Summary
The objectives for the provision of a safe anaesthetic include rendering the patient analgesic for the procedure (amnesic if appropriate), with control of adverse haemodynamic perturbations, and muscle relaxation to facilitate surgery as necessary. This must be done with an understanding of the patient’s pre-existing pathophysiology and drug therapy. This article focuses on the management of medications in the perioperative period from the practitioner’s perspective. Areas of drug therapy examined include drugs affecting the cardiovascular, central nervous, haemostatic and endocrine systems.
Review of the limited data available suggests that the safest course of action for the preoperative management of the vast majority of drug therapy is to continue such therapy until the time of surgery, particularly agents in which a withdrawal syndrome has been described, e.g. β-adrenoceptor blocking agents, α2-adrenoceptor agonists. Exceptions to this generalisation might include discontinuing ACE inhibitors prior to surgery as these agents may be associated with adverse haemodynamic changes during surgery.
The management of drug therapy for patients receiving monoamine oxidase inhibitors (MAOIs) continues to be challenging due to the potential for drug interactions, e.g. severe hypertension with use of indirect-acting vasopressors and excitatory/depressive reactions with administration of pethidine (meperidine) or dextromethorphan. However, recent clinical experience has demonstrated the relative safety of continuing MAOIs prior to surgery by use of specific ‘MAOI safe’ anaesthetic techniques and/or substitution of short-acting MAOIs which do not irreversibly inhibit the enzyme.
For drugs affecting the coagulation system, such as heparin and warfarin, prudence dictates discontinuing these agents whenever possible prior to surgery where it can be anticipated that haemorrhage will occur, e.g. vascular surgery, or where the consequences of even minor bleeding could be catastrophic, e.g. eye surgery. Controversy exists as to the management of patients receiving prophylactic low dose heparin for deep vein thrombosis prophylaxis or in whom intraoperative or postoperative anticoagulation is planned, e.g. aortic surgery, and in whom a regional anaesthetic technique is planned as part of the anaesthetic management. The data available suggest that, where prophylactic use of heparin is concerned, and provided the administration of the last dose of heparin and the institution of a regional anaesthetic nerve block does not occur at the same time, use of regional anaesthesia is not contraindicated in such circumstances. Where therapeutic anticoagulation is planned as part of the surgical management, there is a very small risk of the development of epidural or spinal haematoma when major central conduction nerve block is employed for anaesthesia, with resultant spinal cord compression and paralysis. These precautions do not apply to patients receiving aspirin or other nonsteroidal anti-inflammatory agents as there is a large clinical and published experience of the safety of regional anaesthesia in this group of patients. Patients treated with fibrinolytic agents are at increased risk for bleeding should surgery be required. For these patients, pre- and intraoperative use of agents with antifibrinolytic activity, e.g. aprotinin, has been demonstrated in case reports to be beneficial.
Finally, recommendations for the management of patients who have received or are receiving glucocorticoids are given. Throughout the review, areas of uncertainty where further research is required are identified.
Similar content being viewed by others
References
Olsson GL, Hallen B, Hambraeus-Jonzon K. Aspiration during anesthesia: a computer-aided study of 185,358 anaesthetics. Acta Anaesthesiol Scand 1986; 30: 84–92
