From the Guidelines
Medications can be taken periprocedurally, but with caution and careful consideration of the specific medication and patient factors.
Periprocedural Medication Management
- The decision to continue or withhold medications periprocedurally depends on the type of medication, the patient's medical history, and the surgical procedure 1.
- Sedative medications should be avoided whenever possible, as they can delay postoperative recovery and impair mobility and oral intake 1.
- Opioid analgesics can be continued periprocedurally, but with careful consideration of the patient's opioid tolerance and the potential for increased dosing or adjunctive nonopioid analgesia 1.
- Beta blockers can be effective in reducing the risk of in-hospital mortality and perioperative myocardial ischemia, and can be continued periprocedurally in patients without contraindications 1.
- Muscle relaxants, such as baclofen, can be taken preoperatively, including on the day of operation, but with careful consideration of potential drug interactions and adverse effects 1.
- Buprenorphine, a partial mu opioid receptor agonist, can be continued periprocedurally, but with careful consideration of the patient's dose and potential for withdrawal symptoms 1.
From the Research
Periprocedural Management of Medications
- The management of patients taking oral anticoagulants in the peri-procedural period poses a challenge due to the competing risks of thrombosis and hemorrhage 2.
- The decision to interrupt or continue anticoagulants is anchored on patient and procedure-related risks for bleeding and thrombosis 3.
- For many procedures, anticoagulants can be safely continued without interruption, whereas in cases where anticoagulants cannot be safely continued, the timing of interruption and resumption, as well as the need for heparin bridging, requires consideration 3, 4.
Medication Interruption and Bridging
- Bridging therapy has been used to minimize time without anticoagulation when warfarin is interrupted for invasive procedures, but validated strategies based on high-quality data are lacking 2.
- The use of bridging therapy may increase the risk of bleeding for some patients without reducing the risk of thrombosis 2.
- There is a diminishing role for periprocedural bridging low molecular weight heparin (LMWH) overall and no role for bridging LMWH for the procedural interruption of direct oral anticoagulants (DOACs) 5.
Patient-Specific Considerations
- Decisions surrounding periprocedural anticoagulation management must balance thromboembolic and procedural bleed risk, considering anticoagulant pharmacokinetics, procedural bleed risk, and patient characteristics 5, 4.
- A clinical approach to perioperative DOAC management based on operative bleeding risk and renal function is safe and effective 5.
- Clear communication of the anticoagulation interruption plan to both the patient and the patient's care team is essential 2, 6.