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What Should Pre Operative Clinics Do to Optimize Patients for Major

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What Should Pre Operative Clinics Do to Optimize Patients for Major What Should Pre operative Clinics Do to Optimize Patients for Major Surgery? Arjun P. Meka, BS1 and Uchenna Okoro, BS1; Todd A. Jaffe, BBA1; David Cron, BS1; Daniel Z. Semaan, BS1; Charles Hwang, BS1; Joseph Papin IV, BS1; William Palazzolo, PA- C1; Meredith Barrett, MD1 Introduction reoperative evaluation anesthesiologists, and surgeons. and care are essential for A further literature review was P optimal surgical outcomes conducted to provide both preop- and can provide health benefits erative and postoperative recom- long after surgical intervention.1 mendations for anesthesiologists Perioperative patient interactions and surgeons. We offer the follow- should be utilized to improve out- ing review and recommendations comes and empower change in in order to provide the best care patient’s lives. The aims of preop- practices during the periopera- erative evaluation are to reduce tive period to help mitigate com- the risks associated with sur- plications after patients undergo gery, increase quality, decrease surgery. unnecessary costs, and ultimately restore the patient to the desired Preoperative Care level of functioning.2 However, Management Domains Author Affiliations: guidelines for care differ among • Smoking Department of Surgery, University hospitals and clinical settings.3,4 • Physical activity of Michigan Medical School, Ann The objective of this review is • Nutrition Arbor, MI; 2Michigan Surgical Quality to provide an overview of clinical • Alcohol use Collaborative, Ann Arbor, MI domains that can affect surgical • Cardiac disease outcomes. The following domains • Deep vein thrombosis / Corresponding Authors: Arjun Meka were selected as common health venous thromboembolism (ameka @med .umich.edu); issues affecting patients’ postop- • Chronic narcotic use Uchenna Okoro erative outcomes after interview- • Obstructive sleep apnea (uchokoro @med .umich.edu) ing nurses, physician assistants, • Diabetes 78 ARJUN P. MEKA, BS ET AL Review of Domains • Institutions are encouraged to develop pro- Smoking tocols that emphasize postsurgical smoking LITERATURE cessation to all active smokers. Extensive research has demonstrated that cessa- tion of smoking prior to an operation improves out- Physical Activity comes. Smokers face far more complications than LITERATURE nonsmoking surgical patients, including hypoxia, The literature supporting preoperative exercise is delayed wound healing, increased inflammation, modest. However, preoperative walking programs and higher incidence of pneumonia.5,6 Smoking are becoming the standard of care for all elective cessation is ideal, but the duration of smoking ces- surgery patients at our institution. Several stud- sation prior to surgery is contested. ies report that preoperative exercise, commonly Smoking cessation prior to surgery can be known as “prehabilitation,” may reduce the aver- helpful in reducing complication rates. Moller age hospital length of stay by 2 days.9,12,13 Addition- et al found that smoking cessation 6 to 8 weeks ally, prehabilitation programs have been noted to prior to surgery reduced the overall complication increase muscle mass (up to 20% in joint replace- rate from 52% for those who continued smoking ment patients).10 to 18%.8 But in a study by Warner et al, postop- There is robust support of prehabilitation, as erative complication rates in those who stopped seen in the orthopedic literature. Six weeks of pre- smoking for fewer than 2 months before surgery habilitation has been associated with a reduced were almost 4 times higher than patients who need for inpatient rehabilitation postoperatively had avoided smoking for more than 2 months.7 (OR = 0.25). This has a potential benefit not only Despite compelling data to initiate smoking cessa- for patients but also for reducing institutional tion early for improved surgical outcomes,11 only cost.14 In addition, these prehabilitation patients 31% of physicians advise patients on the health are more likely than postoperative rehabilitation risks of smoking, and only 23% recommend smok- patients to achieve initial baseline or improved ing cessation before surgery.10 Thus this is an area exercise capacity (84% vs 62%, respectively).15 where further work has the potential to have a The Michigan Surgical and Health Optimization profound impact. Program (MSHOP) is a University of Michigan pro- We advocate smoking cessation for all sur- gram that analyzes surgical outcomes and their gery patients—it engages and empowers patients economic burden to insurance companies and to take control of operative outcomes. Effective payers. The program has implemented preoper- preoperative counseling can encourage patients ative