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  1. Pre-Operative NPO Recommendations

    There are many medications patients should take with a small sip of water when NPO and awaiting surgery. Here are some recommendations from Anesthesia Associates of Boise. Staff should always follow surgeon/proceduralist directions if provided.

    1. Continue beta blockers and diuretics.
    2. Hold any ACE medications DAY OF SURGERY unless otherwise directed.
    3. Hold any ARB medications DAY OF SURGERY unless otherwise directed.
    4. Hold phentermine for 7 DAYS prior to surgery.
    5. Continue analgesics. Patients who are opioid tolerant and on chronic narcotics, such as oxycodone or fentanyl patches, should continue their medication. Patients taking gabapentanoids (pregabalin and gabapentin) and acetaminophen should continue taking these medications.
    6. Continue GI prophylaxis medications, such as H2 blockers and proton pump inhibitors.
    7. Diabetics: Hold oral hypoglycemics day of surgery. Any diabetic patients taking insulin should follow the instructions of their surgeon, PCP, or the pre-operative hospitalist if consulted for management.
    8. Continue anti-seizure medication.
    9. Please use your judgment with other medications or refer to the perioperative medication management document on this website. Most of them are probably not necessary on the day of surgery.

    Simplified MINIMUM NPO guidelines: (excluding medications)

    All Ages:

    • 2 hours for clear liquids (CLEAR juices with no pulp, plain jello, black coffee, CLEAR sodas*)
    • 4 hours for breast milk
    • 6 hours for infant formula
    • 8 hours for non-clear liquids and solids** (includes non-human milk, hard candy and chewing tobacco)

    Longer fasting times improve flexibility in moving cases up. When in doubt, follow surgeon instructions.

    Anesthesia recommends Ensure Pre-Surgery as the clear carbohydrate drink of choice.

    If Ensure Pre-Surgery not available or provided, an alternative 8oz CLEAR carbohydrate drink with NO PROTEIN such as a soda or Gatorade is encouraged no later than 2 hours prior to surgery unless contraindicated by surgeon (diabetic patients excluded).

    **Gastric tube feedings are considered solids.

  2. Perioperative Medication Management

    NOTE: These recommendations are to serve as guidelines for physicians and their staff when providing education to patients regarding their medications prior to surgery. If there are specific concerns related to a medication, clarification and discussion should occur between the surgeon, the patient and the anesthesia provider and should include the risks, benefits and alternatives to proceeding, rescheduling or cancelling the procedure.

    1.  Cardiovascular and Hypertensive Medication

    •Beta Blockers-continue through surgery

    •Alpha 2 Blockers(clonidine)-continue through surgery

    •Calcium Channel Blockers-continue through surgery

    •Diuretics-Update December 2019. Current recommendations are to hold day of surgery if used for HTN and continue for heart failure. This is in alignment with ERAS recommendations.

    •ACE/ARB and renin inhibitor(Aliskiren/Tekturna)-Do not take day of surgery

    •Non statin lipid agents, niacin, and fibric acid agents(gemfibrozil, fenofibrate) and ezetimibe(zetia)-stop day prior to surgery

    •Statins-continue through surgery

    2.  Gastrointestinal Agents

    •H2 Blockers and PPIs-continue through surgery

    3.  Pulmonary Medication

    •Metered dose inhalers-continue through surgery

    •Theophylline-stop the night before surgery

    •Leukotriene Inhibitors(Zytlo, Accolate, Singulair)-continue through surgery

    4.  Endocrine Medications

    •Glucocorticoids

    I. Patient taking glucocorticoids < 3 weeks or daily dose < 5mg or taking chronic every other day therapy are unlikely to need stress doses, continue usual meds through surgery

    II. Patient with daily dose > 5mg or treated with > 5mg/day for > 3 weeks in the past year need stress dosing.

    III. Stress dose Steriods

    Type of SurgeryStress Dose IV hydrocortisone 24 hrs   Duration
    Moderate Complexity-(Total joint, hysterectomy, etc.) 

