1

Preoperative Testing and Medication Management

I. Preoperative Testing and Workup for Non-Cardiac Procedures

a. Preoperative Management

II. Preoperative Medication Management

a. Medication Specific Recommendations by Class
i. Anticoagulants/Antithrombotics Medications
ii. Antidepressants
iii. Cancer Medications
iv. Cardiovascular and Antihypertensives
v. Corticosteroids and Glucocorticoids
vi. Diabetes Medications
vii. Disease Modifying Antirheumatic Drugs (DMARD)
viii. Gastrointestinal Medications
ix. Genitourinary Medications
x. Herbal Agents
xi. Hormonal Medications
xii. Investigational Medications
xiii. Pulmonary Medications
xiv. Substance Abuse
xv. TNF alpha Inhibitors
xvi. Miscellaneous Other Medications

III. Additional Perioperative Recommendations, Considerations, and Guidelines

a. Indications for Electrocardiography Based on Cardiac Risk
b. OSU Preoperative Assessment Center/Preadmission Test (OPAC/PAT) Carotid Bruit Algorithm
c. Preoperative Testing Grid
d. Management of Obstructive Sleep Apnea (OSA)
e. Management of Antiplatelet Therapy in Patients with Arterial Stents
f. Perioperative / Periprocedure Glucose Management
g. Blood Type and Cross with appropriate allocation per Surgical Blood Order Schedule (SBOS)
h. Prevention of Surgical Site Infections (SSIs) with Antimicrobial Prophylaxis
i. Antibiotic Prophylaxis for Infective Endocarditis
j. Deep Venous Thrombosis (DVT) - Prevention
k. Anticoagulation Reversal
i. Dabigatran (Pradaxa) Reversal Treatment for Bleeding Events
ii. Rivaroxaban, Apixaban: Factor Xa Inhibitors - Reversal Treatment for Bleeding
iii. Warfarin - Management of Elevated INR and Reversal
l. Inpatient Tobacco Cessation Clinical Protocol
m. Contrast Induced Neuropathy

Disclaimer
Clinical practice guidelines and algorithms at The Ohio State University Wexner Medical Center
(OSUWMC) are standards that are intended to provide general guidance to clinicians. Patient
choice and clinician judgment must remain central to the selection of diagnostic tests and
therapy. OSUWMCs guidelines and algorithms are reviewed periodically for consistency with
new evidence; however, new developments may not be represented.
Copyright 2017. The Ohio State University Wexner Medical Center. All rights reserved. No
part of this document may be reproduced, displayed, modified, or distributed in any form without
the express written permission of The Ohio State University Wexner Medical Center.
 2

Preoperative Testing and Medication Management for Non-Cardiac Surgical Procedures

Preoperative Evaluation o Functional capacity

A preoperative evaluation must be done within
30 days before a surgical procedure.
History and physical examination information
must be reviewed and updated within 24 hours
of admission or registration and prior to the
planned surgical procedure.
The preoperative evaluation is not a substitute
for preventive health care but may be used as
an opportunity to address preventive services.
Medical History
Indication(s) for the surgical procedure
o Allergies and adverse medication
reactions
o It is most helpful to specify the
approximate date, the type of reaction,
the treatment, the response, and if the
agent was subsequently taken.
Current medications including prescriptions,
over-the-counter, and herbal and dietary
supplements
o Specify the generic and brand name,
specific preparation (tablet, capsule,
liquid), dose in each unit, route by which
the agent is taken (oral, feeding tube,
transdermal), number of units taken,
and time(s) of day taken.
o Pay special attention to high-risk
medications including opioids, diabetes
medications, antihypertensives,
anticoagulants (warfarin, heparins,
antiplatelet medications), and oral
cancer/chemotherapy medications.
Medical problems, including current status
o Use the IHIS Problem List
o Pay special attention to sleep apnea
risk, abnormal airway, recent stroke or
heart attack and intravascular stents
Factors that increase infection risk
o Skin disease (e.g., open lesions)
o Diabetes mellitus
o Malnutrition
o Smoking
Thorough evaluation of issues relevant to the
planned procedure and anesthesia:
o History of anesthesia complication,
personal and family (e.g., obstructive
sleep apnea, malignant hyperthermia)
o Cardiac and pulmonary function
o History of clotting or bleeding
abnormality, personal and family
o History of tobacco, alcohol, drug use
Physical Examination
Height, weight, and body mass index (BMI)
Vital signs:
o Blood pressure
o Pulse (rate and rhythm)
o Respiratory rate
Airway assessment
Pulmonary
Cardiovascular
Neurologic
Other findings pertinent to the patient and the
procedure
Preoperative Risk Assessment
The American Society of Anesthesiology (ASA)
classification is a global impression of the
clinical state of a patient based upon all
available history, physical examination findings,
and laboratory data (Table 1 on page 3).
Document ASA class, as it is a robust predictor
of perioperative complications.
Determine the perioperative cardiac risk based on
the type of procedure planned (Table 2 on
page 3).
See page 4 for a more detailed algorithm on
cardiac risk. (The algorithm addresses ordering
electrocardiography and scoring cardiac risk.)
Preoperative Testing
Laboratory and diagnostic tests are not routinely
necessary unless there is a specific patient or
procedural indication.
Nothing by Mouth (NPO)*
Type Duration
Clear Liquid 2 hours
6 hours
Light Meal (A light meal consists of
dry toast and clear liquids)
Full Meal 8 hours
Infant Formula/Non-Human Milk 6 hours
Breast Milk 4 hours
Tube Feeds 6 hours
*Recommendations for generally healthy patients who undergo
elective procedures. Not recommended for women in labor.
Reference: Anesthesiology 3 2011, Vol.114, 495-511.
doi:10.1097/ALN.0b013e3181fcbfd9
 3

Preoperative Testing and Medication Management for Non-Cardiac Surgical Procedures

Table 1: American Society of Anesthesiologists' (ASA) Physical Table 2: Cardiac Risk by Surgical Procedure
Status Classification
ASA Examples, including, but not HIGH RISK >5%
Definition
limited to:
Emergent major operations, particularly in older adults
(especially those >75 years of age)
A normal Healthy, non-smoking, no or
ASA I Aortic and other major vascular surgical procedures
healthy patient minimal alcohol use
Peripheral vascular surgical procedures

Mild diseases only without

Major cardiac and thoracic surgical procedures
substantive functional limitations. Anticipated prolonged surgical procedures associated
A patient with Examples include (but not limited with large fluid shift and/or blood loss
ASA II mild systemic to): current smoker, social alcohol
disease drinker, pregnancy, obesity (30 < INTERMEDIATE RISK 1-5%
BMI < 40), well-controlled
DM/HTN, mild lung disease Carotid endarterectomy
Non-major head and neck surgery / procedures
Substantive functional limitations; Non-major intraperitoneal and intrathoracic surgery /
One or more moderate to severe
procedures
diseases. Examples include (but
not limited to): poorly controlled Orthopedic surgical procedures
DM or HTN, COPD, morbid obesity
A patient with (BMI 40), active hepatitis, alcohol Prostate surgical procedures
ASA III severe systemic dependence or abuse, implanted
disease pacemaker, moderate reduction of Urologic surgical procedures
ejection fraction, ESRD undergoing LOW RISK <1%
regularly scheduled dialysis,
premature infant PCA < 60 weeks, Biopsies and superficial procedures (e.g., breast biopsy)
history (>3 months) of MI, CVA,
TIA, or CAD/stents. Endoscopic procedures
Cataract surgery / ophthalmologic procedures
Examples include (but not limited
to): recent ( < 3 months) MI, CVA, Breast surgery
A patient with
TIA, or CAD/stents, ongoing
severe systemic Minor prostate procedures (e.g., cystoscopy)
cardiac ischemia or severe valve
ASA IV disease that is a
dysfunction, severe reduction of
constant
ejection fraction, sepsis, DIC, ARD
threat to life
or ESRD not undergoing regularly
scheduled dialysis

Examples include (but not limited

A moribund to): ruptured abdominal/thoracic
patient who is aneurysm, massive trauma,
ASA V not expected to intracranial bleed with mass effect,
survive without ischemic bowel in the face of
the operation significant cardiac pathology or
multiple organ/system dysfunction

A declared
brain-dead
patient whose
ASA VI organs are
being removed
for donor
purposes

Reference: American Society of Anesthesiologists' (ASA) Physical Status

Classification/1991 is reprinted with permission of the American Society of
Anesthesiologists, 1061 American Lane, Schaumburg, Illinois 60173-4973
 4
Indications for Electrocardiography Based on Cardiac Risk

Note: If the past medical history shows Preoperative history

the patient has a medical issue which and physical examination
would indicate the appropriateness of
an EKG (and this can be seen on the
chart review before the provider does
their own history and physical) consider
obtaining an EKG
Signs or symptoms of
YES Electrocardiography*
cardiovascular disease?