walking and activity tracking prior to elective toward long- term smoking cessation.10 major surgery.13 Initial data from MSHOP suggest the prehabilitation program reduces costs and RECOMMENDATIONS length of stay.13 After enrolling more than 1000 • Smoking cessation intervention, at least 6 to patients and with patient compliance with the pro- 8 weeks prior to surgery, should be provided gram above 85%, MSHOP has delivered positive to all smokers. outcomes, and patients feel engaged and empow- • Local and national resources (ie, National ered in their care. Smoking Cessation Collaborative, hospital- specific smoking cessation programs, etc.) RECOMMENDATIONS can aid in maximizing the number of patients • All ambulatory patients should participate who are able to quit and providing support. in a preoperative walking program (with MICHIGAN JOURNAL OF MEDICINE 2016 • 79 WHAT SHOULD CLINICS DO TO OPTIMIzE PATIENTS FOR SURGERY? • http://dx.doi.org/10.3998/mjm.13761231.0001.013 tracking of steps), with ideally 6 weeks of stay, and lower costs.21 Additionally, patients may preoperative training. gain further benefit from newer immunonutrition • Patients should be encouraged to con- formulations as well as disease- specific enteral tinue walking and tracking steps after sur- formulas.22- 24 Close collaboration with nutrition- gery as part of health care maintenance ists in perioperative nutritional optimization is modification. ideal, as it results in better nutritional support and decreased energy deficits.25 Nutrition LITERATURE RECOMMENDATIONS Proper nutrition is vital to reduce the risk of post- • For all preoperative patients, a properly operative complications— well- nourished patients balanced diet of key nutrients, including had a 25% reduction in complication rates com- carbohydrates, fats, protein, vitamins, and pared to patients with 1 abnormality in weight loss, minerals, as well as nutrition education, serum albumin level, and arm muscle circumfer- should be part of the preoperative process. ence.16 Optimizing patients for surgery requires • All patients should undergo screening to allow careful attention to their nutritional status. The pre- for early detection of malnutrition preoper- operative period is a unique time to engage patients atively. Patients who screen positive should in their health, and for many patients, properly pre- initiate immediate nutritional support and paring for surgery includes following nutritional warrant a full assessment by a nutritionist. recommendations. • Physicians and nutritionists should consider Screening tools for malnutrition should be disease- specific formulas when recommend- used to assess a patient’s nutritional status pre- ing nutritional supplementation if available operatively. Multiple validated risk questionnaires, for the clinical condition. including the Nutritional Risk Score (NRS), can be utilized in the office setting to screen for malnour- Alcohol Use ishment.17 Levels of prealbumin, a marker for pro- LITERATURE tein nourishment, accurately predict outcomes for According to the World Health Organization, 7.4% chronically ill patients.18 Risk stratification based on of the US population has alcohol use disorder.26 prealbumin suggests a poor prognosis for those Preoperative alcohol consumption is associated with levels less than 5.0 mg/dL and significant risk with an increased risk of general postoperative for those with levels of 5.0 to 10.9 mg/dL.19 We sug- morbidity and mortality, infection, wound compli- gest patients be screened using prealbumin levels cations, pulmonary complications, prolonged stay in tandem with other malnutrition screening tools in the hospital, and admission to the intensive to better understand their general nutrition. care unit.27 Postoperative alcohol withdrawal is In patients found to be nutritionally depleted, associated with significant morbidity and mortality consultation with a nutritionist for dietary inter- if not recognized and treated early in its course. vention should be employed. Nutritional support The first step in mitigating these risks is a proper should begin at least 7 to 10 days prior to sur- preoperative work- up and identification of those gery.16,20 Nutritional modulation in malnourished at highest risk. Utilization of simple questionnaires, patients reduces surgical stress, insulin resistance, including CAGE or AUDIT- C, can be performed at protein losses, and postoperative complications. preoperative visits.28 Patients who screen positive When choosing a nutritional supplement, enteral should undergo evaluation of substance use dis- compared to parenteral nutrition is associated with orders and undergo treatment prior to surgery as fewer complications, decreased length of hospital requested by an expert. 80 • MICHIGAN JOURNAL OF MEDICINE 2016 ARJUN P. MEKA, BS ET AL Abstinence for 4 weeks prior
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