Tiret L, Nivoche Y, Hatton F, et al. Complications related to anaesthesia in infants and children: a prospective survey of 40240 anesthetics. Br J Anaesth 1988; 61: 263–9
Cheney FW, Posner KL, Caplan RA. Adverse respiratory events infrequently leading to malpractice suits: a closed claims analysis. Anesthesiology 1991; 75: 932–9
Warner MA, Warner ME, Weber JG. Clinical significance of pulmonary aspiration during the perioperative period. Anesthesiology 1993; 78: 56–62
Coté CJ. NPO after midnight for children — a reappraisal [editorial]. Anesthesiology 1990; 72: 589–92
Crawford M, Lerman J, Christensen S, et al. Effects of duration of fasting on gastric fluid pH and volume in healthy children. Anesth Analg 1990; 71: 400–3
Shevde K, Trivedi N. Effects of clear liquids on gastric volume and pH in healthy volunteers. Anesth Analg 1991; 72: 528–31
Schreiner MS, Triebwasser A, Keon TP. Ingestion of liquids compared with preoperative fasting in pediatric outpatients. Anesthesiology 1990; 72: 593–7
Maltby JR, Lewis P, Martin A, et al. Gastric fluid volume and pH in elective patients following unrestricted oral fluid until three hours before surgery. Can J Anaesth 1991; 38: 425–9
Phillips S, Hutchinson S, Davidson T. Preoperative drinking does not affect gastric contents. Br J Anaesth 1993; 70: 6–9
Sreide E, Holst-Larsen K, Reite K, et al. Effects of giving water 20-450 ml with oral diazepam premedication 1-2 h before operation. Br J Anaesth 1993; 71: 503–6
Goresby GV, Maltby JR. Fasting guidelines for elective surgical patients. Can J Anaesth 1990; 37: 493–5
Hjorts E, Mandorf T. Does oral premedication increase the risk of gastric aspiration? Acta Anaesthesiol Scand 1982; 26: 505–6
McGrady EM, MacDonald AG. Effect of the preoperative administration of water on gastric volume and pH. Br J Anaesth 1988; 60: 803–5
Miller M, Wishart HY, Nimmo WS. Gastric contents at induction of anaesthesia: is a 4-hour fast necessary? Br J Anaesth 1983; 55: 1185–8
Sutherland AD, Maltby JR, Sale JP, et al. The effect of preoperative oral fluid and ranitidine on gastric fluid volume and pH. Can J Anaesth 1987; 34: 117–21
Maltby JR, Sutherland AD, Sale JP, et al. Preoperative oral fluids: is a five-hour fast justified prior to elective surgery? Anesth Analg 1986; 65: 1112–6
Brocks K, Jensen JS, Schmidt JF, et al. Gastric contents and pH after oral premedication. Acta Anaesthesiol Scand 1987; 31: 448
Splinter WM, Schaefer JD. Ingestion of clear fluids is safe for adolescents up to 3 h before anaesthesia. Br J Anaesth 1991; 66: 48–52
Splinter WM, Schaefer JD. Unlimited clear fluid ingestion two hours before surgery in children does not affect volume or pH of stomach contents. Anaesth Intens Care 1990; 18: 522–6
Pontén J, Biber B, Henriksson B-Å, et al. Beta-receptor blockade and neurolept anaesthesia: withdrawal vs continuation of long-term therapy in gall-bladder and carotid artery surgery. Acta Anaesthesiol Scand 1982; 26: 576–88
Berggren H, Ekroth R, Herlitz J, et al. Myocardial protective effect of maintained beta-blockade on aorto-coronary bypass surgery. Scand J Thor Cardiovasc Surg 1983; 17: 29–32
Prys-Roberts C, Meloche R, Foëx P. Studies of anaesthesia in relation to hypertension: I. cardiovascular responses of treated and untreated patients. Br J Anaesth 1971; 43: 122–37
Prys-Roberts C. Hypertension and anesthesia-fifty years on [editorial]. Anesthesiology 1979; 50: 281–4
Tarnow J, Müller RK. Cardiovascular effects of low-dose epi-nephrine infusions in relation to the extent of preoperative β-adrenoceptor blockade. Anesthesiology 1991; 74: 1035–43
Hart GR, Anderson RJ. Withdrawal syndromes and the cessation of antihypertensive therapy. Arch Intern Med 1981; 141: 1125–7
Nattel S, Rangno RE, Van Loon G. Mechanism of propranolol withdrawal phenomena. Circulation 1979; 59: 1158–64
Bruce DL, Croley TF, Lee JS. Preoperative clonidine withdrawal syndrome. Anesthesiology 1979; 51: 90–2