NO

Low risk surgery** Intermediate risk surgery** High-risk surgery**

(risk < 1%) (risk 1-5%) (risk > 5%)

Electrocardiography At least one RCRI***

NO YES Electrocardiography*
NOT Indicated clinical risk factor?

*ECG is valid for 6 months if patient is clinically stable

**Please refer to Table 2 on page 3 for cardiac risk by procedure

***RCRI = Revised Cardiac Risk Index (see below)

Risk Factor Points

History of stroke or transient ischemic attack (TIA) 1
History of MI, CABG, or PTCA 1
Heart failure 1
Serum creatinine level > 2.0mg/dL 1
Diabetes mellitus requiring insulin 1
Major vascular, intrathoracic, intra-abdominal, or
intracranial procedure 1

Revised Cardiac Risk Index (RCRI)***

Points Risk %
0 0.4
1 0.9
2 6.6
>3 >11

RCRI Source: Lee, T.H. Lee, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major
noncardiac surgery Circulation, 100 (1999), pp. 10431049
 5
OPAC/PAT Carotid Bruit Algorithm

This algorithm is for patients who have a carotid bruit discovered during preoperative examination.
First, determine if the patient has had stroke/TIA symptoms in the previous 9 months. Examples of stoke/TIA symptoms
include, but are not limited to:
Shade coming down over the eye or other sudden vision change
Sudden confusion or difficulty talking
Sudden loss of balance or difficulty walking
Sudden focal weakness or loss of dexterity
If the patient has had stroke/TIA symptoms in the previous 9 months, and, if there is no contraindication, then ensure they
are taking aspirin 81mg PO daily.
Next, obtain carotid duplex ultrasound within the previous 6 months.
OSUWMC order vasc duplex carotid bilateral

Result of carotid duplex ultrasound

< 50% internal carotid stenosis 70-99% internal carotid stenosis

(both sides) (either side)

Asymptomatic Symptomatic

Refer to
OK for Consider atrial fibrillation as well as Endovascular
surgery/procedure other causes and consult Cardiology, Neurosurgery OR
Stroke Neurology, or Neurovascular/ Vascular Surgery at
Stroke Neurosurgery as indicated. the preference of the
referring physician.

50-69% internal carotid stenosis

(one or both sides, but no more than 69% either side)

Asymptomatic Symptomatic

OK for
Refer to
surgery/procedure
Endovascular
Neurosurgery OR
Vascular Surgery at
Refer to the preference of
Endovascular the referring
Neurosurgery OR physician.
Vascular Surgery at
the preference of
the referring
physician.
 Preoperative Testing Grid
6

CBC TSH, UA Total

OPAC/ ECG CXR2 4 Hgb A1c Chem 6 K+ LFTs MRSA/ HCG
Coagulation Tests with
T&C MSSA
PAT Ediff Plt Free T4 Reflex to UCG
Screen7
Culture
Timing Prior to Procedure 30 days 6 mos 1 yr 6 wks INR/PT PTT 30 days 4 wks 6 wks DOS 6 wks 6 wks 6 wks 6 wks DOS3

Medical Condition or Current Treatment

Anem ia X
Anesthesia complications (history) X
Atrial fibrillation (current or paroxysmal) X X X
Bleeding disorder X X DOS DOS X
Chemotherapy ( recent < 6 months) X X X
CNS disease X
Acute or symptomatic heart failure X X X X X
Coronary artery disease and planned intermediate- or high-
risk surgery (see page 3 of guideline) X X
Diabetes mellitus (DM) or DM risk X X X
ESRD (on dialysis) X X X DOS X DOS
Factor deficiency X X DOS X
Functional capacity (poor, < 4 mets) X X
Hepatic (liver) disease X X X X X
Hypertension (poorly controlled) X X X
Hyperthermia (malignant) X
Immigrant (recent, < 2 years) X X X
Intubation difficulty in the past or at high risk for difficulty X
Cachexia (Malabsorption and/or malnutrition) X X X X X X
Malignancy (current) X X
Muscular dystrophy X X
Nausea and vomiting (severe or active) X X
Neck mobility poor or unable to open mouth (trismus) X
Obesity (morbid, BMI > 40 kg/m 2) X X X
Pacer/ICD X X X
Premenopausal unless S/P TAH and/or BSO DOS
Pulmonary disease-symptomatic X X X X
Radiation therapy to chest (history) X X X X
Radiation therapy to neck (history) and not taking thyroid
replacement X
Renal Insufficiency (not on dialysis) X X X X DOS X
Rheumatoid arthritis (receiving treatment) X
Scoliosis/Kyphosis (moderate to severe) X
Sickle cell anemia X X
Sleep apnea or risk for sleep apnea5 X X
Stroke (CVA/TIA), History of X X X
Thrombocytopenia X X
Upper airway or mediastinal lesion X
Venous thromboembolism (DVT, PE) (recent < 6 months) X X X

Appropriate for OPAC/PAT visit if also has ASA score of 3-4

PA & Lateral CXR or equivalent radiologic examination
3
DOS = Day of Surgery
4
See Surgical Blood Order Schedule (SBOS) for maximum recommended blood volume per procedure
5
See OSUWMC Obstructive Sleep Apnea guideline
6
Also refer to surgeons preference list
7
If MRSA/MSSA Screen positive, order mupirocin/bactroban

Preoperative screening and laboratory testing is unwarranted and may be harmful unless the patient has a specific clinical indication.
 7
Preoperative Testing Grid

UA Total
TSH, MRSA/
OPAC/ CBC Coagulation Tests T&C 4
Hgb A1c Chem 6 K+ LFTs with HCG
ECG CXR2 MSSA
PAT Ediff Plt Free T4 Reflex to 7 UCG
Screen
Culture

Timing Prior to Procedure 30 days 6 mos 1 yr 6 wks INR/PT PTT 30 days 4 wks 6 wks DOS 6 wks 6 wks 6 wks 6 wks DOS3

Medication History
Coumadin/ Warfarin X X DOS
Digoxin X X X DOS
Diuretic X DOS
PTT/TT
Dabigatran X
DOS
Rivaroxaban X DOS
Apixaban/edoxaban X
Anticipated IV contrast for procedure X
6
Types of Procedures
Major vascular, peripheral vascular-including carotid X X X X X X X X
Craniotomy X X X X X X X X X
Head/Neck surgery-major X X X X X
Major cerebral vascular X X X X X X X X X
Open abdominal cases X X X X X
Orthopedic surgery-major X X X X X X X
Procedures with anticipated EBL > 500 mL X X X X X X X
Prolonged procedures with major fluid shifts and/or blood
X X X X X X X
loss
Spine surgery-major X X X X X X X X
Thoractomy/lung resection/VATS X X X X X X X

Appropriate for OPAC/PAT visit if also has ASA score of 3-4

PA & Lateral CXR or equivalent radiologic examination
3
DOS = Day of Surgery
4
See Surgical Blood Order Schedule (SBOS) for maximum recommended blood volume per procedure
5
See OSUWMC Obstructive Sleep Apnea guideline
6
Also refer to surgeons preference list
7
If MRSA/MSSA Screen positive, order mupirocin/bactroban

Preoperative screening and laboratory testing is unwarranted and may be harmful unless the
patient has a specific clinical indication.
 8

Perioperative Medication Management by Class

Limited clinical trials data are available to guide medication management in the perioperative period. Therefore,
perioperative medication management is largely based on estimating the risks and benefits of either continuing or
discontinuing the medication and the urgency of the surgery or procedure being performed. Management must be
tailored to the specific patient and procedure and should be based upon:
The patients medication allergies and prior adverse reactions
The patients medical problems/comorbidities
The specific procedure being performed including anesthesia/analgesia management (e.g. neuraxial
anesthesia).
For specific recommendations on antiplatelets and anticoagulants with regional anesthesia while the
catheter is in place and post-catheter removal see Appendix A.

