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Perioperative Medicine TABLE 20. Risk Factors for Delirium During Hospitalization recent stroke or neuromuscular disease), bowel obstruction or ileus, dementia, delirium, or progressive somnolence. Aspiration Predisposing Factors prevention strategies include elevation of the head of the bed, Advanced age (>70 y) swallow evaluation by a speech therapist, assisted feeding, and Preexisti ng cognitive impairment avoidance of nasogastric tubes. Poor nutritional status Several fall prevention strategies can be used in the hospi Poor functional status tal setting. These strategies include physical and occupational Multiple medical comorbidities therapy, bed alarms, limitation of medications that cause pos- tural hypotension or weakness, and hospital sitter services for Renal disease patients with cognitive impairment. Although no single inter Alcohol use disorder vention has been shown to decrease falls in hospitalized Depression patients, various bundles of multifactorial intervention pro Polypharmacy grams have been successful in reducing falls in the hospital Deliriogenic medications (e.g., benzodiazepines, anticholinergics, setting (see MKSAP 19 General Internal Medicine 1). opioids)" Prevention of pressure related injury is a prioriry espe- History of delirium cially in patients at higher risk. For more interventions. see Vision or hearing impairment MKSAP 19 General Internal Medicine 1. Medication errors are one of the most common elTors Provoking Factors during hospitalization and can be reduced by vigilance with Poorly controlled pain medication review and reconciliation upon admission and Deliriogenic medications (e.g., benzodiazepines, discharge as well as upon transfer between services (see anticholinergics, opioids)" Patient Safety and Quality Improvement). Disruption of sleep-wake cycle l(EY POll{Tt Sleep deprivation r Thrombotic risk in hospitalized patients can be deter- Constipation mined by using a validated risk assessment model (e.9., Dehydration Padua Prediction Score) to inform the use ofpharmaco- Urinary retention logic prophylaxis. Severe illness o Strategies to prevent delirium in hospitalized patients lnfection include the use of assistive visual and hearing devices, Hypoxia optimization of pain control, minimization of psychoac- Surgical stress tive medications, frequent reorientation, early mobiliza- tion, and allowance of unintemrpted sleep to promote Use of urinary catheter and other tethers a normal sleep-wake cycle. Sensory deprivation (e.g., no hearing aids or glasses)

TABLE 20. Risk Factors for Delirium During Hospitalization recent stroke or neuromuscular disease), bowel obstruction or ileus, dementia, delirium, or progressive somnolence. Aspiration Predisposing Factors prevention strategies include elevation of the head of the bed, Advanced age (>70 y) swallow evaluation by a speech therapist, assisted feeding, and Preexisti ng cognitive impairment avoidance of nasogastric tubes. Poor nutritional status Several fall prevention strategies can be used in the hospi Poor functional status tal setting. These strategies include physical and occupational Multiple medical comorbidities therapy, bed alarms, limitation of medications that cause pos- tural hypotension or weakness, and hospital sitter services for Renal disease patients with cognitive impairment. Although no single inter Alcohol use disorder vention has been shown to decrease falls in hospitalized Depression patients, various bundles of multifactorial intervention pro Polypharmacy grams have been successful in reducing falls in the hospital Deliriogenic medications (e.g., benzodiazepines, anticholinergics, setting (see MKSAP 19 General Internal Medicine 1). opioids)" Prevention of pressure related injury is a prioriry espe- History of delirium cially in patients at higher risk. For more interventions. see Vision or hearing impairment MKSAP 19 General Internal Medicine 1. Medication errors are one of the most common elTors Provoking Factors during hospitalization and can be reduced by vigilance with Poorly controlled pain medication review and reconciliation upon admission and Deliriogenic medications (e.g., benzodiazepines, discharge as well as upon transfer between services (see anticholinergics, opioids)" Patient Safety and Quality Improvement). Disruption of sleep-wake cycle l(EY POll{Tt Sleep deprivation r Thrombotic risk in hospitalized patients can be deter- Constipation mined by using a validated risk assessment model (e.9., Dehydration Padua Prediction Score) to inform the use ofpharmaco- Urinary retention logic prophylaxis. Severe illness o Strategies to prevent delirium in hospitalized patients lnfection include the use of assistive visual and hearing devices, Hypoxia optimization of pain control, minimization of psychoac- Surgical stress tive medications, frequent reorientation, early mobiliza- tion, and allowance of unintemrpted sleep to promote Use of urinary catheter and other tethers a normal sleep-wake cycle. Sensory deprivation (e.g., no hearing aids or glasses) 'See the American Geriatrics Society Beers criteria for potentially inappropriate medication use in older adults. Perioperative Med ici ne uninterrupted sleep to promote a normal sleep-wake cycle. General Responsi bi lities Early detection of delirium is of equal importance for preven Perioperative medicine encompasses risk assessment and tion of additional complications. The Confusion Assessment optimization of comorbidities before surgery intraoperative Method is an evidence-based screening tool that should be management. and postoperative care. The internist's role is to used regularly in high risk patients. determine operative risk; communicate this information to Hospitalists play a key role in preventing hospital-acquired patients, surgeons, and anesthesiologists; and recommend infections by championing early removal of urinary and central strategies to mitigate this risk. Decisions regarding the modal venous catheters and judicious use of antibiotics. Antibiotic ity ofsurgical approach and anesthesia are best deferred to the stewardship activity in collaboration with infectious disease anesthesiologist and surgeon. Commonly, hospitalists are also specialists and pharmacists targets appropriate and timely involved in the postoperative management of surgical patients. antibiotic use to prevent antibiotic resistance and decrease the Internists can also assist with setting patient and family likelihood of complications of antibiotic therapy, including expectations in the perioperative period and ensuring that Clostridioides difficile infection (see MKSAP 19 Infectious expected outcomes align with their goals. Disease). Aspiration and resultant respiratory distress can be a devastating pulmonary complication in hospitalized patients, Preoperative Laboratory Testin g leading to pneumonitis and/or pneumonia. Patients at higher AII preoperative laboratory testing should be tailored on the risk for aspiration include those with dysphagia (for example, basis of the nature of surgery known comorbidities, and

'See the American Geriatrics Society Beers criteria for potentially inappropriate medication use in older adults. Perioperative Med ici ne uninterrupted sleep to promote a normal sleep-wake cycle. General Responsi bi lities Early detection of delirium is of equal importance for preven Perioperative medicine encompasses risk assessment and tion of additional complications. The Confusion Assessment optimization of comorbidities before surgery intraoperative Method is an evidence-based screening tool that should be management. and postoperative care. The internist's role is to used regularly in high risk patients. determine operative risk; communicate this information to Hospitalists play a key role in preventing hospital-acquired patients, surgeons, and anesthesiologists; and recommend infections by championing early removal of urinary and central strategies to mitigate this risk. Decisions regarding the modal venous catheters and judicious use of antibiotics. Antibiotic ity ofsurgical approach and anesthesia are best deferred to the stewardship activity in collaboration with infectious disease anesthesiologist and surgeon. Commonly, hospitalists are also specialists and pharmacists targets appropriate and timely involved in the postoperative management of surgical patients. antibiotic use to prevent antibiotic resistance and decrease the Internists can also assist with setting patient and family likelihood of complications of antibiotic therapy, including expectations in the perioperative period and ensuring that Clostridioides difficile infection (see MKSAP 19 Infectious expected outcomes align with their goals. Disease). Aspiration and resultant respiratory distress can be a devastating pulmonary complication in hospitalized patients, Preoperative Laboratory Testin g leading to pneumonitis and/or pneumonia. Patients at higher AII preoperative laboratory testing should be tailored on the risk for aspiration include those with dysphagia (for example, basis of the nature of surgery known comorbidities, and 28

i L t t Perioperative Medicine t I I t High quality evidence to guide perioperative medication I TABLE 21. Selected lndicationsfor Preoperative L Laboratory Testing management is lacking. Recommendations are largely derived i LaboratoryTesta Preoperativelndications from theoretical drug interactions and expert consensus. L Although most medications are tolerated throughout the peri I Hemoglobin History of anemia L operative period, there are some important exceptions. Table 22 Signs/symptoms or examination findings provides recommendations for medications with potential suggestive of anemia I t

t High quality evidence to guide perioperative medication I TABLE 21. Selected lndicationsfor Preoperative L Laboratory Testing management is lacking. Recommendations are largely derived i LaboratoryTesta Preoperativelndications from theoretical drug interactions and expert consensus. L Although most medications are tolerated throughout the peri I Hemoglobin History of anemia L operative period, there are some important exceptions. Table 22 Signs/symptoms or examination findings provides recommendations for medications with potential suggestive of anemia I t surgery-related risk. Patients, surgeons, and inpatient provid i Underlying disease that predisposes to ers should be given clear instmctions on which medications to t anemia (e.g., kidney disease, I myelodysplasia) withhold preoperatively and guidance for when to safely I Expected substantial operative blood loss resume. For antithrombotic management, collaboration with 1 Platelet count History of thrombocytopenia or surgery cardiolos/, anesthesiolos/, neurolos/, and/or antico- I cirrhosis; signs or symptoms of bleeding agulation services is critical. I or liver disease Coagulation Warfarin or heparin use Postoperative Care I studies Many strategies are used to reduce postoperative complica- History of abnormal bleeding I I tions. ln some settings, multimodal, evidence based interven Medical conditions that predispose to coagulopathy (e.9., liver disease, tions have been standardized and bundled with preoperative t nutritional disorders, and hemophilia) and intraoperative protocols aimed at improving overall out- i E lectro lyte Diseases that predispose to electrolyte comes. These initiatives have been associated with reduced l derangements (e.g., kidney disease) length of hospital stay, decreased complications, and improved \ I Use of medications that can cause functional recovery. I electrolyte abnormalities (e.g., diuretics, Performing preoperative risk stratification in all patients ACE inhibitors, and ARBs) can inform the degree of monitoring necessary for cardiac, pul t Creatinine Kidney disease monary renal, or neurologic dysfunction. Early detection of Expected large intraoperative fluid and concerning changes in clinical status is the most effective way to I blood pressure shifts prevent further decline. Laboratory monitoring should be driven : I Creatinine is also used in preoperative by patient comorbidities, clinical status, and surgery type (for cardiovascular risk calculators and for calculation of the MELD score example, monitoring serum creatinine levels in patients with chronic kidney disease and large intraoperative fluid shifts). Liver chemistry Cirrhosis, history of abnormal liver ; tests (including chemistry tests, or signs or symptoms of Postoperative urinary retention is a common postoperative bilirubin) liver disease complication. fusk factors include type of surgery (anorectal Fasting glucose and Known or suspected diabetes mellitus surgery hernia repair, joint arthroplasty), longer surgery type of hemoglobin 41. anesthesia, use ofopioids and anticholinergic agents, advanced Urinalysis Suspected urinary tract infection age, constipation, history of urinary retention, and neurologic Planned urologic procedures disease. Reversible causes of postoperative urinary retention, including medications such as opioids, should be addressed. In Pregnancy test Women of childbearing age patients with benign prostatic hyperplasia, crr-blockers should ARB = angiotensin receptor blocker; MELD = Model for End-stage Liver Disease. be continued, whereas medications with associated anticholin 'lf the patient is clinically stable and there are no medication changes, tests other ergic effects, such as oxybutynin, should be withheld. Early test need not be repeated if performed within 4 months of the removal of indwelling catheters and voiding trials are recom mended, with ongoing close monitoring of urine output. In patients with low urine output after catheter removal, bladder findings from the history or physical examination (taUte Zf). ultrasonography should be performed to evaluate for urinary Routine laboratory panels are not recommended because they retention. When a voiding trial is unsuccessful (postvoid residual rarely guide management. For patients undergoing ambula >300 400 mL), clean intermittent catheterization is indicated. tory or low-risk surgery (cataract, hernia repair), all preopera Postoperative ileus (POI) is relatively common after sur tive testing is discouraged because there is minimal evidence gery. Abdominal distention and pain, nausea and vomiting, of its usefulness. and inability to flatulate are all hallmarks of POI. Risk factors for POI include abdominal and pelvic surgery; open surgical Perioperative Medication Management technique; and presence olother postoperative complications, Perioperative medication management begins with eliciting a such as pneumonia. Treatment consists of minimizing the use comprehensive medication history including herbal preparations, of opioids, hydration, bowel rest, electrolyte repletion, postop supplements, and over the-counter medications. Medication erative ambulation, and use of chewing gum. Minimally reconciliation should be performed to rectify any discrepan invasive surgical approaches, multimodal analgesia tech cies within the medical record and prevent medication errors. niques, prophylactic bowel regimens, and early ambulation

surgery-related risk. Patients, surgeons, and inpatient provid i Underlying disease that predisposes to ers should be given clear instmctions on which medications to t anemia (e.g., kidney disease, I myelodysplasia) withhold preoperatively and guidance for when to safely I Expected substantial operative blood loss resume. For antithrombotic management, collaboration with 1 Platelet count History of thrombocytopenia or surgery cardiolos/, anesthesiolos/, neurolos/, and/or antico- I cirrhosis; signs or symptoms of bleeding agulation services is critical. I or liver disease Coagulation Warfarin or heparin use Postoperative Care I studies Many strategies are used to reduce postoperative complica- History of abnormal bleeding I I tions. ln some settings, multimodal, evidence based interven Medical conditions that predispose to coagulopathy (e.9., liver disease, tions have been standardized and bundled with preoperative t nutritional disorders, and hemophilia) and intraoperative protocols aimed at improving overall out- i E lectro lyte Diseases that predispose to electrolyte comes. These initiatives have been associated with reduced l derangements (e.g., kidney disease) length of hospital stay, decreased complications, and improved \ I Use of medications that can cause functional recovery. I electrolyte abnormalities (e.g., diuretics, Performing preoperative risk stratification in all patients ACE inhibitors, and ARBs) can inform the degree of monitoring necessary for cardiac, pul t Creatinine Kidney disease monary renal, or neurologic dysfunction. Early detection of Expected large intraoperative fluid and concerning changes in clinical status is the most effective way to I blood pressure shifts prevent further decline. Laboratory monitoring should be driven : I Creatinine is also used in preoperative by patient comorbidities, clinical status, and surgery type (for cardiovascular risk calculators and for calculation of the MELD score example, monitoring serum creatinine levels in patients with chronic kidney disease and large intraoperative fluid shifts). Liver chemistry Cirrhosis, history of abnormal liver ; tests (including chemistry tests, or signs or symptoms of Postoperative urinary retention is a common postoperative bilirubin) liver disease complication. fusk factors include type of surgery (anorectal Fasting glucose and Known or suspected diabetes mellitus surgery hernia repair, joint arthroplasty), longer surgery type of hemoglobin 41. anesthesia, use ofopioids and anticholinergic agents, advanced Urinalysis Suspected urinary tract infection age, constipation, history of urinary retention, and neurologic Planned urologic procedures disease. Reversible causes of postoperative urinary retention, including medications such as opioids, should be addressed. In Pregnancy test Women of childbearing age patients with benign prostatic hyperplasia, crr-blockers should ARB = angiotensin receptor blocker; MELD = Model for End-stage Liver Disease. be continued, whereas medications with associated anticholin 'lf the patient is clinically stable and there are no medication changes, tests other ergic effects, such as oxybutynin, should be withheld. Early test need not be repeated if performed within 4 months of the removal of indwelling catheters and voiding trials are recom mended, with ongoing close monitoring of urine output. In patients with low urine output after catheter removal, bladder findings from the history or physical examination (taUte Zf). ultrasonography should be performed to evaluate for urinary Routine laboratory panels are not recommended because they retention. When a voiding trial is unsuccessful (postvoid residual rarely guide management. For patients undergoing ambula >300 400 mL), clean intermittent catheterization is indicated. tory or low-risk surgery (cataract, hernia repair), all preopera Postoperative ileus (POI) is relatively common after sur tive testing is discouraged because there is minimal evidence gery. Abdominal distention and pain, nausea and vomiting, of its usefulness. and inability to flatulate are all hallmarks of POI. Risk factors for POI include abdominal and pelvic surgery; open surgical Perioperative Medication Management technique; and presence olother postoperative complications, Perioperative medication management begins with eliciting a such as pneumonia. Treatment consists of minimizing the use comprehensive medication history including herbal preparations, of opioids, hydration, bowel rest, electrolyte repletion, postop supplements, and over the-counter medications. Medication erative ambulation, and use of chewing gum. Minimally reconciliation should be performed to rectify any discrepan invasive surgical approaches, multimodal analgesia tech cies within the medical record and prevent medication errors. niques, prophylactic bowel regimens, and early ambulation 29

