O&G · Perioperative care — gynaecological surgery
Perioperative medication management
Also known as Perioperative drug management · Bridging anticoagulation · Perioperative warfarin · Perioperative DOAC · Perioperative diabetes management · Stress-dose steroids · Perioperative ACEi/ARB · Pre-admission medication review
FRANZCOG reference on perioperative medication management anchored on fetched trial and guideline abstracts: ACCP 2022 against heparin bridging in atrial fibrillation, BRIDGE (no-bridge noninferior for arterial thromboembolism with less major bleeding), PAUSE standardised DOAC interruption without bridging, POISE-1 and POISE-2 harm signals, ENOXACAN-II four-week enoxaparin after abdominal or pelvic cancer surgery, Marik 2008 versus Woodcock 2020 on glucocorticoid cover, Hollmann ACEi/ARB withholding on the morning of surgery, and SGLT2 hold as a guideline interval under challenge. ANZ-first, globally tagged.
Checked against its sources on 3 Sept 2026
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Red flags
- Active major bleeding on a DOAC — idarucizumab 5 g IV for dabigatran; andexanet alfa (bolus then 2-hour infusion) for factor Xa inhibitors where licensed
- Do not extrapolate BRIDGE (atrial fibrillation, no routine heparin bridge) to mechanical heart valves — that trial did not answer valve bridging
- Primary adrenal insufficiency or physiologic replacement steroids — Woodcock 2020: stress-dose hydrocortisone is mandatory and is in addition to usual treatment
- SGLT2 inhibitor through a prolonged fast, especially in a patient on insulin — euglycaemic DKA risk; international guidelines recommend a 3-to-4-day hold
- Starting a new beta-blocker 2 to 4 hours before non-cardiac surgery — POISE-1 increased death and stroke
- Unexplained postoperative hypotension in a steroid-dependent patient — treat as possible adrenal crisis; delays may prove fatal
It is the Wednesday before Mrs Lim's cytoreductive surgery. She takes apixaban for atrial fibrillation, metformin and glargine for type 2 diabetes, ramipril for hypertension, and prednisolone 10 mg daily for polymyalgia rheumatica. The pre-admission clinic is where this list becomes a written day-of-surgery prescription. This topic is the script for that conversation — restricted to numbers that sit in fetched abstracts.[1][16]
Overview and definition
Perioperative medication management turns a chronic drug list into a safe day-of-surgery plan. It has three complementary parts:[1][4]
- Stratify the drug — continue unchanged, withhold on the day, withhold for one or more days, or reverse in haemorrhage.
- Stratify the patient — thrombotic indication (atrial fibrillation, mechanical valve, recent VTE, active cancer) versus bleeding risk of the procedure.
- Stratify the surgery — magnitude, anaesthetic technique (including neuraxial), and urgency (elective versus emergent).[3][4]
The four-trial summary at the door
"BRIDGE / PAUSE / POISE / ENOX" — BRIDGE ended routine heparin bridging for atrial fibrillation; PAUSE standardised DOAC interruption without bridging; POISE-1 showed harm from starting metoprolol immediately before non-cardiac surgery; ENOXACAN-II supported four weeks of enoxaparin after abdominal or pelvic cancer surgery.[2][3][8][10]
References22ShowHide
- [1]Douketis JD, Spyropoulos AC, Murad MH, et al. Executive Summary: Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. Chest, 2022.PMID 35964703
- [2]Douketis JD, Spyropoulos AC, Kaatz S, Becker RC, et al. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. N Engl J Med, 2015.PMID 26095867
- [3]Douketis JD, Spyropoulos AC, Duncan J, Carrier M, et al. Perioperative Management of Patients With Atrial Fibrillation Receiving a Direct Oral Anticoagulant. JAMA Intern Med, 2019.PMID 31380891
- [4]Douketis JD, Spyropoulos AC Perioperative Management of Patients Taking Direct Oral Anticoagulants: A Review. JAMA, 2024.PMID 39133476
- [5]Pollack CV Jr, Reilly PA, Eikelboom J, et al. Idarucizumab for Dabigatran Reversal. N Engl J Med, 2015.PMID 26095746
- [6]Connolly SJ, Crowther M, Eikelboom JW, et al. Full Study Report of Andexanet Alfa for Bleeding Associated with Factor Xa Inhibitors. N Engl J Med, 2019.PMID 30730782
- [7]Devereaux PJ, Mrkobrada M, Sessler DI, et al. Aspirin in patients undergoing noncardiac surgery. N Engl J Med, 2014.PMID 24679062
- [8]Devereaux PJ, Yang H, Yusuf S, et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet, 2008.PMID 18479744
- [9]Devereaux PJ, Sessler DI, Leslie K, Kurz A, et al. Clonidine in patients undergoing noncardiac surgery. N Engl J Med, 2014.PMID 24679061
- [10]Bergqvist D, Agnelli G, Cohen AT, et al. Duration of prophylaxis against venous thromboembolism with enoxaparin after surgery for cancer. N Engl J Med, 2002.PMID 11919306
- [11]Gould MK, Garcia DA, Wren SM, Karanicolas PJ, et al. Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest, 2012.PMID 22315263
- [12]American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Gynecology Prevention of Venous Thromboembolism in Gynecologic Surgery: ACOG Practice Bulletin, Number 232. Obstet Gynecol, 2021.PMID 34259490
- [13]Hollmann C, Fernandes NL, Biccard BM A Systematic Review of Outcomes Associated With Withholding or Continuing Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers Before Noncardiac Surgery. Anesth Analg, 2018.PMID 29381513
- [14]Marik PE, Varon J Requirement of perioperative stress doses of corticosteroids: a systematic review of the literature. Arch Surg, 2008.PMID 19075176
- [15]Woodcock T, Barker P, Daniel S, Fletcher S, et al. Guidelines for the management of glucocorticoids during the peri-operative period for patients with adrenal insufficiency: Guidelines from the Association of Anaesthetists, the Royal College of Physicians and the Society for Endocrinology UK. Anaesthesia, 2020.PMID 32017012
- [16]Barker P, Creasey PE, Dhatariya K, et al. Peri-operative management of the surgical patient with diabetes 2015: Association of Anaesthetists of Great Britain and Ireland. Anaesthesia, 2015.PMID 26417892
- [17]Kotagal M, Symons RG, Hirsch IB, et al. Perioperative hyperglycemia and risk of adverse events among patients with and without diabetes. Ann Surg, 2015.PMID 25133932
- [18]Haziri F, Durak K, Glarner N, Ergin E, et al. Perioperative discontinuation of SGLT2-inhibitors and cardiac complications after noncardiac surgery: secondary analysis of two prospective observational cohort studies. Br J Anaesth, 2026.PMID 42270529
- [19]Lozada GA, Chen RB, Davoud S, Lee GS Perioperative Management of Glucagon-like Peptide-1 Receptor Agonists and Sodium-Glucose Co-transporter 2 Inhibitors. Anesthesiol Clin, 2026.PMID 42069389
- [20]American Society of Anesthesiologists Committee on Standards and Practice Parameters Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures: An Updated Report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. Anesthesiology, 2017.PMID 28045707
- [21]Nelson G, Bakkum-Gamez J, Kalogera E, et al. Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations-2019 update. Int J Gynecol Cancer, 2019.PMID 30877144
- [22]Duggan EW, Klopman MA, Berry AJ, Umpierrez G The Emory University Perioperative Algorithm for the Management of Hyperglycemia and Diabetes in Non-cardiac Surgery Patients. Curr Diab Rep, 2016.PMID 26971119