Anticoagulant/Antithrombotics
Consider the procedure and need for neuraxial anesthesia when planning perioperative medication management.

Oral Anticoagulant/Antithrombotic Medications

Restart time depends on the procedure and risk for bleeding
Prior to Procedure
Minimum recommended
Minimum
time between last dose of
Class Examples Recommended Additional Considerations
antithrombotic and
Holding Time
neuraxial catheter
placement
Patient- and procedure-
specific decision should Before holding any of these
aspirin1 Do not hold* medications see
be made with patient and
care team. OSUWMC Management of
Antiplatelet Antiplatelet Therapy in
clopidogrel (Plavix)1,2 5 - 7 days * 7 days Patients with Arterial Stents
medications
prasugrel (Effient)1,3 7 days* 10 days Around the Time of Surgeries
ticagrelor (Brilinta)1,4 5 days* 5 days and Procedures guideline

vorapaxar (Zontivity) 40 - 50 days Contraindicated

Elective procedures
with a low bleeding
risk
CrCl > 80 mL/min:
> 24 hours

CrCl 50 79 mL/min:
> 36 hours

CrCl 30 49 mL/min:
> 48 hours

CrCl 15 29 mL/min:
> 72 hours
Depending on indication for
CrCl <15 mL/min:
anticoagulation, risk of
> 96 hours and normal
bleeding with the procedure
PTT and TT
Direct Thrombin CrCl > 15 mL/min: 5 days and renal function patient may
dabigatran (Pradaxa)5
Inhibitor CrCl < 15 mL/min: 6 days require longer holding time
Procedures at
and/or bridging.
moderate - high
bleeding risk
Check PTT or TT to verify
CrCl > 80 mL/min:
> 48 hours

CrCl 50 79 mL/min:
> 72 hours

CrCl 30 49 mL/min:
> 96 hours

CrCl 15 29 mL/min:
> 120 hours

CrCl <15 mL/min:

> 120 hours and normal
PTT and TT
*Patient- and procedure-specific decision should be made with patient and care team whether to hold medication.
A
Consider the procedure and need for neuraxial anesthesia prior to holding anticoagulation medications.
 9

Oral Anticoagulant/Antithrombotic Medications (Continued)

Restart time depends on the procedure and risk for bleeding
Prior to Procedure
Minimum
Minimum recommended time between Additional
Class Examples Recommended
last dose of antithrombotic and Considerations
Holding Time
neuraxial catheter placement
Elective procedures CrCl > 30 mL/min: 3 days
5
apixaban (Eliquis ) with a low bleeding
risk CrCl < 30 mL/min: 5 days
CrCl > 30 mL/min:
> 24 hours
Depending on
indication for
CrCl 15 29 mL/min: anticoagulation,
> 36 hours risk of bleeding
with the
Factor Xa Inhibitors CrCl <15 mL/min: procedure and
> 48 hours CrCl > 50 mL/min: 3 days
rivaroxaban (Xarelto)5 renal function
5
edoxaban (Savaysa) patient may
Procedures at CrCl < 50 mL/min: 5 days
require longer
moderate - high holding time
bleeding risk and/or bridging.
CrCl > 30 mL/min:
> 48 hours

CrCl < 30 mL/min:

> 72 hours
celecoxib (Celebrex)
Discontinue
No need to hold dose
NSAID 5 days
ibuprofen (Motrin,
If holding other prior to surgical
Advil) If the decision is made to hold, the time
antiplatelets or procedure if not
NSAIDs to hold should be based upon 5 half-
anticoagulants, hold on any other
meloxicam (Mobic) lives of specific NSAID. Contact
NSAID concurrently antiplatelet or
Pharmacy for assistance. See Appendix
anticoagulant.
naproxen (Aleve, A
Naproxyn)
Phosphodiesterase cilostazol (Pletal) Do not hold 48 hours*
Inhibitors dipyridamole-aspirin
Do not hold* 7 days
(Aggrenox)
dipyridamole
Do not hold 48 hours*
(Persantine)

pentoxifylline (Trental) Do not hold Do not hold

Depending on
indication for
anticoagulation
and risk of
bleeding with
the procedure
warfarin (Coumadin, the holding time
Vitamin K Antagonist 0 - 5 days* 5 days, normalization of INR may vary and
Jantoven)*5,6
bridging may be
required.
Check INR to
verify. Do not
use Point-of-
care.
*Patient- and procedure-specific decision should be made with patient and care team whether to hold medication.
A
Consider the procedure and need for neuraxial anesthesia prior to holding anticoagulation medications.
 10

Intravenous or Subcutaneous Anticoagulant/Antithrombotic Medications

Restart time depends on the procedure and risk for bleeding
Prior to Procedure
Minimum
Minimum recommended time between Additional
Class Examples Recommended
last dose of antithrombotic and Considerations
Holding Time
neuraxial catheter placement
unfractionated heparin 3 - 4 hours Inpatients: No time restriction.
(UFH) - subcutaneous Consider the peak effect of
5000 units q12h subcutaneous heparin at 2 hours when
placing catheter.
3 - 4 hours
3 - 4 hours Outpatients: 8 hours

5000 units q8h 8 hours

7500 units q8h 8 hours
CrCl > 30mL/min: 24 hours
dalteparin (Fragmin )
24 hours
therapeutic
CrCl 30mL/min: 48 hours
CrCl > 30mL/min: 12 hours
dalteparin (Fragmin)
12 hours
prophylaxis
CrCl 30mL/min: 24 hours
CrCl > 30 mL/min: 24 hours
enoxaparin (Lovenox)
24 hours Consider LMWH
therapeutic
CrCl < 30 mL/min: 72 hours anti-Xa level to
CrCl > 30 mL/min: 12 hours assess level of
Heparin and related enoxaparin (Lovenox )
12 hours anticoagulation
medications6 prophylaxis
CrCl < 30 mL/min: 72 hours

CrCl > 50 mL/min: 4 days
fondaparinux (Arixtra )
3 days
therapeutic
CrCl 50 mL/min: 5 days
CrCl > 50 mL/min: 3 - 4 days
fondaparinux (Arixtra)
48 hours
prophylaxis
CrCl < 50 mL/min: 4 days
Verify PTT is
normal
Heparin should
be resumed at
the discretion of
unfractionated heparin Hold 4-6 hours prior to the surgeon/
4 hours if normal PTT
(UFH) infusion procedures medical team
when
postoperative
hemostasis
deemed to be
adequate
Rate > 1.5 mcg/kg/min -
hold 6
hours and recheck PTT

Rate 0.5 - 1.5

mcg/kg/min - hold 8
If neuroaxial anesthesia is needed,
hours and recheck PTT
decision should be based upon
Argatroban7
discussion with the Anesthesiologist, See Bivalirudin
Rate < 0.5 mcg/kg/min -
surgical team, and pharmacy specialist Dosing and
hold for 12 hours and
Monitoring
recheck PTT
Guide
*Hepatic and/or renal
See Argatroban
insufficiency may need
Dosing and
to hold longer
Monitoring
Direct Thrombin CrCl >60 mL/min: Hold
Inhibitor for 2 - 4 hours and Verify PTT is
recheck PTT Normal
If neuroaxial anesthesia is needed,
CrCl 10 60 mL/min:
bivalirudin decision should be based upon
Hold for 4 - 6 hours and
(Angiomax)8 discussion with the Anesthesiologist,
recheck PTT
surgical team, and pharmacy specialist
Intermittent HD off-
dialysis: (May need to
hold longer)
Depending on
indication may
require longer
desirudin (Iprivask) 24 hours 24 hours if normal PTT
holding time
and/or bridging.
 11