I 'l I Perioperative Medicine 't TASLE 22. Perioperative Medication Management. : Medication Perioperative Special Considerations : Recommendation Cardiovascular Agents I o1-Blockers Continue Noti{y surgeon of risk for intraoperative floppy iris syndrome in cataract surgery; temporary cessation may not decrease risk a2-Blockers Continue Do not initiate clonidine for preoperative cardiovascular risk reduction (increases risk for perioperative hypotension) I

't TASLE 22. Perioperative Medication Management. : Medication Perioperative Special Considerations : Recommendation Cardiovascular Agents I o1-Blockers Continue Noti{y surgeon of risk for intraoperative floppy iris syndrome in cataract surgery; temporary cessation may not decrease risk a2-Blockers Continue Do not initiate clonidine for preoperative cardiovascular risk reduction (increases risk for perioperative hypotension) I I p-Blockers Continue Consider init:ating preoperatively in patients with three or more RCRI riskfactors and those with intermediate- or high-risk myocardial ischemia on preoperative stresstesting Begin p-blocker with enough time to assess tolerability; P-blocker should not be started on the day of surgery (>2 wk before surgery is preferred) Calcium channel blockers Continue ACE inhibitors and ARBs lndividualize lncreases risk for hypotension and AKI and may increase risk for adverse cardiovascular events; typically withhold if prescribed for hypertension (unless blood pressure is poorly controlled); check institutional anesthesiology guidelines; restart as soon as possible postoperatively Diuretics Withhold Monitor volume status closely if heart failure is present and restart as soon as possible postoperatively Nitrates Continue Vasodilators Continue Statins Continue Thought to have beneficial pleiotropic effects in addition to lipidJowering properties Starting preoperatively recommended in patients undergoing vascular surgery and those undergoing elevated-risk noncardiac surgery with long-term indication for statin Withhold all other li medications Analgesic Agents NSAIDs Withhold Withhold for 3-7 days before surgery depending on half-life of NSAID Opioids lndividualize lf surgery is elective, may consider preoperative pain management consultation and opioid taper Continue in most patients receiving long-term opioid therapy Risk for poorly controlled postoperative pain and respiratory depression Acetami Continue Gastro:ntestinal Agents Antacid medications Continue (including H2-blockers and proton pump inhibitors) ne withhold Risk for side effects Rheumatologic Agents Hydroxychloroquine Continue Methotrexate lndividualize Limited high-quality evidence Probably safe to continue in most situations; withhold if significant concern for infection or history of septic complications; dose adjust in cases of kidney injury Biologics withhold Balance risks for infection and postoperative disease flare Reasonable to schedule surgery at end of dosing cycle, withholding dose at time of surgery and not resuming for 22 wk after surgery Tofacitinib withhold Hold for >7 d before elective total hip or total knee replacement and do not resume for 22 wk after su Psychiatric Agents Selective serotonin Usually continue May increase risk for bleeding, especially in conjunction with antiplatelet agents; risk for reuptake inhibitors withdrawal symptoms with abrupt cessation Benzodiazepines Continue Risk for withdrawal with abrupt cessation; monitor for respiratory depression Antipsvchotics Continue Potential for QT orolonqation Supplements Herbal preparations Withhold Withhold 1-2 wk preoperatively Vitamins and supplements Withhold

I p-Blockers Continue Consider init:ating preoperatively in patients with three or more RCRI riskfactors and those with intermediate- or high-risk myocardial ischemia on preoperative stresstesting Begin p-blocker with enough time to assess tolerability; P-blocker should not be started on the day of surgery (>2 wk before surgery is preferred) Calcium channel blockers Continue ACE inhibitors and ARBs lndividualize lncreases risk for hypotension and AKI and may increase risk for adverse cardiovascular events; typically withhold if prescribed for hypertension (unless blood pressure is poorly controlled); check institutional anesthesiology guidelines; restart as soon as possible postoperatively Diuretics Withhold Monitor volume status closely if heart failure is present and restart as soon as possible postoperatively Nitrates Continue Vasodilators Continue Statins Continue Thought to have beneficial pleiotropic effects in addition to lipidJowering properties Starting preoperatively recommended in patients undergoing vascular surgery and those undergoing elevated-risk noncardiac surgery with long-term indication for statin Withhold all other li medications Analgesic Agents NSAIDs Withhold Withhold for 3-7 days before surgery depending on half-life of NSAID Opioids lndividualize lf surgery is elective, may consider preoperative pain management consultation and opioid taper Continue in most patients receiving long-term opioid therapy Risk for poorly controlled postoperative pain and respiratory depression Acetami Continue Gastro:ntestinal Agents Antacid medications Continue (including H2-blockers and proton pump inhibitors) ne withhold Risk for side effects Rheumatologic Agents Hydroxychloroquine Continue Methotrexate lndividualize Limited high-quality evidence Probably safe to continue in most situations; withhold if significant concern for infection or history of septic complications; dose adjust in cases of kidney injury Biologics withhold Balance risks for infection and postoperative disease flare Reasonable to schedule surgery at end of dosing cycle, withholding dose at time of surgery and not resuming for 22 wk after surgery Tofacitinib withhold Hold for >7 d before elective total hip or total knee replacement and do not resume for 22 wk after su Psychiatric Agents Selective serotonin Usually continue May increase risk for bleeding, especially in conjunction with antiplatelet agents; risk for reuptake inhibitors withdrawal symptoms with abrupt cessation Benzodiazepines Continue Risk for withdrawal with abrupt cessation; monitor for respiratory depression Antipsvchotics Continue Potential for QT orolonqation Supplements Herbal preparations Withhold Withhold 1-2 wk preoperatively Vitamins and supplements Withhold AKI = acute kidney injury; ARB = angiotensin receptor blocker; RCRI = Revised Cardiac Risk lndex. 'Perioperative management of antiplatelet agents, anticoagulants, antiepileptic drugs, glucoconicoids, and diabetes medications is discussed later in this chapter. lnformation from Fleisher LA, Fleischmann KE, Auerbach AD, et al; American College of Cardiology. 201 4 ACC/AHA guideline on perioperative cardiovascular evaluation and management oI patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am

AKI = acute kidney injury; ARB = angiotensin receptor blocker; RCRI = Revised Cardiac Risk lndex. 'Perioperative management of antiplatelet agents, anticoagulants, antiepileptic drugs, glucoconicoids, and diabetes medications is discussed later in this chapter. lnformation from Fleisher LA, Fleischmann KE, Auerbach AD, et al; American College of Cardiology. 201 4 ACC/AHA guideline on perioperative cardiovascular evaluation and management oI patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am undergoing noncardiac surgery. N Engl J Med. 201 4;370:1 504 13.IPMID: 24679061 ] doi:1 0.1 056/NEJMoa 1 40 1 1 06 and Goodman SM, Springer B, Guyatt G, et al. 201 7 American College of Rheumatology/American Association of Hip and Knee Surgeons guideline for the perioperative management of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty. Arthritis Rheumatol. 201 7;69:1 538 5 1 . IPMID: 28620948] doi:1 0.1 O02l an.401 49 30

Perioperative Medicine may help to prevent POI. When POI is prolonged (lasting longer than 3-5 days), mechanical bowel obstruction should r Early removal of indwelling andvoidingtrials HVC be considered. are recommended postoperatively, with ongoing close Postoperative nausea and vomiting is a common event monitoring of urine output. that results in significant patient distress. Risk factors include use of general anesthesia, opioids, female sex, and younger . Treatment of postoperaflve ileus includes minimization of postoperative opioids, adequate hydration, bowel rest, age. The internist plays an important role in ensuring adequate postoperative hydration, minimizing the use of opioids, and electrolyte repletion, and postoperative ambulation. providing pharmacologic antiemetic therapy. The occurrence of new postoperative atrial fibrillation, even iftransient, is associated with increased short- and long- C,a rd iovascu I a r Pe rio perative term mortality and incidence of stroke. When self-limited Management postoperative atrial fibrillation occurs, postoperative follow- Cardiovascu lar Risk Assessment up is indicated, including echocardiography and consideration The preoperative cardiac evaluation is intended to assess of anticoagulation in at-risk patients. patient risks for a major adverse cardiac event (MACE), such as ischemia, cardiac arrest, heart failure, and dysrhythmias, both HUC . Preoperative routine laboratory panels are not recom- during and after surgery. The widely accepted approach to risk mended and can lead to unnecessary additional testing. stratification recommended by the American College of o In general, most medications are tolerated throughout Cardiologr (ACC)/American Heart Association (AHA) for patients undergoing noncardiac surgery is shown in Figure 2. the perioperative period. Risk calculators can be used to determine the risk for (Continued) perioperative MACE. The Revised Cardiac Risk Index (RCRI)

may help to prevent POI. When POI is prolonged (lasting longer than 3-5 days), mechanical bowel obstruction should r Early removal of indwelling andvoidingtrials HVC be considered. are recommended postoperatively, with ongoing close Postoperative nausea and vomiting is a common event monitoring of urine output. that results in significant patient distress. Risk factors include use of general anesthesia, opioids, female sex, and younger . Treatment of postoperaflve ileus includes minimization of postoperative opioids, adequate hydration, bowel rest, age. The internist plays an important role in ensuring adequate postoperative hydration, minimizing the use of opioids, and electrolyte repletion, and postoperative ambulation. providing pharmacologic antiemetic therapy. The occurrence of new postoperative atrial fibrillation, even iftransient, is associated with increased short- and long- C,a rd iovascu I a r Pe rio perative term mortality and incidence of stroke. When self-limited Management postoperative atrial fibrillation occurs, postoperative follow- Cardiovascu lar Risk Assessment up is indicated, including echocardiography and consideration The preoperative cardiac evaluation is intended to assess of anticoagulation in at-risk patients. patient risks for a major adverse cardiac event (MACE), such as ischemia, cardiac arrest, heart failure, and dysrhythmias, both HUC . Preoperative routine laboratory panels are not recom- during and after surgery. The widely accepted approach to risk mended and can lead to unnecessary additional testing. stratification recommended by the American College of o In general, most medications are tolerated throughout Cardiologr (ACC)/American Heart Association (AHA) for patients undergoing noncardiac surgery is shown in Figure 2. the perioperative period. Risk calculators can be used to determine the risk for (Continued) perioperative MACE. The Revised Cardiac Risk Index (RCRI) Yes Proceed to $rrgery with managem€nt Emergency surgery?. ofCAD is otherwise indicated No

Yes Proceed to $rrgery with managem€nt Emergency surgery?. ofCAD is otherwise indicated No Yes Delay surgcry for managemont per Acute coronary syndrome?b other ACC,/AHA guideliries No No Risk factors for CAD?! Proceed to surgery Yes Low risk (<1%) of MACE based Yes on combined clinical/surgical risk? No Moderate or greater functional Yes capacity (14 METs)?d tIGUXE 2. Perioperative ischemiccardiacdiseaseevaluation No Proceed to surgery with management for noncardiac surgery. of CAD as otherwise indicated ACC=American College of Cardiology; AHA=AmeriGn HeartAssociation; CAD = c0ro nary artery disease; MACE = major adverse cardiac event; l\4ET= metabolic equivalent. Will coronary evaluation No '[mergenrysurgery required within 6 h0ursto avoid los of life or limb. change management? bA(ute coronary syndromes; myocardial infardion <30 days ago, unstable or severe angina. Yes

tIGUXE 2. Perioperative ischemiccardiacdiseaseevaluation No Proceed to surgery with management for noncardiac surgery. of CAD as otherwise indicated ACC=American College of Cardiology; AHA=AmeriGn HeartAssociation; CAD = c0ro nary artery disease; MACE = major adverse cardiac event; l\4ET= metabolic equivalent. Will coronary evaluation No '[mergenrysurgery required within 6 h0ursto avoid los of life or limb. change management? bA(ute coronary syndromes; myocardial infardion <30 days ago, unstable or severe angina. Yes 'Risk fact06 for CAD: not specifically delined in ACC/AHA guidelines; examples include Normal known CID cerebrovascular disease(i.e., stroke ortransient ischemitattack), chroni( Pharmacologic stress test kidney disease, diabetes mellalus, and hean failure. dBest determined using an objectivetool,such as the DukeActivity Status lndexscore, Abnormal because subjective estimation is unreliable.

