A general internist is conducting preoperative evaluations for several patients scheduled for elective surgeries next week. Match each patient's chronic medication scenario to the most appropriate perioperative management recommendation.
- Lisinopril for essential hypertension in a patient undergoing an elective laparoscopic cholecystectomy.Withhold on the morning of surgery to minimize the risk of refractory intraoperative hypotension.
- Warfarin for atrial fibrillation (CHA2DS2-VASc score = 1) in a patient scheduled for an elective total hip arthroplasty.Discontinue 5 days prior to surgery without initiating bridging anticoagulation therapy.
- Empagliflozin for type 2 diabetes mellitus in a patient undergoing an elective open bowel resection.Discontinue 3 to 4 days prior to surgery to reduce the risk of perioperative euglycemic ketoacidosis.
- Sublingual buprenorphine-naloxone for opioid use disorder in a patient scheduled for an elective lumbar spinal fusion.Continue the current maintenance dose throughout the perioperative period and utilize multimodal analgesia.
- Raloxifene for osteoporosis in a patient undergoing an elective total knee arthroplasty.Discontinue 4 weeks prior to surgery due to the significantly elevated risk of postoperative venous thromboembolism.
Answer
Lisinopril is withheld the morning of surgery; Warfarin is stopped 5 days prior without bridging; Empagliflozin is stopped 3-4 days prior; Buprenorphine is continued throughout; and Raloxifene is stopped 4 weeks prior.
Correct matching requires identifying the specific physiological risks posed by each medication during surgery and anesthesia. ACE inhibitors risk severe vasoplegia; SGLT2 inhibitors risk euglycemic DKA; SERMs risk VTE. Conversely, stopping buprenorphine risks severe withdrawal, and low-risk warfarin patients do not require bridging.
Step-by-Step Solution
Key Concept
Perioperative medication management requires balancing the risks of disease exacerbation upon discontinuation against the physiological stresses and drug interactions associated with anesthesia and surgery.