    50-75 mg/day1-2 days
    Major Complexity-(CABG, Trauma, Prolonged Procedure)
    100-150 mg/day2-3 days

    •Diabetic Medications

    I. Hold sulfonylureas, metformin and other oral agents on day of surgery (if risk of hypotension or need IV contrast, hold metformin for 48 hours).

    II. Evening prior to surgery

    a)FBS > 120—give usual dose of PM insulin

    b)FBS < 120—or late day surgery give 50% of usual dose

    III. Day of Surgery

    a)Give 50% dose of AM Lantus if morning regimen includes SSI

    b)Give 50% dose AM Lantus if patient taking oral DM medication or Lantus is >50% of total daily insulin

    c)Detemir or NPH give 50% of usual dose on day of surgery

    d)Mixed dosage insulin (70/30, 75/25) severely reduce or avoid all together am of surgery

    e)Insulin Pump—continue basal rate

    f)U500-hold surgery and cover with short acting insulin, resume post op (in hospital) at 50% of previous dose. If used in hospital, use U500 pen to avoid dose problems

    g)The following meds are ok for surgery-won’t cause hypoglycemia BUT hold for GI surgery if ileus expected or may cause nausea and vomiting. Ok to hold also.

    i. GLP-1 receptor Agonist

    Exenatide (Bydrueon, Byetta)

    Lixisenatide (Aldyxin)

    Liraglutide (Victoza)

    Abliglutide (Tanzeum)

    Dulaglutide (Trulicity)

    ii. Dipeptidyl Peptidase-4 Inhibitors

    Sitagliptin (Januvia)

    Saxagliptin (Ongliza)

    Linagliptin (Tradjenta)

    Alogliptin (Nesina)

    •Hormone Medications

    I. Oral Contraceptives

    a)Low risk surgery for VTE can continue

    b)Intermediate risk or high risk procedures consider stopping 4-6 weeks prior to surgery (will need alternative contraceptive and pre surgery pregnancy test)

    II. Post-Menopausal Hormone Therapy

    a)Low risk procedure for VTE can continue treatment

    b)Intermediate and high risk procedures can consider stopping 4-6 weeks prior to surgery

    III. Thyroid Medication-continue to take

    5.  Medications Affecting Homeostasis

    •Antiplatelet Agents

    I. Patient at high risk for CV event and low risk for complications if bleeding occurs—continue ASA (call surgeon or see list)

    II. Stop ASA 7 days prior to surgery where bleeding would be catastrophic (e.g. intracranial, spinal, urological procedures-see Table #2) or where pt low risk for CV event

    III. Avoid stopping dual antiplatelet therapy for PTCA < 2 weeks, BMS < 3 months, DESL < 12 months. ACC/AHA guidelines suggest MAY be able to stop Plavix after 6 months with DES but need to clear with cardiology. After this time continue ASA 81 mg and stop other agent. 

    IV. Stop Plavix(clopidogrel) x 7 days

    V. Stop Effient(parsogrel) x 7 days

    VI. Stop Brilinta(ticargrelor) x 5 days

    •Other Antiplatelet Agents

    a)Stop cilostazol(pletal) x 5 days

    b)Stop dipyridamole x 2 days

    c)Stop Aggrenox x 7 days

    •NSAID

    a)Stop 5-7 days prior to surgery. In case of Celebrex, if needed can consider to continue through surgery as little effect on platelets (elevated CV mortality)

    •Anticoagulants

    a)Coumadin—see bridging protocol

    INR > 3.0 STOP > to 6 days prior to surgery

    INR 2.0 to 3.0 STOP 5 days prior to surgery

    If any question, order preop PT/INR

    b)Dabigitran CRCL > 50 ml/min stop 2 days prior to surgery

    CRCL < 50 ml/min stop 3 to 5 days prior to surgery

    c)Rivaroxaban and apixaban—stop 2 days prior to surgery, only 1/3 renal cleared—consider additional time for severe renal disease

    d)SPINAL OR EPIDURAL ANESTHESIA—hold Factor Xa inhibitors or DTI 72 hours minimum before procedure

    6.  Psychiatric Medications

    •TCA—continue through surgery

    •SSRIs—may affect platelet function, generally continue

    •Lithium and Valprate—continue through surgery

    •Antipsychotics—may increase QT, especially with volatile anesthetics, continue with care for volatile anesthetics and antibiotics

    •Psychostimulants—for ADHD hold on day of surgery

    •Antianxiety Agents—continue through surgery

    •MAOIs - please hold 24 hours preoperatively

    •Muscle relaxants including Baclofen and Flexeril-continue throughout surgery.