'Risk fact06 for CAD: not specifically delined in ACC/AHA guidelines; examples include Normal known CID cerebrovascular disease(i.e., stroke ortransient ischemitattack), chroni( Pharmacologic stress test kidney disease, diabetes mellalus, and hean failure. dBest determined using an objectivetool,such as the DukeActivity Status lndexscore, Abnormal because subjective estimation is unreliable. Recommendations from fleisher [A, Fleischmann Kt,Auerbach AD, etal; American Col' Coronary revascularization lege of Cardiology.2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of palients undergoing nontardia( surgery: a report oftheAmelican according to existing College of Grdiology/AmeiGn Heanlssociation Task Force on pradice guid€lines. J Am clinical practice guideline Coll Cardiol. 201 4;64:e77t 37. PMID: 25091 544 doi:1 0.1 01 6/jjact.201 4.07.944 31

Perioperative Medicine TABLE 23, Revised Cardiac Risk lndex and Prediaed Rate Patients with low calculated cardiovascular risk (<l'7, risk of Major Cardiac Complications Perioperatively for perioperative MACE) may proceed to surgery whereas Risk Factor (1 point for each) patients with elevated risk (>1'7, risk for perioperative MACE) High-risk surgery (intrathoracic, intraperitoneal, suprainguinal should have functional capacity assessed. Metabolic equiva vascular) lents (METs) are used to represent a patient's functional capac lschemic heart disease ity based on the intensity of activity the patient is able to perform. According to the ACC/AHA guideline, if functional Heart failure (compensated) capacity exceeds 4 METs, the patient may proceed to surgery Diabetes mellitus (requiring insulin) without further testing. The Duke Activity Starus Index (DASI) Cerebrovascular disease score (Table 25) is a standardized and accurate means of esti- Chronic kidney disease (serum creatinine >2.0 mg/dL mating exercise capacity; data lrom the METS trial showed [176.8 gmol/L])" that clinician estimates of exercise capacity without use of a Number of Points Risk for Major Cardiac Complicationsb standardized tool do not correlate with actual patient perfor- 0 0.47"-0.5o/" mance on cardiopulmonary exercise testing nor with postop 1 1.0%-2.6% erative cardiac outcomes. Preoperative cardiac stress testing should be considered in patients at elevated risk for MACE 2 2.4"/"-7.2"/" with functional capaci[z objectively assessed to not be low risk, .J 5.4%-14.4"/" but only if the results will change perioperative management. aEstimated glomerular filtration rate <30 mUmin/1 .73 m2 is also shown to predict An alternative approach from the Canadian Cardiovascular cardiovascular risk. Society does not use preoperative cardiac stress testing and bDefined as cardiac death, nonfatal myocardial infarction, and nonfatal cardiac arrest (original validation also included pulmonary edema and complete heart instead suggests assessing perioperative risk using patient age, block). Percentages represent incidence measured during inpatient timeframe. presence of known cardiovascular disease, the RCRI, and Validations using 30 day time frames have demonstrated significantly higher rates, l even among patients with a score of 0. B-type natriuretic peptide. Data from Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospenrve Preoperative ECG is reasonable in patients with known validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1 999;100:1043-9. IPMID: 10477528] doi:10.1 1 61l01. cardiovascular disease undergoing moderate to high risk sur- L

TABLE 23, Revised Cardiac Risk lndex and Prediaed Rate Patients with low calculated cardiovascular risk (<l'7, risk of Major Cardiac Complications Perioperatively for perioperative MACE) may proceed to surgery whereas Risk Factor (1 point for each) patients with elevated risk (>1'7, risk for perioperative MACE) High-risk surgery (intrathoracic, intraperitoneal, suprainguinal should have functional capacity assessed. Metabolic equiva vascular) lents (METs) are used to represent a patient's functional capac lschemic heart disease ity based on the intensity of activity the patient is able to perform. According to the ACC/AHA guideline, if functional Heart failure (compensated) capacity exceeds 4 METs, the patient may proceed to surgery Diabetes mellitus (requiring insulin) without further testing. The Duke Activity Starus Index (DASI) Cerebrovascular disease score (Table 25) is a standardized and accurate means of esti- Chronic kidney disease (serum creatinine >2.0 mg/dL mating exercise capacity; data lrom the METS trial showed [176.8 gmol/L])" that clinician estimates of exercise capacity without use of a Number of Points Risk for Major Cardiac Complicationsb standardized tool do not correlate with actual patient perfor- 0 0.47"-0.5o/" mance on cardiopulmonary exercise testing nor with postop 1 1.0%-2.6% erative cardiac outcomes. Preoperative cardiac stress testing should be considered in patients at elevated risk for MACE 2 2.4"/"-7.2"/" with functional capaci[z objectively assessed to not be low risk, .J 5.4%-14.4"/" but only if the results will change perioperative management. aEstimated glomerular filtration rate <30 mUmin/1 .73 m2 is also shown to predict An alternative approach from the Canadian Cardiovascular cardiovascular risk. Society does not use preoperative cardiac stress testing and bDefined as cardiac death, nonfatal myocardial infarction, and nonfatal cardiac arrest (original validation also included pulmonary edema and complete heart instead suggests assessing perioperative risk using patient age, block). Percentages represent incidence measured during inpatient timeframe. presence of known cardiovascular disease, the RCRI, and Validations using 30 day time frames have demonstrated significantly higher rates, l even among patients with a score of 0. B-type natriuretic peptide. Data from Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospenrve Preoperative ECG is reasonable in patients with known validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1 999;100:1043-9. IPMID: 10477528] doi:10.1 1 61l01. cardiovascular disease undergoing moderate to high risk sur- L geries. Preoperative ECG may be considered for asymptomatic I patients except those undergoing low-risk procedures. ECG l rarely alters preoperative decision making but may provide a useful baseline to guide postoperative management in the (Table 23), the American College of Surgeons National Surgical event of complications. Quality Improvement Program Surgical Risk Calculator Echocardiography should not be routinely performed (https, //riskcalculator.facs.org/RiskCalculator), and the Gupta preoperatively. Specific indications for echocardiography Perioperative Risk for Myocardial Infarction or Cardiac Arrest include the presence of dyspnea of unknown origin, heart (MICA) Calculator (www.surgicalriskcalculator.com/miorcar failure with worsening dyspnea or change in clinical status, diacarrest) incorporate patient and surgery specific risk fac known left ventricular dysfunction without echocardio- tors. Each calculator varies in terms of the population used for graphic assessment in the last year, and known or suspected validation and overall performance (Table 2a). moderate to severe valvular stenosis or regurgitation without

geries. Preoperative ECG may be considered for asymptomatic I patients except those undergoing low-risk procedures. ECG l rarely alters preoperative decision making but may provide a useful baseline to guide postoperative management in the (Table 23), the American College of Surgeons National Surgical event of complications. Quality Improvement Program Surgical Risk Calculator Echocardiography should not be routinely performed (https, //riskcalculator.facs.org/RiskCalculator), and the Gupta preoperatively. Specific indications for echocardiography Perioperative Risk for Myocardial Infarction or Cardiac Arrest include the presence of dyspnea of unknown origin, heart (MICA) Calculator (www.surgicalriskcalculator.com/miorcar failure with worsening dyspnea or change in clinical status, diacarrest) incorporate patient and surgery specific risk fac known left ventricular dysfunction without echocardio- tors. Each calculator varies in terms of the population used for graphic assessment in the last year, and known or suspected validation and overall performance (Table 2a). moderate to severe valvular stenosis or regurgitation without TABLE 24. Comparison of Tools for Estimating Major Adverse Cardiovascular Event Risk ASC NSOIP Calculators Characteristic RCRI MtCA Risk Surgical Risk External validation Multiple studies Minimal Minimal Surgical population Inpatient (hospitalization for All, except for some low-risk All, except for some low-risk 2 d) for most validations procedures procedures Measured cardiovascular Ml, cardiac death/ventricular MICA Ml and cardiac death outcomes fibrillation, pulmonary edema, complete heart block Outcome measurement time lnpatient only {or most 30 d postoperatively 30 d postoperatively frame validations Limitations Tendency to overestimate risk Surgical types combined into Tendency to overestimate risk broad categories that could lead to inaccurate assessment of risk I acs NSOIP = American Cancer Society National Surgical Ouality lmprovement Program; Ml = myocardial infarction; N4ICA = myocardial infarction and cardiac arrest; ] acnr = Revised Cardiac Risk lndex l

TABLE 24. Comparison of Tools for Estimating Major Adverse Cardiovascular Event Risk ASC NSOIP Calculators Characteristic RCRI MtCA Risk Surgical Risk External validation Multiple studies Minimal Minimal Surgical population Inpatient (hospitalization for All, except for some low-risk All, except for some low-risk 2 d) for most validations procedures procedures Measured cardiovascular Ml, cardiac death/ventricular MICA Ml and cardiac death outcomes fibrillation, pulmonary edema, complete heart block Outcome measurement time lnpatient only {or most 30 d postoperatively 30 d postoperatively frame validations Limitations Tendency to overestimate risk Surgical types combined into Tendency to overestimate risk broad categories that could lead to inaccurate assessment of risk I acs NSOIP = American Cancer Society National Surgical Ouality lmprovement Program; Ml = myocardial infarction; N4ICA = myocardial infarction and cardiac arrest; ] acnr = Revised Cardiac Risk lndex l 32

Perioperative Medicine TABLE 25. Duke Activity Status lndex (DAS|) Score considered 90 days after drug-eluting placement. patients Questionnaire with an acute coronary syndrome not managed with coro Ouestionnaire ltem Points (each nary intervention are still at elevated risk for postoperative "Yes" answer)" MACE, and elective surgery should be delayed for at least 1. Can you take care of yourself (e.g., 2.75 60 days after the event. eat, dress, bathe, or use the toilet)? Patients taking B blockers, statins, and most antihyper 2. Can you walk indoors (e.g., 1.75 tensive medications (with the possible exceptions of diuretics throughout the rooms of your and ACE inhibitors) should continue these medications peri house)? operatively unless prohibited by hypotension. In some circum 3. Can you walk one to two blocks on 2.75 stances, p-blocker or statin therapy is initiated preoperatively level ground? (see Table 22). Postoperative p blocker administration should 4. Can you climb a flight of stairs or walk 5.50 be guided by clinical circumstances, but dose reduction is pre, up a hill? ferred to discontinuation if hypotension develops. 5. Can you run a shortdistance? 8.00 The ACC/AHA perioperative evaluation and management 6. Can you do /ight work around the 2.70 guideline does not recommend routine measurement of post- house (e.9., dusting, washing dishes)? operative troponin or ECG, but these studies should be obtained 7. Can you do moderate work around 3.50 if signs or symptoms of myocardial ischemia develop. However, the house (e.g., vacuuming, sweeping floors, or carrying groceries)? in many cases, postoperative myocardial ischemia is asympto matic or presents a!/pically. The Canadian Cardiovascular :

TABLE 25. Duke Activity Status lndex (DAS|) Score considered 90 days after drug-eluting placement. patients Questionnaire with an acute coronary syndrome not managed with coro Ouestionnaire ltem Points (each nary intervention are still at elevated risk for postoperative "Yes" answer)" MACE, and elective surgery should be delayed for at least 1. Can you take care of yourself (e.g., 2.75 60 days after the event. eat, dress, bathe, or use the toilet)? Patients taking B blockers, statins, and most antihyper 2. Can you walk indoors (e.g., 1.75 tensive medications (with the possible exceptions of diuretics throughout the rooms of your and ACE inhibitors) should continue these medications peri house)? operatively unless prohibited by hypotension. In some circum 3. Can you walk one to two blocks on 2.75 stances, p-blocker or statin therapy is initiated preoperatively level ground? (see Table 22). Postoperative p blocker administration should 4. Can you climb a flight of stairs or walk 5.50 be guided by clinical circumstances, but dose reduction is pre, up a hill? ferred to discontinuation if hypotension develops. 5. Can you run a shortdistance? 8.00 The ACC/AHA perioperative evaluation and management 6. Can you do /ight work around the 2.70 guideline does not recommend routine measurement of post- house (e.9., dusting, washing dishes)? operative troponin or ECG, but these studies should be obtained 7. Can you do moderate work around 3.50 if signs or symptoms of myocardial ischemia develop. However, the house (e.g., vacuuming, sweeping floors, or carrying groceries)? in many cases, postoperative myocardial ischemia is asympto matic or presents a!/pically. The Canadian Cardiovascular : 8. Can you do heavywork around the 8.00 house (e.9., scrubbing floors, lifting or Society recommends daily measurement of troponin levels for moving heavy furn iture)? up to 3 days after surgery in patients at elevated risk for MACE, 9. Can you do yard work (e.9., raking 4.50 although the best means of managing patients with postopera leaves, weeding, pushing a power tive low leveltroponin elevations is unclear. lawnmower)? L 1 0. Can you have sexual relations? 5.25 Heart Failure 1 1. Can you participate in moderate 6.00 Medical management of decompensated heart failure should recreational activities (e.9., goll be optimized before surgery (see MKSAP 19 Cardiovascular bowling, dancing, doubles tennis, or throwing a ball)? Medicine). 12. Can you participate in strenuous 7.50 sports (e.9., swimming, singles tennis, Cardiac Arrhythmias football, basketball, or skiing)? Risk management strategies for patients with a cardiac "ln Wijeysundera and colleagues 2020, a DASI score of 34 (equivalent to -5 METs arrhythmia who are undergoing surgery include continuation in the study population) was the cutoff below which patients experienced elevated of antiarrhythmic medications and, flor some patients, con risk for 30 day mortality and myocardial infarction. tinuous cardiac monitoring. Reproduced with permission from Hlatky MA, Boineau RE, Higginbotham l\48, et al. A brief self-administered questionnaire to determine functional capacity (the Duke Patients with atrial fibrillation are at risk for rapid ven- ActivityStatuslndex).AmJCardiol. 1989;64:651 4.IPMID:2782256]doi:10.1016/ oo02-9 1 49189)9049 6.7 tricular rate due to surgical stress, fluid shifts, and postoperative pain. Maintaining euvolemia, optimizing pain management, Wijeysundera DN, Beattie WS, Hillis GS, et al; Measurement of Exercise Tolerance before Surgery Study lnvestigators. lntegration of the Duke Activity Status lndex and continuing baseline rate control medications can reduce into preoperative risk evaluation: a multicentre prospective cohort study. Br J Anaest6,.2020;124:261 70.lPMlD:318647191doi:10.1016/j.6ja.2019.11.025 this risk. A cardiologist should be consulted in patients with a pacemaker or implantable cardioverter-defibrillator who are echocardiographic assessment in the past year or with a undergoing surgery to assure normal device function and change in clinical status. obtain recommendations for perioperative management of the device. Patients in whom a device has been deactivated for Cardiovascular Risk Management surgery should undergo continuous cardiac monitoring until Coronary Artery Disease the device is reprogrammed. Patients with coronary artery disease should not undergo routine coronary angiography or revascularization before Valvular Heart Disease surgery. These procedures should be reserved for patients The ACC/AHA guideline states that it is reasonable to perform with recognized indications based on clinical practice guide elective noncardiac surgery in patients with severe asympto lines. It is recommended that elective surgery be delayed matic aortic stenosis, mitral regurgitation, or aortic regurgita- 14 days after balloon angioplasty, 30 days after bare metal tion with preserved left ventricular function. However, these stent implantation, and 6 months after drug-eluting stent patients are at higher risk for cardiovascular complications, placement. However, if the risk of surgical delay outweighs necessitating awareness among surgical teams. Efforts to the risk for ischemia and stent thrombosis, surgery may be avoid large volume shifts and minimizing hypotension and