Kaukinen S, Kaukinen L, Eerola R. Preoperative and postoperative use of clonidine with neurolept anaesthesia. Acta An-aesthesiol Scand 1978; 23: 113–20
Quintin L, Cicala R, Kent M, et al. Effect of clonidine on myo-cardial ischaemia: a double-blind pilot trial. Can J Anaesth 1993; 40: 85–6
Fulgencio JP, Rimaniol JM, Catiore P, et al. Clonidine and postoperative myocardial ischaemia. Can J Anaesth 1994; 41: 550–1
Colson P, Médioni P, Saussine M, et al. Hemodynamic effect of calcium channel blockade during anesthesia for coronary artery surgery. J Cardiothorac Vasc Anesth 1992; 6: 424–8
Schick Jr EC, Liang C, Heupler Jr FA, et al. Randomized withdrawal from nifedipine: placebo-controlled study in patients with coronary artery spasm. Am Heart J 1982; 104: 690–7
Subramanian VB, Bowles MJ, Khurmi NS, et al. Calcium antagonist withdrawal syndrome: objective demonstration with frequency-modulated ambulatory ST-segment monitoring. BMJ 1983; 286: 520–1
Larach DR, Hensley FAJ, Pae WE, et al. Diltiazem withdrawal before coronary artery bypass surgery. J Cardiothorac Vasc Anesth 1989; 3: 688–99
Chung F, Houston PL, Cheng DCH, et al. Calcium channel blockade does not offer adequate protection from perioperative myocardial ischemia. Anesthesiology 1988; 69: 343–7
Slogoff S, Keats AS. Does chronic treatment with calcium entry blockers reduce perioperative myocardial ischemia? Anesthesiology 1988; 68: 676–80
Yates_AP, Hunter DN. Anaesthesia and angiotensin-converting enzyme inhibitors: the effect of enalapril on peri-operative cardiovascular stability. Anaesthesia 1988; 43: 935–8
Coriat P, Richer C, Douraki T, et al. Influence of chronic angiotensin-converting enzyme inhibition on anesthetic induction. Anesthesiology 1994; 81: 299–307
McCarthy GJ, Lindsay K, Wright JM, et al. Pressor response to tracheal intubation after sublingual captopril: a pilot study. Anaesthesia 1990; 45: 243–5
Sill JC, Nugent M, Moyer TP, et al. Influence of propranolol plasma levels on hemodynamics during coronary artery bypass surgery. Anesthesiology 1984; 60: 455–63
Hedberg A, Gerber JG, Nies AS, et al. Effects of pindolol and propranolol on beta adrenergic receptors on human lymphocytes. J Pharmacol Exp Ther 1986; 239: 117–23
Stone JG, Foëx P, Sear JW, et al. Myocardial ischemia in untreated hypertensive patients: effect of a single small oral dose of abeta-adrenergic blocking agent. Anesthesiology 1988; 68: 495–500
Roizen MF. Should we all have a sympathectomy at birth? Or at least preoperatively? [editorial]. Anesthesiology 1988; 68: 482–4
Kostis JB. Beta-blocker duration of action and implications for therapy. Am J Cardiol 1990; 66: 60G–2G
Gerber JG, Nies AS. Antihypertensive agents and the drug therapy of hypertension. In: Gilman AG, Rall TW, Nies AS, et al., editors. The pharmacological basis of therapeutics. New York: Pergamon, 1990: 784–813
Hayashi Y, Maze M. Alpha2 adrenoceptor agonists and anaesthesia. Br J Anaesth 1993; 71: 108–18
Flacke JW, Bloor BC, Flacke WE, et al. Reduced narcotic requirement by clonidine with improved hemodynamic and adrenergic stability in patients undergoing coronary artery bypass surgery. Anesthesiology 1987; 67: 11–9
Reves JG, Kissin I, Lell WA, et al. Calcium entry blockers: uses and implications for anesthesiologists. Anesthesiology 1982; 57: 504–18
Schlanz KD, Myre SA, Bottorff MB. Pharmacokinetic interactions with calcium channel antagonists (part II). Clin Phar-macokinet 1991; 21: 448–60
Lehot JJ, Durand PG, Boulieu R, et al. Concentrations plasmatiques du diltiazem et de ses métabolites en chirurgie coronarienne: relation avec le traitement préopératoire. Ann Fr Anesth Rean 1993; 12: 452–6
Finegan BA, Hussain MD, Tarn YK. Pharmacokinetics of diltiazem in patients undergoing coronary artery bypass grafting. Ther Drug Monitor 1992; 14: 485–92
Casson WR, Jones RM, Parsons RS. Nifedipine and cardiopul-monary bypass: post-bypass management after continuation or withdrawal of therapy. Anaesthesia 1984; 39: 1197–201
