Perioperative Pharmacology for Surgeons — Continue-or-Hold Lists, Cardiac and Diabetes Drugs, Anticoagulation, Analgesia, LAST, MH, VTE and SSI Principles

The surgeon does not dose the anaesthetic and does not run the anticoagulation clinic — but the surgeon owns the list: which tablets continue to the morning of surgery, which stop and when, which restart before discharge, what the trade-off numbers are, and where the referral goes. Learn perioperative pharmacology as list doctrine: continue chronic beta-blockade but never acutely initiate it; hold-or-continue RASI is patient-specific equipoise with a hypotension-hypertension trade; SGLT2 inhibitors stop days ahead with euglycaemic-ketoacidosis vigilance; GLP-1 agonists stratify by fasting, recency and gut symptoms; DOACs stop and restart by bleeding-risk band with no bridging; aspirin continues through stented surgery with P2Y12 stopped by recovery time; steroids stay at maintenance without high-dose cover; conventional DMARDs continue while targeted and biologic agents pause; multimodal analgesia spares opioids with nausea-and-vomiting as its most consistent dividend; motility agents and cautious lidocaine speed the gut; dosing discipline plus lipid rescue contains LAST; dantrolene answers malignant hyperthermia; VTE timing is equipoise with mechanical adjuncts; antibiotics redose intraoperatively; herbals stop one to two weeks out; and the older adult's list shrinks by design.^{[1][3][6][8][12][13][21][24][25][30][33][37][38][41][42][44]}

A stented patient needing a colectomy, a diabetic on a flozin and a weekly gut-slowing injection booked for a hernia repair, a rheumatic on a biologic needing the same operation, an older adult on a dozen tablets with a frailty label, a long case where the anaesthetist asks about the morning ACE inhibitor, and a wound infiltration that turns into ringing ears and a rhythm — all sit on the same teaching list. The examiner will ask for the beta-blocker trade numbers, the RASI hypertension-hypotension exchange, the DOAC stop-restart bands with their event rates, the DAPT stent timeline with platelet-recovery days, the hernia-specific antiplatelet answer, the SGLT2 hold rule with SAPKA numbers, the GLP-1 aspiration strata, the steroid maintenance verdict with DMARD holds, the multimodal drug set with its honest benefit, the motility-agent and lidocaine numbers, the LAST fractional-dose rule with lipid rescue, the dantrolene rarity numbers, the VTE timing equipoise with compression odds, the redosing odds ratio, the herbal stop window, and the older-adult prescribing rule. This page answers each question with every statement taken from the paper named beside it.^{[1][3][6][8][12][13][17][18][21][24][25][33][37][38][41][42][44]}

Continue-or-Hold Doctrine — the List Is the Operation

Every elective list starts with reconciliation: the perioperative question for each long-term drug is bleeding versus thrombosis and control versus harm — answered per class, per operation, per owner guideline, never by blanket rule.^[12] The Cochrane humility clause governs the whole topic: for antiplatelet continuation versus discontinuation the entire randomised base is five trials with 666 adults — mortality, surgical-rescue bleeding and ischaemic events all low-certainty either-way, with moderate certainty only that transfusion need probably differs little either way.^[15] State those numbers at the viva before giving any confident-sounding rule — the trials never gave one.^[15]

The older adult sharpens the doctrine into subtraction. The American College of Surgeons 7-component older-adult protocol names minimisation of potentially inappropriate medications as its own component — alongside delirium prevention and screening, fall prevention, aspiration precautions, spirometry and bowel regimen.^[44] Polypharmacy with inappropriate medications tracks higher mortality, complications and readmission — and frailty independently predicts intraoperative and postoperative complications, mortality and length of stay, so preoperative assessment gives special attention to polypharmacy and multimorbidity.^[44][45] The rule: the older adult's list shrinks by design, not by accident.^[44][45]

