Will skipping the morning dose of gabapentin (Neurontin) and myotop (generic name not specified, possibly a brand name for a muscle relaxant) affect the patient's condition who is scheduled for debridement of soft tissue surgery and is currently nil per os (NPO)?

Perioperative Management of Gabapentin and Myotop for NBM Patient

Continue gabapentin on the morning of surgery with a small sip of water, even though the patient is NBM (nil by mouth), as skipping the dose may increase risks of withdrawal seizures, inadequate pain control, and postoperative complications. 1, 2

Gabapentin Perioperative Management

Why Continue Gabapentin

• Gabapentin should be administered preoperatively as part of multimodal opioid-sparing analgesia, with timing optimized to achieve peak effect at surgery onset 1
• The ERAS Society specifically recommends gabapentinoids as pre-anesthetic medication for opioid-sparing effects, administered orally before surgery 1
• Abrupt discontinuation of gabapentin can precipitate withdrawal seizures, even in patients without prior seizure history, particularly in those on chronic therapy 3
• A single preoperative dose of gabapentin (1200 mg) significantly reduces postoperative morphine consumption and pain scores specifically in burn debridement surgery patients 4

Administration Guidelines

• Gabapentin can be taken with a small sip of water (typically 30-50 mL) even when NBM, as this minimal fluid volume does not increase aspiration risk 1
• For debridement surgery, administer gabapentin 2 hours before the procedure to achieve optimal pharmacodynamic effect 1, 4
• The FDA label permits gabapentin administration with or without food, making NBM status not a contraindication 2

Dosing Considerations

• If the patient is on chronic gabapentin therapy, continue the morning dose at the usual prescribed amount 2, 5
• For opioid-sparing in surgery, a single preoperative dose of 1200 mg has proven efficacy in burn wound debridement specifically 4
• Adjust dose if renal impairment is present (creatinine clearance <60 mL/min requires dose reduction per FDA guidelines) 2

Important Safety Considerations

Postoperative Monitoring

• Patients on chronic gabapentin who continue therapy postoperatively have significantly increased risk of requiring naloxone for over-sedation or respiratory depression (OR 6.30,95% CI 2.4-16.7) 5
• Elderly patients (≥65 years) receiving perioperative gabapentin have increased risk of delirium (RR 1.28), new antipsychotic use (RR 1.17), and pneumonia (RR 1.11) 6
• Enhanced postoperative monitoring is warranted, particularly for patients with obstructive sleep apnea, high comorbidity burden, or chronic kidney disease 5, 6

Withdrawal Risk

• Missing even 2 days of gabapentin in patients on chronic high-dose therapy can precipitate status epilepticus, as documented in a patient on 8000 mg/day 3
• Gabapentin discontinuation should be gradual over minimum 1 week, not abrupt 2

Myotop (Muscle Relaxant) Management

The morning dose of myotop can be safely skipped for NBM status, as:

• Muscle relaxants are not part of evidence-based perioperative protocols and are not mentioned in ERAS guidelines 1
• Unlike gabapentin, muscle relaxants do not have documented withdrawal seizure risk and are not critical for multimodal analgesia 1
• Muscle relaxants may contribute to postoperative sedation without clear analgesic benefit 1

Clinical Algorithm

1. Verify patient's chronic gabapentin dose and indication (pain vs. seizure disorder)
2. Check renal function - adjust gabapentin dose if CrCl <60 mL/min 2
3. Administer gabapentin 2 hours preoperatively with small sip of water (30-50 mL) 1, 4
4. Hold myotop on morning of surgery - not essential for perioperative care 1
5. Arrange enhanced postoperative monitoring if patient is elderly, has OSA, or high comorbidity burden 5, 6
6. Resume gabapentin postoperatively cautiously, recognizing increased naloxone risk with continuation 5

Common Pitfalls to Avoid

• Do not withhold gabapentin due to NBM status - the small amount of water needed poses negligible aspiration risk 1, 2
• Do not assume all oral medications must be held NBM - critical medications like gabapentin should continue 1
• Do not underestimate withdrawal risk - even short interruptions can cause seizures in chronic users 3
• Do not overlook renal dosing adjustments - gabapentin is renally cleared and requires dose reduction in renal impairment 2