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28 Percutaneous Ultrasound-Guided Gastrostomy Placement
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27. Tramel R, Sandow T, April D, Ramalingam V.Safety and feasibility of percutaneous gastrostomy placement in patients on antiplatelet therapy. Ochsner J. 2021;21:158–62.
28. Bechtold ML, etal. Early versus delayed feeding after placement of a percutaneous endoscopic gastrostomy: a meta-analysis. Am J Gastroenterol. 2008;103:2919–24.
29. Chaves DM, etal. EUS-guided percutaneous endoscopic gastrostomy for enteral feeding tube
placement. Gastrointest Endosc. 2008;68:1168–72.
30. Shukla PA, et al. Safety and feasibility of ultrasound-guided gastric access for percutaneous
transabdominal gastrostomy tube placement. Gastroenterol Res. 2019;12:115–9.
31. Wu TS, Leech SJ, Rosenberg M, Huggins C, Papa L.Ultrasound can accurately guide gastrostomy tube replacement and conrm proper tube placement at the bedside. J Emerg Med.
2009;36:280–4.
32. Bleck JS, etal. Percutaneous sonographic gastrostomy: method, indications, and problems.
Am J Gastroenterol. 1998;93:941–5.
33. Church JT, Speck KE, Jarboe MD.Ultrasound-guided gastrostomy tube placement: a case
series. J Pediatr Surg. 2017;52:1210–4.
34. Marshall JD, etal. Length of stay and hospital cost reductions after implementing bedside
percutaneous ultrasound gastrostomy (PUG) in a critical care unit. J Intensive Care Med.
2022;37:1667–72.
35. Olivieri PP, Abdulmahdi M, Heavner JJ.Bedside percutaneous ultrasound gastrostomy tube
placement by critical care physicians. J Clin Ultrasound. 2021;49:28–32.
36. Cool DW, Chung J, Wiseman D, Kribs S, Mujoomdar A.Percutaneous ultrasound gastrostomy:
rst-in-human experience with the PUMA-G system. J Vasc Interv Radiol. 2020;31:808–11.
37. Olivieri P, Heavner J, Abdulmahdi M.Concomitant percutaneous dilatation tracheostomy and
percutaneous ultrasound gastrostomy: methods to ensure safe practice standards during the
COVID-19 pandemic. Chest. 2020;158:A2470.
38. Accorsi F, etal. Percutaneous ultrasound gastrostomy (PUG): rst prospective clinical trial.
Abdom Radiol N Y. 2021;46:5377–85.
39. Yuan Y, Zhao Y, Xie T, Hu Y. Percutaneous endoscopic gastrostomy versus percutaneous radiological gastrostomy for swallowing disturbances. Cochrane Database Syst Rev.
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40. González-González JA, etal. Bleeding complications during percutaneous endoscopic gastrostomy treated with hemoclips. Med Univ. 2009;11:270–2.
41. Strijbos D, etal. Percutaneous endoscopic versus radiologic gastrostomy for enteral feeding:
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Chapter 29
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Optimal Pharmacotherapy Strategies
forEnhanced Postoperative Recovery
inHigh-Risk Surgeries
RichardParrish andRachelleFindley
Introduction: General Principles ofPerioperative
Pharmacotherapy Optimization
Numerous Enhanced Recovery After Surgery (ERAS®) protocols have incorporated
evidence-based pharmacotherapy recommendations that aid in minimizing the frequency and severity of postoperative complications (POCs) [1, 2]. A recent report
from an ERAS® Center of Excellence validated guideline-informed pharmacotherapies to minimize the incidence of surgical site infection (SSI) and venous thromboembolism (VTE), with lower lengths of stay in hospital (LOSH) and readmission
rates in colorectal and gynecologic oncology patients [3] (Fig.29.1). Decisions to
continue or withhold medications in the preoperative phase help to avoid adverse
events; however, these require clear and consistent communication with and participation from patients and caregivers to achieve optimum benet [4, 5].
R. Parrish (*)
Department of Biomedical Sciences, School of Medicine, Mercer University,
Columbus, GA, USA
R. Findley
Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
e-mail: rachelle.ndley@nshealth.ca
Switzerland AG 2024
J. Faintuch, S. Faintuch (eds.), Recent Strategies in High Risk Surgery,
https://doi.org/10.1007/978-3-031-56270-9_29
489© The Author(s), under exclusive license to Springer Nature
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R. Parrish and R. Findley
Complete thorough medication history including prescription and non‐prescription use
Is medication potentially harmful?