8. Can you do heavywork around the 8.00 house (e.9., scrubbing floors, lifting or Society recommends daily measurement of troponin levels for moving heavy furn iture)? up to 3 days after surgery in patients at elevated risk for MACE, 9. Can you do yard work (e.9., raking 4.50 although the best means of managing patients with postopera leaves, weeding, pushing a power tive low leveltroponin elevations is unclear. lawnmower)? L 1 0. Can you have sexual relations? 5.25 Heart Failure 1 1. Can you participate in moderate 6.00 Medical management of decompensated heart failure should recreational activities (e.9., goll be optimized before surgery (see MKSAP 19 Cardiovascular bowling, dancing, doubles tennis, or throwing a ball)? Medicine). 12. Can you participate in strenuous 7.50 sports (e.9., swimming, singles tennis, Cardiac Arrhythmias football, basketball, or skiing)? Risk management strategies for patients with a cardiac "ln Wijeysundera and colleagues 2020, a DASI score of 34 (equivalent to -5 METs arrhythmia who are undergoing surgery include continuation in the study population) was the cutoff below which patients experienced elevated of antiarrhythmic medications and, flor some patients, con risk for 30 day mortality and myocardial infarction. tinuous cardiac monitoring. Reproduced with permission from Hlatky MA, Boineau RE, Higginbotham l\48, et al. A brief self-administered questionnaire to determine functional capacity (the Duke Patients with atrial fibrillation are at risk for rapid ven- ActivityStatuslndex).AmJCardiol. 1989;64:651 4.IPMID:2782256]doi:10.1016/ oo02-9 1 49189)9049 6.7 tricular rate due to surgical stress, fluid shifts, and postoperative pain. Maintaining euvolemia, optimizing pain management, Wijeysundera DN, Beattie WS, Hillis GS, et al; Measurement of Exercise Tolerance before Surgery Study lnvestigators. lntegration of the Duke Activity Status lndex and continuing baseline rate control medications can reduce into preoperative risk evaluation: a multicentre prospective cohort study. Br J Anaest6,.2020;124:261 70.lPMlD:318647191doi:10.1016/j.6ja.2019.11.025 this risk. A cardiologist should be consulted in patients with a pacemaker or implantable cardioverter-defibrillator who are echocardiographic assessment in the past year or with a undergoing surgery to assure normal device function and change in clinical status. obtain recommendations for perioperative management of the device. Patients in whom a device has been deactivated for Cardiovascular Risk Management surgery should undergo continuous cardiac monitoring until Coronary Artery Disease the device is reprogrammed. Patients with coronary artery disease should not undergo routine coronary angiography or revascularization before Valvular Heart Disease surgery. These procedures should be reserved for patients The ACC/AHA guideline states that it is reasonable to perform with recognized indications based on clinical practice guide elective noncardiac surgery in patients with severe asympto lines. It is recommended that elective surgery be delayed matic aortic stenosis, mitral regurgitation, or aortic regurgita- 14 days after balloon angioplasty, 30 days after bare metal tion with preserved left ventricular function. However, these stent implantation, and 6 months after drug-eluting stent patients are at higher risk for cardiovascular complications, placement. However, if the risk of surgical delay outweighs necessitating awareness among surgical teams. Efforts to the risk for ischemia and stent thrombosis, surgery may be avoid large volume shifts and minimizing hypotension and 33

Perioperative Medicine tachycardia are critical. Valvular intervention should be per Pu I monary Perioperative formed before elective noncardiac surgery in patients who are candidates fbr vahular intervention owing to symptoms or Management severity ofdisease. Perioperative pulmonary complications include pneumonia, respiratory failure, and exacerbation of underlying lung dis Pulmonary H5rpertension ease. Pulmonary perioperative management involves pulmo Patients with pulmonary hypertension undergoing noncar- nary risk assessment, including screening for obstructive sleep diac surgery have higher mortality and morbidity, including apnea (OSA) , assessment of underlying lung disease and treat nonfatal myocardial ischemia, VTE. cardiogenic shock, and ment optimization, and use of perioperative risk reduction dysrhythmias. Preoperative evaluation by a pulmonary hyper strategies. tension specialist is advised for patients with high risk fea tures, including group l pulmonary hypertension (pulmonary Pulmonary Risk Assessment arterial hypertension), pulmonary artery systolic pressure Patients should be asked preoperatively about any recent signs greater than 70 mm Hg, moderate or severe right ventricular or symptoms of acute respiratory illness or chronic lung dis systolic dysfunction, and New York Heart Association func ease exacerbation. tional class III or IV symptoms attributable to pulmonary Pulmonary risk factors can be categorized as patient hypertension. Postoperatively, maintaining preload, optimal related factors or procedure-related factors (Table 26). Risk pain control, and normal heart rate and blood pressure are calculators that include many of the important risk factors important. Patients should be continued on pulmonaryvascu and other predictors may help determine postoperative risk lar targeted therapies, such as phosphodiesterase-5 inhibitors for respiratory failure, pneumonia, and overall pulmonary and prostacyclin analogues. complications. The ARISCAT score has been externally vali dated and measures risk for a wide variety of perioperative H5rpertension pulmonary complications (wvwv.mdcalc.com/ariscat score In patients with hypertension, urgent blood pressure lowering postoperative-pulmonary complications). To date, ARISCAT is not mandatory preoperatively unless there is evidence of end organ dysfunction, in which case surgery should be TABLE 26. Pulmonary Risk Factors delayed and blood pressure treated. Deferral of surgery may Patient-Related Risk Factors also be considered in patients with a systolic blood pressure of Age 180 mm Hg or higher or diastolic blood pressure of 110 mm Hg or higher. Moderate preoperative hypertension has not been I COPD linked to adverse perioperative outcomes, although evidence is Cigarette use lacking regarding a specific blood pressure threshold. The ASA class >2u perioperative use of specific antihypertensive agents is out Functional dependence lined in Table 22. Obstructive sleep apnea l(EY POll{IS Heart failure HVC o Patients with low cardiovascular risk (<1'1, risk for peri- Serum albumin level <3 g/dL (30 g/L) operative major adverse cardiac event [MACE]) may Procedure-Related Risk Factors proceed to surgery whereas patients with elevated risk Surgery in close proximity to the airway or diaphragm (aortic, (>17, risk for perioperative MACEs) should undergo thoracic, abdominal) objective assessment of functional capacity. Head and neck surgery HVC . Preoperative ECG is reasonable in patients with known Neurosurgery cardiovascular disease undergoing moderate- to high- Major vascular surgery risk surgeries and may be considered for other asymp- tomatic patients, except those undergoing low-risk Procedure duration >2 h procedures. Emergency surgery

tachycardia are critical. Valvular intervention should be per Pu I monary Perioperative formed before elective noncardiac surgery in patients who are candidates fbr vahular intervention owing to symptoms or Management severity ofdisease. Perioperative pulmonary complications include pneumonia, respiratory failure, and exacerbation of underlying lung dis Pulmonary H5rpertension ease. Pulmonary perioperative management involves pulmo Patients with pulmonary hypertension undergoing noncar- nary risk assessment, including screening for obstructive sleep diac surgery have higher mortality and morbidity, including apnea (OSA) , assessment of underlying lung disease and treat nonfatal myocardial ischemia, VTE. cardiogenic shock, and ment optimization, and use of perioperative risk reduction dysrhythmias. Preoperative evaluation by a pulmonary hyper strategies. tension specialist is advised for patients with high risk fea tures, including group l pulmonary hypertension (pulmonary Pulmonary Risk Assessment arterial hypertension), pulmonary artery systolic pressure Patients should be asked preoperatively about any recent signs greater than 70 mm Hg, moderate or severe right ventricular or symptoms of acute respiratory illness or chronic lung dis systolic dysfunction, and New York Heart Association func ease exacerbation. tional class III or IV symptoms attributable to pulmonary Pulmonary risk factors can be categorized as patient hypertension. Postoperatively, maintaining preload, optimal related factors or procedure-related factors (Table 26). Risk pain control, and normal heart rate and blood pressure are calculators that include many of the important risk factors important. Patients should be continued on pulmonaryvascu and other predictors may help determine postoperative risk lar targeted therapies, such as phosphodiesterase-5 inhibitors for respiratory failure, pneumonia, and overall pulmonary and prostacyclin analogues. complications. The ARISCAT score has been externally vali dated and measures risk for a wide variety of perioperative H5rpertension pulmonary complications (wvwv.mdcalc.com/ariscat score In patients with hypertension, urgent blood pressure lowering postoperative-pulmonary complications). To date, ARISCAT is not mandatory preoperatively unless there is evidence of end organ dysfunction, in which case surgery should be TABLE 26. Pulmonary Risk Factors delayed and blood pressure treated. Deferral of surgery may Patient-Related Risk Factors also be considered in patients with a systolic blood pressure of Age 180 mm Hg or higher or diastolic blood pressure of 110 mm Hg or higher. Moderate preoperative hypertension has not been I COPD linked to adverse perioperative outcomes, although evidence is Cigarette use lacking regarding a specific blood pressure threshold. The ASA class >2u perioperative use of specific antihypertensive agents is out Functional dependence lined in Table 22. Obstructive sleep apnea l(EY POll{IS Heart failure HVC o Patients with low cardiovascular risk (<1'1, risk for peri- Serum albumin level <3 g/dL (30 g/L) operative major adverse cardiac event [MACE]) may Procedure-Related Risk Factors proceed to surgery whereas patients with elevated risk Surgery in close proximity to the airway or diaphragm (aortic, (>17, risk for perioperative MACEs) should undergo thoracic, abdominal) objective assessment of functional capacity. Head and neck surgery HVC . Preoperative ECG is reasonable in patients with known Neurosurgery cardiovascular disease undergoing moderate- to high- Major vascular surgery risk surgeries and may be considered for other asymp- tomatic patients, except those undergoing low-risk Procedure duration >2 h procedures. Emergency surgery HVC . Patients with coronary artery disease should not ASA = American Society of Anesthesiologists.

tachycardia are critical. Valvular intervention should be per Pu I monary Perioperative formed before elective noncardiac surgery in patients who are candidates fbr vahular intervention owing to symptoms or Management severity ofdisease. Perioperative pulmonary complications include pneumonia, respiratory failure, and exacerbation of underlying lung dis Pulmonary H5rpertension ease. Pulmonary perioperative management involves pulmo Patients with pulmonary hypertension undergoing noncar- nary risk assessment, including screening for obstructive sleep diac surgery have higher mortality and morbidity, including apnea (OSA) , assessment of underlying lung disease and treat nonfatal myocardial ischemia, VTE. cardiogenic shock, and ment optimization, and use of perioperative risk reduction dysrhythmias. Preoperative evaluation by a pulmonary hyper strategies. tension specialist is advised for patients with high risk fea tures, including group l pulmonary hypertension (pulmonary Pulmonary Risk Assessment arterial hypertension), pulmonary artery systolic pressure Patients should be asked preoperatively about any recent signs greater than 70 mm Hg, moderate or severe right ventricular or symptoms of acute respiratory illness or chronic lung dis systolic dysfunction, and New York Heart Association func ease exacerbation. tional class III or IV symptoms attributable to pulmonary Pulmonary risk factors can be categorized as patient hypertension. Postoperatively, maintaining preload, optimal related factors or procedure-related factors (Table 26). Risk pain control, and normal heart rate and blood pressure are calculators that include many of the important risk factors important. Patients should be continued on pulmonaryvascu and other predictors may help determine postoperative risk lar targeted therapies, such as phosphodiesterase-5 inhibitors for respiratory failure, pneumonia, and overall pulmonary and prostacyclin analogues. complications. The ARISCAT score has been externally vali dated and measures risk for a wide variety of perioperative H5rpertension pulmonary complications (wvwv.mdcalc.com/ariscat score In patients with hypertension, urgent blood pressure lowering postoperative-pulmonary complications). To date, ARISCAT is not mandatory preoperatively unless there is evidence of end organ dysfunction, in which case surgery should be TABLE 26. Pulmonary Risk Factors delayed and blood pressure treated. Deferral of surgery may Patient-Related Risk Factors also be considered in patients with a systolic blood pressure of Age 180 mm Hg or higher or diastolic blood pressure of 110 mm Hg or higher. Moderate preoperative hypertension has not been I COPD linked to adverse perioperative outcomes, although evidence is Cigarette use lacking regarding a specific blood pressure threshold. The ASA class >2u perioperative use of specific antihypertensive agents is out Functional dependence lined in Table 22. Obstructive sleep apnea l(EY POll{IS Heart failure HVC o Patients with low cardiovascular risk (<1'1, risk for peri- Serum albumin level <3 g/dL (30 g/L) operative major adverse cardiac event [MACE]) may Procedure-Related Risk Factors proceed to surgery whereas patients with elevated risk Surgery in close proximity to the airway or diaphragm (aortic, (>17, risk for perioperative MACEs) should undergo thoracic, abdominal) objective assessment of functional capacity. Head and neck surgery HVC . Preoperative ECG is reasonable in patients with known Neurosurgery cardiovascular disease undergoing moderate- to high- Major vascular surgery risk surgeries and may be considered for other asymp- tomatic patients, except those undergoing low-risk Procedure duration >2 h procedures. Emergency surgery HVC . Patients with coronary artery disease should not ASA = American Society of Anesthesiologists. undergo routine coronary angiography or revasculariza- 'ASA classes are as follows: class 1, normal healthy patient; class 2, patient with mild system c disease; class 3, patient with severe systemic disease; class 4, patient tion before surgery exclusively to reduce perioperative with systemlc disease that is a constant threat to li{e; and class 5, moribund patient events. who s not expected to survive for 24 hours with or wrthout operation.