Selby DG, Richards JD, Marshman JM. ACE inhibitors [letter]. Anaesth Intens Care 1989; 17: 110–1
Böttcher M, Behrens JK, Møller EA, et al. ACE inhibitor pre-medication attenuates sympathetic responses during surgery. Br J Anaesth 1994; 72: 633–7
Williams GH. Converting-enzyme inhibitors in the treatment of hypertension. N Engl J Med 1988; 319: 1517–25
Frishman WH. Comparative pharmacokinetic and clinical profiles of angiotensin-converting enzyme inhibitors and calcium antagonists in systemic hypertension. Am J Cardiol 1992; 69: 17C–25C
Pinaud M, Blanloeil Y Operating on a cardiac patient: stopping or continuing preoperative treatment. Ann Fr Anesth Rean 1986; 5: 138–53
Vaughan Williams EM. A classification of antiarrhythmic actions reassessed after a decade of new drugs. J Clin Pharmacol 1984; 24: 129–47
Liberman_BA, Teasdale SJ. Anaesthesia and amiodarone. Can Anaesth Soc J 1985; 32: 629–38
Mason JW. Amiodarone. N Engl J Med 1987; 316: 455–66
Kupferschmid JP, Rosengart TK, Mclntosh CL, et al. Amiodarone-induced complications after cardiac operation for obstructive hypertrophie cardiomyopathy. Ann Thorac Surg 1989; 48: 359–64
Teasdale S, Downar E. Amiodarone and anaesthesia [editorial]. Can J Anaesth 1990; 37: 151–5
Kannan R, Nademanee K, Hendrickson JA, et al. Amiodarone kinetics after oral doses. Clin Pharmacol Ther 1982; 31: 438–44
Puech P. Practical aspects of the use of amiodarone. Drugs 1991; 41 Suppl. 2: 67–73
Stoelting RK. Cardiac antidysrhythmic drugs. In: Stoelting RK, editor. Pharmacology and physiology in anesthetic practice. Philadelphia (PA): JB Lippincott, 1987: 322–34
Colucci RD, Somberg JC. Treatment of cardiac arrhythmias. In: Chernow B, editor. Essentials of critical care pharmacology. Baltimore (MD): Williams and Wilkins, 1994: 313–37
Baldessarini RJ. Drugs in the treatment of psychiatric disorders. In: Gilman AG, Rall TW, Nies AS, et al., editors. The pharmacological basis of therapeutics. New York: Pergamon, 1990: 383–435
Elis J, Laurence DR, Mattie H, et al. Modification by monoamine oxidase inhibitors of the effect of some sympatho-mimetics on blood pressure. BMJ 1967; 2: 75–8
Stack CG, Rogers P, Linter SPK. Monoamine oxidase inhibitors and anaesthesia. Br J Anaesth 1988; 60: 222–7
Gevirtz C. Anesthesia and monoamine oxidase inhibitors, [letter]. JAMA 1989; 261: 3407
Mallinger AG, Smith E. Pharmacokinetics of monoamine oxi-dase inhibitors. Psychopharmacol Bull 1991; 27: 493–502
Boakes AJ, Laurence DR, Teoh PC, et al. Interactions between sympathetic amines and antidepressant agents in man. BMJ 1973; 1: 311–5
Ramanathan KB, Davidson C. Cardiac arrhythmia and imipramine therapy. BMJ 1975; 1: 661–2
Edwards RP, Miller RD, Roizen MF, et al. Cardiac responses to imipramine and pancuronium during anesthesia with halo-thane or enflurane. Anesthesiology 1979; 50: 421–5
Johnston RR, Eger El, Wilson C. A comparative interaction of epinephrine with enflurane, isoflurane, and halothane in man. Anesth Analg 1976; 55: 709–12
Wong KC, Puerto AX, Puerto BA, et al. Influence of imipramine and pargyline on the arrhythmogenicity of epinephrine during halothane, enflurane or methoxyflurane anesthesia in dogs [abstract]. Anesthesiology 1980; 53: S25
Sprague DH, Wolf S. Enflurane seizures in patients taking ami-triptyline. Anesth Analg 1982; 61: 67–8
Amsterdam J, Brunswick D, Mendels J. The clinical application of tricyclic antidepressant pharmacokinetics and plasma levels. Am J Psychiatry 1980; 137: 653–62
Hill GE, Wong KC, Hodges MR. Lithium carbonate and neuro-muscular blocking agents. Anesthesiology 1977; 46: 122–6
Richelson E, El-Fakahany E. Changes in the sensitivity of receptors for neurotransmitters and the actions of some psycho-therapeutic drugs. Mayo Clin Proc 1982; 57: 576–82