Is there any potential for adverse
drug interactions with anesthesia?
MEDICATION IS CONSIDERED
OPTIONAL FOR DAY OF SURGERY
Theoretical benefit
CONTINUE IF DESIRED
(dose, frequency, last dose taken)
NO
Is medication essential?
NO
NO
NO
No obvious benefit
WITHHOLD
YES
YES
YES
CONTINUE
WITHHOLD
(TIMING DEPENDS ON MED)
WITHHOLD
Fig. 29.1 Preoperative medication management decision-making algorithm (continue or withhold) (Cohn, 2021 with permission)
Preoperative Review ofMedications
Cardiovascular
Concern in this area is related to medication controlling blood pressure and pulse
rate, coagulation, and plaque stabilization [3, 6, 7]. Angiotensin converting enzyme
inhibitor (ACEI) and angiotensin receptor blocker (ARB) continuation before noncardiac surgery may provoke hypotension, but withholding them has no appreciable
impact on acute kidney injury (AKI), major adverse cardiac event (MACE), death,
or LOSH, suggesting that stopping 24h preoperatively may be best [6, 7]. AKI is
becoming a focus for hospitals in the United States through the Patient Safety
Indicator (PSI-10). The PSI-10 is reported across healthcare institutions and is a
quality metric for third party payers [8].
For hydroxymethylglutaryl-coenzyme A reductase inhibitors (HMG-CoA inhibitors or “statins”), perioperative initiation is reasonable for patients with vascular
procedures and continuation in those already prescribed statins. Perioperative use
29 Optimal Pharmacotherapy Strategies for Enhanced Postoperative Recovery…
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491
is important for primary and secondary prevention of plaque rupture [7]. Betablockers should not be started in patients undergoing non-cardiac or low risk procedures and may need to be given intravenously in patients having cardiac surgery
due to potential gastrointestinal malabsorption [7]. Centrally acting alpha-2 adrenergic agonists (clonidine, dexmedetomidine) are associated with increased hypotension and bradycardia; however, the drug class may lower anesthetic
requirements [7].
Anti-Diabetic
Prolonged preoperative fasting should be avoided by providing complex carbohydrate liquids [9]. With the exception of sodium-glucose cotransporter-2 (SGLT2)
inhibitors, diabetes medications should be given at the same dose on the day before
surgery and withheld on postoperative day zero (POD0) [9, 10] (Table29.1).
Table 29.1 Preoperative medication management in patients with diabetes (adapted from [9,
10, 58])
Medication Day before surgery Day of surgery Restart
Metformin, DPP4I Same preoperative doses Continue at
Sulfonylureas Same preoperative doses Withhold Restart with eating and
SGLT2I (canagliozin,
dapagliozin,
empagliozin)
Injectable non-insulins
(GLP-1, GIP)
Glargine, detemir, NPH
(long-acting basal
insulin)
Combination of long
and short acting (mixed
insulin; 75/25, 70/30)
DPP4 Dipeptidil peptidase 4 inhibitors, SGLT2I sodium glucose cotransporter 2 inhibitors, NPO
nothing per os, GLP-1 glucagon like peptide 1 receptor agonist, GIP gastric inhibitory peptide
receptor agonist, NPH neutral protamine Hagedorn (insulin)
Stop three days before
surgery (ertugliozin—
Stop four days before
surgery)
Same preoperative doses Continue at
Same bedtime dose Half normal
Same bedtime dose Based on fasting
usual dose
Withhold Restart with eating and
usual dose
morning dose
blood glucose:
If>200mg/dL:
Half normal
dose;
If<200mg/dL:
None
Only withhold
metformin if
glomerular ltration
rate<mL/min/1.73m
drinking well
drinking well
Continue even if NPO
Continue even if NPO
Continue even if NPO
2
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R. Parrish and R. Findley
A blood glucose range of between 140 and 180mg/dL (7.8—10mmol/L) should
be maintained and reassessed every 2h [10]. Blood glucose can be managed in the
operating room with rapid acting insulin, and usually a regular insulin infusion is
used in patients with expected temperature and hemodynamic changes, inotrope
use, and longer procedure times, as well as in diabetics and those that will miss
more than a meal [10].