    •Phentermine-used for weight loss. Stop 7 days before surgery

    7.  Chronic Opioid Therapy

    •Continue through surgery

    •For patients on high does narcotics, consider Pain Management consultation for management postoperatively

    •Suboxone—hold greater than or equal to 5 days prior. DO NOT resume until 2-3 days after patients last opioid dose.  Send pts to providers that are prescribers for instructions on hold/not hold

    •Contrave-Stop 72 hours before surgery

    •**Disulfiram(Antabuse)

    -Stop 10 days before surgery

    -May decrease effectiveness of analgesics/sedatives

    8.  Neurological Medications

    •Seizure medication—continue through surgery

    •Muscle relaxants-see under psych meds. Continue throughout surgery

    •Antiparkinson Medication

    a)Sinemet and Dopamine agonist—continue through surgery if patient will be taking oral meds. If expected period NPO (greater than or equal to several days) decrease dose by half the week prior to surgery to avoid Parkinsonism Hyperpyrexia Syndrome.

    b)MAOB—hold for two weeks before surgery

    c)Myasthenia Gravis

    i.Pyridostigmine (Mestinon)—continue through surgery

    9.  Rheumatologic Medications

    •NSAIDS—stop 5-7 days prior to surgery.

    •Non-biologic DMARDS

    a)Sulfasalazine, azathioprine, mycophenolate/cellcept, cyclophosphamide—consider holding one week prior to surgery due to neutropenia

    b)Methotrexate, hydroxychloroquine, leflunomide—continue through surgery

    c)Nonacetylated NSAIDs (i.e. salsalate) have no effect on PLT and can continue through surgery

    •Biologic DMARDS

    a)Hold for 2-3 half-lives before surgery—restart with wound closure ~ 2 weeks after surgery. Consult with rheumatology if any questions about medication management.

    i.  TFN

    Entanercept (Enbrel)—t ½ 3.5-5.5d—hold 7-10 days prior to surgery

    Apremilast—hold three days prior—resume when stitches out

    Infliximab (Remicade)—t ½ 9.5d—hold 3 weeks prior to surgery

    Adalimumab (Humira)—t ½ 10-20d—hold 4 weeks prior to surgery

    Certolizumab (Cimzia)—t ½ 14d—hold 4 weeks prior to surgery

    Golimumab (Simponi)—t ½ 14d—hold 4 weeks prior to surgery

    ii.  T cell cosimulator

    Abatacept (Orencia)—t ½ 13d—hold 4 weeks prior to surgery

    iii.  Interleukins antagonist

    Toxilizumab (Actemra)—t ½ 11-13d—hold 3 weeks prior to surgery

    Anakinra (Kineret)—t ½ 4-6 hrs—hold 1 day prior to surgery

    iv.  B cell depleting agent

    Rituximab (Rituxan)—t ½ 18 d—hold 4 weeks prior to surgery

    Tofacitimib (Xeljanz)—hold 5-7 d prior and resume 5-7 d post-op if ok

    Belimumab (BenLysta)—hold 3 wks prior to surgery and about 10-14 d after surgery

    Alirocumab (Praluent)—not immune modulating, do not need to stop for surgery

    Secukinumab (Cosentryx)—hold 4 wks prior to surgery and about 10-14 d after surgery

    •Gout Medications

    a)Hold Colchicine, allopurinol, and probenecid on day of surgery

    10.  Herbal Medications   *Stop all herbal supplements for two weeks prior to surgery

    a)Ginseng—increased bleeding risk

    b)Garlic—increased bleeding risk

    c)Ginkgo biloba—increased bleeding risk

    d)Ephedra (mahuang)—labile blood pressure

    e)Kava Kava—excess sedation

    f)St. John’s Wort—alters drug metabolism

    11.  Immunosuppressants for transplant

    --Continue through surgery

  3. Ordering Protocol for Labs and Imaging for Perioperative Evaluation

    Contributed by Elizabeth Olberding MD FHM FACP, Site Manager St. Luke’s Perioperative clinic

    *Sources for recommendations will be cited at the end of the document. These references included evidence based literature, best practice recommendations, expert opinion and advisory council recommendations. The overall consensus recommendation is to use the patient’s history to guide preoperative testing.