Intravenous or Subcutaneous Anticoagulant/Antithrombotic Medications (Continued)

Prior to Procedure
Minimum
Minimum recommended time between Additional
Class Examples Recommended
last dose of antithrombotic and Considerations
Holding Time
neuraxial catheter placement
9 Platelet function
abciximab (Reopro ) 12 hours 5 days
may remain
abnormal for up
eptifibatide to 7 days post
10
Antiplatelets (Integrilin ) abciximab
4 hours 24 hours infusion due to
11 irreversible
tirofiban (Aggrastat ) platelet
inhibition.
Therapeutic Alteplase Minimum 48 hours for Minimum 48 hours for emergency

Thrombolytic (TPA ) emergency procedures procedures
Catheter Clearance No need to hold dose No need to hold dose
*Patient- and procedure-specific decision should be made with patient and care team whether to hold medication.
A
Consider the procedure and need for neuraxial anesthesia prior to holding anticoagulation mediations.

Antidepressants
Benefits of Usual
Class Examples Risks of Continuation Additional Considerations
Continuation Management
Can cause hypertensive Clearly document to avoid
crisis when used with both drug and food
Monoamine phenelzine (Nardil)
Maintain control of sympathomimetics. interactions during the
Oxidase
psychiatric Continue procedure and
Inhibitors selegiline
symptoms Can cause neuroleptic hospitalization.
(MAOIs) (Emsam)
malignant syndrome when
used with meperidine. Requires low tyramine diet.
SSRI need to be
discontinued for up to 3
sertraline (Zoloft) weeks to be out of the
Selective Maintain control of
system and clinical benefit
Serotonin paroxetine (Paxil) psychiatric Increased bleeding risk due
may not occur for several
Reuptake symptoms to inhibition of platelet Continue
weeks after reinitiating.
Inhibitors citalopram Avoid withdrawal aggregation
(SSRIs) (Celexa) syndrome
Use methylene blue with
caution because of risk of
serotonin syndrome
SNRI need to be
duloxetine discontinued for up to 3
Selective (Cymbalta) weeks to be out of the
Maintain control of
Serotonin and system and clinical benefit
psychiatric Increased bleeding risk due
Norepinephrine Milnacipran may not occur for several
symptoms to inhibition of platelet Continue
Reuptake (Savella) weeks after reinitiating.
Avoid withdrawal aggregation
Inhibitors
syndrome
(SNRIs) Venlafaxine Use methylene blue with
(Effexor) caution because of risk of
serotonin syndrome
Benefits of Usual
Class Examples Risks of Continuation Additional Considerations
Continuation Management
amitriptyline
(Elavil) Maintain control of
May increase risk of
psychiatric
arrhythmia in combination
Tricyclic doxepin symptoms
with some volatile Continue
Antidepressants (Sinequan)
anesthetics or
Avoid withdrawal
sympathomimetics.
imipramine syndrome
(Tolfranil)
May increase risk for
Maintain control of
prolongation of muscle Consider checking free T4
psychiatric
relaxant effects. May and TSH prior to the
symptoms
Lithium increase risk for Continue procedure. Monitor fluid
nephrogenic diabetes balance and check
Avoid withdrawal
insipidus and thyroid electrolytes frequently.
syndrome
dysfunction.
*Patient- and procedure-specific decision should be made with patient and care team whether to hold medication.
 12

Cancer Medications *
Class Examples Minimum Recommended Holding Times Additional Considerations

bevacizumab (Avastin )

ramucirumab (Cyramza )
At least 4 weeks prior to the procedure per the package Wait at least 4 weeks
insert, although based on pharmacokinetics, at least 6 postoperatively or until wound
VEGF Inhibitor ziv-Aflibercept (Zaltrap )
weeks is desired in most cases is healed to start

regorafenib (Stivarga) 2 weeks

axitinib (Inlyta ) 24 hours

cabozantinib (Cometriq ) 28 days
Consider holding these

ibrutinib (Imbruvica ) medications based upon the
3 - 7 days

indication for the medication,
Tyrosine olaratumab (Lartruvo ) procedure, and risk for wound
No data Consult Clinical Pharmacy Specialist
Kinase healing.
Inhibitors pazopanib (Votrient)
7 days
Hold ibrutinib 3 - 7 days after
ponatinib (Iclusig ) the procedure depending on
7 days the risk of bleeding with the
sorafenib (Nexavar)
procedure
6 days
sunitinib (Sutent)
2 - 3 weeks
Fibrinogen should be
checked preoperatively if
Asparaginase given within 4 weeks of the
pegaspargase (Oncaspar)
derivative procedure. For fibrinogen
< 100 mg/dL consider
cryoprecipitate.

Cancer/Immunomodulation Medications *
Minimum
Additional
Class Examples Recommended Risks of Continuation
Considerations*
Holding Time
Minor Surgery: Stop Wound healing, bleeding to Minor Surgery: Resume at
Lenalidomide (Revlimid) 1 day before secondary to least 7 days after surgery
thrombocytopenia/concurrent
Immunomodulator Pomalidomide (Pomalyst) Ortho, GI or GU anticoagulation, increased risk Ortho, GI or GU Surgery:
(IMiDs) Surgery: Stop 1 of thrombosis if Follow up with Multiple

Thalidomide (Immunoprin ) week before aspirin/anticoagulant Myeloma physician before
resuming
*Discontinuation/continuation or holding times for procedures must be determined by the attending physician for each case
 13

Cardiovascular and Antihypertensives

Benefits of Usual
Class Examples Risks of Continuation Additional Considerations*
Continuation Management
aliskiren

(Tekturna )

candesartan
cilexetil

(Atacand )

enalapril

(Vasotec )

irbesartan

(Avapro )

ACE Inhibitors, lisinopril (Zestril, Hold 24 hours

ARBs, Neprilysin Prinivil ) Blood pressure prior to
Intraoperative hypotension
inhibitor/ARB, and control surgical
12
Renin Inhibitors losartan procedure

(Cozaar )

quinapril
(Accupril)

ramipril (Altace)

valsartan
(Diovan)

sacubitril-
valsartan
(Entresto)
doxazosin
(Cardura) Blood pressure
control

Alpha Blocker terazosin (Hytrin ) Hypotension Continue
Less postoperative
tamsulosin urinary retention
(Flomax)
clonidine Blood pressure and
(Catapress) heart rate control
Alpha 2 Agonists Hypotension Continue
methyldopa Avoid withdrawal
(Aldomet) syndrome
Consider obtaining baseline
amiodarone preoperative 12-lead ECG in
(Cordarone) patients with changes in renal
function (sotalol, dofetilide).
dronedarone Consider monitoring
(Multaq) potassium and magnesium
Induce arrhythmia (sotalol and dofetilide).
Suppress
Antiarrhythmics Continue Minimize medications that
dofetilide arrhythmia
QT prolongation prolong QT interval.
(Tikosyn )

sotalol * All patients receiving IV

(Betapace, antiarrhythmic therapy must
Betapace AF) be continuously monitored on
telemetry
metoprolol
If beta-blocker is combined
(Lopressor,
with thiazide diuretic, e.g.
Toprol XL) Less cardiac
atenolol-chlorthalidone, then
ischemia
treat as a beta-blocker and
carvedilol
Hypotension usually continue.
(Coreg) Blood pressure and
Beta-Blockers13 Continue
heart rate control
Bradycardia Ideally, initiation of beta-
atenolol
blocker therapy should be
(Tenormin) Avoid withdrawal
long enough in advance to
syndrome
assess safety and tolerability
bisoprolol
before surgery.
(Zebeta, Ziac)
 14

Cardiovascular and Antihypertensives (continued)

Benefits of Usual
Class Examples Risks of Continuation Additional Considerations*
Continuation Management
Dihydropyridine:
amlodipine

(Norvasc )
Blood pressure Hypotension some of
nifedipine these drugs have a long

(Procardia , Heart rate control half- life
Adalat)
If blood pressure or heart rate
Calcium Channel
felodipine (Plendil ) Continue is too low, then hold 24 hours
Blockers
prior to surgical procedure.
Non-
dihydropyridine:
diltiazem Blood pressure Hypotension

(Cardizem )
Heart rate control Bradycardia

verapamil (Calan ,

Isoptin )

Consider obtaining digoxin

level prior to surgical
Lower heart rate Induce arrhythmia
procedure.
Digoxin digoxin (Lanoxin) Continue
Consider obtaining potassium
Less heart failure Toxicity
and magnesium prior to
surgical procedure.