Anticoagulants andAntiplatelets
While discontinuing aspirin is not associated with inferior outcomes, initiating or
resuming aspirin doesn’t improve outcomes. In contrast, in myocardial infarction
after non-cardiac surgery (MINS), direct oral anticoagulant dabigatran lowered vascular complication risk without signicant bleeding. Outcomes for postoperative
atrial brillation (AFib) are comparable to nonsurgical nonvalvular AFib, and anticoagulation lowers stroke and death risk. Fewer patients are anticoagulated postoperatively [6]. Antiplatelet medications should be stopped prior to neuraxial
anesthesia (4–8h for eptibatide, 1–2days for abciximab, and 7days for clopidogrel); however, aspirin in dual antiplatelet therapy (DAPT) patients should be continued for secondary prevention [7]. Recommendations for anticoagulation with
vitamin K antagonists (VKAs), direct oral anticoagulants (DOACs), low molecular
weight heparins (LMWHs), aspirin, and P2Y12 inhibitors are presented in Figs.29.2,
29.3, and 29.4 [11–13].
High-bleed-risk
w-to-moderate-bleed-risk
Minimal-bleed-risk
Fig. 29.2 Perioperative management of warfarin (vitamin K antagonists/VKAs) (Douketis etal.,
2022 with permission)
a
Bridging suggested for high thrombotic risk populations with full-dose, subcutaneous LMWH
(enoxaparin, dalteparin, or tinzaparin), with the last dose given in the morning of the day before
the procedure (POD-1);
dose LMWH resumed 2–3days post-procedure; cVKAs can be resumed on the evening of the
procedure (POD0) for most patients, or the day after procedure (POD1) at the patient’s usual
maintenance dose; LMWH low-molecular-weight heparin, LMWH low molecular weight heparin,
VKA vitamin K antagonist
A
Warfarin
Warfarin
7 6 5 4 3 2 10
b
Low-dose LMWH can be used for rst 24–72h post-procedure, with full-
LWMH
A
LWMH
Warfarin
Day of surgery/procedure
Warfarin
LMWH
Warfarin
12345
C
A
C
LMWH
A, B
29 Optimal Pharmacotherapy Strategies for Enhanced Postoperative Recovery…
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A
Post-Procedure Resumption (Day)
Surgery/Procedure
Day 0
493
Pre-Procedure DOAC Interruption (Day)
6 5 4 3 2 1 1 2 3 4
Risk
Bleeding
Procedure
Direct Oral
Anticoagulant
High
Low/Mod
Apixaban
High
Dabigatran
(CrCl 50
Low/Mod
ml/min)
High
Dabigatran
Low/Mod
(CrCl 50
High
ml/min)
Low/Mod
Edoxaban
High
Rivaroxaban
Low/Mod
No DOAC administered that day
DOAC can be resumed approximately 24h after low/moderate-bleed-risk procedures, and 48–72h after high-bleed-risk procedures. In selected patients at
high risk for venous thromboembolism, low-dose anticoagulants can be given for the rst 48–72h post-procedure; DOAC direct oral anticoagulants, CrCl
Fig. 29.3 Perioperative management of direct oral anticoagulants (Douketis etal., 2022 with permission)
a
creatinine clearance
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R. Parrish and R. Findley
Cangrelor
A
P2Y12 inhibitors
F
1–6h 4–6h Day 1
Day of surgery/procedure
0
B
Cangrelor
F
Aspirin continued
Clopidogrel
Prasugrel
9 8
Fig. 29.4 Perioperative management of antiplatelet drugs (Douketis etal. 2022 with permission)
a
Based on surgery/procedure bleed risk assessment; bP2Y12 inhibitors can be resumed within 24h
post-procedure at a maintenance dose;
5 days interruption;
Platelet P2Y
12
C
D
E
Ticagrelor
7
e
5
6
4 3 2 1
c
For ticagrelor, 3–5days interruption; dFor clopidogrel,
For prasugrel, 7–10 days interruption; fRoutine use not suggestedP2Y12:
receptor inhibitors (antiplatelet agents), such as clopidogrel/ ticagrelor/prasugrel
Neuropsychiatric
Depression, antidepressants, and perioperative anesthetic/analgesic medications
interact and may precipitate hypotension, cardiac arrhythmias, and persistent postoperative cognitive dysfunction and pain [14]. Stress-induced proinammatory
cytokines from surgical procedures, such as IL-1, may adversely affect neuronal
plasticity and combined with growth factor inhibition, reduce neurogenesis, and
magnify depressive symptomatology [14]. Stress also activates the hypothalamuspituitary- adrenal axis, leading to increased cortisol, growth hormone, and catecholamine release [14, 15]. Patients should continue most antidepressants, anxiolytics,
and mood-stabilizing agents (carbamazepine, lamotrigine, oxcarbazepine, and valproate, but not lithium) preoperatively and on POD0 to avoid discontinuation syndrome (dizziness, lethargy, anxiety, confusion, sleep disorders, tremor, delirium,
and headache) [14, 15]. Amphetamine and amphetamine-like agents (methylphenidate, atomoxetine) for adult attention decit hyperactivity should be withheld on
POD0; however, guanfacine should be continued [15]. Lithium should be stopped
on POD-3 for major procedures, and concomitant ketorolac should be avoided due
to precipitous increases in lithium serum levels [14, 15].
