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If a drug is needed for treatment preoperatively, it should be continued through surgery. We provide patients and other professionals with a detailed list ( Table 27-51 ) that we supply through our preanesthesia and preprocedure assessment clinic. It must often be specifically requested because many patients and nurses perceive the NPO directive to include drugs.[1037] [1038] The only exception to this general rule of not altering preoperative drug therapy might pertain to (1) MAOIs, (2) anticoagulants and fibrinolytic
| Drug (Trade Name) | Toxicities and Specific Treatments |
|---|---|
| Glaucoma: Primary goal is to reduce IOP by | |
| Miotics and epinephrine: increase outflow of aqueous humor | |
| β-Blockade and carbonic anhydrase inhibitors: reduce production of aqueous humor | |
| Osmotic drugs: transiently decrease volume | |
| Miotics |
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| Parasympathomimetics |
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| Pilocarpine (Adsorbocarpine, Isopto Carpine, Pilocar, Pilocel) |
|
| Carbachol |
|
| Acetylcholinesterase inhibitors | Tox: Hypersalivation, sweating, N/V, bradycardia, hypotension, bronchospasm, CNS effects, coma, respiratory arrest, death |
| Physostigmine |
|
| Demecarium | Rx: Atropine, pralidoxime (Protopam) |
| Isoflurophate (Floropryl) | Ix: Succinylcholine—prolonged apnea (drugs must be discontinued 4 wk before) |
| Echothiophate (Echodide, Phospholine) |
|
| Epinephrine (Epitrate, Murocoll, Mytrate, Epifrin, Glaucon, Epinal, Eppy) | Tox: (rare) Tachycardia, PVCs, HTN, headache, tremors |
|
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Ix: Avoid drugs that sensitize to catecholamines, e.g., halothane |
| β-Blockers | Tox: J-blockade with bradycardia, exacerbation of asthma, CNS depression, lethargy, confusion |
| Timolol (Timoptic) |
|
| Betaxolol (Betoptic [? β1 selective]) | Synergy noted with systemic drugs |
| Levobunolol (Betagan) |
|
| Carbonic anhydrase inhibitors | Tox: Anorexia, Gl disturbances, "general miserable feeling" and malaise, paresthesias, diuresis, hypokalemia (transient), renal colic and calculi, hyperuricemia, thrombocytopenia, aplastic anemia, acute respiratory failure in patients with COPD |
| Acetazolamide (Diamox) |
|
| Dichlorphenamide (Daranide, Oratrol) |
|
| Ethoxzolamide (Cardrase, Ethamide) |
|
| Methazolamide (Neptazane) |
|
| Osmotic drugs | Tox: Dehydration, hyperglycemia, nonketotic hyperosmolar coma (rare). Fatalities with mannitol secondary to CHF or intracranial bleeding |
| Glycerin (Glyrol, Osmoglyn) |
|
| Isosorbide (Ismotic) |
|
| Urea (Urevert, Ureaphil) | Urea may cause thrombosis |
| Mannitol (Osmitrol) |
|
| Intraocular acetylcholine (Miochol) | Tox: Hypotension, bradycardia |
|
|
Rx: Atropine |
| Mydriatics and cycloplegics: Provide pupillary dilatation and paralysis of accommodation | |
| Anticholinergics block muscarinic receptors; paralyzing in iris | |
| α-Adrenergics contract the dilator of the iris | |
| Anticholinergics | Tox: Dry mouth, flushing, thirst, tachycardia, seizure, hyperactivity, transient psychosis, rare coma, and death |
| Atropine (Atropisol, Bufopto, Isopto Atropine) |
|
| Cyclopentolate, alone (Cyclogyl) or with phenylephrine-homatropine (Cyclomydril) | Rx: Physostigmine |
| Scopolamine tropicamide (Homatrocel, Isopto Homatropine, Isopto Hyoscine, Murocoll #19, Mydriacyl) |
|
| α-Adrenergics | Tox: Tachycardia, HTN, PVCs, myocardial ischemia, agitation |
| Phenylephrine (Efricel, Mydfrin, Neo-Synephrine) |
|
| Hydroxyamphetamine (Paredrine) |
|
| CHF, congestive heart failure; CNS, central nervous system; COPD, chronic obstructive pulmonary disease; Gl, gastrointestinal; HTN, hypertension; IOP, intraocular pressure; Ix, interaction; N/V, nausea and vomiting; PVCs, premature ventricular contractions; Rx, treatment; Tox, toxicity. | |
When in doubt about a disease or a drug, we consult the following textbooks: Harrison's Principles of Internal Medicine; Anesthesia and Uncommon Diseases: Pathophysiologic and Clinical Correlations; Anesthesia and Co-Existing Disease; Essence of Anesthesia Practice; Anesthetic Implications of Congenital Anomalies in Children; Pharmacology and
| Instruct patients to take the following medications with a small sip of water EVEN IF OTHERWISE NPO: |
| Antihypertensive medications—Continue on the day of the operation or procedure |
| Diuretics—Continue on the day of the operation or procedure |
| Cardiac medications (e.g., digoxin)—Continue on the day of the procedure |
| Antidepressant, antianxiety, and psychiatric medications—Continue on the day of the operation or procedure |
| Thyroid medications—Continue on the day of the operation or procedure |
| Birth control pills—Continue on the day of the operation or procedure |
| Eye drops—Continue on the day of the operation or procedure |
| Heartburn or reflux medications (e.g., Prilosec, Zantac)—Continue on the day of the operation or procedure |
| Narcotic pain medications—Continue on the day of the operation or procedure |
| Antiseizure medications—Continue on the day of the operation or procedure |
| Asthma medications—Continue on the day of the operation or procedure |
| Steroids (oral and inhaled)—Continue on the day of the operation or procedure |
| Statins (e.g., Zocor, Lipitor)—Continue on the day of the operation or procedure |
| Aspirin—Usually continue; discontinue 7 days before plastic surgery and surgery on the retina |
| COX-2 inhibitors—Continue on the day of the operation or procedure unless the surgeon specifies (usually concerned about bone healing) |
| NSAIDs—Usually continue; discontinue 48 hr before plastic surgery and surgery on the retina |
| Vitamins, iron, Premarin—Discontinue on the day of the operation or procedure |
| Topical medications (e.g. creams and ointments)—Discontinue on the day of the operation or procedure |
| Oral hypoglycemic drugs—Discontinue on the day of the operation or procedure |
| Insulin—For all patients, discontinue all regular or combination (70/30 preparations) insulin on the day of the operation or procedure. Type 2 diabetics should discontinue all insulins of any type. Type 1 diabetics should take a small amount (usually ⅓) of their usual AM long-acting insulin (e.g., Lente or NPH) on the day of the operation or procedure. Type 1 diabetics should not take any short-acting insulin such as regular insulin on the day of the procedure. Patients with an insulin pump should continue their basal rate only. |
| Viagra, Levitra, Cialis or similar drugs—Discontinue 36 hr before surgery |
| Warfarin (Coumadin)—Discontinue 4 days before surgery except for patients undergoing cataract surgery without a bulbar block |
| Plavix (clopidogrel)—Discontinue 7 days before surgery except for vascular patients or those undergoing cataract surgery |
| Herbals and nonvitamin supplements—Discontinue 7 days before surgery |
| MAOIs—Patients taking these antidepressant medications need an anesthesia consultation before surgery (preferably 3 wk before surgery) |
| COX, cyclooxygenase; MAOIs, monoamine oxidase inhibitors; NPO, nothing by mouth; NSAIDs, nonsteroidal anti-inflammatory drugs. |
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