Ivabradine ivabradine
Lower heart rate Induce arrhythmia Continue
(Corlanor)

chlorthalidone
(Thalitone)

furosemide (Lasix)

torsemide
(Demadex)
Hypotension
bumetanide Continue diuretics in diuretic-
(Bumex) dependent heart failure
Hypokalemia
patients. If a thiazide diuretic
Do not take on
hydrochlorothiazide Avoid fluid is combined with a beta-
Diuretics Hyperkalemia day of
(Mircozide) overload blocker, e.g. atenolol-
procedure
chlorthalidone, then treat as a
Hyponatremia
metolazone beta-blocker and usually
(Zaroxolyn) continue.
Hypernatremia
spironolactone
(Aldactone)

triamterene/hydroc
hlorothiazide

(Dyazide ,
Maxzide)
isosorbide dinitrate
(Isordil)
Continue Consider risks of hypotension
isosorbide
mononitrate Blood pressure versus hypertension when
Nitric Oxide
(Imdur) Hypotension making decisions to either
Vasodilators
Angina control give or hold anti-
hydralazine
Do not take on hypertensives
(Apresoline)
day of
procedure
minoxidil (Loniten)

Hyperkalemia
Do not take on If the patient will be receiving
potassium chloride Avoid
Potassium day of a diuretic, then continue
(K-Dur, Klor-con) hypokalemia Irritation of esophagus or
procedure potassium.
stomach
 15

Cardiovascular and Antihypertensives (continued)

Benefits of Usual
Class Examples Risks of Continuation Additional Considerations*
Continuation Management
atorvastatin
(Lipitor)

pravastatin
Lower risk of
(Pravachol )
thrombotic stroke
Statin Rhabdomyolysis Continue
and myocardial
rosuvastatin
infarction
(Crestor )

simvastatin
(Zocor)
Cholestyramine

(Questran )
Cholestyramine can
ezetimibe (Zetia)
sequester other medications
Do not take on
fenofibrate
Fibrate-induced day of
Non-Statin Lipid- (Tricor )
rhabdomyolysis procedure
Lowering Niacin-induced vasodilation
Medications gemfibrozil
and itching
(Lopid)

niacin (Niaspan)
Hold for 7 days May consider continuing in
Fish oil (> 3
Increased risk of bleeding prior to patients treated for very high
grams/day)
procedure triglycerides.
*Patient- and procedure-specific decision should be made with patient and care team whether to hold medications

Corticosteroids and Glucocorticoids

For relative potencies of corticosteroids please see the OSUWMC Pharmacy Intranet site


Examples: prednisone (Deltasone ), methylprednisolone (Medrol , Medrol Dosepak ), dexamethasone

(Decadron )
o Plan for stress dose in patients who have been taking immunosuppressants or immunomodulators for
an extended period of time.
If receiving steroids for transplant immunosuppression, consider consulting transplant team for
specific recommendations

This table applies to patients with adrenal suppression caused by exogenous steroids. For patients with
endogenous adrenal failure consult the patients endocrinologist for steroid management. (Note: patients
with primary adrenal insufficiency will require mineralocorticoids perioperatively with oral fludrocortisones, higher
doses of hydrocortisone, or liberal use of saline solutions)
Dose/Duration of
Adrenal Reserves Usual Choice Additional Considerations*
Corticosteroid
Less than 3 weeks
duration For hypotension unresponsive to
intravenous fluid boluses treat with
Likely has adequate
Continue usual dose of corticosteroid on the hydrocortisone sodium succinate
cortisol reserves in
Dose equivalent to 5 morning of the procedure and afterwards (Solu-Cortef, A-Hydrocort) 50-75 mg
mg/day or less or 10 mg adrenal glands
IV Q8H x3 during postoperative period
every other day of or equivalent alternate corticosteroid
prednisone
Adrenal reserves testing is expensive, time
consuming and unreliable in this setting. Most If patient has not received stress dose
patients will not need stress dose corticosteroids and develops
corticosteroids and should continue usual hypotension unresponsive to
Dose equivalent to 5 - 20 May or may not be
doses of corticosteroids on the morning of the intravenous fluid boluses treat with
mg/day prednisone for adequate reserve cortisol
procedure and afterwards. However, for major hydrocortisone sodium succinate
more than 3 weeks in adrenal glands
procedures consider hydrocortisone sodium (Solu-Cortef, A-Hydrocort) 50-75 mg
succinate (Solu-Cortef, A-Hydrocort) 50- IV Q8H x3 during postoperative period
75mg IV Q8H x3 during postoperative period or or equivalent alternate corticosteroid
equivalent alternate corticosteroid
Dose greater than or
Should usually receive stress dose
equal to 20 mg/day
Likely has minimal corticosteroids, e.g. hydrocortisone sodium
prednisone for three
reserve cortisol available succinate (Solu-Cortef, A-Hydrocort) 50-75
weeks or more and
in adrenal glands mg IV Q8H x3 during postoperative period or
patients with Cushingoid
equivalent alternate corticosteroid
appearance
*Patient- and procedure-specific decision should be made with patient and care team whether to hold medication.
 16

Diabetes Medications
See OSUMC Perioperative / Periprocedure Glucose Management guideline

Disease Modifying Antirheumatic Drugs (DMARD)

Benefits of Usual Additional
Class Examples Risks of Continuation
Continuation Management Considerations*
If normal
renal function
methotrexate ok to

(Trexall ) continue in
perioperative
period
hydroxychloroquine
Continue
(Plaquenil )
sulfasalazine Avoid disease
DMARD Myelo/ immunosuppression Continue
(Azulfidine ) flares
azathioprine
Continue
(Imuran )
Stop 2 weeks
prior to
procedures,
leflunomide (Arava )
resume when
wound fully
healed
*Patient- and procedure-specific decision should be made with patient and care team whether to hold medication.