Whitwam JG, Russell WJ. The acute cardiovascular changes and adrenergic blockade by droperidol in man. Br J Anaesth 1971; 43: 581–91
Vohra SB. Convulsions after enflurane in a schizophrenic patient receiving neuroleptics. Can J Anaesth 1994; 41: 420–2
Mohler H, Richards JG. The benzodiazepine receptor: a pharmacological control element of brain function. Eur J Anes-thesiol 1988; 2: 15–24
Perisho JA, Buechel DR, Miller Ronald D. The effect of diaze-pam (Valium) on minimum alveolar anaesthetic requirement (MAC) in man. Can Anaesth Soc J 1971; 18: 536–40
Gyermek L. Clinical effects of diazepam prior to and during general anesthesia. Curr Ther Res 1975; 17: 175–88
Torpey DJ, Ingram MD. Shock. In: Kirby RR, Gravenstein N, editors. Clinical anesthesia practice. Toronto: WB Saunders Co., 1994: 663–98
Haefely W. The preclinical pharmacology of flumazenil. Eur J Anesthesiol 1988; 2: 25–36
Stanski DR. Monitoring depth of anesthesia. In: Miller RD, editor. Anesthesia. New York (NY): Churchill Livingstone, 1990: 1001–30
Litt B, Krauss GL. Pharmacologic approach to acute seizures and antiepileptic drugs. In: Chernow B, editor. Essentials of critical care pharmacology. Baltimore (MD): Williams and Wilkins, 1994: 352–74
Rall TW, Schleifer LS. Drugs effective in the therapies of the epilepsies. In: Gilman AG, Rall TW, Nies AS, et al., editors. The pharmacological basis of therapeutics. 8th ed. New York (NY): McGraw-Hill Inc., 1990: 436–62
Cedarbaum JM, Schleifer LS. Drugs for Parkinson’s disease, spasticity, and acute muscle spasms. In: Goodman AG, Rall TW, Nies AS, et al., editors. The pharmacological basis of therapeutics. New York (NY): Pergamon, 1990: 463–84
Friedman JH, Feinberg SS, Feldman RG. A neuroleptic malignantlike syndrome due to levodopa therapy withdrawal. JAMA 1985; 254: 2792–5
Stow PJ, Burrows FA. Anticoagulants in anaesthesia. Can J Anaesth 1987; 34: 632–49
Kakkar VV, Corrigan TP, Fossard DP. Prevention of fatal postoperative pulmonary embolism by low doses of heparin: an international multicenter trial. Lancet 1975; 2(7924): 45–51
Majerus PW, Broze GJJ, Miletich JP, et al. Anticoagulant, thrombolytic, and antiplatelet drugs. In: Gilman AG, Rall TW, Nies AS, et al., editors. The pharmacological basis of therapeutics. New York (NY): Pergamon, 1990: 1311–31
Stoelting RK. Anticoagulants. In: Stoelting RK, editor. Pharmacology and physiology in anesthetic practice. Philadelphia (PA): Lippincott, 1991: 466–76
Bromage PR. Continuous epidural analgesia. In: Bromage PR, editor. Epidural analgesia. Toronto: WB Saunders Co, 1978: 215–57
Horlocker TT, Wedel DJ. Anticoagulants, antiplatelet therapy and neuraxis blockade. Anesthesiol Clin North Am 1992; 10 Suppl. 1: 1–11
Owens EL, Kasten GW, Hessel II EA. Spinal subarachnoid hematoma after lumbar puncture and heparinization: a case report, review of the literature, and discussion of anesthetic implications. Anesth Analg 1986; 65: 1201–7
Metzger G, Singbartl G. Spinal epidural hematoma following epidural anesthesia versus spontaneous spinal subdural hematoma: two case reports. Acta Anaesthesiol Scand 1991; 35: 105–7
Parnass SM, Rothenberg DM, Fischer RL, et al. Spinal anesthesia and mini-dose heparin [letter]. JAMA 1990; 263: 1496
Lowson SM, Goodchild CS. Low-dose heparin therapy and spinal anaesthesia [letter]. Anaesthesia 1989; 44: 67
Wille-Jørgensen P, Jørgensen LN, Rasmussen LS. Lumbar regional anaesthesia and prophylactic anticoagulant therapy: is the combination safe? Anaesthesia 1991; 46: 623–7
Eichhorn JH. Spinal anaesthesia and anticoagulant therapy [letter]. JAMA 1989; 262: 411
Vandermeulen EP, Van Aken H, Vermylen J. Anticoagulants and spinal-epidural anesthesia. Anesth Analg 1994; 79: 1165–77
Bergqvist D, Lindblad B, Mätzsch T. Risk of combining low molecular weight heparin for thromboprophylaxis and epidural or spinal anesthesia. Semin Thromb Hemost 1993; 19 Suppl. 1: 147–51
