Perioperative Clinical Pharmacy Practice

Megan Echevarria LaCrone, PharmD, BCPS

​

Perioperative Clinical Pharmacist - Residency Program Coordinator

Saint Alphonsus Regional Medical Center - Boise, ID

megan.echevarria@saintalphonsus.org

Objectives

• Evaluate Perioperative Distribution: Analyze unique medication procurement and storage workflows within surgical environments.
• Map the Clinical Continuum: Trace the patient journey and the specific roles of the interdisciplinary surgical team from pre-op to discharge.
• Target Pharmacy Interventions: Identify high-impact opportunities for clinical pharmacists to optimize patient care across all surgical phases.
• Develop Practice Models: Utilize professional resources to implement or expand specialized pharmacy services in a perioperative setting.

Surgery and Anesthesiology Pharmaceutical Services ¹

“The successful establishment of pharmaceutical services in surgery and anesthesiology will depend to a large extent on the OR pharmacist’s ability to positively affect drug-use management, take a leadership role in all aspects of cost containment, and contribute to improving patient care and outcomes” - ASHP, 1999

• Drug preparation, distribution, inventory control
• Waste reduction, drug cost reduction
• Improved revenue generation/billing
• Improved documentation
• Formulary management
• Drug accountability and control
• Compliance with regulatory standards
• Clinical activities
• Quality assurance/improvement
• Education/research
• Involvement with drug administration devices
• Enhanced interdisciplinary decision-making

The Perioperative Environment ^2,3

“To understand and optimize the unique role of the perioperative pharmacist, significant differences found in the perioperative environment must be recognized” - ASHP, 2019

• The medication use process is different from inpatient units
• In the ORs, meds are administered by providers (surgeons, anesthesia, perfusionists, etc.), not nurses
• A significant proportion of meds used in surgery/anesthesia are high-alert medications
• Medications are often used for off-label indications and via routes with which pharmacists may be unfamiliar
• Multiple documentations systems exist within perioperative settings
• Patients receive medications in numerous “phases of care” throughout the perioperative continuum

Medication Distribution ^1,2,3,

Essential Roles of the Perioperative Pharmacist ²

• Medication procurement, preparation, distribution, and flow
• Promotion of safe medication use according to regulations and institutional policies
• Controlled substance management and surveillance
• Preoperative and postanesthesia care (PACU) order review
• Provision of drug information and education
• Performance improvement and quality assurance
• Leadership duties and professional service
• Financial management

Perioperative Clinical Pharmacy Services ³

Perioperative Medication Management ³

The Surgical Care Continuum ^2,3

ERAS® Society Guidelines ⁴

• The Enhanced Recovery After Surgery (ERAS®) Society publishes guidelines on how to optimize surgical outcomes
• Initially developed to improve outcomes in colorectal surgery
• Guidelines now exist for nearly 30 surgical specialties
• Perioperative pharmacists can optimize patient outcomes by helping surgeons generate order sets according to ERAS guidelines
• Antimicrobial prophylaxis/stewardship
• PONV prophylaxis treatment
• Glycemic control
• Multimodal pain prevention and management
• Constipation/ileus prevention

Antimicrobial Stewardship ^5,6

Anesthesia ⁷

Local/Regional Anesthetics:

• Benzoic acid esters: procaine, chloroprocaine
• Benzoic acid amides: bupivacaine, lidocaine, ropivacaine

General Anesthetics:

• Inhalational:
• Gas: nitrous oxide
• Volatile: ether, isoflurane, sevoflurane, desflurane
• Intravenous:
• Induction agents: propofol, etomidate
• Opioids: fentanyl, remifentanil
• Benzodiazepines: midazolam, lorazepam, diazepam
• Dissociative: ketamine
• Adjuvant: dexmedetomidine, magnesium sulfate, beta blockers
• Neuromuscular blockers: succinylcholine, rocuronium, vecuronium, cisatracurium

Reversal agents

• Naloxone, flumazenil, neostigmine/glycopyrrolate, sugammadex

Unique Medications, Products, & Uses

Perioperative Emergency Response ^8,9,10

Perioperative Pharmacy Services at Saint Al’s

Saint Al’s Perioperative Pharmacy Scope

• Main OR - 17
• Endovascular surgery
• Orthopedic surgery
• General surgery
• Trauma surgery
• Eye surgery
• Neurosurgery
• Organ procurement
• Day Surgery Center - 8
• ENT surgery
• Hand/foot surgery
• Plastic surgery
• Cardiovascular OR - 3
• CABG, valve replacement
• Cardiac Cath Lab - 5
• Obstetric Surgery - 2
• Endoscopy - 4
• Interventional Radiology - 4
• MRI - 1

Justification of Perioperative Clinical Pharmacist ³

Quality metric compliance → CMS reimbursement penalties

• Postoperative VTE, SSI,
• Readmission rates/patient satisfaction
• Discharge prescription delivery/education, transitions of care
• TJC accreditation, compliance with NPSGs
• DEA compliance

Medication use/expenditure

• Stewardship/MUE of high cost procedural meds
• Exparel, sugammadex, etc.
• 340b discount program, mitigate waste, manage formulary