Gastrointestinal Medications
Benefits of Usual Additional
Class Examples Risks of Continuation
Continuation Management Considerations*
calcium carbonate

aluminum Temporary May substitute H 2

Additional matter in the Do not take on day
Antacids hydroxide neutralization of
stomach of procedure blocker or PPI
(AlternaGEL, Alu- stomach acid
Cap, Alu-Tab,

Amphojel )
mesalamine
(Pentasa,
Avoid flare of
Asacol)
Anti-inflammatory irritable bowel Continue
disease
balsalazide
(Colazal)
cimetidine
Reduction in If on cimetidine,
(Tagamet)
stomach acid and consider replacing
GERD symptoms with other H 2
H2 Blockers famotidine Continue
blocker due to
(Pepcid)
Avoid rebound multiple drug
hyperacidity interactions.
ranitidine (Zantac)
esomeprazole
(Nexium)
Reduction in
lansoprazole
stomach acid and
(Prevacid )
Proton Pump reflux symptoms
Continue
Inhibitors
omeprazole
Avoid rebound
(Prilosec)
hyperacidity
pantoprazole
(Protonix)
*Patient- and procedure-specific decision should be made with patient and care team whether to hold medication.
 17

Genitourinary Medications
Recommended Additional
Class Examples Risk of Continuation Usual Management
Holding Time Considerations*

alfuzosin (Uroxatral )

doxazosin (Cardura)

dutasteride (Avodart )
Less postoperative
BPH Hypotension Continue
finasteride (Proscar ) urinary retention

tamsulosin (Flomax )

terazosin (Hytrin )

*Patient- and procedure-specific decision should be made with patient and care team whether to hold medication

Herbal Agents
There is no evidence herbal medications improve surgical outcomes and there are theoretical reasons these
agents may increase perioperative morbidity and the exact purity of some herbal medications is unclear
Stop the following agents 7 days prior to procedures because of the potential increased risk of bleeding
o Aloe, Burdock root, Chamomile, Chondroitin, Dong quai, Evening primrose, Flaxseed, Fish oil, Garlic,
Ginger, Ginkgo, Ginseng, Glucosamine, Green tea, Hu zhang, Melatonin, Saw palmetto, Tumeric,
Vitamin A and E
The above list in not all inclusive - Consult pharmacy if there are any concerns with additional herbal agent

Hormonal Medications
Benefits of Usual Additional
Class Examples Risks of Continuation
Continuation Management Considerations*
Advise the patient
Avoid unplanned
oral contraceptives to use other forms
pregnancy
of birth control if
oral
Decrease contraceptives are
hormone
postmenopausal held
replacement therapy
symptoms
Hormonal For specific very
medications high DVT risk
anastrozole Increased risk of Venous Continue
patients/
(Arimidex) Thromboembolism
procedures it may
be appropriate to
exemestane discontinue their
(Aromasin) estrogen
containing
medications 4 6
letrozole (Femara) weeks prior to the
procedure.
raloxifene (Evista)
Stop 4 weeks
prior to
Selective tamoxifen
procedures for
estrogen receptor (Nolvadex)
patients at
modulator
moderate/high
toremifene risk of VTE
(Fareston)

Investigational Medications
1. Summary protocol procedures are on the Pharmacy Intranet
a. Provides study name and #, location of investigational medication, and protocol link.
b. Procedures include drug preparation, dose, storage/stability parameters, randomization process,
and more.
2. For Non-Oncology studies:
a. A Drug Order Form, (customized paper Rx) will be faxed to the pharmacy executing the study.
b. For additional protocol information such as inclusion/exclusion criteria the Investigational Drug
Services (IDS) can provide this during business hours or the study coordinator can after IDS hours
of operation. The study team is responsible for ensuring the patient meets all criteria before and
during their enrollment.
3. For Oncology studies:
a. Treatment plans including the pertinent investigational medications are available in Beacon (IHIS).
b. The protocol can be found in OnCore
 18

Pulmonary Medications
Benefits of Usual Additional
Class Examples Risks of Continuation
Continuation Management Considerations*
ipratropium
(AtroventHFA)
Anti-cholinergic side
Anti-Cholinergics
effects
tiotropium (Spiriva

HandiHaler )
Reduced risk of
albuterol
postoperative
(Proventil or
pulmonary
Ventolin HFA) Continue
complications in
patients with reactive
formoterol
Beta-Agonists airway disease Tachycardia
(Foradil ,

Perforomist )

salmeterol
(Serevent)
bosentan
(Tracleer)
Avoid withdrawal,
Endothelin receptor macitentan
rebound pulmonary Hypotension Continue
antagonists (Opsumit )
hypertension
ambrisentan
(Letairis)
Improved control of
Inhaled fluticasone
reactive airway Thrush Continue
Glucucorticoids (Flovent)
disease
montelukast
(Singulair)
Leukotriene Improved control of No known perioperative
zafirlukast Continue
Inhibitors asthma adverse effects
(Accolate)

zileuton (Zyflo)
epoprostenol

(Flolan , Veletri ) Consult to
Intravenous Prosta
Hypotension cardiovascular
cyclin/ analogues
treprostinil anesthesia is required.
(Remodulin)
iloprost (Ventavis)
Inhaled Prostacycli
Hypotension
n/ analogues treprostinil
(Tyvaso)

Oral Prostacyclin/ a treprostinil

Hypotension
nalogues (Orenitram)

Interruption for 3
Hypotension days, will need to re-
Oral prostacyclin titrate
Selexipag
receptor (IP)
(Uptravi)14
agonist Hemoglobin drops were
Avoid withdrawal, Anemia Continue seen in selexipag in
rebound pulmonary clinical trials
sildenafil (Revatio) hypertension Concomitant use of
Phosphodiesterase
Hypotension riociguat or nitrates is
(PDE5) inhibitors15
tadalafil (Adcirca ) contraindicated
Risk of anemia,
hemorrhage, and
hemoptysis
Hypotension Interruption for 3
Soluble guanylate Riociguat days, will need to re-
cyclase stimulator (Adempas)16 titrate
Anemia
Contraindicated with
nitrates, nitric oxide
donors, or PDE5
inhibitors
Subcutaneous Pros treprostinil
Hypotension
tacyclin/ analogues (Remodulin)
Hold 24 hours
theophylline No known Arrhythmia
Theophylline before
(Theodur) perioperative benefits Neurotoxicity
procedures
*Patient- and procedure-specific decision should be made with patient and care team whether to hold medication.
 19

Substance Abuse
Benefits of Usual Additional
Class Examples Risks of Continuation
Continuation Management Considerations*
Likely safe for
continuation: lack of
Nicotine evidence from human
replacement studies that NRT
Maintain abstinence
products (gum, increases risk of post-op
from smoking to Per surgeons
lozenge, patch, Vasospams complications (healing or
reduce smoking- preference
nasal spray, cardiovascular).
17 related complications
inhaler, etc.)

NRT may yield positive

cotinine test

Smoking Cessation Maintain abstinence

Varenicline from smoking to
18,19 Continue
(Chantix ) reduce smoking-
related complications

Maintain abstinence
Decreased seizure Use methylene blue with
Bupropion from smoking to
threshold (doses > 450 Continue caution because of risk
(Zyban)20 reduce smoking-
mg/day) of hypertensive reactions
related complications

Acamprosate Maintain abstinence

None Continue
(Campral)21 from alcohol intake

Consider regional
analgesia or the use of
non-opioid analgesics if
clinically appropriate
Inadequate perioperative
pain control with opioid
Oral: Hold 5 IM formulation may take
analgesics (ex.
days at least 4 weeks to be
Naltrexone Maintain abstinence Hydromorphone,
eliminated from body
(Revia, from alcohol intake or fentanyl, remifentanil)
IM: Contact
Vivitrol)22,23 opioid use
prescribing Naltrexone should be
Induction of opioid
physician restarted at the
Opioid/Alcohol Use withdrawal upon
discretion of the
Deterrents administration of opioids
prescribing chronic
pain
management/substanc
e use physician
Consider regional
analgesia or the use of
Buprenorphine non-opioid analgesics if
(Subutex) Inadequate perioperative Continue clinically appropriate
Buprenorphine/na pain control with opioid unless patient
Maintain abstinence
loxone analgesics (ex. was otherwise If held, restarting may be
from opioid use;
(Suboxone) Hydromorphone, instructed by the deemed re-initiation
Control chronic pain
Buprenorphine fentanyl, remifentanil) prescribing depending on length of
patch physician hold
(Butrans)24-26
Recommend to alert
surgeon
For other products which contain any of the above ingredients but are not listed in the table, recommend following the
perioperative management guidance for the agent which is most restrictive.
 20

TNF alpha inhibitors

Recommended Usual Additional
Class Examples Risk of Continuation
Holding Time Management Considerations*

abatacept (Orencia )

adalimumab (Humira )

anakinra (Kineret)

certolizumab (Cimzia )

etanercept (Enbrel ) Stop 2 weeks prior to Resume when the wound
procedures Myelo/immunosuppression is fully healed

golimumab (Simponi )

infliximab (Remicade )

rituximab (Rituxan )

tocilizumab (Actemra )

Other medications to continue BEFORE and ON the MORNING of the procedure:

Alzheimer and dementia medications
Anti-psychotics
Anti-seizure medications
Anti-Parkinson's medications
Antibiotics*
Anxiolytics benzodiazepines
Gout medications

o Allopurinol (Zyloprim )

o Colchicine (Colcrys , Mitigare )
HIV medications


Mupirocin (Bactroban ) nasal ointment
Myasthenia Gravis medications
o Notify Anesthesia pre-operatively
Thyroid medications**
Transplant immunosuppression***

* Unless otherwise directed by Surgeon or Proceduralist

** Can be held up for 5 - 7 days postoperatively if patient is NPO
*** Sirolimus (Rapamune), everolimus (Zortress, Afinitor), Temsirolimus (Torisel) may be associated with
impaired wound healing, but there are no formal recommendations for holding suggest consulting with the
prescriber.
 21

References:
1. OSUWMC Clinical Practice Guideline. Management of Antiplatelet Therapy in Patients with Arterial Stents
Around the Time of Surgeries and Procedures. 2014.

