Can patients who are NPO (nothing by mouth) for surgery still take PO (per oral) blood pressure medication?

Management of Oral Blood Pressure Medications in NPO Patients for Surgery

Patients who are NPO (nothing by mouth) for surgery should continue taking their oral blood pressure medications with a small sip of water on the morning of surgery, with the exception of ACE inhibitors and ARBs which may be discontinued 24 hours before surgery.

Preoperative Management of Antihypertensive Medications

Medications to Continue

• Beta blockers should be continued in patients who have been taking them chronically, particularly when prescribed according to guideline-directed medical therapy, to reduce the risk of rebound hypertension 1, 2
• Calcium channel blockers should be continued until the day of surgery 2
• It is reasonable to continue most antihypertensive medications until surgery with a small sip of water, even when NPO 1
• Diuretics for hypertension can typically be discontinued on the day of surgery and resumed orally when possible 1
• Diuretics for heart failure should be continued up to the day of surgery 1

Medications to Consider Discontinuing

• ACE inhibitors or ARBs may be discontinued 24 hours before surgery to reduce the risk of intraoperative hypotension 1, 3
• Recent evidence shows that patients who stopped ACE inhibitors or ARBs 24 hours before noncardiac surgery were less likely to experience adverse outcomes including death, stroke, myocardial injury, and intraoperative hypotension 1

Medications Never to Discontinue Abruptly

• Abrupt preoperative discontinuation of beta blockers or clonidine is potentially harmful due to the risk of rebound hypertension 1, 2
• If patients are unable to take oral medications, parenteral beta blockers and transdermal clonidine may be used as alternatives 1

Blood Pressure Thresholds and Surgical Timing

• For patients with planned elective major surgery and severe hypertension (≥180/110 mmHg), deferring surgery may be considered 1
• The American Heart Association recommends aiming for blood pressure control to levels <130/80 mmHg before undertaking major elective procedures 1, 2
• For mild to moderate hypertension without associated metabolic or cardiovascular abnormalities, there is no evidence that delaying surgery is beneficial 1, 4

Intraoperative Management

• If oral medications cannot be taken, intravenous alternatives should be used to maintain blood pressure control 1
• Patients with intraoperative hypertension should be managed with intravenous medications (such as clevidipine, esmolol, or nicardipine) until oral medications can be resumed 1, 5
• Assess other potential contributing factors to perioperative hypertension, such as volume status, pain control, oxygenation, and bladder distention 1, 2

Common Pitfalls and Considerations

• Never start beta blockers on the day of surgery in beta blocker–naïve patients as this increases risk of harm 1, 2
• Hypertensive patients are more likely to develop intraoperative hypotension than normotensive patients, particularly those taking ACE inhibitors or ARBs 1
• Intraoperative hypotension may be associated with a greater incidence of perioperative cardiac and renal complications 1
• Uncontrolled hypertension increases the risk of cardiovascular disease, cerebrovascular events, and bleeding during the perioperative period 1, 2, 6
• Approximately 25% of patients undergoing major noncardiac surgery and 80% of patients having cardiac surgery experience perioperative hypertension 1

Special Considerations for Specific Medications

• For patients on diuretics, electrolyte disturbances (especially hypokalemia and hypomagnesemia) should be corrected before surgery 1
• If intravenous antihypertensive therapy is needed, hydralazine, methyldopate, enalaprilat, and nicardipine are appropriate options for patients temporarily requiring IV medications for controlling chronic hypertension 5
• In ambulatory surgery settings, some evidence suggests that continuing all cardiac medications (including ACE inhibitors and ARBs) may be acceptable as any resulting hypotension typically responds to simple treatments 7