undergo routine coronary angiography or revasculariza- 'ASA classes are as follows: class 1, normal healthy patient; class 2, patient with mild system c disease; class 3, patient with severe systemic disease; class 4, patient tion before surgery exclusively to reduce perioperative with systemlc disease that is a constant threat to li{e; and class 5, moribund patient events. who s not expected to survive for 24 hours with or wrthout operation. . Patients with hypertension who are undergoing sur Adapted with permission from Smetana GW, Lawrence VA, Cornell JE; American College of Physicians. Preoperative pulmonary rlsk stratification for gery do not require urgent blood pressure lowering noncardiothoracic surgery: systematic review for the American College of Physicians. Ann lntern Med. 2006;1 44:584, 587. I PMID: 1 66 1 8956] doi: preoperatively unless there is evidence of end-organ 1 0.7 326/ 0003 481 9 1 44.8-200 6A41 80.00009 dysfunction. Copyright 2006, American College of Physicians. 34

Perioperative Medicine TABLE 27. STOP-BANG Obstructive Sleep Apnea muscle training) and postoperative continuous positive pres- Screening Tool sure ventilation. Surgery should be postponed and appropriate Survey ltems (1 point for each) treatment initiated if there is concern for exacerbation of Snoring underlying disease or respiratory illness. Smoking cessation reduces pulmonary risk and should be encouraged as far in Tiredness or sleepiness during the day advance of surgery as possible. Prescribed inhaled medica Observed apnea during sleep tions should be continued throughout the perioperative Pressure, high blood period. Perioperative management should also include goal BMt>35 directed fluid management and consideration of lung protec Age >50 y tive ventilation strategies. In patients diagnosed with OSA, continuous positive air Neck circumference >40 cm (15.7 in) way pressure should be initiated preoperatively when possible. Gender = male For patients with suspected OSA undergoing nonelective sur- STOP-BANG Score Risk Correlation gery, management includes postoperative monitoring with 0-2 Low risk for OSA continuous pulse oximetry or capnography, nonsupine posi >3 lncreased risk for OSA tioning, and limiting sedating medications. Patients with >5 lncreased risk for moderate to severe OSA known OSA should bring their continuous positive airway pressure device to the hospital for use in the perioperative OSA = obstructive sleep apnea. period. Adapted with permission from Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008;108:812-21.{PMlDr 18431 1 161 doi:10.1097/ t(tY PottTs . Preoperative chest radiography is indicated only in HVC patients with signs or symptoms of pulmonary illness or in those with underlying cardiac or pulmonary dis ease and new or unstable symptoms. and other available risk calculators do not incorporate OSA but o Spirometry should not be routinely performed preoper HVC are useful in estimating general pulmonary risk. atively except in patients undergoing lung resection. A11 patients should be screened for OSA, which is associ o All patients undergoing surgery should be screened for ated with cardiac events, pulmonary complications, and ICU obstructive sleep apnea, which is associated with adverse admissions. A commonly used screening tool for OSA is the perioperative outcomes. STOP BANG score (Ihble 27). Although there is a paucity of data supporting delay of surgery in patients at high risk for OSA, the Society of Anesthesia and Sleep Medicine recom mends preoperative sleep medicine evaluation in patients Hematologic Perioperative screened as high risk for OSA who also have evidence of Management hypoventilation (CO2 retention), severe or uncontrolled Venous Thromboembolism Prophylaxis comorbidities, or resting hypoxemia not attributable to other l'he American College of Chest Physicians (ACCP) and the cardiopul monary causes. American Society for Hematologr (ASI'i) provide guidelines for Chest radiography is indicated only in patients with signs WE prophyla-ris in both orthopedic and nonorthopedic surgery or symptoms of pulmonary illness or underlying cardiac or populations (Table 28). In patients undergoing general surgery pulmonary disease with new or unstable symptoms. or abdominal pelvic surgery the Caprini score can be used to Spirometry is not useful fbr predicting risk and should not be esti mate risk for postoperative thronr bosi s (w.vwv. mdca c. com / I

TABLE 27. STOP-BANG Obstructive Sleep Apnea muscle training) and postoperative continuous positive pres- Screening Tool sure ventilation. Surgery should be postponed and appropriate Survey ltems (1 point for each) treatment initiated if there is concern for exacerbation of Snoring underlying disease or respiratory illness. Smoking cessation reduces pulmonary risk and should be encouraged as far in Tiredness or sleepiness during the day advance of surgery as possible. Prescribed inhaled medica Observed apnea during sleep tions should be continued throughout the perioperative Pressure, high blood period. Perioperative management should also include goal BMt>35 directed fluid management and consideration of lung protec Age >50 y tive ventilation strategies. In patients diagnosed with OSA, continuous positive air Neck circumference >40 cm (15.7 in) way pressure should be initiated preoperatively when possible. Gender = male For patients with suspected OSA undergoing nonelective sur- STOP-BANG Score Risk Correlation gery, management includes postoperative monitoring with 0-2 Low risk for OSA continuous pulse oximetry or capnography, nonsupine posi >3 lncreased risk for OSA tioning, and limiting sedating medications. Patients with >5 lncreased risk for moderate to severe OSA known OSA should bring their continuous positive airway pressure device to the hospital for use in the perioperative OSA = obstructive sleep apnea. period. Adapted with permission from Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008;108:812-21.{PMlDr 18431 1 161 doi:10.1097/ t(tY PottTs . Preoperative chest radiography is indicated only in HVC patients with signs or symptoms of pulmonary illness or in those with underlying cardiac or pulmonary dis ease and new or unstable symptoms. and other available risk calculators do not incorporate OSA but o Spirometry should not be routinely performed preoper HVC are useful in estimating general pulmonary risk. atively except in patients undergoing lung resection. A11 patients should be screened for OSA, which is associ o All patients undergoing surgery should be screened for ated with cardiac events, pulmonary complications, and ICU obstructive sleep apnea, which is associated with adverse admissions. A commonly used screening tool for OSA is the perioperative outcomes. STOP BANG score (Ihble 27). Although there is a paucity of data supporting delay of surgery in patients at high risk for OSA, the Society of Anesthesia and Sleep Medicine recom mends preoperative sleep medicine evaluation in patients Hematologic Perioperative screened as high risk for OSA who also have evidence of Management hypoventilation (CO2 retention), severe or uncontrolled Venous Thromboembolism Prophylaxis comorbidities, or resting hypoxemia not attributable to other l'he American College of Chest Physicians (ACCP) and the cardiopul monary causes. American Society for Hematologr (ASI'i) provide guidelines for Chest radiography is indicated only in patients with signs WE prophyla-ris in both orthopedic and nonorthopedic surgery or symptoms of pulmonary illness or underlying cardiac or populations (Table 28). In patients undergoing general surgery pulmonary disease with new or unstable symptoms. or abdominal pelvic surgery the Caprini score can be used to Spirometry is not useful fbr predicting risk and should not be esti mate risk for postoperative thronr bosi s (w.vwv. mdca c. com / I routinely ordered for preoperative evaluation. including in caprini-score venous thromboembolism 2005). patients with COPD. Furthermore, evidence does not support Hip fracture surgery total knee arthroplasty, and total hip a spirometric threshold below which the risk of surgery is arthroplasty pose a very high risk for VTE, and concomitant unacceptable. However, spirometry is warranted in patients mechanical and pharmacologic VTE prophylaxis are recom undergoing lung resection to help predict postoperative lung mended. Mechanical prophylaxis is provided with an inter function. mittent pneumatic compression device lor the duration of the hospital stay. For pharmacologic prophylaxis, direct oral anti Perioperative Risk-Reduction Strategies coagulants (DOACs), aspirin, low molecular-weight heparin, Risk for perioperative pulmonary complications can be miti- warfarin, or low dose unfractionated heparin may be used in gated with selected interventions, including oral hygiene, total joint arthroplasty, and low molecular weight heparin, , early mobilization, use of regional or neuraxial anesthesia low dose unfractionated heparin, or fondaparinux may be and analgesia, prophylactic respiratory physiotherapy (sputum used in hip fracture repair. The minimum recommended clearance techniques, deep breathing exercises, and inspiratory duration of pharmacologic VTE prophylaxis atter these

routinely ordered for preoperative evaluation. including in caprini-score venous thromboembolism 2005). patients with COPD. Furthermore, evidence does not support Hip fracture surgery total knee arthroplasty, and total hip a spirometric threshold below which the risk of surgery is arthroplasty pose a very high risk for VTE, and concomitant unacceptable. However, spirometry is warranted in patients mechanical and pharmacologic VTE prophylaxis are recom undergoing lung resection to help predict postoperative lung mended. Mechanical prophylaxis is provided with an inter function. mittent pneumatic compression device lor the duration of the hospital stay. For pharmacologic prophylaxis, direct oral anti Perioperative Risk-Reduction Strategies coagulants (DOACs), aspirin, low molecular-weight heparin, Risk for perioperative pulmonary complications can be miti- warfarin, or low dose unfractionated heparin may be used in gated with selected interventions, including oral hygiene, total joint arthroplasty, and low molecular weight heparin, , early mobilization, use of regional or neuraxial anesthesia low dose unfractionated heparin, or fondaparinux may be and analgesia, prophylactic respiratory physiotherapy (sputum used in hip fracture repair. The minimum recommended clearance techniques, deep breathing exercises, and inspiratory duration of pharmacologic VTE prophylaxis atter these 35

Perioperative Medicine Surgery and Risks Recommended ProPhYlaxis" General, abdominal-pelvic, Caprinib score 0 Early ambulation urologic, plastic, vascular LowWE risk'(NA) IPC only Caprini score 1-2 Caprini score 3-4 Average bleeding risk; LMWH, LDUH, or IPC moderate WE risk (0.7%)' High bleeding riskd IPC only Caprini score 5-6 Average bleeding risk; LMWH or LDUH (+ IPC) high WE risk (1.87o) Caprini score 7-B High bleeding riskd; high IPC only WE risk(4%) Caprini score >8 High WE risk (10.7%) Orthopedic Hip or knee arthroplasty IPC during hospital stay and aspirin or DOAC for 21-35 days; LMWH over warfarin or LDUH as secondary options; if high bleeding risk, IPC alone during hospital stay

Orthopedic Hip or knee arthroplasty IPC during hospital stay and aspirin or DOAC for 21-35 days; LMWH over warfarin or LDUH as secondary options; if high bleeding risk, IPC alone during hospital stay Hip fracture repair IPC during hospital stay and LMWH or LDUH for 2 1 -35 days; fondaparinux, adjusted-dose VKA, aspirin secondary options; if high bleeding risk, IPC alone during hospital stay lsolated lower leg fracture repairs None Knee arthroscopy with no Early ambulation previous VTE Spine (elective) Average WE risk IPC High VTE risk (e.9., malignancy, IPC + LMWH (when bleeding risk a nterior-posterior approach) sufficiently low)

lsolated lower leg fracture repairs None Knee arthroscopy with no Early ambulation previous VTE Spine (elective) Average WE risk IPC High VTE risk (e.9., malignancy, IPC + LMWH (when bleeding risk a nterior-posterior approach) sufficiently low) Major trauma Average WE risk LMWH, LDUH, or IPC High WE risk (e.g., spinal cord or LMWH or LDUH (+ IPC) brain injury) High bleeding risk' IPC lntracranial AverageVTE risk rPc High WE risk (e.9., malignancy) LMWH or LDUH (+ IPC) Cancer surgery High risk (major open or UFH or LMWH up to 4 wk laparoscopic abdominal or pelvic surgery and restricted mobility, obesity, history of WE, or additional risk factors) Not identified as high risk UFH or LMWH for>7-10 d DOAC = direct oral anticoagulant; IPC = intermittent pneumatic compression; LDUH = low-dose unfractionated heparin; LMWH = low-molecular-weight heparin; NA = not applicable; UFH = unfractionated heparin; VKA = vitamin K antagonist; VTE = venous thromboembolism. uDuration is for postoperative hospitalization unless noted otheMise.

DOAC = direct oral anticoagulant; IPC = intermittent pneumatic compression; LDUH = low-dose unfractionated heparin; LMWH = low-molecular-weight heparin; NA = not applicable; UFH = unfractionated heparin; VKA = vitamin K antagonist; VTE = venous thromboembolism. uDuration is for postoperative hospitalization unless noted otheMise. bSee the Ca pri ni Score for Venous Throm boem bol ism: www. mdca lc.com/caprin i-score-venous-thromboem bolism-2005. 'Caprini and colleagues' 201 7 meta analysis of 1 4,700 patients in 1 I studies showed that Caprini scores >7 benefited from VTE chemoprophylaxis-but it was less clear for intermediate risk {Caprini 3-6). The American Society o{ Hematology does not specifically suggest using the Caprini risk tool for determining high risk for WE but does recommend LMWH or LDUH (tlPC)for patients with acceptable bleeding risk. kidney disease, and sepsis. Recommendations from Gould MK, Garcia DA, Wren SM, et al. Prevention of WE in nonorthopedic surgical patients: antithrombotic therapy and prevention o{ thrombosis, 9th ed Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients: antithrombotic therapy and prevention of thrombosis, fth ed: American College of Chest et al. American Society of Hematology 201 9 guidelines for management of venous thromboembolism: prevention of venous thromboembolism in surgical hospitalized patients. Blood Adv. 201 9;3:3898-944. IPMID: 3 1 794602] doi:1 0.1 1 82lbloodadvances.20l 9000975 Key NS, Khorana AA, Kuderer NM, et al. Venous thromboembolism prophylaxis and treatment in patients with cancer: ASCO Clinical Practice Guideline Update Ipublished online ahead of print, 20 1 9 Aug 51. J Clin Oncol. 201 9;JCO1 901 461 . [PMID: 31 381 464] doi:1 0.1 200/JCO.1 9.01 46 Pannucci CJ, Swistun L, MacDonald JK, et al. lndividualized venous thromboembolism risk stratification using the 2005 caprini score to identi{y the benefits and harms of chemoprophylaxis in surgical patients: a meta analysis. Ann 5urg. 201 7;265:1 094-1 03. IPMID: 281 06607] doi:1 0.1 097/S1A.0000000000002126 36