Beta-Blockers — Continue, Never Newly Initiate

The ACC/AHA systematic review set out to test whether beta-blockade started within 45 days before noncardiac surgery cuts 30-day cardiovascular morbidity and mortality — seventeen studies, sixteen of them randomised trials with 12,043 participants plus one cohort of 348.^[1] Outside the DECREASE trials, every randomised trial started blockade within a day or less of surgery — and that acute initiation is exactly what the numbers condemn.^[1] Among randomised trials, blockade cut nonfatal myocardial infarction (relative risk 0.69) but raised nonfatal stroke (1.76), hypotension (1.47) and bradycardia (2.61).^[1] The one-line verdict: blockade started within a day or less before noncardiac surgery prevents nonfatal infarction while increasing stroke, death, hypotension and bradycardia risks.^[1] Strip out the controversial DECREASE studies and insufficient data remain on blockade started two or more days out — so the surgeon continues chronic therapy and never acutely initiates for the operation.^[1]

Modern workup frames the same patient stepwise: clinical risk indices, functional capacity and selective testing — not routine screens — with natriuretic peptides and troponins improving prediction and catching myocardial injury after noncardiac surgery, which strongly predicts death.^[2] Stable patients get no routine stress testing and no prophylactic coronary revascularisation; sustained statins with attentive antiplatelet and beta-blocker management carry the risk mitigation.^[2] Myocardial ischaemia and injury after noncardiac surgery remain prevalent drivers of postoperative morbidity and mortality — which is why the list, not the catheter, is the surgeon's instrument.^[2]

RASI and Statins — Equipoise With a Trade, Humility With a Hint

Renin-angiotensin inhibitors carry the topic's cleanest equipoise. The British mixed-model study found five randomised trials with 2,848 patients: stopping shows no mortality-or-MACE signal (odds ratio 1.21, wide confidence interval) while trading more acute hypertension (odds ratio 1.90) for fewer hypotension events (odds ratio 0.62).^[3] The updated meta of ten randomised trials with 3,740 patients agrees: no difference in major cardiac events, all-cause mortality, infarction, heart failure, pulmonary oedema, stroke, postoperative hypotension, perioperative hypertension or kidney injury — except withholding cuts intraoperative hypotension (relative risk 0.82).^[4] The practice paradox: 79% of 316 United Kingdom service-evaluation patients had RASI stopped with 93% restarted within 48 hours, while over 80% of surveyed clinicians routinely ask for stopping — yet the optimal approach remains uncertain and routine withholding could cause harm.^[3] The viva answer is patient-specific, not protocol: name the hypotension-hypertension exchange and decide per patient.^[3][4]

Statins get humility with a hint. Their anti-inflammatory and immunomodulatory pleiotropy motivated perioperative study in colorectal-cancer surgery — but five cohorts give inconsistent leak, infection and mortality signals across heterogeneous designs, regimens and definitions.^[5] Three cohorts examined anastomotic leak: two found no significant difference, one a marginally higher rate in statin users.^[5] The hint: consistently lower 30-day mortality in propensity-matched groups, with 90-day mortality variable.^[5] Quote continued-statin principle from guideline-directed medical therapy and refuse to promise any anastomotic benefit — the randomised proof does not exist.^[2][5]

SGLT2 Inhibitors — Hold Days Ahead, Suspect Ketoacidosis at Normal Glucose

The flozins are the list's trap drug: perioperative management remains controversial, while the United States regulator says stop 3 to 4 days before surgery regardless of diabetes status.^[6] The SPAQI multidisciplinary consensus answers with a tailored Delphi approach — diabetes status, comorbidities, surgical and dietary fasting context — plus monitoring and prevention strategies for euglycaemic ketoacidosis.^[6] The adjudicated numbers behind the caution: 128 perioperative ketoacidosis case reports, expert-rated likely in 41%, possible in 30%, unlikely in 21%, with the rest unvalidatable.^[7] Perioperative SGLT2-associated postoperative ketoacidosis in type 2 diabetes is therefore a real, counted entity — not a theoretical risk.^[7]

The bedside rule follows the physiology: euglycaemic-ketoacidosis risk concentrates with insulin use and prolonged fasting — so hold the drug before elective procedures.^[8] SGLT2 inhibitors are known to raise euglycaemic-ketoacidosis risk, full stop.^[9] Suspect ketoacidosis on ketonaemia with metabolic acidosis even when glucose reads normal, and reach for blood-ketone testing — that is the whole diagnostic lesson.^[8][9]