Perioperative medication charge capture

• Perioperative/anesthesia documentation/billing
• OR case time/turnover efficiency
• PACU/post-op length of stay, patient satisfaction

Saint Al’s Perioperative Pharmacy Services

• Optimization of medication inventory/delivery
• Coordination of med delivery from central pharmacy
• Expansion of pharmacy technician involvement in procedural departments
• Preparation of ready to use products for anesthesia
• Ongoing evaluation of Pyxis/kit contents
• Committee Involvement
• Joint Preservation, Anesthesia, Emergency General Surgeons, Surgical Site Infection Review, Drug Shortage Mitigation, Medication Safety, Perioperative Nursing Education
• Projects
• Bariatric Surgery Quality Improvement - ERAS/Multimodal Pain Management
• Antimicrobial Stewardship - antimicrobial prophylaxis optimization protocol
• Entereg - ileus prevention, REMS program adherence/documentation, timely discontinuation
• P&T reviews/requests - Exparel, Journavx
• Expand “Meds-2-Go” program to the PACUs
• Education
• Malignant Hyperthermia, LAST, ACLS, Nurse Administered Propofol Sedation, Beta-lactam allergy education
• Precepting
• IPPE - Elective, APPE - Periop/Inpatient Surgery floor, PGY1 Residency - Perioperative elective

ACCP Perioperative Care Practice & Research Network ^4,8,11,12

ASHP Perioperative Pharmacy Services Certificate ¹³

Additional Pharmacy Resources ¹⁴

The Idaho Society of Health-System Pharmacy partnered with Idaho State University College of Pharmacy to create the Idaho Pharmacy Leadership, Education, Advancement & Development (I-LEAD) fellowship program

• I-LEAD is a 1-year certificate program on organizational leadership geared toward practicing pharmacists and pharmacy technicians
• I-LEAD fellows and mentors complete the didactic curriculum and participate in ISHP committees to promote legislative advocacy, strategic planning, financial management, education, and outreach

Questions?

megan.echevarria@saintalphonsus.org

References

1. ASHP guidelines on surgery and anesthesiology pharmaceutical services. American Society of Health-System Pharmacists. Am J Health Syst Pharm. 1999 May 1;56(9):887-95. doi: 10.1093/ajhp/56.9.887.
2. Bickham P, et al. ASHP guidelines on perioperative pharmacy services. Am J Health Syst Pharm. 2019 Jun 3;76(12):903-820. doi: 10.1093/ajhp/zxz073.
3. Patel GP, et al. Perioperative clinical pharmacy practice: Responsibilities and scope within the surgical care continuum. J Am Coll Clin Pharm. 2020; 3: 501–519.
4. Gustafsson UO, et al. Guidelines for perioperative care in elective colorectal surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations 2025. Surgery. 2025 Aug;184:109397. doi: 10.1016/j.surg.2025.109397.
5. ASHP Therapeutic Guidelines on Antimicrobial Prophylaxis in Surgery. American Society of Health-System Pharmacists. Am J Health Syst Pharm. 1999 Sep 15;56(18):1839-88. doi: 10.1093/ajhp/56.18.1839.
6. Khan DA, et al. Drug allergy: A 2022 practice parameter update. J Allergy Clin Immunol. 2022 Dec;150(6):1333-1393. doi: 10.1016/j.jaci.2022.08.028.
7. Smith G, et al. General Anesthesia for Surgeons. [Updated 2023 Aug 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493199/
8. Hyland SJ, Wolfe RC, Patel G, Johnson EG. Perioperative medical emergencies: The role of clinical pharmacists and a review of pharmacotherapy considerations. J Am Coll Clin Pharm. 2023; 6(9): 1053-1070. doi:10.1002/jac5.1762
9. “Managing a Crisis.” MHAUS, Malignant Hyperthermia Association of the United States, www.mhaus.org/healthcare-professionals/managing-a-crisis/. Accessed 7 Mar. 2025.
10. "Checklist for Treatment of Local Anesthetic Systemic Toxicity." ASRA, American Society of Regional Anesthesia and Pain Medicine, 1 Nov. 2020, www.asra.com/news-publications/asra-updates/blog-landing/guidelines/2020/11/01/checklist-for-treatment-of-local-anesthetic-systemic-toxicity. Accessed 7 Mar. 2026.
11. "Practice and Research Networks (PRNs)." ACCP, American College of Clinical Pharmacy, www.accp.com/prns/. Accessed 7 Mar. 2026.
12. "Perioperative Emergencies Part I – References." Pharmacy to Dose, 30 May 2023, pharmacytodose.com/2023/05/30/perioperative-emergencies-part-i-references/. Accessed 10 Mar. 2026.
13. "Perioperative Pharmacy Services Certificate." ASHP Learning Center, American Society of Health-System Pharmacists, 7 May 2025, elearning.ashp.org/products/12609/perioperative-pharmacy-services-certificate. Accessed 7 Mar. 2026.
14. "ILEAD." Idaho Society of Health-System Pharmacy, ishp.wildapricot.org/ilead. Accessed 10 Mar. 2026.