Bergqvist D, Lindblad B, Mätzsch T. Low molecular weight heparin for thromboprophylaxis and epidural/spinal anaesthesia — is there a risk? Acta Anaesthesiol Scand 1992; 36: 605–9
Wolf H. Experience with regional anesthesia in patients receiving low molecular weight heparins. Semin Thromb Hemost 1993; 19 Suppl. 1: 152–4
Odoom JA, Sih IL. Epidural analgesia and anticoagulant therapy: experience with one thousand cases of continuous epi-durals. Anaesthesia 1983; 38: 254–9
Rao TLK, El-Etr AA. Anticoagulation following placement of epidural and subarachnoid catheters: an evaluation of neurologic sequelae. Anesthesiology 1981; 55: 618–20
Stevens DS. Epidural hematoma: was catheter removed during complete anticoagulation? [letter]. Anesth Analg 1992; 75: 863–4
Wildsmith JAW, McClure JH. Anticoagulant drugs and central nerve blockade [editorial]. Anaesthesia 1991; 46: 613–4
Tekkok IH, Cataltepe O, Tahta K, et al. Extradural haematoma after continuous extradural anaesthesia. Br J Anaesth 1991; 67: 112–5
Onishchuk JL, Carlsson C. Epidural hematoma associated with epidural anesthesia: complications of anticoagulant therapy. Anesthesiology 1992; 77: 1221–3
Dickman CA, Shedd SA, Spetzler RF, et al. Spinal epidural hematoma associated with epidural anesthesia: complications of systemic heparinization in patients receiving peripheral vascular thrombolytic therapy. Anesthesiology 1990; 72: 947–50
Dahlgren N, Törnebrandt K. Neurological complications after anesthesia. A follow-up of 18000 spinal and epidural anaesthetics performed over 3 years. Acta Anaesthesiol Scand 1995; 39: 872–80
Renck H. Neurological complications of central nerve blocks [editorial]. Acta Anaesthesiol Scand 1995; 39: 859–68
Breivik H. Safe perioperative spinal and epidural analgesia: importance of drug combinations, segmental site of injection, training and monitoring [editorial]. Acta Anaesthesiol Scand 1995; 39: 869–71
Horlocker TT, Wedel DJ, Schlichting JL. Postoperative epidural analgesia and oral anticoagulant therapy. Anesth Analg 1994; 79: 89–93
May JR, DiPiro JT, Sisley JF. Drug interactions in surgical patients. Am J Surg 1987; 153: 327–35
Verbeeck RK, Blackburn JL, Loewen GR. Clinical pharmaco-kinetics of non-steroidal anti-inflammatory drugs. Clin Phar-macokinet 1983; 8: 297–331
Denson DD, Katz JA. Nonsteroidal anti-inflammatory agents. In: Sinatra RS, Hord AH, Ginsberg B, et al., editors. Acute pain. Toronto: Mosby-Year Book Inc., 1992: 112–23
Patrono C, Ciabattoni G, Patrignani P, et al. Clinical pharmacology of platelet cyclooxygenase inhibition. Circulation 1985; 72: 1177–84
Rodgers RPC, Levin J. A critical reappraisal of the bleeding time. Semin Thromb Hemost 1990; 16: 1–20
MacDonald R. Aspirin and extradural blocks [editorial]. Br J Anaesth 1991; 66: 1–3
Williams HD, Howard R, O’Donnell N, et al. The effect of low dose aspirin on bleeding times. Anaesthesia 1993; 48: 331–3
Bromage PR. Bleeding time [letter]. Br J Anaesth 1992; 69: 330
Wildsmith JAW, McClure JH. Aspirin, bleeding time and central neural block [letter]. Br J Anaesth 1993; 70: 112
CLASP Collaborative Group. CLASP: a randomized trial of low-dose aspirin for the prevention and treatment of pre-eclampsia among 9364 pregnant women. Lancet 1994; 343: 619–29
Shnider SM, Levinson G. Anesthesia for cesarean section. In: Shnider SM, Levinson G, editors. Anesthesia for obstetrics. Philadelphia (PA): Williams and Wilkins, 1993: 211–45
de Swiet M, Redman CWG. Aspirin, extradural anaesthesia and the MRC collaborative low-dose aspirin study in pregnancy (CLASP) [letter]. Br J Anaesth 1992; 69: 109
Horlocker TT, Wedel DJ, Offord KP. Does preoperative anti-platelet therapy increase the risk of hemorrhagic complications associated with regional anesthesia?. Anesth Analg 1990; 70: 631–4
Horlocker TT, Wedel DJ, Schroeder DR, et al. Preoperative anti-platelet therapy does not increase the risk of spinal hematoma associated with regional anesthesia. Anesth Analg 1995; 80: 303–9