GLP-1 Agonists, Metformin, Insulin — Aspiration Against Hypoglycaemia

Gut-slowing injections stratify by story, not by blanket hold. Highest aspiration risk sits with non-fasting patients who recently started the drug, recently escalated dose, or carry active gastrointestinal symptoms.^[8] Asymptomatic patients on stable doses may continue through the perioperative period.^[8] The mechanism the examiner wants: retained gastric contents from slowed emptying raises aspiration risk — countered by predefined withholding windows, gastric ultrasound to check contents, airway-plan modification, or deferring elective surgery.^[9]

The wider diabetic list resists one protocol. About one third of the United States population carries prediabetes, with even higher surgical prevalence — so avoid prolonged fasting and monitor glucose from induction through recovery with euglycaemia as the goal.^[10] Insulin, DPP-4 inhibitors, GLP-1 agonists, SGLT2 inhibitors and metformin each bring distinct mechanisms, benefits and hazards — and professional organisations agree on elements while differing on cessation and dosing, leaving no single global protocol.^[11] Hyperglycaemia, thyroid dysfunction and adrenal insufficiency each raise perioperative risk that appropriate management mitigates — with preop glycaemic optimisation, class-by-class noninsulin handling, insulin including intravenous indications, and a thyroid-delay strategy for dysfunction completing the frame.^[46]

Anticoagulation — CHEST Buckets With DOAC Stop-Restart Maths

The CHEST clinical-practice guideline organises the whole field into 43 PICO questions across four buckets — vitamin K antagonists, heparin bridging for VKA patients, direct oral anticoagulants, antiplatelets — graded into 44 recommendations with exactly two strong ones: against heparin bridging in atrial fibrillation, and for VKA continuation at pacemaker or defibrillator implantation.^[12] That no-bridging strong recommendation is the doctrine's spine: interruption without low-molecular-weight-heparin bridging is the default for planned procedures.^[12][14]

The JAMA DOAC review gives the stop-restart maths for apixaban, rivaroxaban, edoxaban and dabigatran in atrial fibrillation and venous thromboembolism.^[13] Minimal-bleed procedures continue the drug — or hold only on the day if bleeding worries dominate.^[13] Low-to-moderate risk operations such as cholecystectomy and inguinal hernia repair stop one day before and restart one day after.^[13] High-risk operations such as major cancer or joint replacement stop two days before and restart two days after.^[13] With that strategy, thromboembolism runs 0.2 to 0.4% and major bleeding 1 to 2%, with few delays or cancellations.^[13] The 2025 guidance adds three comforts: DOACs need no routine laboratory testing, specific reversal agents exist for life-threatening uncontrollable bleeding, and dose selection follows indication with patient-factor adjustment to minimise bleeding.^[14]

Antiplatelets and Stents — Aspirin Continues, P2Y12 Pauses by Recovery Time

The bleeding ledger first: over 30,000 noncardiac-surgery patients show aspirin raising transfusion risk (relative risk 1.14) and dual therapy more (1.33), with clopidogrel elevated but too heterogeneous to pool.^[16] Against that, the Cochrane base finds continuation versus discontinuation may make little or no mortality difference to six months (relative risk 1.21, low certainty), probably little or no transfusion difference (relative risk 1.37, moderate certainty), and may make little or no difference to surgical-rescue bleeding or 30-day ischaemic events including peripheral ischaemia, cerebral infarction and myocardial infarction.^[15] Low certainty with few participants and few events, three ongoing trials pending — quote the ledger, refuse the dogma.^[15][16]

The stent timeline then decides. During the re-endothelialisation window, stent thrombosis outweighs bleeding — except inside the cranium.^[17] Elective noncardiac surgery waits six months after new-generation drug-eluting stents, three months only if delay is impossible.^[17] Past that window, stop the P2Y12 inhibitor for platelet-recovery time — clopidogrel five to seven days, prasugrel seven to ten, ticagrelor three to five — and continue aspirin through the operation.^[17]

The hernia answer is surgeon-specific and examinable. Thirteen articles cover elective inguinal hernia repair — ten on antiplatelets, nine on anticoagulation, six on both.^[18] For open and laparoscopic repair alike there is no need to stop antiplatelets, aspirin or clopidogrel — while warfarin continuation or cessation stays case-by-case on limited evidence with individual complexity.^[18] Quote ONLY this hernia endpoint here; bridging regimens and stop intervals belong to transfusion-coagulation.^[18]