Perioperative Medicine procedures is l0 to 14 days; however, provided that the bleed with the surgical team. If bridging is required, therapeutic ing risk is low extended duration postoperative prophylaxis anticoagulation is typically delayed until 24 hours after proce (up to 35 days from the day of surgery) is preferred. dures with low bleeding risk and 48 to72 hours after surgery If bleeding risk is especially high, mechanical prophylaxis with higher bleeding risk. Owing to their delayed effect, the is recommended over no prophylaxis. first dose of a vitamin K antagonist is typically administered 12 Both ACCP and ASH recommend against preoperative to 24 hours after surgery. Postoperative timing of DOAC rein- placement of inferior vena cava filters for VTE prophylaxis and stitution depends on postoperative kidney function, bleeding routine surveillance for VTE with venous compression risk, and hemostasis. DOACs reach therapeutic levels in 1 to ultrasonography. 3 hours and can typically be resumed 48 to 72 hours after major surgery. Perioperative Management of Because of the risk for spinal epidural hematoma, antico- Anticoagulant Therapy agulant use with concomitant neuraxial (spinal and epidural) Anticoagulant therapy increases the risk for perioperative hem anesthesia should be avoided. orrhage and should be withheld in most patients before major surgery. For minor surgery such as cataracts, simple skin sur Atrial Fibrillation gery or simple dental extractions, anticoagulation may be con According to AHA/ACC/Heart Rhythm Society and ACCP tinued. When necessary to discontinue, vitamin K antagonists guidelines, preoperative bridging is not recommended in should be withheld at least 5 days before surgery; most proce patients with atrial fibrillation taking warfarin unless they dures can be safely perfbrmed with an INR less than 1.5. The have a mechanical valve. Decisions on bridging therapy should duration for which DOACs are withheld before surgery depends balance the risks ofstroke and bleeding. on the bleeding risk of the procedure, kidney function, and medication half life; in general, DOACs can be stopped 2 to Prosthetic Heart Valves 3 days preoperatively because oftheir shorter half lives. In patients receiving warfarin anticoagulant therapy for a Bridging anticoagulation is the administration of thera- mechanical prosthetic heart valve, continuation of anticoagu- peutic doses of short-acting parenteral therapy, usually a hep- lation is recommended when the surgical procedure is minor. arin, when oral anticoagulant therapy is being withheld In patients undergoing surgery with a higher risk for bleeding, during the perioperative period. Newer guidelines recom the 2017 ACC/AHA guideline on valvular heart disease suggests mend against bridging in most scenarios due to Iimited benefit that bridging should be considered on an individualized basis and elevated bleeding risk. Bridging with a parenteral agent in patients with a mechanical mitral valve; a mechanical aortic should only be considered in patients with a high thrombotic valve with thromboembolic risk factors (such as atrial fibrilla- risk (atrial fibrillation with a high CHATDS, VASc score, recent tion, previous stroke or transient ischemic attack, hyperten thromboembolic event [e.g., such as stroke or presence of a sion, diabetes mellitus, heart failure, or age >75 years); or an high thrombotic risk mechanical valvel). Bridging is not older generation mechanical aortic valve. Bridging is not nec indicated with DOACs owing to the rapid onset and short half- essary in patients with a bileaflet mechanical aortic valve and lif'e of these drugs. no other risk factors for thrombosis. The ACCP provides simi Postprocedural management of anticoagulation should lar recommendations for bridging anticoagulation in patients be guided by thrombotic and bleeding risk and collaboration with prosthetic heart valves (Table 29).

procedures is l0 to 14 days; however, provided that the bleed with the surgical team. If bridging is required, therapeutic ing risk is low extended duration postoperative prophylaxis anticoagulation is typically delayed until 24 hours after proce (up to 35 days from the day of surgery) is preferred. dures with low bleeding risk and 48 to72 hours after surgery If bleeding risk is especially high, mechanical prophylaxis with higher bleeding risk. Owing to their delayed effect, the is recommended over no prophylaxis. first dose of a vitamin K antagonist is typically administered 12 Both ACCP and ASH recommend against preoperative to 24 hours after surgery. Postoperative timing of DOAC rein- placement of inferior vena cava filters for VTE prophylaxis and stitution depends on postoperative kidney function, bleeding routine surveillance for VTE with venous compression risk, and hemostasis. DOACs reach therapeutic levels in 1 to ultrasonography. 3 hours and can typically be resumed 48 to 72 hours after major surgery. Perioperative Management of Because of the risk for spinal epidural hematoma, antico- Anticoagulant Therapy agulant use with concomitant neuraxial (spinal and epidural) Anticoagulant therapy increases the risk for perioperative hem anesthesia should be avoided. orrhage and should be withheld in most patients before major surgery. For minor surgery such as cataracts, simple skin sur Atrial Fibrillation gery or simple dental extractions, anticoagulation may be con According to AHA/ACC/Heart Rhythm Society and ACCP tinued. When necessary to discontinue, vitamin K antagonists guidelines, preoperative bridging is not recommended in should be withheld at least 5 days before surgery; most proce patients with atrial fibrillation taking warfarin unless they dures can be safely perfbrmed with an INR less than 1.5. The have a mechanical valve. Decisions on bridging therapy should duration for which DOACs are withheld before surgery depends balance the risks ofstroke and bleeding. on the bleeding risk of the procedure, kidney function, and medication half life; in general, DOACs can be stopped 2 to Prosthetic Heart Valves 3 days preoperatively because oftheir shorter half lives. In patients receiving warfarin anticoagulant therapy for a Bridging anticoagulation is the administration of thera- mechanical prosthetic heart valve, continuation of anticoagu- peutic doses of short-acting parenteral therapy, usually a hep- lation is recommended when the surgical procedure is minor. arin, when oral anticoagulant therapy is being withheld In patients undergoing surgery with a higher risk for bleeding, during the perioperative period. Newer guidelines recom the 2017 ACC/AHA guideline on valvular heart disease suggests mend against bridging in most scenarios due to Iimited benefit that bridging should be considered on an individualized basis and elevated bleeding risk. Bridging with a parenteral agent in patients with a mechanical mitral valve; a mechanical aortic should only be considered in patients with a high thrombotic valve with thromboembolic risk factors (such as atrial fibrilla- risk (atrial fibrillation with a high CHATDS, VASc score, recent tion, previous stroke or transient ischemic attack, hyperten thromboembolic event [e.g., such as stroke or presence of a sion, diabetes mellitus, heart failure, or age >75 years); or an high thrombotic risk mechanical valvel). Bridging is not older generation mechanical aortic valve. Bridging is not nec indicated with DOACs owing to the rapid onset and short half- essary in patients with a bileaflet mechanical aortic valve and lif'e of these drugs. no other risk factors for thrombosis. The ACCP provides simi Postprocedural management of anticoagulation should lar recommendations for bridging anticoagulation in patients be guided by thrombotic and bleeding risk and collaboration with prosthetic heart valves (Table 29). TABLE 29. Recommendations for Perioperative Bridging in Patients With a Prosthetic Heart Valve RiskforThromboembolism PatientHistory Bridging Anticoagulation Recommendation High (annual risk >10%) Any mitral valve prosthesis Bridging Any caged-ball or tilting disc aortic valve prosthesis I Recent (within 6 mo) stroke or TIA Moderate (annual risk of Bileaflet aortic valve prosthesis and one or more Bridging unless procedure is associated 5%-10y"\ of the following risk factors: atrialfibrillation, with a high bleeding risk previous stroke or TlA, hypertension, diabetes mellitus, heart failure, age >7 5 y Low (annual risk <5%) Bileaflet aortic valve prosthesis without atrial No bridging fibrillation and no other risk factors for stroke TIA = transient ischemic attack.

TABLE 29. Recommendations for Perioperative Bridging in Patients With a Prosthetic Heart Valve RiskforThromboembolism PatientHistory Bridging Anticoagulation Recommendation High (annual risk >10%) Any mitral valve prosthesis Bridging Any caged-ball or tilting disc aortic valve prosthesis I Recent (within 6 mo) stroke or TIA Moderate (annual risk of Bileaflet aortic valve prosthesis and one or more Bridging unless procedure is associated 5%-10y"\ of the following risk factors: atrialfibrillation, with a high bleeding risk previous stroke or TlA, hypertension, diabetes mellitus, heart failure, age >7 5 y Low (annual risk <5%) Bileaflet aortic valve prosthesis without atrial No bridging fibrillation and no other risk factors for stroke TIA = transient ischemic attack. Recommendations from Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy: antithrombotic therapy and prevention of 2298 and Nishimura RA, Otto CM, Bonow RO, et al. 201 7 AHA,/ACC focused update o{ the 201 4 AHA/ACC guideline lor the management of patients with valvular heart disease: a repon of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. J Am Coll Cardiol. 2017:70:252-29. IPMID:283157321 doi:1 O.1 01 6/j.jacc.20 1 7.03.0 1 1 37

Perioperative Medicine TABLE 3O. Recommendations for Perioperative Bridging in Patients With Venous Thromboembolism Requiring lnterruption of Vitamin K Antagonist Therapy Risk for Patient History Bridging Anticoagulation Thromboembolism Recommendation High (annual risk >10%) Recent (within 3 mo)WE Bridging Severe thrombophilia (e.9., deficienry of protein C, protein S, or antithrombin; antiphospholipid antibodies; multiple thrombophilic abnormalities) Moderate (annual risk of 5%-10ol.) WE within the past 3,12 mo No bridging Nonsevere thrombophilia (e.g., heterozygous factor V Leiden or prothrombin gene mutation) Recurrent VTE Active cancer (treated within 6 mo or palliative) Low (annual risk <5%) VTE >12 mo ago and no other risk factors No bridging VTE = venous thromboembolism Recommendations from Witt DlV, Nieuwlaat R, Clark NP, et al. American Society oI Hematology 2018 guidelines for management of venous rhromboembolism: optimal management of anticoagulation therapy. Blood Adv. 20 1 8;2:3257 91 . IPMID:30482 7651 doi:1 0.1 1 82lbloodadvances.2o 1 8024893 and Gould M K, Garcia DA, Wren SM, et al. practice guidel nes. Chest. 20 1 2;1 4 1:e2215 e2775. IPMID: 22315263) dot:10.1318/cl-,est.1 1 2297

Recommendations from Witt DlV, Nieuwlaat R, Clark NP, et al. American Society oI Hematology 2018 guidelines for management of venous rhromboembolism: optimal management of anticoagulation therapy. Blood Adv. 20 1 8;2:3257 91 . IPMID:30482 7651 doi:1 0.1 1 82lbloodadvances.2o 1 8024893 and Gould M K, Garcia DA, Wren SM, et al. practice guidel nes. Chest. 20 1 2;1 4 1:e2215 e2775. IPMID: 22315263) dot:10.1318/cl-,est.1 1 2297 Venous Thromboembolic Disease events. However, a subgroup analysis of this trial showed Recommendations for bridging anticoagulation in patients greater benefit than harm to continuing perioperative aspirin with a history of VTE, including those with thrombophilias, in patients with prior percutaneous coronary intervention are listed in Table 30. during any time frame.

Venous Thromboembolic Disease events. However, a subgroup analysis of this trial showed Recommendations for bridging anticoagulation in patients greater benefit than harm to continuing perioperative aspirin with a history of VTE, including those with thrombophilias, in patients with prior percutaneous coronary intervention are listed in Table 30. during any time frame. Perioperative Management of Perioperative Management of Anemia, Antiplatelet Medications Coagulopathies, and Thrombocytopenia The perioperative management of dual antiplatelet therapy A careful preoperative bleeding history including a family his (DAPT), comprising aspirin plus a P2Y,, inhibitor, in patients tory should be obtained from all patients before surgery to with coronary artery disease depends on the presence of a evaluate for underlying bleeding disorders and anemia. bare metal or drug eluting coronary stent; time since stent Laboratory testing should be reserved for patients with a sug placement; and, to some degree, the indication for DAPT (sta- gestive history. Patients with known factor deficiencies, plate- ble ischemic heart disease or acute coronary syndrome within let function defects, and other coagulopathies should have a the past year). preoperative consultation with a hematologist. ln patients with coronary stents. DAPT should be contin In orthopedic and cardiac surgery patients and those with ued uninterrupted fbr at least 14 to 30 days after bare metal a history of preexisting cardiovascular disease, the American stent placement and 3 to 6 months after drug eluting stent Association of Blood Banks recommends a restrictive transfu placement, whereas 12 months of DAPT is preferred following sion threshold (hemoglobin level of B g/dl [80 g/L1) because an acute coronary syndrome. Elective surgery should be post studies indicate equivalent or improved patient outcomes poned during these time fiames if DAPT cannot be safely compared with higher transfusion thresholds. In all other continued throughout the perioperative period. However, if hospitalized hemodynamically stable patients, a transfusion the risk of surgical delay exceeds the risk for stent thrombosis, threshold of 7 gldL (7O glL) is recommended. discontinuation of the P2Y,,, inhibitor can be considered after The American Association of Blood Banks recommends a a minimum of 3 months in patients with a drug eluting stent. platelet transfusion threshold of 50,000 cellsi [1. (50 x 10'qcells/L) Aspirin (preferably low dose) should be continued if at all pos for patients undergoing major non neurologic surgery or lum sible, and DAPT should be restarted as soon as bleeding risk bar puncture. Postoperative thrombocytopenia can result ftom has suffi ciently diminished. blood loss, consumption, ordrugs (especially heparin induced In most patients receiving long term aspirin monother- thrombocytopenia). For a discussion of heparin-induced apy for both primary and secondary prevention ofcardiovas thrombocytopenia, see MKSAP 19 Hematologr. cular events, aspirin should be discontinued at least 5 days Preoperative anemia and postoperative red cell transfu before surgery and restarted postoperatively once bleeding sion are associated with increased complications and mortal risk has decreased. This recommendation is based on the ity. When anemia is identified before elective surgery/, effofts POISE-2 trial, which showed that perioperative aspirin use should be made to correct reversible causes and optimize red resulted in increased bleeding without a decrease in cardiac blood cell mass.

