Medications to withhold or continue in the preoperative consultation

[Perioperative adverse events related to antidepressive agents use]

OBJECTIVE

Depression is the most common psychiatric disease, which is treated by the use of antidepressive agents possessing various mechanisms of action. Thus, the use in preoperative period of antidepressive agents is frequent (7% of patients scheduled for surgery). The objective of this review was to update the knowledge on the drug interactions between antidepressive agents and drugs used in perioperative period.

METHODS

(i) Medline and Ovid databases using combination of antidepressive agent and perioperative period as keywords; (ii) national and European epidemiologic database; (iii) expert recommendation and official French health agency; (iv) reference book chapters.

RESULTS

The clinical practice showed a limited risk of adverse event related to antidepressant agents interaction with perioperative used drugs. In the two past decades, few relevant observations of adverse event related with imipramine and monoamine oxidase inhibitors use was reported. The most recent antidepressive agents had no serious adverse interaction. Nevertheless, the serotonin syndrome has to be known as far as it is more and more reported. In case of hypotension, the use of vasopressive agent has to be careful because of excessive response.

Psychotropic Drugs and the Perioperative Period: A Proposal for a Guideline in Elective Surgery

Evidence-based guidelines for the perioperative management of psychotropic drugs are lacking. The level of evidence is low and is based on case reports, open trials, and non-systematic reviews. However, the interactions and effects mentioned indicate that patients who use psychotropics and require surgery have an enhanced perioperative risk. A group of clinicians from several clinical disciplines determined which risks should be considered in an integrated preoperative assessment, as well as how psychotropics might interfere with these risks. The risks that should be considered in the perioperative period are the extent of the surgery, the patient's physical state, anesthesia, the direct and indirect (Phase I and II) effects of psychotropics, risk of withdrawal symptoms, and risk of psychiatric recurrence or relapse. Because of new drug developments, the risk of interactions increases. The literature has not provided articles that systematically address these risks. On the basis of a systematic analysis of the available literature guided by the formulated perioperative risks, a proposal for the perioperative management of psychotropics was formulated. Patients who use lithium, monoamine oxidase inhibitors, tricyclics, and clozepine have serious drug-drug interactions, with increased physical risks, including withdrawal, and therefore qualify for American Society of Anesthesiologists (ASA) Classification 3. From the perspective of the physical risk, they require discontinuation. However, from the perspective of the risk of withdrawal and psychiatric relapse and recurrence, these patients deserve intensive, integrated anesthetic/psychiatric management. For patients on selective serotonin reuptake inhibitors (SSRIs) who are mentally and physical stable (ASA Classification 2), the risk of withdrawal seems to justify their continuation. Yet, patients on SSRIs with higher physical or psychiatric risks should be seen in consultation. Both the physical and psychiatric risks of patients who use antipsychotics and other antidepressants should be regarded as enhanced. From a physical perspective, they qualify for ASA Classification 2. From the perspective of withdrawal and psychiatric recurrence or relapse, they should be seen by (their) psychiatrists. Preoperative assessment clinics offer the opportunity to assess and evaluate these risks in order to deliver patient-tailored integrated care. Authors propose a model for quality management.

Guidelines for preoperative administration of patients’ home medications

Currently, there are no agreed upon guidelines for the administration of preoperative medications. Institutional guidelines were formulated after a review of the literature, recommendations by experts, and a consensus among anesthesiologists, surgeons, pharmacists, and nursing educators. These guidelines were then provided to the preadmission staff to instruct patients regarding preoperative medications. These guidelines will have to be reassessed periodically as new medications and medical evidence emerge.