Psychotropics, Steroids, DMARDs — Interact, Cover, Hold

Psychotropics demand awareness without invented rules: evidence-based perioperative guidelines are lacking, with a low base of case reports, open trials and non-systematic reviews.^[20] Weigh six risks per patient — operation extent, physical state, anaesthesia, direct and indirect drug effects, withdrawal, psychiatric relapse — across antidepressants, antipsychotics, mood stabilisers, anxiolytics and stimulants with their anaesthetic interactions.^[19][20] The 2025 synthesis screened 12,569 citations down to eleven narrative-review articles — state that thinness openly rather than reciting confident holds the literature never gave.^[19]

Steroids carry the maintenance-dose synthesis, with cover regimens owned by surgical-immunology. Adrenal-insufficiency incidence on chronic glucocorticoids runs low, and withholding stress steroids shows no survival or haemodynamic difference — but the studies are small with limited universality.^[21] So every patient takes the regular daily dose preoperatively regardless of dose or chronicity, with extra stress dosing set by suppression risk and surgical stress.^[21] The six-decade supraphysiologic standard yields: no high-dose perioperative cover — stay on baseline maintenance and suspect secondary insufficiency in unexplained perioperative hypotension.^[22]

DMARD holds quote as principle only. The 2022 ACR/AAHKS GRADE guideline, built by rheumatologists, orthopaedic and infection specialists with patient consensus, updates when to continue, withhold and restart disease-modifying therapy with optimal periop glucocorticoid dosing.^[23] The working ledger: conventional DMARDs — methotrexate, hydroxychloroquine, sulfasalazine, leflunomide — continue; targeted synthetics suspend three to seven days by drug and restart three to five days after; biologics withhold a dosing cycle and resume at fourteen days minimum with a healed wound.^[24] Full holds, flare balancing and lupus exceptions stay fenced to surgical-immunology.^[23][24]

Multimodal Opioid-Sparing — the Continuum With an Honest Dividend

Opioids earned their centrality and their reckoning: nausea and vomiting, respiratory depression, ileus and persistent postoperative use now drive minimisation strategies.^[25] Opioid-sparing and opioid-free sit on one continuum of exposure reduction — not opposing religions — built from multimodal and regional techniques.^[25] The honest dividend: across mixed and procedure-specific populations the most consistent benefit is tolerability, particularly less nausea and vomiting — not large pain-intensity reduction — while going fully opioid-free shifts adverse effects toward bradycardia and hypotension.^[25] Over 80% of surgical patients still face significant postoperative pain with prolonged stay, delayed recovery and chronic-pain progression — so minimisation is strategy, never abandonment.^[26]

The drug set: gabapentinoids, acetaminophen, NSAIDs, ketamine, intravenous lidocaine, dexmedetomidine and glucocorticoids — with peripheral blocks and neuraxial techniques where appropriate, newer agents still controversial.^[27] Nonopioid multimodality works by synergistic targeting of distinct pain pathways and now anchors contemporary perioperative and ERAS care.^[28] The most opioid-sparing combination the evidence names is NSAIDs with dexamethasone or regional anaesthesia.^[26] Run it coordinated — pathways that cut opioid need and lift satisfaction beat ad-hoc prescribing.^[27] And mind the discharge gap: prescribed opioid quantities consistently exceed actual consumption, perpetuating avoidable harm without better outcomes — so the inpatient multimodal regimen with limited opioids continues home.^[26]

ERAS Gut Recovery — Motility Agents In, Lidocaine Cautious

Sixteen abdominal-and-thoracic ERAS Society guidelines compared for pharmacotherapy core items show consensus on choices across 21 items — but doses, regimens, timing and operation-specific details remain unharmonised research gaps.^[29] Quote consensus choices; name the gaps; never invent a dose the guidelines never fixed.^[29]

Two numbered answers sit inside that frame. Motility agents after elective colorectal surgery: seven randomised trials with 849 patients show GI-2 recovery faster by 1.01 days and first defaecation by 1.07 days with no safety difference — cheap, available, safe-profiled candidates for ERAS integration.^[30] Intravenous lidocaine after minimally invasive colorectal surgery: twelve randomised trials with 1,208 patients, proposed through analgesic plus anti-inflammatory properties yet inconsistent since a major trial's retraction — modestly better gastrointestinal recovery and early pain, with no effect on ileus, stay or opioid use — so routine use stays cautious pending better trials.^[31]

