Version June 2024
| Name or class of drug | Clinical considerations | Recommended strategy for surgery with brief NPO state | Recommended strategy for surgery with prolonged NPO state |
| Antipsychotics | Some agents are associated with QT prolongation and occasionally cause hypotension or arrythmias. | Continue therapy up to and including day of surgery in patients with high risk of developing psychoses. | Continue therapy up to and including day of surgery. Parenteral formulations are available for haloperidol, chlorpromazine, aripriprazole, olanzapine, and ziprasidone. If prolonged NPO state is anticipated, depot formulations (eg, haloperidol decanoate) could be considered, to begin well before surgery in consultation with psychopharmacologist. |
| Benzodiazepines | Abrupt withdrawal can result in agitation, hypertension, delirium, and seizures. | Continue therapy up to and including day of surgery. | Continue therapy up to and including day of surgery. Parenteral diazepam, lorazepam, and chlordiazepoxide are available for prolonged NPO state. |
| Buspirone | No known adverse effects. | Continue therapy up to and including day of surgery. | Continue therapy up to and including day of surgery. No parenteral substitution available but parenteral diazepam, lorazepam, or chlordiazepoxide can be used for prolonged NPO state. |
| Lithium | Continuation may prolong the effect of muscle relaxants and, due to impaired renal concentrating ability, can cause hypovolemia and hypernatremia. | Continue therapy up to and including day of surgery with close monitoring of electrolytes and volume status. | Resume with oral intake. No parenteral substitution available. When needed, may use parenteral valproate or a second-generation antipsychotic. |
| Monoamine oxidase (MAO) inhibitors | If continued and direct acting sympathomimetic agents like ephedrine are used during anesthesia, can result in severe hypertension. If agents like meperidine or dextromethorphan are used, can result in "serotonin syndrome." | For emergency procedures, a MAO-safe anesthetic technique should be used. For other surgeries, anesthesiologist and psychiatrist should collaborate and decide either to use MAO-safe anesthetic technique or discontinue the medication. If discontinued should be stopped for two weeks prior to surgery. | Resume with oral intake. No parenteral substitution available. |
| Serotonin reuptake inhibitors | Increased risk of bleeding. | Discontinue therapy three weeks prior to surgery in patients undergoing high-risk procedures (such as certain CNS procedures). | Resume with oral intake. No parenteral substitution available. |
| Tricyclic antidepressants | Continuation may increase the potential for arrythmias. Abrupt withdrawal can lead to insomnia, nausea, headache, increased salivation, and increased sweating. | Continue therapy up to and including day of surgery for patients on high doses. Patients on low doses and in whom perioperative arrhythmia is a concern should discontinue for seven days prior to surgery. | Resume with oral intake. No parenteral substitution available. |
| Valproic acid | No known adverse effects. | Continue therapy up to and including day of surgery. | Continue therapy up to and including day of surgery. Resume with oral intake. A parenteral formulation (valproate sodium) is available. |
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