Perioperative lidocaine has been shown to reduce tricyclic antidepressant (TCA)
cardiotoxicity; however, due to catecholamine depletion, patients may become
hypotensive, and uid boluses with vasopressors may be necessary [14]. Selective
serotonin reuptake inhibitors (SSRI) may increase bleeding risk in patients coadministered non-steroidal anti-inammatories (NSAIDs), such as ibuprofen,
ketorolac, and celecoxib [14]. Synthetic opioids and related molecules such as dextromethorphan, meperidine, and tramadol should be avoided in patients on monoamine oxidase inhibitors (MAOI) [14]. Seizure activity should be closely monitored
29 Optimal Pharmacotherapy Strategies for Enhanced Postoperative Recovery…
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in patients on bupropion, a monocyclic antidepressant structurally similar to
amphetamines [14, 15].
Serotonin syndrome (altered mental status, tremor, clonus, hypertonia, and diaphoresis) triggered by SSRIs, TCAs, MAOIs, amphetamines, serotonin norepinephrine inhibitors (SNRIs), and St. John’s Wort may be exacerbated from use of
common perioperative medications including 5HT2 and 3 inhibitors (granisetron,
ondansetron, palonosetron), fentanyl, meperidine, methadone, and metoclopramide
[14]. Rare, serious adverse events with analeptics, neuroleptics, volatile anesthetics,
and depolarizing neuromuscular blocking agents (NMBs) include neuroleptic
malignant syndrome (antipsychotics and dopamine antagonists) and malignant
hyperthermia (anesthetics, NMBs) [14, 15].
495
Corticosteroids andImmunomodulators
Roughly 3% of the perioperative population receive preoperative chronic glucocorticoids which are linked to a three-fold increase (2.9–5%) in surgical site infection
(SSI), a 3.4-times increase in wound dehiscence, and a four-fold increase (1.6–6%)
in death [16–18]. Dexamethasone and other corticosteroids are often administered
to prevent postoperative nausea and vomiting (PONV), airway edema, and stridor.
Lower doses (4–5mg) and more frequent monitoring (every 1h for 4 h) are suggested for diabetic patients [8]. While withholding glucocorticoids may reduce
complications, endogenous steroid production in chronically prescribed patients is
often suppressed and discontinuation could precipitate adrenal crisis, which is especially concerning in transplant patients. Return of adrenal function is conrmed
with preoperative serum cortisol levels or insulin tolerance and cosyntropin stimulation testing [18].
Reducing steroid dosing to a minimum level is performed on a case-by-case
basis [18]. Patients with a history of hypopituitarism should be evaluated accordingly and may require a pre-operative dose of hydrocortisone 100–200mg prior to
surgery. Inhaled steroids should be continued [19]. Purine analogues and methotrexate can be continued; however, all monoclonal antibody and TNF-alpha blockers should be withheld for at least one dosing interval. Tofacitinib and other Janus
kinase inhibitors should be withheld beginning POD-7 and ozanimod and other
sphingosine-1-phosphate receptor modulators, 60days prior to procedure [19].
Opioids andAdjunctive Agents
Patients receiving opioids within 90days of surgery have signicantly higher complication rates, especially pain and infection: SSI, urinary tract infection [UTI], and
sepsis, with higher healthcare resource utilization (LOSH and hospital costs) [20].
Patients weaned from preoperative use have similar outcomes to opioid-naïve
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patients [20]. Opioid agonists, mixed agonist-antagonists, calcitonin-gene related
peptide (CGRP), antispasmodics (baclofen and tizanidine), and acetaminophen
should be continued through the perioperative period while serotonin receptor agonists (“triptans”), opioid antagonists (alvimopan, naltrexone [hold 3–4days], naloxegol), ergotamine derivatives, butalbital, and centrally acting muscle relaxants
should not be given on POD0 morning [21].