Greensite FS, Katz J. Spinal subdural hematoma associated with attempted epidural anesthesia and subsequent continuous spinal anesthesia. Anesth Analg 1980; 59: 72–3
Souter AJ, Fredman B, White PF. Controversies in the peri-operative use of nonsteroidal antiinflammatory drugs. Anesth Analg 1994; 79: 1178–90
Woolf CJ, Chong Mun-S. Preemptive analgesia — treating postoperative pain by preventing the establishment of central sen-sitization. Anesth Analg 1993; 77: 362–79
Dahl JB, Kehlet H. Non-steroidal anti-inflammatory drugs: rationale for use in severe postoperative pain. Br J Anaesth 1991; 66: 703–12
Reilly IAG, Fitzgerald GA. Aspirin in cardiovascular disease. Drugs 1988; 35: 154–76
Habib GB. Current status of thrombolysis in acute myocardial infarction: I. Optimal selection and delivery of a thrombolytic drug. Chest 1995; 107: 225–32
Habib GB. Current status of thrombolysis in acute myocardial infarction: part II. Optimal utilization of thrombolysis in clinical subsets. Chest 1995; 107: 528–34
Skinner JR, Phillips SJ, Zeff RH, et al. Immediate coronary bypass following failed streptokinase infusion in evolving myocardial infarction. J Thorac Cardiovasc Surg 1984; 87: 567–70
Harker LA, Malpass TW, Branson HE, et al. Mechanism of abnormal bleeding in patients undergoing cardiopulmonary bypass: acquired transient platelet dysfunction associated with selective α-granule release. Blood 1980; 56: 824–34
Woodman RC, Harker LA. Bleeding complications associated with cardiopulmonary bypass. Blood 1990; 76: 1680–97
Taggart DP, Siddiqui A, Wheatley DJ. Low-dose preoperative aspirin therapy, postoperative blood loss, and transfusion requirements. Ann Thorac Surg 1990; 50: 425–8
Ferraris VA, Ferraris SP, Lough FC, et al. Preoperative aspirin ingestion increases operative blood loss after coronary artery bypass grafting. Ann Thorac Surg 1988; 45: 71–4
van Oeveren W, Jansen NJG, Bidstrup BP, et al. Effects of aprotinin on hemostatic mechanisms during cardiopulmonary bypass. Ann Thorac Surg 1987; 44: 640–5
Emerson Jr TE. Pharmacology of aprotinin and efficacy during cardiopulmonary bypass. Cardiovasc Drug Rev 1989; 7: 127–40
Aoki N, Naito K, Yoshida N. Inhibition of platelet aggregation by protease inhibitors, possible involvement of proteases in platelet aggregation. Blood 1978; 51: 1–12
Dubber AHC, McNicol GP, Uttley D, et al. In vitro and In vivo studies with Trasylol, an anticoagulant and a fibrinolytic inhibitor. Br J Haematol 1968; 14: 31–49
Verstraete M. Clinical applications of inhibitors of fibrinolysis. Drugs 1985; 29: 236–61
Havel M, Teufelsbauer H, Knöbl P, et al. Effect of intraoperative aprotinin administration on postoperative bleeding in patients undergoing cardiopulmonary bypass operation. J Thorac Cardiovasc Surg 1991; 101: 968–72
Royston D, Bidstrup BP, Taylor KM, et al. Effect of aprotinin on need for blood transfusion after repeat open-heart surgery. Lancet 1987; 2(8571): 1289–91
Bidstrup BP, Royston D, Sapsford RN, et al. Reduction in blood loss and blood use after cardiopulmonary bypass with high dose aprotinin (Trasylol). J Thorac Cardiovasc Surg 1989; 97: 364–72
Alajmo F, Calamai G, Perna A, et al. High-dose aprotinin: hemostatic effects in open heart operations. Ann Thorac Surg 1989; 48: 536–9
van Oeveren W, Harder MP, Roozendaal KJ, et al. Aprotinin protects platelets against the initial effect of cardiopulmonary bypass. J Thorac Cardiovasc Surg 1990; 99: 788–98
Lemmer Jr JH, Stanford W, Bonney SL, et al. Aprotinin for coronary bypass operations: efficacy, safety, and influence on early saphenous vein graft patency. J Thorac Cardiovasc Surg 1994; 107: 543–53
Murkin JM, Lux JoA, Shannon NA, et al. Aprotinin significantly decreases bleeding and transfusion requirements in patients receiving aspirin and undergoing cardiac operations. J Thorac Cardiovasc Surg 1994; 107: 554–61