2. Plavix (clopidogrel bisulfate) [package insert]. Bridgewater, NJ; Bristol-Myers Squibb/Sanofi
Pharmaceuticals Partnership; Revised May 2009.

3. Effient (prasugrel hydrochloride) [package insert]. Indianapolis, IN; Eli Lilly and Company; Revised January
2011.

4. Brilinta (ticagrelor) [package insert]. Wilmington, DE; AstraZeneca; Revised September 2016.
5. Doherty JU, Gluckman TJ, Hucker WJ, et al. 2017 ACC Expert Consensus Decision Pathway for
Periprocedural Management of Anticoagulation in Patients With Nonvalvular Atrial Fibrillation. J Am Coll
Cardiol. 2017 Feb 21; 69 (7): 871-898.
6. Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative Management of Antithrombotic Therapy.
CHEST. 2012 Feb; 141 (2 Suppl): e326S-50S.
7. The Ohio State University Wexner Medical Center. Argatroban Dosing and Monitoring. Revised October
2016.
8. The Ohio State University Wexner Medical Center. Bivalirudin Dosing and Monitoring. Revised October
2016.

9. Reopro (abciximab) [package insert]. Horsham, PA; Janssen Biotech, Inc; Revised December 2016.

10. Integrilin (eptifibatide) [package insert]. Whitehouse Station, NJ; Merck Sharp & Dohme Corp; Revised April
2014.

11. Aggrastat (tirofiban) [package insert]. Somerset, NJ; Medicure Pharma, Inc; Revised 2016
12. Roshanov PS, Rochwerg B, Patel A, et al. Withholding versus Continuing Angiotensin-converting Enzyme
Inhibitors or Angiotensin II Receptor Blockers before Noncardiac Surgery. Anesthesiology. 2017 Jan;
126(1): 16-27.
13. POISE Study Group. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac
surgery (POISE trial). Lancet. 2008 May 31; 371(9627): 1839-47.

14. Uptravi (selexipag) [package insert]. South San Francisco; Actelion Pharmaceuticals US, Inc; Revised
December 2015.
15. Shim JK, Choi YS, Oh YJ, et al. Effect of oral sildenafil citrate on intraoperative hemodynamics in patients
with pulmonary hypertension undergoing valvular heart surgery. J Thorac Cardiovasc Surg. 2006 Dec;
132(6): 1420-5.

16. Adempas (riociguat) [package insert]. Whippany, NJ; Bayer HealthCare Pharmaceuticals Inc; Revised
February 2017.
17. Nolan MB, Warner DO. Safety and Efficacy of Nicotine Replacement Therapy in the Perioperative Period: A
Narrative Review. Mayo Clin Proc. 2015 Nov;90(11):1553-61
18. Wong JJ. Anesthesiology (Philadelphia): A perioperative smoking cessation intervention with varenicline: a
double-blind, randomized, placebo-controlled trial. American Society of Anesthesiologists 2012; 117:755

19. Chantix (varenicline) [package insert]. New York, NY. Pfizer Labs; Revised 2016 Dec.

20. Zyban (bupropion hydrochloride) [package insert]. Research Triangle Park, NC. GlaxoSmithKline; Revised
2016 June.

21. Campral (acamprosate) [package insert]. St. Louis, MO. Forest Pharmaceuticals, Inc.: 2004.
22. Revia (naltrexone hydrochloride) [package insert]. Hazelwood, MO. Mallinckrodt, Inc: Revised 2014 Nov.

23. Vivitrol (naltrexone for extended-release injection) [package insert]. Waltham, MA. Alkermes, INC.: Revised
2015 Dec.

24. Suboxone (buprenorphine/naloxone) [package insert]. Richmond, VA. Indivior, Inc: Revised 2016 Dec.

25. Butrans (buprenorphine extended release) prescribing information. Stamford, CT. Purdue Pharma LLP:
Revised 2016 Dec.
26. Alford DP, Compton P, Samet JH. Acute pain management for patients receiving maintenance methadone
or buprenorphine therapy. Ann Intern Med. 2006 Jan 17;144(2):127-34.
 22

References

Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, et al. 2014 ACC/AHA
Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac
Surgery. Journal of the American College of Cardiology (2014), doi:10.1016/j.jacc.2014.07.944.
Kaufman RM, Djulbegovic B, Gernsheimer T, Kleinman S, Tinmouth AT, Capocelli KE, et al. Platelet Transfusion:
A Clinical Practice Guideline From the AABB. Annals of Internal Medicine (2014), doi:10.7326/M14-1589

Guideline Authors
Erica Stein, MD
Barbara Rogers, MD
Carl Schmidt, MD
Michael Guertin, MD
Kristin Brower, PharmD BCPS
Danielle Blais, PharmD, BCPS
Sarah Dickey, PharmD, BCPS
Donna Heavener, RN
Dawn Bachert, RN
Joyce Porginski, RN

Guideline Approved

_June 28, 2017. Second Edition

Disclaimer: Clinical practice guidelines and algorithms at The Ohio State University Wexner Medical Center (OSUWMC) are standards
that are intended to provide general guidance to clinicians. Patient choice and clinician judgment must remain central to the selection of
diagnostic tests and therapy. OSUWMCs guidelines and algorithms are reviewed periodically for consistency with new evidence;
however, new developments may not be represented.

Copyright 2017. The Ohio State University Wexner Medical Center. All rights reserved. No part of this document may be reproduced,
displayed, modified, or distributed in any form without the express written permission of The Ohio State University Wexner Medical
Center.
 Appendix A: Guideline for Antiplatelet and Anticoagulant Therapy Management Surrounding Regional Anesthesia

1
Neuraxial complications are extremely rare. Epidural hematomas are one possible complication of neuraxial anesthesia.

2
Antiplatelet or anticoagulant medications may increase the incidence of a neuraxial bleed.
Contact the Department of Anesthesiology Acute Pain Team with questions about resuming antiplatelet or anticoagulant medications in relation to
neuraxial anesthesia.
These recommendations do not apply to patients with perineural catheter placement.

