.