    Laboratory Evaluation

    CBC

    Patients with history of anemia

    History of recent GI bleeding

    Patients with CKD III or greater

    Patients undergoing surgeries with possible large blood loss including but not limited to joint surgery or joint revision, intra-abdominal surgery, urology procedures, large neurosurgical procedures including multiple level spinal surgeries, OB-GYN surgeries.

    No CBC in the system within one year unless low risk surgery or low risk for anemia

    History of cancer on recent chemotherapy

    History of liver disease

    Interval: Recommend 30-90 days before surgery unless clinical situation has changed

    Chemistry-basic

    Patients with hypertension

    Patients with diabetes

    Patients with chronic kidney disease

    On digoxin, lithium, seizure medications

    Morbid obesity

    Older patients > 65 due to risk of CKD

    Recent electrolyte abnormality without recheck

    ESRD patients and these patients need chem day of surgery also

    Interval: Within 30 days of surgery

    Chemistry-complete

    Patients with liver disease or known abnormality on LFT

    Patients with significant alcohol use

    Patients on medications with known hepatotoxicity

    Coagulation Studies

    Only indicated by H and P

    Known bleeding disorders

    On anticoagulation with warfarin

    History of liver disease or abnormal LFT

    HgA1C

    Diabetics, no A1C within 3 months 

    Elevated glucose on chemistry

    Urinalysis

    Major urologic procedures

    Should avoid routine preoperative UA unless patient has urinary symptoms. Asymptomatic bacteriuria leads to overuse of antibiotics.

    Nasal Swab for MRSA/MSSA

    Patients with surgeries with implants or mesh per St. Luke’s policy

    EKG 

    1.  Preoperative EKG is reasonable for patients with known CAD, arrhythmia, peripheral arterial disease, and cerebrovascular disease except those undergoing low risk surgery.  Level of evidence-B

    2.  Preoperative resting EKG may be considered for asymptomatic patients without known coronary artery disease except for low risk surgery.  Level of evidence-B

    3.  Routine Preoperative EKG is not useful for asymptomatic patients undergoing low risk surgery.  Level of evidence-B

    4.  The implications of abnormalities on Preop EKG increases with age and risks for CAD. A standard age of risk factor cutoff for the use of preoperative EKG has not been defined. The optimal time interval for an EKG preoperatively has not been determined but within 3 to 6 months is reasonable. (Expert opinion)

    5.  See attachment on EKG recommendations per ACC/AHA update 2014

    Chest X-Ray

    Based on clinical situation and patient’s clinical presentation. Should be ordered by physician based on clinical situation and not routinely. 


    References:

    2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Non-Cardiac Surgery. Jour Am Coll Card; Vol 64 No. 22, 2014. 77-127

    Practice Advisory for Pre-anesthesia Evaluation: Updated Report by the American Society of Anesthesiologists Task Force on Pre-anesthesia Evaluation. Anesthesiology 2012; 116:522-38.

    Pursuit of Abnormal Coagulation Screening Tests Generates Modest Hidden Preoperative Costs. Bushick et al. Journal of General Internal Medicine Vol 4, 1989; 439-497.

    Optimal Preoperative Assessment of the Geriatric Surgical Patient: Best Practice Guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society: Chow et al, J Am Coll Surg; Vol 215, No 4. 2012 453-465.

    Preoperative evaluation of patients with liver disease. Hanje, James et al. Gastroenterology and Hepatology, May 2007, Vol 4 No 5, 266—276.

    Preoperative Evaluation Clinic Visit is Associated with Decreased Risk of In-hospital Postoperative Mortality. Blitz, MD et all. Anesthesiology 2016; 125: 280-94.