PONV — Score It, Prevent by Class, Mind the Airway

Nausea and vomiting prevention starts from neurophysiology with patient-specific and procedure-specific risk factors, ending in evidence-based prevention and treatment strategies built for practical outpatient delivery.^[32] The oral-surgery stakes generalise: airway compromise, haematoma, wound dehiscence and delayed healing around intraoral wounds or fixation, with delayed discharge and unplanned care when prevention fails.^[32] Stratify by the review's patient-specific and procedure-specific risk factors, prevent and treat by evidence-based class, and bank the opioid-sparing dividend — less opioid exposure is itself antiemetic, with reduced nausea and vomiting minimisation's most consistent gain.^[25][32]

LAST — Dosing Discipline and Lipid Rescue

Local-anaesthetic systemic toxicity is uncommon, spanning vague neurology to cardiac arrest — which is exactly why dosing discipline precedes every infiltration the surgeon performs.^[34] Maximum-dosage discrepancies between guideline sources persist, and the additive toxicity of combined amide agents stays underappreciated — so calculate every dose systematically.^[33] Combining amides? Apply the fractional-dose rule — a pharmacologically justified safety heuristic with acknowledged pharmacokinetic limits — and remember why mixing deserves caution at all: additive toxicity, complex arithmetic, no proven concurrent-mixing benefit, unnecessary exposure, incremental hypersensitivity risk.^[33]

Rescue runs airway first: airway support and oxygenation remain primary, with intravenous lipid emulsion as the specific rescue for severe or cardiovascular toxicity in a setting-stratified response.^[33] The liposomal cautionary tale: 266 mg of liposomal bupivacaine producing arrest with ventricular fibrillation in one lobectomy patient and neurotoxicity in another — both reversed within minutes to hours by lipid — so reduce doses in highly vascular beds and aspirate carefully to avoid intravascular injection.^[34]

Malignant Hyperthermia — Recognise, Stop Triggers, Dantrolene, Refer

Perioperative abnormalities in inherited primary skeletal-muscle disorders can mimic malignant-hyperthermia crisis — and conflicting non-current literature is exactly why these patients route through MH units for perioperative advice.^[35] The surgeon's job is recognition plus referral: stop triggers, call for dantrolene, and send the patient down the investigation pathway — not ordering contracture tests or curating variants.^[35][36] Know the pathway exists: forty years of halothane-caffeine contracture testing now joined by the MH-genotype designation with a variant-curation system and revised referral criteria.^[36]

Dantrolene is the definitive treatment for a rare life-threatening disorder — and the Mayo numbers keep it in proportion: 1.2 million pharmacy records, 118 recipients, one in 10,165 admissions — with seventeen perioperative suspected cases of which nine (53%) confirmed as MH.^[37] Perioperative dantrolene marks suspicion, not diagnosis; rarity explains why the drug must be found fast when suspicion strikes.^[37]

VTE and SSI Prophylaxis — Timing Principles With Fenced Dosing

Chemical-thromboprophylaxis timing after elective major abdominal surgery is equipoise, not dogma. Fourteen studies with 24,922 patients show pre-closure versus postoperative initiation giving comparable symptomatic (relative risk 0.81) and overall (0.74) venous thromboembolism rates.^[38] Mechanical prophylaxis adds honestly: thirteen randomised trials with 1,914 abdominopelvic patients show compression devices beating placebo (odds ratio 0.39) without beating other prophylaxis alone — but adding compression to stockings (0.45) or to chemical prophylaxis (0.25) helps — on openly low-quality, high-bias evidence.^[39] Doses, agents and duration belong to haemostasis-thrombosis; timing awareness with the trade stated is owned here.^[38][39]

Antibiotic prophylaxis quotes as principle only. State-of-the-art surgical antimicrobial prophylaxis spans selection, timing, dosing, intraoperative redosing and avoidance of unnecessary postoperative continuation.^[40] The redosing number: procedures of three hours or more, seven observationals with 4,671 patients, redosing cutting surgical-site infection (odds ratio 0.65).^[41] Choice, weight-based dosing, obesity, infusion and resistant-organism tailoring stay fenced to surgical-infection-antimicrobials.^[40][41]

