What are the typical medications used for indoor preparation (preoperative) for 2-3 days prior to surgery?

Indoor Preoperative Medication Protocol for 2-3 Days Before Surgery

The optimal indoor preoperative medication protocol for 2-3 days before surgery should include opioid-sparing multimodal medications (acetaminophen, NSAIDs, and a single dose of gabapentinoid), antimicrobial prophylaxis within 60 minutes of incision, and avoidance of benzodiazepines, especially in elderly patients. 1

Multimodal Pain Management Medications

• Acetaminophen should be administered orally before surgery as part of a multimodal opioid-sparing approach 1
• NSAIDs should be included in the preoperative regimen unless contraindicated by patient factors such as renal dysfunction 1
• Gabapentinoids (gabapentin or pregabalin) should be limited to a single lowest effective dose to minimize adverse effects such as sedation, dizziness, and visual disturbances 1
  • All doses of pregabalin (75mg, 100-150mg, and 300mg) provide opioid-sparing effects at 24 hours after surgery 1
  • Dose adjustment is necessary for elderly patients and those with renal dysfunction 1

Antimicrobial Prophylaxis

• Intravenous antibiotic prophylaxis should be administered within 60 minutes before surgical incision 1
• For colorectal surgery, a cephalosporin in combination with metronidazole is preferred 1
• Single-dose administration is sufficient; no benefit has been shown for repeated administration 1
• For dental procedures or sinus surgery, specific antimicrobial protocols may vary based on procedure type 1
• For patients undergoing maxillary sinus floor augmentation, antibiotic prophylaxis (e.g., amoxicillin 500mg TID for 7 days or clindamycin 300mg TID for 10 days if penicillin-allergic) is recommended, starting 2 days prior to surgery 1

Anxiolytic Management

• Preoperative education should be the primary method to reduce patient anxiety rather than pharmacologic anxiolysis 1
• Benzodiazepines should be avoided, especially in elderly patients (aged 65 and older) due to increased risk of cognitive impairment, delirium, and falls 1
• If anxiolysis is necessary, melatonin (tablets or sublingual) provides effective preoperative anxiolysis with fewer side effects compared to placebo and is equally effective to midazolam 1

Steroid Administration

• Steroids (methylprednisolone) may be used before hepatectomy in patients with normal liver parenchyma to decrease liver injury and intraoperative stress 1
• Steroids should be avoided in diabetic patients due to impaired glycemic control after hepatectomy 1
• For maxillary sinus floor augmentation, corticosteroids in decreasing daily doses (e.g., dexamethasone 8mg day of surgery, 6mg day after, 4mg two days after, and 2mg three days after) may be considered to reduce postoperative edema and trismus 1

Management of Chronic Medications

• Continue opioid agonists on the morning of surgery to prevent withdrawal and maintain pain control 2
• Continue conventional DMARDs (methotrexate, leflunomide, hydroxychloroquine, sulfasalazine, and apremilast) through surgery 2
• Continue glucocorticoids at the current daily dose rather than administering supraphysiologic doses 2
• Withhold biologics prior to surgery and plan surgery after the next dose is due 2
• Withhold JAK inhibitors (tofacitinib, baricitinib, upadacitinib) for at least 3 days prior to surgery 2
• Withhold SGLT2 inhibitors the day before and day of surgery to reduce the risk of ketoacidosis 2

Common Pitfalls to Avoid

• Administering benzodiazepines to elderly patients increases risk of postoperative delirium 1
• Using multiple doses of gabapentinoids increases risk of sedation, dizziness, and peripheral edema without improving pain outcomes 1
• Administering antibiotics too early (>2 hours before incision) or too late (>3 hours after incision) increases surgical site infection risk 3
• Abrupt discontinuation of medications with withdrawal potential can lead to significant morbidity 2
• Continuing SGLT2 inhibitors through surgery increases the risk of ketoacidosis, especially with prolonged fasting 2

Additional Considerations

• For patients undergoing maxillary sinus floor augmentation, non-steroidal anti-inflammatory medication (e.g., ibuprofen 600mg TID) or analgesics (e.g., acetaminophen 500mg TID) should be prescribed to control postoperative swelling and discomfort 1
• Opioids should be reserved for specific situations where first-line therapy is not effective 1
• For colon surgery, oral antibiotics (ciprofloxacin 750mg every 12h and metronidazole 250mg every 8h) the day before surgery significantly reduces surgical site infections 4