    Top Ten Myths Regarding the Diagnosis and Treatment of Urinary Tract Infections. Schulz, L et al. The Journal of Emergency Medicine, Vol 51, No 1, pp 25-30 2016.

    Update on Perioperative Medicine: Mayo Clinic Meeting. Expert Opinion meeting, Oct 9-11, 2018. 

  4.    Perioperative Management of Cardiac Implantable Devices:

    Pacemakers and Implantable Cardioverter-Defibrillators

    Definitions

    AICD-Automatic Implantable Cardioverter-Defibrillator

    CIED-Cardiac implantable electrical device (global term for devices)

    EMI-Electromagnetic interference

    ICD-Implantable Cardioverter-Defibrillator

    PM-Pacemaker

    1.  All perioperative patients with CIED (cardiac implantable electrical device) should be identified prior to scheduled procedure and been seen by Pre-admission testing (PAT) or Peri-operative Medicine clinic.

    2.  All patients with an ICD should be interrogated within 6 months of procedure.

    3.  All patients with a pacemaker should be interrogated within 1 year of procedure.

    4.  The following CIED information should be available on day of surgery.

    a.Type of device (pacemaker/ICD) and manufacturer

    b.Device setting and mode

    c.Indication for device implantation

    d.Patient’s underlying rhythm and pacemaker dependency

    e.Current battery life expectancy

    f.Response of device to magnet (pacemakers will pace asynchronously and ICDs will have their tachy (shock) therapy disabled)

    5.  This information should be obtained by proceduralist team in coordination with the patient’s CIED team (cardiologist) or by referral through the pre-anesthesia clinic (PAT).

    6.  For emergent procedures, this information can be obtained via patient’s device card or upon examination of a chest x-ray and coordination with device manufacturer. (ICDs will have a much thicker and radiopaque portion of the ICD lead, usually in the RV and near the RA/SVC junction).

    7.  The anesthesia team will coordinate with the procedure team in developing a plan for reducing exposure to EMI (electromagnetic interference), which may include placement of a removable magnet or CIED reprogramming on day of surgery by CIED team. CIED reprogramming may be required if:

    a. Anatomical location of procedure is near device (shoulder, chest, or breast surgery)

    b. Patient positioning such that a magnet cannot be used (prone, lateral, severe obesity, etc.)

    c. In general, surgery below the umbilicus will not affect a pacemaker or ICD, and rarely is reprogramming necessary, but a magnet should be immediately available.

    d. In general, a magnet should be sufficient in surgeries above the umbilicus. The operator is encouraged to utilize brief bursts of monopolar electrocautery (the vast majority of surgical cautery) which would minimize pacemaker inhibition or ICD oversensing.

    e. Inactivation of an ICD is recommended for all surgeries above the umbilicus

    f. Rendering a PM asynchronous (with a magnet or pre-op reprogramming) is preferable for surgeries or electrocautery above the umbilicus.

    g. It is helpful if the ground pad or return electrode for the electrocautery can be placed so that the current would not cross the PM, ICD, or leads and if the current path is kept 6 inches from the PM, ICD, or leads

    8.  Intraoperatively, patients with CIED will be monitored with continuous ECG with a pacing mode set to recognize pacing stimuli. External defibrillation equipment should be available in procedures where EMI may occur.

    9.  All patients with ICD’s deactivated should be on continuous cardiac monitor and should have immediate ability of defibrillation until ICD is re-activated.

    10.  Post-procedural device reprogramming/ interrogation will occur prior to discharge from a cardiac telemetry environment if:

    a. Device was reprogrammed to be nonfunctional such as disabling tachycardia detection in ICD or a PM in an asynchronous mode

    b. Any intraoperative events suspicious for EMI

    c. At the discretion of the procedural or anesthesia teams.

    References:

    1.Crossley GH et al. The Heart Rhythm Society Expert Consensus Statement on the perioperative management of patient with implantable defibrillators, pacemakers and arrhythmia monitor: Facilities and patient management. Heart Rhythm 8:1114-1154, 2011.