Herbals, Elderly, Endocrine — Screen, Simplify, Stratify

Ask every patient about herbals — then stop them. Garlic, ginseng, ginkgo, St John's wort and echinacea top preoperative use — yet fifty to seventy percent of patients hide use and most never stop.^[42] Anaesthesia bodies say stop herbals one to two weeks before elective surgery for interaction risk.^[42] Nineteen herbs, three formulas, two teas and other supplements carry perioperative and postoperative bleeding risk — so screen and educate every patient as a stated surgical duty.^[43]

Close the list where it opened: the older adult. Multicomponent delirium prevention, screening that finds hidden delirium, fall, aspiration, spirometry and bowel-regimen processes each carry heterogeneous but supportive evidence — embedded as age-specific processes inside existing enhanced-recovery pathways.^[44] Frailty predicts the bad outcomes; the Clinical Frailty Scale is feasible; prehabilitation runs multidisciplinary; polypharmacy and multimorbidity get special attention.^[45] And the endocrine frame behind much of the list: hyperglycaemia, thyroid dysfunction and adrenal insufficiency each raise perioperative risk that appropriate management mitigates.^[46]

Exam Synthesis and Fence Map — What This Topic Owns

This topic owns surgeon-facing pharmacology: continue-or-hold reconciliation with five-trial 666-patient Cochrane humility; older-adult list-shrinking with the 7-component protocol; beta-blocker continuation without acute initiation with 0.69, 1.76, 1.47 and 2.61 trade numbers; stepwise risk-based cardiac workup with biomarker-enhanced MINS detection and no routine testing or revascularisation; RASI patient-specific equipoise with 1.21, 1.90 and 0.62 exchange numbers plus 79%-stop 93%-restart practice paradox; statin continuation principle with leak-humility and mortality hint; SGLT2 3-to-4-day hold with tailored SPAQI approach and 128-case 41%-likely SAPKA count; euglycaemic-ketoacidosis vigilance with ketone testing at normal glucose; GLP-1 aspiration strata with stable-dose continuation and gastric-ultrasound precautions; diabetes class-by-class variation with fasting avoidance and throughout-monitoring; CHEST 43-PICO 44-recommendation doctrine with two strong rules and no-bridging spine; DOAC banded stop-restart with 0.2-to-0.4% and 1-to-2% event rates plus no-labs, reversal and indication-dosed comforts; aspirin 1.14 and dual-therapy 1.33 transfusion ledger with little-or-no-difference Cochrane counterweight; stent-thrombosis-beats-bleeding rule with 6-month and 3-month timelines and 5-to-7, 7-to-10 and 3-to-5-day P2Y12 pauses under continued aspirin; hernia no-need-to-stop antiplatelets with case-by-case warfarin; psychotropic six-risk weighing on an 11-from-12,569 thin base; steroid regular-dose-always with risk-and-stress-based extras and maintenance-dose synthesis with hypotension watch; ACR/AAHKS GRADE ownership with conventional-continue, 3-to-7-day targeted pause and dosing-cycle biologic hold; opioid continuum with tolerability-first honest dividend and bradycardia-hypotension opioid-free shift; over-80% pain prevalence with NSAIDs-plus-dexamethasone-or-regional best combination and discharge-gap discipline; seven-drug multimodal set with blocks and coordinated pathways; 16-guideline 21-item ERAS consensus with dose-and-timing gaps; motility-agent GI-2-minus-1.01-day numbers with ERAS-integration candidacy; lidocaine modest-gain cautious-use verdict; PONV risk-stratified class prevention with airway stakes and opioid-sparing dividend; LAST maximum-dose discipline with fractional combination rule and airway-first lipid-rescue order plus vascular-bed dose reduction with aspiration; MH mimic recognition with unit referral, genotype-plus-contracture pathway awareness and definitive-dantrolene 1-in-10,165 rarity with 9-of-17 confirmation; VTE timing equipoise with compression add-on odds; SSI selection-timing-dosing-redosing principle with 0.65 redosing odds; herbal top-five screen with 1-to-2-week stop and 19-herb bleeding ledger; and older-adult delirium-fall-aspiration-spirometry-bowel processes with frailty-scale feasibility and prehabilitation multidisciplinarity.^{[1][2][3][5][6][7][8][11][12][13][15][16][17][18][19][21][22][23][24][25][26][27][29][30][31][32][33][35][36][37][38][39][40][41][42][43][44][45][46]}

