Perioperative Management of Desvenlafaxine
Continue desvenlafaxine throughout the perioperative period without interruption. Abrupt discontinuation poses significant risk of withdrawal syndrome, which can manifest with severe symptoms including nausea, dysphoric mood, irritability, agitation, dizziness, and sensory disturbances that may mimic stroke 1, 2.
Preoperative Management
Desvenlafaxine should be continued up to and including the morning of surgery with a small sip of water, following the same principles applied to other chronic psychiatric medications that carry withdrawal risk 3, 4. The medication can be safely administered even when patients are NPO 3.
Key Rationale for Continuation:
Withdrawal syndrome prevention: Discontinuation of SNRIs, including desvenlafaxine, leads to withdrawal symptoms in a significant proportion of patients, with symptoms typically emerging within hours to days and potentially lasting weeks even with gradual tapering 5.
Psychiatric stability: Discontinuing antidepressants preoperatively increases the risk of deterioration of depressive symptoms (20% vs 5%) and perioperative delirium or confusion (30% vs 13%) compared to continuation 6.
No significant cardiovascular risk: Unlike sympathomimetic agents, desvenlafaxine does not pose substantial cardiovascular risks during anesthesia and requires no specific dose adjustments 3.
Intraoperative Considerations
Serotonin Syndrome Risk
Exercise heightened vigilance when combining desvenlafaxine with other serotonergic agents perioperatively, as this represents the primary safety concern 7, 1.
Avoid or carefully monitor concomitant use with serotonergic opioids (fentanyl, meperidine, methadone, tramadol, tapentadol) 7.
Antiemetics with serotonergic activity (ondansetron, granisetron, metoclopramide) increase serotonin syndrome risk when combined with desvenlafaxine 7.
Monitor for serotonin syndrome manifestations: mental status changes (agitation, confusion, delirium), autonomic instability (tachycardia, labile blood pressure, hyperthermia), neuromuscular symptoms (tremor, rigidity, hyperreflexia), and gastrointestinal symptoms 1.
Bleeding Risk
Be aware that desvenlafaxine may increase bleeding risk, particularly when combined with antiplatelet agents, NSAIDs, or anticoagulants 1, 8.
This represents a theoretical concern rather than an absolute contraindication, but warrants careful hemostatic monitoring 1.
Postoperative Management
Resume oral desvenlafaxine as soon as the patient can tolerate oral intake 3. If prolonged NPO status is anticipated:
Consider consultation with psychiatry for alternative administration strategies or temporary substitution with another agent if absolutely necessary.
Monitor closely for emergence of withdrawal symptoms if any delay in resumption occurs 1, 5.
Blood Pressure Monitoring
Monitor blood pressure regularly throughout the perioperative period, as desvenlafaxine can cause dose-dependent increases in blood pressure 1.
Pre-existing hypertension should be controlled before elective surgery, though this does not require discontinuation of desvenlafaxine 1.
Sustained blood pressure elevations may require dose reduction postoperatively, but not acute discontinuation 1.
Common Pitfalls to Avoid
Never discontinue desvenlafaxine abruptly preoperatively - withdrawal symptoms can be severe and may mimic serious neurological events including stroke 2.
Do not assume cardiovascular risks similar to MAOIs - desvenlafaxine does not carry the same anesthetic interaction profile as older antidepressants 3.
Avoid combining multiple serotonergic agents without careful monitoring - the risk of serotonin syndrome increases substantially with polypharmacy involving serotonergic medications 7, 1.
Do not restart at reduced doses postoperatively without psychiatric consultation - maintaining therapeutic levels is important for preventing both withdrawal and psychiatric decompensation 6.