Perioperative Management of Perioperative Management of Anemia, Antiplatelet Medications Coagulopathies, and Thrombocytopenia The perioperative management of dual antiplatelet therapy A careful preoperative bleeding history including a family his (DAPT), comprising aspirin plus a P2Y,, inhibitor, in patients tory should be obtained from all patients before surgery to with coronary artery disease depends on the presence of a evaluate for underlying bleeding disorders and anemia. bare metal or drug eluting coronary stent; time since stent Laboratory testing should be reserved for patients with a sug placement; and, to some degree, the indication for DAPT (sta- gestive history. Patients with known factor deficiencies, plate- ble ischemic heart disease or acute coronary syndrome within let function defects, and other coagulopathies should have a the past year). preoperative consultation with a hematologist. ln patients with coronary stents. DAPT should be contin In orthopedic and cardiac surgery patients and those with ued uninterrupted fbr at least 14 to 30 days after bare metal a history of preexisting cardiovascular disease, the American stent placement and 3 to 6 months after drug eluting stent Association of Blood Banks recommends a restrictive transfu placement, whereas 12 months of DAPT is preferred following sion threshold (hemoglobin level of B g/dl [80 g/L1) because an acute coronary syndrome. Elective surgery should be post studies indicate equivalent or improved patient outcomes poned during these time fiames if DAPT cannot be safely compared with higher transfusion thresholds. In all other continued throughout the perioperative period. However, if hospitalized hemodynamically stable patients, a transfusion the risk of surgical delay exceeds the risk for stent thrombosis, threshold of 7 gldL (7O glL) is recommended. discontinuation of the P2Y,,, inhibitor can be considered after The American Association of Blood Banks recommends a a minimum of 3 months in patients with a drug eluting stent. platelet transfusion threshold of 50,000 cellsi [1. (50 x 10'qcells/L) Aspirin (preferably low dose) should be continued if at all pos for patients undergoing major non neurologic surgery or lum sible, and DAPT should be restarted as soon as bleeding risk bar puncture. Postoperative thrombocytopenia can result ftom has suffi ciently diminished. blood loss, consumption, ordrugs (especially heparin induced In most patients receiving long term aspirin monother- thrombocytopenia). For a discussion of heparin-induced apy for both primary and secondary prevention ofcardiovas thrombocytopenia, see MKSAP 19 Hematologr. cular events, aspirin should be discontinued at least 5 days Preoperative anemia and postoperative red cell transfu before surgery and restarted postoperatively once bleeding sion are associated with increased complications and mortal risk has decreased. This recommendation is based on the ity. When anemia is identified before elective surgery/, effofts POISE-2 trial, which showed that perioperative aspirin use should be made to correct reversible causes and optimize red resulted in increased bleeding without a decrease in cardiac blood cell mass. 38

Perioperative Medicine XEY POI l{IS Thyroid Disease . Hip fracture surgery total knee arthroplasty, and total Preoperative screening fbr thyroid disease is not recom- hip arthroplasty pose a very high risk for VTE, and both mended in the absence of symptoms. ln patients with symp mechanical and pharmacologic VTE prophylaxis are toms suggestive of thyroid disease or in those with a recent recommended. change in levothyroxine dosage, it is reasonable to obtain a preoperative thyroid stimulating hormone level. ! . The minimum recommended duration of pharmaco In patients with hypothyroidism treated with levothyrox logic venous thromboembolism prophylaxis in patients ine, therapy should continue uninterrupted. Patients with undergoing orthopedic surgery is 10 to 14 days; how untreated, asymptomatic mild hypothyroidism may proceed ever, in patients without increased bleeding risk, to surgery because there is no apparent increase in periopera extended-duration postoperative prophylaxis (up to tive mortalily and morbidity. However, severe hypothyroidism 35 days) is preferred. can lead to perioperative myxedema coma, arrhythmias, o In patients treated with percutaneous coronary inter hypotension, and other complications. Elective surgery in t vention who are undergoing elective noncardiac sur- these patients should be postponed. gery dual antiplatelet therapy should be continued In patients with well controlled hyperthyroidism, ther- uninterrupted for 14 to 30 days after bare metal stent apy should be continued. Uncontrolled hyperthyroidism placement and optimally 3 to 6 months after drug- increases risk for thyroid storm perioperatively; thus, surgery I

XEY POI l{IS Thyroid Disease . Hip fracture surgery total knee arthroplasty, and total Preoperative screening fbr thyroid disease is not recom- hip arthroplasty pose a very high risk for VTE, and both mended in the absence of symptoms. ln patients with symp mechanical and pharmacologic VTE prophylaxis are toms suggestive of thyroid disease or in those with a recent recommended. change in levothyroxine dosage, it is reasonable to obtain a preoperative thyroid stimulating hormone level. ! . The minimum recommended duration of pharmaco In patients with hypothyroidism treated with levothyrox logic venous thromboembolism prophylaxis in patients ine, therapy should continue uninterrupted. Patients with undergoing orthopedic surgery is 10 to 14 days; how untreated, asymptomatic mild hypothyroidism may proceed ever, in patients without increased bleeding risk, to surgery because there is no apparent increase in periopera extended-duration postoperative prophylaxis (up to tive mortalily and morbidity. However, severe hypothyroidism 35 days) is preferred. can lead to perioperative myxedema coma, arrhythmias, o In patients treated with percutaneous coronary inter hypotension, and other complications. Elective surgery in t vention who are undergoing elective noncardiac sur- these patients should be postponed. gery dual antiplatelet therapy should be continued In patients with well controlled hyperthyroidism, ther- uninterrupted for 14 to 30 days after bare metal stent apy should be continued. Uncontrolled hyperthyroidism placement and optimally 3 to 6 months after drug- increases risk for thyroid storm perioperatively; thus, surgery I eluting stent placement. should be deferred until thyroid disease can be controlled. I HVC . In orthopedic and cardiac surgery patients and those Consultation with an endocrinologist is advised if emer with a history of coronary artery disease, the American gent surgery is required in patients with severe thyroid disease. Association of Blood Banks recommends a restrictive transfusion threshold (hemoglobin level of 8 g/dl [80 g/L1); otherwise, a transfusion threshold of 7 gldL (ZO gll-) is Adrenal tnsufficiency recommended. High-quality evidence to guide the use of perioperative sup plemental glucocorticoid dosing, known as stress dosing, is Iacking. Increasingly, stress dosing is only administered in the perioperative setting in the case of major surgery when there Perioperative Management is known primary or secondary adrenal insufficiency or if a of Endocrine Diseases patient is at high risk for hypothalamic-pituitary adrenal axis Diabetes Mellitus (HPAA) suppression. Despite the lack of evidence, the anesthe- Evidence demonstrates that patients with perioperative hyper- siologz literature recommends an aggressive approach. glycemia are at increased risk fbr postoperative complications, Guidance for perioperative management of patients at risk fbr including inf'ections, cardiovascular events, and mortality. adrenal insufficiency is provided in Table 31. Patients at risk for diabetes should be evaluated fbr diabetes The exact time course fbr recovery from HPAA suppres before elective surgery. In patients with known diabetes, it is sion ftom previous glucocorticoid use varies between individu reasonable to obtain hemoglobin A," within 3 months of sur als. When perioperative stress dosing is indicated owing to gery. Efforts should be made to optimize glycemic control suspected HPAA suppression, glucocorticoid dosing recom- before major elective surgery; however, it is undecided mendations are tailored to the stress ofthe planned procedure. whether delaying surgery to do so improves outcomes. For minor surgical procedures using only local anesthesia, Oral and injectable noninsulin medications should be patients with primary adrenal insufficiency should take twice withheld the morning of major surgery replaced with insulin their usual dose ofglucocorticoids on the day ofsurgery and fbr during hospitalization, and resumed at hospital discharge 1 to 2 days after; other patients at risk for adrenal insufficiency

eluting stent placement. should be deferred until thyroid disease can be controlled. I HVC . In orthopedic and cardiac surgery patients and those Consultation with an endocrinologist is advised if emer with a history of coronary artery disease, the American gent surgery is required in patients with severe thyroid disease. Association of Blood Banks recommends a restrictive transfusion threshold (hemoglobin level of 8 g/dl [80 g/L1); otherwise, a transfusion threshold of 7 gldL (ZO gll-) is Adrenal tnsufficiency recommended. High-quality evidence to guide the use of perioperative sup plemental glucocorticoid dosing, known as stress dosing, is Iacking. Increasingly, stress dosing is only administered in the perioperative setting in the case of major surgery when there Perioperative Management is known primary or secondary adrenal insufficiency or if a of Endocrine Diseases patient is at high risk for hypothalamic-pituitary adrenal axis Diabetes Mellitus (HPAA) suppression. Despite the lack of evidence, the anesthe- Evidence demonstrates that patients with perioperative hyper- siologz literature recommends an aggressive approach. glycemia are at increased risk fbr postoperative complications, Guidance for perioperative management of patients at risk fbr including inf'ections, cardiovascular events, and mortality. adrenal insufficiency is provided in Table 31. Patients at risk for diabetes should be evaluated fbr diabetes The exact time course fbr recovery from HPAA suppres before elective surgery. In patients with known diabetes, it is sion ftom previous glucocorticoid use varies between individu reasonable to obtain hemoglobin A," within 3 months of sur als. When perioperative stress dosing is indicated owing to gery. Efforts should be made to optimize glycemic control suspected HPAA suppression, glucocorticoid dosing recom- before major elective surgery; however, it is undecided mendations are tailored to the stress ofthe planned procedure. whether delaying surgery to do so improves outcomes. For minor surgical procedures using only local anesthesia, Oral and injectable noninsulin medications should be patients with primary adrenal insufficiency should take twice withheld the morning of major surgery replaced with insulin their usual dose ofglucocorticoids on the day ofsurgery and fbr during hospitalization, and resumed at hospital discharge 1 to 2 days after; other patients at risk for adrenal insufficiency when oral intake and kidney function have normalized. can take their usual daily glucocorticoids dose on the morning Sodium glucose cotransporter 2 inhibitors should be with- of the procedure. Recommendations lbr non minor surgery held 3 to 4 days owing to the risk fbr euglycemic ketoacidosis. vary. For non-minor surgical procedures, the Association of For patients on insulin regimens, basal insulin should be con Anaesthetists recommends giving 100 mg of intravenous (lV) tinued perioperatively. While lasting for surgery, patients hydrocortisone with induction of anesthesia followed by con should receive 50'X, of their usual intermediate acting insulin tinuous infusion of 200 mg/d of IV hydrocortisone until the dose, or 60'7, to B0% of their long acting analogue dose or patient can resume oral glucocorticoids. Once oral glucocorti pump basal insulin rate. coids are resumed, twice the usual daily dose should be admin Postoperatively, if the patient is eating, the ideal insulin istered fbr 48 hours after surgery. Counter to these guidelines, regimen is a basal bolus regimen, with nutritional coverage many experts suggest replacing the continuous infusion with and correction boluses for pre meal hyperglycemia. Fbr a dis- intermittent dosing of 5O mg of hydrocortisone every 6 hours cussion of the management of hyperglycemia in the hospital until oral intake is resumed. In addition, using lower doses setting, see MKSAP 19 Endocrinologr and Metabolism. with induction for minor or intermediate-stress surgeries and

when oral intake and kidney function have normalized. can take their usual daily glucocorticoids dose on the morning Sodium glucose cotransporter 2 inhibitors should be with- of the procedure. Recommendations lbr non minor surgery held 3 to 4 days owing to the risk fbr euglycemic ketoacidosis. vary. For non-minor surgical procedures, the Association of For patients on insulin regimens, basal insulin should be con Anaesthetists recommends giving 100 mg of intravenous (lV) tinued perioperatively. While lasting for surgery, patients hydrocortisone with induction of anesthesia followed by con should receive 50'X, of their usual intermediate acting insulin tinuous infusion of 200 mg/d of IV hydrocortisone until the dose, or 60'7, to B0% of their long acting analogue dose or patient can resume oral glucocorticoids. Once oral glucocorti pump basal insulin rate. coids are resumed, twice the usual daily dose should be admin Postoperatively, if the patient is eating, the ideal insulin istered fbr 48 hours after surgery. Counter to these guidelines, regimen is a basal bolus regimen, with nutritional coverage many experts suggest replacing the continuous infusion with and correction boluses for pre meal hyperglycemia. Fbr a dis- intermittent dosing of 5O mg of hydrocortisone every 6 hours cussion of the management of hyperglycemia in the hospital until oral intake is resumed. In addition, using lower doses setting, see MKSAP 19 Endocrinologr and Metabolism. with induction for minor or intermediate-stress surgeries and 39

Perioperative Medicine TABLE 31. Stress Dosing Strategies in Patients at Risk for Perioperative Management Adrenal lnsufficiency Patient Risk Patient Characteristics Management of Kidney Disease i Patients with chronic kidney disease (CKD) are at increased High risk Established primary or Stress dosing perioperative risk for acute kidney injury (AKI). fluid and secondary adrenal insufficiency electrolyte imbalance, cardiac events, metabolic acidosis, Cushingoid features anemia, and bleeding. In all patients with CKD undergoing surgery it is important to ensure the preoperative stability of Current equivalent of >20 mg/d prednisone kidney function, volume status, and electrolytes. Iodinated for >3 wk contrast dye and other nephrotoxic agents should be avoided Moderate or Past use equivalent of Stress dosing in the perioperative period, and hypotension should be mini- possible risk >20 mg/d prednisone for or mized to maintain renal perfusion pressure. For patients on >3 wk during past year preoperative hemodialysis, a nephrologist should be consulted for input adrenal axis Current or past equivalent on perioperative dialysate prescription, hemodialysis timing testing may be of >5-20 mg/d prednisone indicated and heparin management, and adjustment of fluid removal for >3 wk during past year perioperatively. Chronic high-dose inhaled or topical glucocorticoid therapy Perioperative AKI portends an increased risk for long Recent intra-articular term decline in kidney function (including progression to glucocorticoid therapy end stage kidney disease). The two most important means (>3 injectable glucocorticoid of mitigating risk for AKI are maintenance of renal blood treatments within 3 mo before surgery) flow and avoidance of further insults to the kidneys. Renal blood flow is maintained by avoiding renal hypoper Low risk Equivalent of <5 mg/d of No stress prednisone for any duration dosing fusion ; effectively managing diuresis and antihypertensive medications; and treating anemia, which may impair Any dose steroid for <3 wk peripheral vasodilation. Careful medication review is also Low-dose inhaled or topical glucocorticoid therapy warranted to ensure appropriate dosing based on renal clearance. Adapted from Liu MM, Reidy AB, Saatee S, et al. Perioperative steroid management: approaches based on current evidence. Anesthesiology. XEY POII'I 2011;127:1 66-72.IPMlD: 284528061 doi:1 0.1 097/A1N.0000000000001 659 and Woodcock T, Barker P, Daniel S, et al. Guidelines for the management of o The two most important means of mitigating the risk glucocorticoids during the peri-operative period for patients with adrenal insufliciency: Guidelines from the Association o{ Anaesthetists, the Royal College for acute kidney injury in the perioperative period are of Physicians and the Society for Endocrinology UK. Anaesthesia.2020;75:654 63. IPMID: 3201 701 2] doi:1 0.1 1 1 1 /anae.1 4963 maintenance ofrenal blood flow and avoidance offur ther insults to the kidneys.