    2.Practice advisory for the perioperative management of patients with cardiac implantable electronic devices: pacemakers and implantable cardioverter-defibrillators: an updated report by the American Society of Anesthesiologists task force on perioperative management of patients with cardiac implantable electronic devices. Anesthesiology 114:247-61, 2011.

  5. 1.  It is safe for mothers to resume breastfeeding after anesthesia as soon as they feel ready. There is no need to routinely

    “pump-and-dump”.

    2.  Mothers should “pump” if they do not feel capable of breastfeeding after anesthesia and feel engorged.

    3.  Postoperatively, almost all short and medium duration PO and IV pain medications are safe for breastfeeding mothers, but may result in the infant sleeping for greater periods.

    4.  Breastfeeding mothers receiving long acting opioids (Ex; Methadone, Duragesic, oxycodone, etc.), long acting benzodiazepines (Ex; diazepam), or other chronic use pain/anxiety/sedation medication should be followed by a specialized medical team and do not fall under this policy.

    5.  For mothers that are chronically taking sedatives/narcotics OR for premature infants, breastfeeding recommendations will be on a case by case basis. 


    Explanation of Policy

    • Most of our anesthetic drugs are fat soluble

    • The lipid content of the brain >>> Breast Milk >>> plasma

    • We indirectly measure the concentration anesthetic drugs in the brain biased on the clinical response (sedation-to- anesthesia).

    • When the patient is “awake” the patient has subanesthetic drug concentration in the brain, so breast milk concentration is substantially lower.

    • Although lactating tissue is lipid dense, it also has very high blood flow, resulting in drug concentration levels near plasma levels (unlike adipose tissue stores in waist, hips, etc.).

    Example;

    A lactating mother is administered 10 mg IV morphine and wishes to breastfeed 20 minutes later

    D(total dose) = C(milk) * V(milk)

    D(total dose) – total dose of drug ingested by baby

    C(milk) – concentration of drug in Mother’s breast milk

    V(milk) – Volume of milk per feed (~ 40 to 200 ml)

    • Weight of patient 50 kg (small woman)

    • Weight of Baby 3.5 kg

    • Plasma distribution ½ time of morphine = 4.4 min

    • Plasma elimination ½ time of morphine = 111 min

    • Volume of distribution for morphine = 5.4 L/kg

    • EC50 of morphine for post-op analgesia = 0.0015 mg/ml

    • Dose of Morphine = 10mg / 60 kg = 0.1666667 mg/kg morphine

    • The drug is considered distributed after three plasma distribution ½ times, which is ~ 13 minutes. So the distribution of morphine is complete

    • Let’s assume that plasma morphine concentration approximates breast milk concentration (at its short peak, breast tissue may be 1.5 to 2 times greater than plasma)

    • Maternal plasma morphine concentration is 0.1666667 mg/kg ÷ 5.4 L/kg = 0.031 mg/ml (D(total dose) = C(milk) * V(milk))

    • The baby drinks 200 ml of breast milk which results in an infant PO morphine dose of 0.0062 mg or 0.0018 mg/kg

    • The pediatric PO dose of morphine is 0.1 to 0.3 mg/kg (up to 1 mg for our example)

    • This subtherapeutic dose is now subject to the baby’s hepatic metabolism (first pass effect)

    References

    1.Ilett, K.F. Drug distribution in human milk. Australian Prescriber 1997. 20, 35-40

    2.Seivers, E., et al. Feeding patterns in breast-fed and formula-fed infants. Annals of Nutrition and Metabolism 2002. 46, 243-248

    3.Wittels, B., et al. Postcesarean analgesia with both epidural morphine and intravenous patient controlled analgesia: neurobehavioural outcomes

    among nursing neonates. Anesthesia & Analgesia 1997. 85, 600-606

    4.Nitsun, M., et al. (2006). Pharmacokinetics of midazolam, propofol, and fentanyl transfer to human breast milk. Clinical pharmacology and

    therapeutics, 79(6), 549–57.

    5.Chestnut’s Obstetrical Anesthesia 4th edition.

    Contributed by Eric Deutsch, MD 8/22/13