What medications are commonly used for indoor preparation prior to surgery?

Medications Commonly Used for Preoperative Preparation

The most effective preoperative medication regimen includes acetaminophen, NSAIDs, and gabapentinoids for pain management, along with appropriate antimicrobial prophylaxis, while avoiding benzodiazepines especially in elderly patients. 1

Multimodal Preoperative Pain Management

• Acetaminophen: Should be administered preoperatively as part of multimodal analgesia to reduce postoperative opioid requirements and provide effective pain relief 1, 2
• NSAIDs: Should be administered preoperatively unless contraindicated (e.g., bleeding risk, renal dysfunction) to provide opioid-sparing effects 1, 3
• Gabapentinoids (gabapentin, pregabalin): Should be limited to a single, lowest effective preoperative dose to minimize sedative side effects while providing opioid-sparing benefits 1
  • Dose adjustment is necessary for elderly patients and those with renal dysfunction 1
  • Higher doses increase risk of sedation, dizziness, and visual disturbances 1

Antimicrobial Prophylaxis

• Cefazolin: Should be administered 30-60 minutes before surgical incision 1, 4
  • Standard dose: 1-2g IV for adults 4
  • Additional doses should be given during prolonged operations according to drug half-life 1
• Skin preparation: Chlorhexidine-alcohol should be used for skin antisepsis 1

Anxiolysis and Sedation

• Avoid benzodiazepines: Long or short-acting sedative medications should be avoided preoperatively, especially in elderly patients (≥65 years) 1
  • Benzodiazepines can cause psychomotor impairment, cognitive dysfunction, and increased risk of delirium 1
  • The American Geriatrics Society Beers Criteria strongly recommends against benzodiazepines in older patients 1
• Alternative anxiolytics: If anxiolysis is needed, consider melatonin which provides effective preoperative anxiolysis with fewer side effects compared to benzodiazepines 1
• Patient education: Preoperative education can effectively reduce anxiety without medication 1

Special Considerations for Patients on Chronic Medications

• Buprenorphine: For patients on buprenorphine for pain or opioid use disorder, individualize management based on dose and expected postoperative pain 1
  • For minor procedures with expected low pain: continue buprenorphine without taper 1
  • For procedures with moderate-severe pain: consider dose adjustment 2-3 days before surgery 1
• Antidepressants (e.g., desvenlafaxine): Should be continued perioperatively to avoid withdrawal symptoms 5
• Opioid agonists: For patients on chronic opioid therapy, continue baseline medications and plan for higher postoperative opioid requirements 1

Timing of Preoperative Medications

• Fasting guidelines: Clear liquids allowed up to 2 hours and solids up to 6 hours before anesthesia induction 1
• Timing of analgesics: Administer oral preoperative analgesics with timing to achieve optimal effect coinciding with surgical incision 1
• Antimicrobial timing: Administer 30-60 minutes before incision for optimal tissue levels at time of surgery 1, 4

Combination Therapy Benefits

• The combination of acetaminophen and ibuprofen provides superior analgesia compared to either medication alone, with reduced need for rescue analgesia 6
• Multimodal analgesia (combining different classes of medications) reduces opioid requirements and associated side effects 1, 7

Cautions and Contraindications

• NSAIDs: Avoid in patients on curative doses of anticoagulants due to increased bleeding risk 1
• Gabapentinoids: Use with caution in elderly patients and those with renal dysfunction; adjust dose accordingly 1
• Benzodiazepines: Avoid in elderly patients due to increased risk of delirium, falls, and cognitive impairment 1