Bridging regimens, stop intervals beyond the bands above, and transfusion triggers belong to transfusion-coagulation; antimicrobial choice, weight-based dosing and resistant-organism tailoring to surgical-infection-antimicrobials; feeding formulas and nutrition regimens to surgical-nutrition; wound-phase detail and closure decisions to wound-healing; checkpoint science and tumour markers to oncology-tumour-biology; steroid-cover regimens, DMARD flare balancing and anaphylaxis order to surgical-immunology; fluids, pressures and electrolytes to fluids-electrolytes and acid-base-balance; resuscitation, pressors and massive-transfusion triggers to shock, trauma and haemostasis topics; VTE agent dosing and duration to haemostasis-thrombosis; MH testing and variant curation to MH units and anaesthesia topics; volatile and regional technique dosing to anaesthesia topics — this topic claims only the general principles above with the numbers named beside them.^{[12][18][23][38][40]}

Exam Pearls — the One-Liners That Score

• Cochrane antiplatelet base: five trials, 666 adults, low certainty either-way — state before any rule.^[15]
• Beta-blockade within a day: infarction 0.69 down, stroke 1.76, hypotension 1.47, bradycardia 2.61 up — continue, never initiate.^[1]
• Beyond DECREASE: insufficient data on blockade started two-plus days out — multicentre trials needed.^[1]
• Modern workup: stepwise indices plus function plus selective tests; peptides and troponins catch MINS; no routine stress tests or revascularisation in stable patients.^[2]
• RASI stop: mortality-MACE 1.21 no-signal, hypertension 1.90 up, hypotension 0.62 down; practice stops 79% and restarts 93% within 48 hours.^[3]
• RASI meta of ten: no MACE, mortality, infarction, failure, stroke or kidney-injury difference; withholding cuts intraoperative hypotension 0.82.^[4]
• Statins: five cohorts, leak signals inconsistent, 30-day mortality hint in matched groups — continue per guidance, promise nothing anastomotic.^[5]
• SGLT2: regulator says stop 3 to 4 days regardless of diabetes; SPAQI tailors by status, comorbidity, fasting and diet with eDKA monitoring.^[6]
• SAPKA: 128 cases, likely 41%, possible 30%, unlikely 21% — counted, not theoretical.^[7]
• GLP-1 high aspiration risk: non-fasting plus recent start, escalation or gut symptoms; stable asymptomatic may continue.^[8]
• GLP-1 mechanism: retained gastric contents from slow emptying — withhold window, gastric ultrasound, airway plan or deferral.^[9]
• Prediabetes in a third; avoid prolonged fasting; monitor glucose throughout for euglycaemia.^[10]
• Diabetes classes differ in mechanism, benefit and hazard; organisations vary on cessation and dosing — no global protocol.^[11]
• CHEST: 43 PICO, four buckets, 44 recommendations, two strong — no bridging in fibrillation, VKA on for devices.^[12]
• DOAC bands: minimal continues or day-holds; low-moderate stops one day out and back one day after; high stops two out and back two after; events 0.2 to 0.4% clot, 1 to 2% major bleed.^[13]
• DOAC comforts: no routine labs, specific reversal for life-threatening bleed, interrupt without heparin bridging, dose by indication with patient factors.^[14]
• Aspirin transfusion 1.14, dual therapy 1.33, clopidogrel unpoolable — the bleeding ledger.^[16]
• Stent thrombosis beats bleeding except intracranial; elective waits six months after new DES, three if undelayable; P2Y12 pauses 5-to-7, 7-to-10, 3-to-5 days with aspirin continued.^[17]
• Hernia: thirteen articles — no need to stop aspirin or clopidogrel open or laparoscopic; warfarin case-by-case.^[18]
• Psychotropics: no evidence-based guidelines; case-report base; six risks weighed across five drug categories with anaesthetic interactions.^[19][20]
• Psychotropic thinness: 12,569 citations to eleven narrative reviews — say so openly.^[19]
• Steroids: low insufficiency incidence, no withholding difference but small studies — daily dose always, stress extras by risk and surgical stress.^[21]