Table 1:

Antiplatelet Agents
Prior to Procedure While Catheter in Place Post Procedure
Minimum recommended time between Restrictions while neuraxial catheter in Minimum recommended time between
Medication Dose last dose of antithrombotic agent and place neuraxial catheter removal or neuraxial
neuraxial catheter placement or procedure and next dose of antithrombotic
neuraxial procedure agent
3 Refer to OSUWMC Clinical Practice Guideline: Management of Antiplatelet Therapy in Patients with Arterial Stents Around the Time of Surgeries and
Aspirin*
Procedures
Aspirin/ Patient- and procedure-specific decision should be made with patient and care team.
Dipyridamole*
3
(Aggrenox ) All doses 7 days* 24 hours
Refer to OSUWMC Clinical Practice Guideline: Management of Antiplatelet Therapy in Patients with Arterial Stents Around the Time of Surgeries and
Clopidogrel* Procedures
3
(Plavix ) 12 hours;
75mg daily 7 days Avoid while catheter is in place
24 hours if administering a loading dose
Dipyridamole
5 All doses 48 hours* 24 hours
(Persantine )
Prasugrel * Refer to OSUWMC Clinical Practice Guideline: Management of Antiplatelet Therapy in Patients with Arterial Stents Around the Time of Surgeries and
3 Procedures
(Effient )
All doses 10 days** Avoid while catheter is in place 24 hours
Ticagrelor* Refer to OSUWMC Clinical Practice Guideline: Management of Antiplatelet Therapy in Patients with Arterial Stents Around the Time of Surgeries and
3 Procedures
(Brilinta )
All doses 5 days Avoid while catheter is in place 24 hours
Cilostazol
4 All doses 48 hours* 24 hours
(Pletal )
No need to hold dose

If the decision is made to hold, the 4 hours

Non-Selective
Non-Aspirin duration to hold should be based upon
5
NSAIDs 5 half-lives of specific NSAID. Contact
Pharmacy for assistance. See Table 3
COX-2
No need to hold dose
Selective
Voraxapar
All doses Contraindicated Avoid while catheter is in place
(Zontivity )
 Prior to Procedure While Catheter in Place Post Procedure
Minimum recommended time between Restrictions while neuraxial catheter in Minimum recommended time between
Medication Dose last dose of antithrombotic agent and place neuraxial catheter removal or neuraxial
neuraxial catheter placement or neuraxial procedure and next dose of antithrombotic
procedure agent
GP IIb/IIIa inhibitors
Abciximab
5
(Reopro ) 5 days
Eptifibatide
5 All doses Avoid while catheter is in place 12 hours**
(Integrilin )
Tirofiban
5 24 hours
(Aggrastat )
Direct Thrombin Inhibitors (Injectable)
Argatroban If neuraxial anesthesia is needed,
Bivalirudin Continuous decision should be discussed with
Avoid while catheter is in place
(Angiomax ) Infusion Anesthesiologist, surgical team, and
24 hours
pharmacy specialist
Desirudin All doses 24 hours Avoid while catheter is in place

(Iprivask )
Thrombolytic Agents
Not recommended, but maintain
Alteplase Therapeutic catheter if emergency thrombolytic
5 Minimum 48 hours for emergency
(TPA ) dose for therapy is required and notify 48 hours or normalization of fibrinogen
procedures
stroke, etc. Department of Anesthesiology
Acute Pain Team.
1mg 2mg
Alteplase
(catheter No need to hold dose
(TPA)
clearance)
Injectable Anticoagulants
Inpatients: No time restriction. 5000 units Q12H may be given
Consider the peak effect of while indwelling catheter in place
subcutaneous heparin at 2 hours with concurrent SCDs
5000 units SQ
when placing catheter.
Q12H
Can be restarted a minimum of 2
Outpatients: 8 hours hours post-neuraxial anesthesia
Heparin
catheter placement. 2 hours- Consider PTT if concern for
unfractionated
2,5 ASRA guidelines prefer the use of bleeding risk
5000 units SQ Q12H dosing, however risk of
8 hours
Q8H bleed vs clot must be considered
when using TID dosing
7500 units SQ
8 hours Avoid while catheter is in place
Q8H
IV Infusion 4 hours if normal PTT Avoid while catheter is in place
 Prior to Procedure While Catheter in Place Post Procedure
Minimum recommended time between Restrictions while neuraxial catheter in Minimum recommended time between
Medication Dose last dose of antithrombotic agent and place neuraxial catheter removal or neuraxial
neuraxial catheter placement or neuraxial procedure and next dose of antithrombotic
procedure agent
CrCl > 30mL/min: 12 hours
Must wait 8 hours post-catheter
5000 units SQ
CrCl 30mL/min: 24 hours (consider placement to re-initiate dosing 24 hours **
QDay
anti-Xa level to assess level of
Dalteparin anticoagulation)***
6
(Fragmin ) CrCl > 30mL/min: 24 hours
200 units/kg
SQ QDay
CrCl 30 mL/min: 48 hours Avoid while catheter is in place 24 hours
100 units/kg
(consider anti-Xa level to assess
SQ Q12H
level of anticoagulation)***
Must wait 12 hours post-catheter
40mg SQ
CrCl > 30 mL/min: 12 hours placement to re-initiate dosing
QDay
30mg SQ CrCl 30mL/min: 72 hours (consider 24 hours**
Q12H anti-Xa level to assess level of
Enoxaparin 40mg SQ anticoagulation )***
5,7,8
(Lovenox ) Q12H
CrCl > 30 mL/min: 24 hours Avoid while catheter is in place
1mg/kg Q12H
1 1.5mg/kg CrCl 30 mL/min: 72 hours 24 hours
SQ QDay (consider anti-Xa level to assess
level of anticoagulation)***
CrCl > 50 mL/min: 3 4 days
2.5mg SQ
CrCl 50 mL/min: 4 days (consider 24 hours
QDay
anti-Xa level to assess level of
Fondaparinux
5 anticoagulation)***
(Arixtra ) Avoid while catheter is in place
CrCl > 50 mL/min: 4 days
5 10mg SQ
CrCl 50 mL/min: 5 days (consider 24 hours
QDay
anti-Xa level to assess level of
anticoagulation)***
 Oral Anticoagulants
Prior to Procedure While Catheter in Place Post Procedure
Minimum recommended time between Restrictions while neuraxial catheter in Minimum recommended time between
Medication Dose last dose of antithrombotic agent and place neuraxial catheter removal or neuraxial
neuraxial catheter placement or neuraxial procedure and next dose of antithrombotic
procedure agent
Apixaban CrCl > 30 mL/min: 3 days
5
(Eliquis ) All doses 24 hours
CrCl 30mL/min: 5 days
Dabigatran CrCl > 15 mL/min: 5 days
5
(Pradaxa ) All doses 24 hours
CrCl 15mL/min: 6 days
Edoxaban CrCl > 50mL/min: 3 days
5
(Savaysa ) All doses Avoid while catheter is in place 24 hours
CrCl 50mL/min: 5 days
Rivaroxaban CrCl > 50mL/min: 3 days
5 All doses
(Xarelto ) 24 hours
CrCl 50mL/min: 5 days
Warfarin
,
(Jantoven All doses 5 days, normalization of INR 24 hours
5
Coumadin )
Hemorrheologic Agents
Pentoxifylline (Trental) No need to hold dose
Herbal Agents
Herbal Agents
Including (but not limited to):
Aloe, burdock root, chamomile,
Preferred hold time 24 hours. Contact
chondroitin, dong quai, evening
Pharmacy Specialist for
primrose, flaxseed, fish oil, garlic, 7 days Avoid while catheter is in place
recommendation for specific medication
ginger, ginko, ginseng,
recommendation.
glucosamine, green tea, hu zhang,
saw palmetto, turmeric, vitamin a
and e

*Patient- and procedure-specific decision should be made with patient and care team whether to hold medication.

** For medications wherein ASRA guidelines recommend a range of holding, we have elected to recommend the more conservative holding time due to renal
elimination of medications and lack of reversal agents.

*** Order anti-Xa level specific to Low Molecular Weight Heparins (anti-Xa LMW Heparin). For other agents that effect Factor Xa, the presence of an elevated Xa
indicates presence of the medication and does not necessarily reflect the degree of anticoagulation.
 5, 9-18
Table 3: Half-Lives of Commonly Administered Non-Aspirin NSAIDs

NSAID Half- life, h Discontinuation Time, 5 Half-lives, h

Diclofenac 1-2 5-10
Etodolac 6-8 30-40
Ibuprofen 2-4 10-20
Indomethacin 5-10 25-50
Ketorolac 5-6 25-30
Meloxicam 15-20 75-100
Nabumetone 22-30 110-150
Naproxen 12-17 60-85
Oxaprozin 40-60 200-240
Piroxicam 45-50 225-250

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