TABLE 31. Stress Dosing Strategies in Patients at Risk for Perioperative Management Adrenal lnsufficiency Patient Risk Patient Characteristics Management of Kidney Disease i Patients with chronic kidney disease (CKD) are at increased High risk Established primary or Stress dosing perioperative risk for acute kidney injury (AKI). fluid and secondary adrenal insufficiency electrolyte imbalance, cardiac events, metabolic acidosis, Cushingoid features anemia, and bleeding. In all patients with CKD undergoing surgery it is important to ensure the preoperative stability of Current equivalent of >20 mg/d prednisone kidney function, volume status, and electrolytes. Iodinated for >3 wk contrast dye and other nephrotoxic agents should be avoided Moderate or Past use equivalent of Stress dosing in the perioperative period, and hypotension should be mini- possible risk >20 mg/d prednisone for or mized to maintain renal perfusion pressure. For patients on >3 wk during past year preoperative hemodialysis, a nephrologist should be consulted for input adrenal axis Current or past equivalent on perioperative dialysate prescription, hemodialysis timing testing may be of >5-20 mg/d prednisone indicated and heparin management, and adjustment of fluid removal for >3 wk during past year perioperatively. Chronic high-dose inhaled or topical glucocorticoid therapy Perioperative AKI portends an increased risk for long Recent intra-articular term decline in kidney function (including progression to glucocorticoid therapy end stage kidney disease). The two most important means (>3 injectable glucocorticoid of mitigating risk for AKI are maintenance of renal blood treatments within 3 mo before surgery) flow and avoidance of further insults to the kidneys. Renal blood flow is maintained by avoiding renal hypoper Low risk Equivalent of <5 mg/d of No stress prednisone for any duration dosing fusion ; effectively managing diuresis and antihypertensive medications; and treating anemia, which may impair Any dose steroid for <3 wk peripheral vasodilation. Careful medication review is also Low-dose inhaled or topical glucocorticoid therapy warranted to ensure appropriate dosing based on renal clearance. Adapted from Liu MM, Reidy AB, Saatee S, et al. Perioperative steroid management: approaches based on current evidence. Anesthesiology. XEY POII'I 2011;127:1 66-72.IPMlD: 284528061 doi:1 0.1 097/A1N.0000000000001 659 and Woodcock T, Barker P, Daniel S, et al. Guidelines for the management of o The two most important means of mitigating the risk glucocorticoids during the peri-operative period for patients with adrenal insufliciency: Guidelines from the Association o{ Anaesthetists, the Royal College for acute kidney injury in the perioperative period are of Physicians and the Society for Endocrinology UK. Anaesthesia.2020;75:654 63. IPMID: 3201 701 2] doi:1 0.1 1 1 1 /anae.1 4963 maintenance ofrenal blood flow and avoidance offur ther insults to the kidneys. administering a similar dose of postoperative IV hydrocorti sone may be an acceptable stratery. Perioperative Management In all situations, the patient's individual characteristics (for example, risk for hyperglycemia) and the surgical stress of Liver Disease should be carefully considered. Furthermore, if preoperative Liver disease increases risk for perioperative infection, encephalopathy, bleeding, fluid retention, and acute kid stress dosing is not used, clinicians should assure that patients take their usual glucocorticoid dose on the morning of the ney and liver decompensation. Patients with chronic liver procedure and remain vigilant for signs and symptoms of disease require careful preoperative evaluation and risk adrenal insuffi ciency postoperatively. stratification using the Model lor End stage Liver Disease (MELD) score and/or Child-Turcotte Pugh classification. XEY POIf,TS For more information, see MKSAP 19 Gastroenterology and . In patients with diabetes mellitus who are undergoing Hepatology. Patients with compensated liver disease, surgery oral and injectable noninsulin medications including those with a MELD score of less than B to 10, are should be withheld, replaced with insulin, and resumed typically able to proceed with surgery with optimal medi at hospital discharge when oral intake and kidney func- cal management. In patients with intermediate risk, refer- tion have normalized. ral to a hepatologist is reasonable before proceeding with HVC o Patients with untreated, asymptomatic mild hypothy surgery. Those with severe liver disease are at often pro- roidism may proceed to surgery without further testing hibitive risk for perioperative complications and deathr or treatment. patients with a MELD score greater than 15 should be o Elective surgery should be deferred in patients with referred for transplant evaluation before surgery if appro- priate. Patients with Child-Pugh class C disease or a MELD uncontrolled hypo or hyperthyroidism. score greater than 20 are at high risk for death, and all but

administering a similar dose of postoperative IV hydrocorti sone may be an acceptable stratery. Perioperative Management In all situations, the patient's individual characteristics (for example, risk for hyperglycemia) and the surgical stress of Liver Disease should be carefully considered. Furthermore, if preoperative Liver disease increases risk for perioperative infection, encephalopathy, bleeding, fluid retention, and acute kid stress dosing is not used, clinicians should assure that patients take their usual glucocorticoid dose on the morning of the ney and liver decompensation. Patients with chronic liver procedure and remain vigilant for signs and symptoms of disease require careful preoperative evaluation and risk adrenal insuffi ciency postoperatively. stratification using the Model lor End stage Liver Disease (MELD) score and/or Child-Turcotte Pugh classification. XEY POIf,TS For more information, see MKSAP 19 Gastroenterology and . In patients with diabetes mellitus who are undergoing Hepatology. Patients with compensated liver disease, surgery oral and injectable noninsulin medications including those with a MELD score of less than B to 10, are should be withheld, replaced with insulin, and resumed typically able to proceed with surgery with optimal medi at hospital discharge when oral intake and kidney func- cal management. In patients with intermediate risk, refer- tion have normalized. ral to a hepatologist is reasonable before proceeding with HVC o Patients with untreated, asymptomatic mild hypothy surgery. Those with severe liver disease are at often pro- roidism may proceed to surgery without further testing hibitive risk for perioperative complications and deathr or treatment. patients with a MELD score greater than 15 should be o Elective surgery should be deferred in patients with referred for transplant evaluation before surgery if appro- priate. Patients with Child-Pugh class C disease or a MELD uncontrolled hypo or hyperthyroidism. score greater than 20 are at high risk for death, and all but 40

Perioperative Medicine the most urgent and life saving surgeries should be avoided Rheumatolog ic Perioperative until after liver transplantation. Complications of liver disease should be optimally man- Management aged in all patients; however, the American Association for Perioperative Management During the Study of Liver Diseases recommends against periopera Disease-Modifying Antirheumatic tive transjugular intrahepatic portosystemic shunt placement Drug and Biologic Therapy because evidence that the procedure improves outcomes is Deferring elective surgery until the rheumatic condition is lacking. under optimal control can reduce infection risk and improve In general, patients with liver disease should be advised to outcomes. Traditional oral disease modif,iing antirheumatic abstain from alcohol consumption for at least 12 weeks before drugs should be continued through the perioperative period; elective surgery. this will reduce risk for postoperative disease flare with little or no effect on surgical risk. Biologic agents should be with- held for one dosing cycle preoperatively, before the surgery Perioperative Management with surgery performed at the end of the cycle. Janus kinase inhibitors, such as tofacitinib, should be withheld for at least of Neurologic Disease 7 days before surgery. Once the wound shows evidence of heal Patients with neurologic disease are at increased periop- ing (typically around i4 days), agents that have been withheld erative risk fbr disease exacerbation and other complica should be resumed at the previously established dose (see tions. Antiepileptic medications should be continued Table 22). uninterrupted. Patients with Parkinson disease are predisposed to perioperative delirium, hallucinations, orthostatic hypoten- sion, and complications related to dysphagia. Patients Perioperative Ma nagement should maintain their normal treatment regimen. Surgery of Special Populations should be scheduled early in the day to minimize missed Geriatric Patients doses, and antidopaminergic antiemetics should be avoided. As the U.S. population ages, there has been a steep rise in the Parkinsonism hyperpyrexia syndrome is a potentially life- number of adults older than 65 years undergoing major sur threatening complication resulting fiom withdrawal of or gery. It is well established that advanced age, functional reduction in the dosage of dopamine agonists; it is charac dependence, cognitive impairment, and other geriatric terized by rigidity, f'ever, altered mental status, and auto syndromes are strong predictors of adverse postoperative nomic instability. outcomes, including pulmonary and cardiac complications, Perioperative stroke is associated with increased res, functional decline, and delirium. The American College of piratory and cardiac complications and markedly increased Surgeons National Surgical Quality Improvement Program/ mortality. Those at highest risk for perioperative stroke American Geriatric Society preoperative guidelines focus on include patients with history of prior stroke or transient best practices to prepare geriatric patients for surgery and ischemic attack (TIA), advanced age, diabetes, heart failure, mitigate risk. The preoperative evaluation for older adults peripheral vascular disease, CKD, and AKI. Elective noncar- includes functional, nutritional, and cognitive assessments; diac surgery should probably be delayed for a minimum of medication screening for polypharmacy and high-risk medi 6 months after stroke or TIA owing to unacceptably high risk cations; and expanded discussion between clinicians and for recurrent stroke during that time; the risk decreases to a patients regarding goals and expectations for surgery. new baseline risk at 9 to 12 months after the event but Frailty, defined as decreased physiologic reserves and remains elevated compared with persons who never had a increased vulnerability to stressors, is present in up to 2O'k of stroke or TIA. adults older than 65 years. Frailty can be assessed by several Delirium commonly occurs in the postoperative setting, tools (see MKSAP 19 General Internal Medicine 1). Frail{y is especially in elderly persons. Risk factors and treatment are associated with worse postoperative outcomes and is thus a similar to those for delirium in the general hospital setting. focus for preoperative intervention. Preoperative multimodal Beyond delirium, patients can also have prolonged cognitive interventions aimed at mitigating frailty risk have been devel difficulties postoperatively, which may persist for months or oped. These programs are designed to improve patients' overall longer. health and fitness before surgery and most often include phys rtr P0rr{r ical therapy, nutritional interventions, and stress reduction . Patients with Parkinson disease should continue anti- techniques. Malnutrition is a risk factor for perioperative morbidity parkinson agents through surgery and surgery should and may be present in up to 60'l, of older adults. Preoperative be scheduled for as early in the day as possible to mini* screening for malnutrition with such tools as the Nutritional mize missed doses. Risk Screening Tool, which incorporates age, BMI, weight

the most urgent and life saving surgeries should be avoided Rheumatolog ic Perioperative until after liver transplantation. Complications of liver disease should be optimally man- Management aged in all patients; however, the American Association for Perioperative Management During the Study of Liver Diseases recommends against periopera Disease-Modifying Antirheumatic tive transjugular intrahepatic portosystemic shunt placement Drug and Biologic Therapy because evidence that the procedure improves outcomes is Deferring elective surgery until the rheumatic condition is lacking. under optimal control can reduce infection risk and improve In general, patients with liver disease should be advised to outcomes. Traditional oral disease modif,iing antirheumatic abstain from alcohol consumption for at least 12 weeks before drugs should be continued through the perioperative period; elective surgery. this will reduce risk for postoperative disease flare with little or no effect on surgical risk. Biologic agents should be with- held for one dosing cycle preoperatively, before the surgery Perioperative Management with surgery performed at the end of the cycle. Janus kinase inhibitors, such as tofacitinib, should be withheld for at least of Neurologic Disease 7 days before surgery. Once the wound shows evidence of heal Patients with neurologic disease are at increased periop- ing (typically around i4 days), agents that have been withheld erative risk fbr disease exacerbation and other complica should be resumed at the previously established dose (see tions. Antiepileptic medications should be continued Table 22). uninterrupted. Patients with Parkinson disease are predisposed to perioperative delirium, hallucinations, orthostatic hypoten- sion, and complications related to dysphagia. Patients Perioperative Ma nagement should maintain their normal treatment regimen. Surgery of Special Populations should be scheduled early in the day to minimize missed Geriatric Patients doses, and antidopaminergic antiemetics should be avoided. As the U.S. population ages, there has been a steep rise in the Parkinsonism hyperpyrexia syndrome is a potentially life- number of adults older than 65 years undergoing major sur threatening complication resulting fiom withdrawal of or gery. It is well established that advanced age, functional reduction in the dosage of dopamine agonists; it is charac dependence, cognitive impairment, and other geriatric terized by rigidity, f'ever, altered mental status, and auto syndromes are strong predictors of adverse postoperative nomic instability. outcomes, including pulmonary and cardiac complications, Perioperative stroke is associated with increased res, functional decline, and delirium. The American College of piratory and cardiac complications and markedly increased Surgeons National Surgical Quality Improvement Program/ mortality. Those at highest risk for perioperative stroke American Geriatric Society preoperative guidelines focus on include patients with history of prior stroke or transient best practices to prepare geriatric patients for surgery and ischemic attack (TIA), advanced age, diabetes, heart failure, mitigate risk. The preoperative evaluation for older adults peripheral vascular disease, CKD, and AKI. Elective noncar- includes functional, nutritional, and cognitive assessments; diac surgery should probably be delayed for a minimum of medication screening for polypharmacy and high-risk medi 6 months after stroke or TIA owing to unacceptably high risk cations; and expanded discussion between clinicians and for recurrent stroke during that time; the risk decreases to a patients regarding goals and expectations for surgery. new baseline risk at 9 to 12 months after the event but Frailty, defined as decreased physiologic reserves and remains elevated compared with persons who never had a increased vulnerability to stressors, is present in up to 2O'k of stroke or TIA. adults older than 65 years. Frailty can be assessed by several Delirium commonly occurs in the postoperative setting, tools (see MKSAP 19 General Internal Medicine 1). Frail{y is especially in elderly persons. Risk factors and treatment are associated with worse postoperative outcomes and is thus a similar to those for delirium in the general hospital setting. focus for preoperative intervention. Preoperative multimodal Beyond delirium, patients can also have prolonged cognitive interventions aimed at mitigating frailty risk have been devel difficulties postoperatively, which may persist for months or oped. These programs are designed to improve patients' overall longer. health and fitness before surgery and most often include phys rtr P0rr{r ical therapy, nutritional interventions, and stress reduction . Patients with Parkinson disease should continue anti- techniques. Malnutrition is a risk factor for perioperative morbidity parkinson agents through surgery and surgery should and may be present in up to 60'l, of older adults. Preoperative be scheduled for as early in the day as possible to mini* screening for malnutrition with such tools as the Nutritional mize missed doses. Risk Screening Tool, which incorporates age, BMI, weight 41