Alajmo F, Calamai G. High-dose aprotinin in emergency coronary artery bypass after thrombolysis [letter]. Ann Thorac Surg 1992; 54: 1022
Akhtar TM, Goodchild CS, Boylan MKG. Reversal of strepto-kinase-induced bleeding with aprotinin for emergency cardiac surgery. Anaesthesia 1992; 47: 226–8
Efstratiadis T, Munsch C, Crossman D, et al. Aprotinin used in emergency coronary operation after streptokinase treatment. Ann Thorac Surg 1991; 52: 1320–1
van Doom CA, Munsch CM, Cowan JC. Cardiac rupture after thrombolytic therapy: the use of aprotinin to reduce blood loss after surgical repair. Br Heart J 1992; 67: 504–5
Horrow JC, DiGregorio GJ, Ruch E. The dose-plasma concentration relationship of tranexamic acid during surgery. Am J Ther 1994; 1: 206–9
Horrow JC, Hlavacek J, Strong MD, et al. Prophylactic tranexamic acid decreases bleeding after cardiac operations. J Thorac Cardiovasc Surg 1990; 99: 70–4
Horrow JC, Van Riper DF, Strong MD, et al. Hemostatic effects of tranexamic acid and desmopressin during cardiac surgery. Circulation 1991; 84: 2063–70
DelRossi AJ, Cernaianu AC, Botros S, et al. Prophylactic treatment of postperfusion bleeding using EACA. Chest 1989; 96: 27–30
Lambert CJ, Marengo-Rowe AJ, Leveson JE, et al. The treatment of postperfusion bleeding using e-aminocaproic acid, cryoprecipitate, fresh-frozen plasma, and protamine sulfate. Ann Thorac Surg 1979; 28: 440–4
Karski JM, Teasdale SJ, Norman PH, et al. Prevention of post-bypass bleeding with tranexamic acid and £-aminocaproic acid. J Cardiothorac Vasc Anesth 1993; 7: 431–5
Horrow JC, Van Riper DF, Strong MD, et al. The dose-response relationship of tranexamic acid. Anesthesiology 1995; 82: 383–92
Salem M, Tainsh Jr RE, Bromberg J, et al. Perioperative glucocorticoid coverage: a reassessment 42 years after emergence of a problem. Ann Surg 1994; 219: 416–25
Fraser CG, Preuss FS, Bigford WD. Adrenal atrophy and irreversible shock associated with cortisone therapy. JAMA 1952; 149: 1542–3
Lewis L, Robinson RF, Yee J, et al. Fatal adrenal cortical insufficiency precipitated by surgery during prolonged continuous cortisone treatment. Ann Intern Med 1953; 39: 116–26
Chernow B, Alexander HR, Smallridge RC, et al. Hormonal responses to graded surgical stress. Arch Intern Med 1987; 147: 1273–8
Udelsman R, Norton JA, Jelenich SE, et al. Responses of the hypothalamic-pituitary-adrenal and renin-angiotensin axes and the sympathetic system during controlled surgical and anesthetic stress. J Clin Endocrinol Metab 1987; 64: 986–94
Udelsman R, Goldstein DS, Loriaux DL, et al. Catecholamine-glucocorticoid interactions during surgical stress. J Surg Res 1987; 43: 539–45
Udelsman R, Ramp J, Gallucci WT, et al. Adaptation during surgical stress — a reevaluation of the role of glucocorticoids. J Clin Invest 1986; 77: 1377–81
Axelrod L. Glucocorticoid therapy. Medicine 1976; 55: 39–65
Dujovne CA, Azarnoff DL. Clinical complications of cortico-steroid therapy: a selected review. Med Clin North Am 1973; 57: 1331–42
Schaffner A. Therapeutic concentrations of glucocorticoids suppress the antimicrobial activity of human macrophages without impairing their responsiveness to gamma interferon. J Clin Invest 1985; 76: 1755–64
Baltch AL, Hammer MC, Smith RP, et al. Comparison of the effect of three adrenal corticosteroids on human granulocyte function against Pseudomonas aeruginosa. J Trauma 1986; 26: 525–33
Goodwin JS, Atluru D, Sierakowski S, et al. Mechanism of action of glucocorticosteroids — inhibition of T cell proliferation and interleukin 2 production by hydrocortisone is reversed by leukotriene B4. J Clin Invest 1986; 77: 1244–50
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Smith, M.S., Muir, H. & Hall, R. Perioperative Management of Drug Therapy. Drugs 51, 238–259 (1996). https://doi.org/10.2165/00003495-199651020-00005
Published:
Issue Date:
DOI: https://doi.org/10.2165/00003495-199651020-00005