• Six-decade supraphysiologic standard yields to maintenance continuation with hypotension watch for secondary insufficiency.^[22]
• ACR/AAHKS GRADE updates continue, withhold, restart and glucocorticoid dosing for rheumatic arthroplasty.^[23]
• DMARD ledger: conventional continue; targeted synthetics 3-to-7-day pause with 3-to-5-day restart; biologics a dosing-cycle hold with 14-day healed-wound restart.^[24]
• Opioid harms: nausea-vomiting, respiratory depression, ileus, persistent use — minimisation's motive force.^[25]
• Honest dividend: tolerability first, less nausea-vomiting most consistent — not big pain-score cuts; opioid-free shifts to bradycardia-hypotension.^[25]
• Pain over 80%, stay lengthened, chronicity threatened — minimisation is strategy, never abandonment.^[26]
• Best combination named: NSAIDs with dexamethasone or regional anaesthesia.^[26]
• Discharge gap: prescribed exceeds consumed with harm and no outcome gain — send multimodality home with limited opioids.^[26]
• Seven-drug set plus blocks and neuraxial where fitting; coordinated pathways cut need and lift satisfaction.^[27]
• Nonopioid synergy across pathways anchors modern and ERAS care.^[28]
• ERAS: sixteen guidelines, 21-item consensus on choices, dose-timing-operation gaps unharmonised.^[29]
• Motility agents: seven trials, 849 patients, GI-2 minus 1.01 days, defaecation minus 1.07 days, safety even — ERAS candidates.^[30]
• Lidocaine: twelve trials, 1,208 patients, modest gut and early-pain gain, ileus-stay-opioid unchanged, post-retraction inconsistency — cautious routine use.^[31]
• PONV: neurophysiology plus patient and procedure risks into practical prevention and treatment; airway, haematoma and dehiscence stakes.^[32]
• LAST: maximum-dose discrepancies persist, amide combinations add underappreciated toxicity — calculate every dose.^[33]
• Fractional-dose rule: justified heuristic with pharmacokinetic limits; mixing caution is arithmetic and exposure, not pathways.^[33]
• LAST rescue: airway and oxygenation first, lipid emulsion specific for severe or cardiovascular toxicity.^[33]
• LAST spans vague neurology to arrest; vascular beds get smaller doses with careful aspiration — even liposomal 266 mg arrested.^[34]
• MH mimics in inherited myopathies route through MH units on conflicting literature.^[35]
• MH workup now: contracture test plus MH-genotype designation with variant curation and revised referral criteria.^[36]
• Dantrolene definitive; 1.2 million records, 118 recipients, one in 10,165 admissions; seventeen suspected perioperative, nine confirmed.^[37]
• VTE timing: fourteen studies, 24,922 patients, pre-closure versus postop comparable at 0.81 symptomatic and 0.74 overall — equipoise.^[38]
• Compression: thirteen trials, 1,914 patients — beats placebo 0.39, not other prophylaxis alone, add-on wins at 0.45 with stockings and 0.25 with chemical — low-quality openly.^[39]
• SSI prophylaxis: selection, timing, dosing, redosing, no needless continuation.^[40]
• Redosing at three-plus hours: seven observationals, 4,671 patients, SSI odds 0.65.^[41]
• Herbals top five: garlic, ginseng, ginkgo, St John's wort, echinacea; fifty to seventy percent hide use; stop one to two weeks pre-elective.^[42]
• Bleeding ledger: nineteen herbs, three formulas, two teas and more — screen and educate every patient.^[43]
• Older-adult protocol: seven components including inappropriate-medication minimisation; polypharmacy tracks mortality, complications, readmission.^[44]
• Frailty predicts complications, mortality and stay; scale feasible, prehabilitation multidisciplinary, polypharmacy multimorbidity watched.^[45]
• Endocrine frame: hyperglycaemia, thyroid dysfunction and adrenal insufficiency raise mitigable perioperative risk.^[46]

References46ShowHide

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