R. Parrish and R. Findley
Hormones, Bone Medications, Urologicals, andModulators
Continue all androgenics, antidiuretic hormone, aromatase inhibitors, bromocriptine, cabergoline, calcitonin, cinacalcet, corticosteroids, denosumab, growth hormone, estrogens, progestins, selective estrogen receptor modulators, somatostatin
analogues, 5-alpha reductase inhibitors, alpha-1 adrenergic antagonists, antineoplastic urologics, and thyroid preparations [9]. Withhold all bisphosphonates, anticholinergic bladder agents, and PDE5 inhibitors (withhold beginning POD-3 unless
used for pulmonary hypertension) on POD0 [19]. Endogenous sex hormone levels
are not associated with the same VTE risk as exogenous hormone replacement [22],
although elevated levels of estradiol and sex-hormone-binding globulin and free
androgen index in polycystic ovarian syndrome may increase risk, especially with
hormonal contraception [23].
Since the most likely time for experiencing VTE on estrogen-containing oral
contraception (eOCPs) is within 3months from initiation, whether to discontinue
eOCPs throughout the perioperative period is based on patient history and the
potential downside risk of a pregnancy in the preoperative period [24]. Of note,
sugammadex and aprepitant use may reduce the effectiveness of eOCPs. Patients
should be advised to use other non-hormonal contraception for at least 7 days
(sugammadex) and 28days (aprepitant) [25, 26].
Herbals, Vitamins, andSupplements
Chondroitin, ephedra (Ma-Huang), sh oil, garlic, ginseng, glucosamine, kava, milk
thistle, saw palmetto, St. John’s Wort, valerian, and vitamin E (tocopherol) should
be withheld at least till POD-14 while there is no specic recommendation for axseed, coenzyme Q10, and green tea [27]. In general, any dietary supplement should
be withheld (Table29.2) between 2 and 3weeks preoperatively [28].
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497
Table 29.2
Medication or supplement Preoperative hold
ACEI (captopril, lisinopril, ramipril) or ARB (azilsartan, candesartan,
irbesartan, losartan, olmesartan, valsartan, telmisartan)
Amphetamines, methylphenidate, atomoxetine POD0
Anticholinergic bladder agents (bethanechol, mirabegron) POD-1 and POD0
Bisphosphonates (alendronate, risedronate, ibandronate) POD-3 and POD0
Butalbital POD0
Centrally acting muscle relaxants (carisoprodol, cyclobenzaprine,
metaxalone, methocarbamol, orphenadrine)
Ergotamine derivatives POD0
Lithium POD-3 and POD0
Monoclonal antibody (ustekinumab, natalizumab, vedolizumab) One dosing interval
Monoamine oxidase inhibitors (phenelzine, tranylcypromine,
isocarboxazid, selegiline)
Naltrexone POD-3 or -4
Sphingosine-1-phosphate receptor modulators (ozanimod, ngolimod,
siponimod)
PDE5 inhibitors (sildenal, tadalal, vardenal) POD-3 (continue for
Oral supplements (chondroitin, ephedra [ma-Huang], sh oil, garlic,
ginseng, glucosamine, kava, milk thistle, saw palmetto, St. John’s
wort, valerian, vitamin E [tocopherol])
TNF-α blockers (adalimumab, iniximab, and biosimilars) One dosing interval
Janus kinase inhibitors (tofacitinib, baricitinib, ruxolitinib,
upadacitinib, fedratinib, abrocitinib, ruxolitinib)
ACEI angiotensin converting enzyme inhibitors, ARB angiotensin receptor blockers, PDE5 phos-
phodiesterase 5 inhibitors
Medications that should be withheld preoperatively
POD-1 and POD0
(especially in elderly)
POD0
(usually POD-14 to -28)
POD-14 with
psychiatric consult
POD-60
pulmonary
hypertension)
POD-14-21
(usually POD-14 to -28)
POD-7
Minimizing Risk fromCommon Comorbidities
Coexisting Infection
Preoperative sepsis has been identied as an independent predictor of postoperative
mortality [29]. Those with sepsis are more likely to require an emergent operation
which further increases the perioperative mortality risk [29]. UTI at the time of
surgery is also associated with increased risk of infectious and non-infectious complications [30]. Despite the risks of POCs, there are no strong data to support treating asymptomatic bacteriuria. Therefore, it is not recommended to screen for
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