Perioperative Medication Management for Elective Cubital Tunnel Release
Direct Answer
For elective cubital tunnel release, continue lisinopril, Lipitor, Procardia, Paxil, and Remeron through surgery, but stop Lyrica on the morning of surgery and restart postoperatively.
Medication-Specific Recommendations
Lisinopril (ACE Inhibitor)
- Continue perioperatively for this minor peripheral nerve surgery 1
- The American College of Cardiology recommends continuation of ACE inhibitors for most patients undergoing non-cardiac surgery, with particular emphasis on continuation for minor procedures 1
- While withholding ACEIs 24 hours before elevated-risk surgery may limit intraoperative hypotension, cubital tunnel release is a low-risk peripheral procedure where the cardiovascular benefits of continuation outweigh minimal hypotension risk 1
- If held, restart as soon as clinically feasible postoperatively 1
Lyrica (Pregabalin)
- Hold on the morning of surgery to avoid excessive sedation and potential interaction with anesthesia
- Restart postoperatively once the patient is alert and tolerating oral intake
- No specific guideline evidence addresses pregabalin for minor hand surgery, but standard practice avoids unnecessary CNS depressants perioperatively
Lipitor (Atorvastatin)
- Continue through surgery 1
- Statins provide cardiovascular protection and have no bleeding risk
- No evidence supports discontinuation for any surgical procedure
- Abrupt discontinuation may increase cardiovascular risk
Procardia (Nifedipine - Calcium Channel Blocker)
- Continue through surgery 2
- The European Society of Cardiology recommends calcium channel blockers can generally be continued during non-cardiac surgery 2
- Unlike ARBs, CCBs do not typically cause significant intraoperative hypotension that would warrant discontinuation 2
- Calcium channel blockers reduce perioperative ischemia and supraventricular tachycardia 2
Paxil (Paroxetine - SSRI)
- Continue through surgery
- Abrupt discontinuation of SSRIs can cause withdrawal symptoms including anxiety, dizziness, and mood changes
- SSRIs have minimal bleeding risk in minor procedures
- No guideline evidence supports discontinuation for peripheral nerve surgery
Remeron (Mirtazapine)
- Continue through surgery
- Abrupt discontinuation can cause withdrawal symptoms
- No significant bleeding risk or anesthetic interaction
- Provides benefit for mood and sleep that aids postoperative recovery
Key Clinical Considerations
Bleeding Risk Context
- Cubital tunnel release is a low bleeding risk procedure involving peripheral nerve decompression without major vascular structures 3, 4
- The primary surgical concerns are nerve injury, medial antebrachial cutaneous nerve damage, and postoperative ulnar nerve kinking—not bleeding 5
- None of these medications significantly increase bleeding risk in this surgical context
Common Pitfalls to Avoid
- Do not discontinue cardiovascular medications unnecessarily for minor peripheral procedures, as this increases cardiovascular risk without meaningful bleeding benefit 1
- Ensure clear communication about which medications to take on the morning of surgery to avoid patient confusion 1
- Avoid abrupt psychiatric medication discontinuation, which can cause withdrawal symptoms that complicate postoperative recovery
- Monitor for intraoperative hypotension if continuing lisinopril, though this is rarely problematic in peripheral nerve surgery under regional anesthesia 1
Postoperative Management
- Resume all medications as soon as the patient is tolerating oral intake
- Lyrica should be restarted at the preoperative dose once the patient is alert
- Monitor blood pressure after restarting lisinopril if it was held 2
Algorithm Summary
Morning of Surgery:
- ✓ Take: Lisinopril, Lipitor, Procardia, Paxil, Remeron
- ✗ Hold: Lyrica only
Postoperatively:
- Resume Lyrica once alert and tolerating oral intake
- Continue all other medications without interruption