What Should Preoperative­ 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

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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.

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Abstinence for 4 weeks prior to surgery has causes of increased mortality is myocardial infarc- been shown to decrease complications from 71% tion.32 The optimal approach in management to 31%.29 If surgery is needed in an urgent fashion, involves assessing a combination of patient-­ postoperative monitoring of withdrawal should be specific risk factors, surgery-­specific risk factors, performed in a systematic fashion. Utilization of a and exercise tolerance.33 The Revised Cardiac Risk protocol for both monitoring and treatment of with- Index (RCRI) can provide a quick way of assessing drawal should be implemented. At our institution, surgical risk in cardiac patients based on clinical the Michigan Alcohol Withdrawal Severity (MAWS) conditions (ischemic heart disease, heart failure, Assessment Scale is both a scoring and a treatment diabetes mellitus, cerebrovascular disease, high-­ protocol that utilizes frequent patient assessment risk surgery).34 The American College of Cardiol- for signs and symptoms of withdrawal, including ogy and the American Heart Association (ACC/ central nervous system excitation, adrenergic AHA) have published clinical practice guidelines hyperactivity, and delirium. Nearly all protocoled for the optimal evaluation and management of patients are initiated on thiamine and folate sup- patients with high cardiac risk. These guidelines plementation with the addition of benzodiazepines are extensive and provide detailed advice for a or haloperidol based on MAWS and clinical assess- wide spectrum of cardiac conditions. The com- ment. It is strongly encouraged to quickly transfer plete guidelines can be found in published data patients to higher-level­ care centers if symptoms from the ACC/AHA (http://​my​.americanheart​.org/​ of withdrawal worsen.30 professional/​StatementsGuidelines/​ByTopic).35 Key recommendations from the most recent 2014 RECOMMENDATIONS guidelines are summarized below. • All patients should be assessed for alcohol use prior to surgery. Consider CAGE, TASE, RECOMMENDATIONS or AUDIT-­C questionnaires for screening of • Patients with known coronary or structural alcohol use disorder. heart disease should be assessed with a 12-­ • Patients who screen positive should be lead electrocardiogram. evaluated by a mental health professional • Assessment of left ventricular function using regarding their need for substance abuse echocardiography should be performed in treatment prior to surgery. patients with dyspnea of unknown origin and • Perioperatively, patients with a history of sig- for patients with known heart failure or heart nificant alcohol use, or any patient displaying failure symptoms. signs and symptoms of alcohol withdrawal, • Exercise stress testing should be employed should undergo protocoled monitoring to to assess patients with elevated cardiac prevent morbidity and mortality. risk and poor functional capacity. Those • All patients with alcohol use disorder or who cannot tolerate exercise stress testing those who experience withdrawal postop- should undergo dobutamine stress echocar- eratively should be encouraged to pursue diogram or myocardial perfusion imaging. alcohol abuse treatment after discharge. • Medication Recommendations: o Beta blockers should be given to patients Cardiac Disease on chronic beta blockers, to those with LITERATURE noted intermediate or high-risk­ ischemia Patients with preexisting cardiac complications on stress tests, or when patients have 3 have a significantly higher morbidity and mortality or more RCRI risk factors. They should rate postoperatively.31 One of the most common be initiated at least 1 day prior to the

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operation to assess their safety/tolerabil- which assesses patient risk based on patient-­ ity but never on the day of the operation. related factors (age, body mass index [BMI]), o Statins should be given to patients on medical history (malignancy, inflammatory bowel chronic beta blockers or to patients disease), deep vein thrombosis (DVT)/VTE history undergoing vascular surgery. (familial clotting disorder, personal history of o Angiotensin modifiers should be continued DVT), and procedure-related­ risks (laparoscopy, throughout the perioperative period. If surgical duration, immobilization). Based on the withheld before surgery, they should be risk score, an appropriate perioperative regimen restarted postoperatively when clinically is assigned, ranging from mechanical prophylaxis feasible. alone to pharmacologic anticoagulation. Docu- • Patients with cardiac electronic implantable mentation of patients deemed inappropriate for devices should be monitored continuously postoperative anticoagulation due to intraoper- during any period of perioperative inacti- ative coagulopathy, large blood losses, and intra- vation, and external defibrillators should operative anticoagulation should be noted in the be available. If inactivation occurs, proper chart, and reinstitution of appropriate anticoagu- reprogramming after surgery should be lation should be assessed daily to avoid DVT/VTE ensured. complications. An additional option for patients when antico- Deep Vein Thrombosis and agulation is contraindicated is the use of inferior Venous Thromboembolism vena cava (IVC) filters. The ease of deployment of LITERATURE these filters and the fact that they can be retrieved In the absence of prophylaxis, the incidence has made their use appealing.41 of venous thromboembolism (VTE) in surgical patients has been shown to range from 15% RECOMMENDATIONS to 30%.36 VTE is a major source of preventable • All patients should be screened for DVT/VTE perioperative mortality and morbidity, with a risk prior to surgery using a validated risk complication of fatal pulmonary embolism occur- calculator. ring at a rate of 0.2% to 0.9%.37 Administering • Institutional protocols should be used either unfractionated heparin or low-molecular-­ ­ to facilitate the implementation of pro- weight heparin (LMWH) immediately preopera- phylaxis strategies that are effective and tively until discharge reduces the risk of VTE by generalizable. at least 60% in surgical patients.38 Despite these • Patients determined to be inappropriate for guidelines, more than 50% of patients receive anticoagulation due to bleeding risk or other inappropriate thromboprophylaxis, defined patient factors should be documented and as administering no prophylaxis when indicated, regularly reassessed. administering the wrong type of prophylaxis, or • An IVC filter should be considered when the administering prophylaxis in the absence of there is an absolute contraindication to proper indications.39 The first step to eliminat- anticoagulation. ing inappropriate therapy is proper preoperative screening. Screening is easily performed preop- Chronic Narcotic Use eratively by utilizing a number of risk assessment LITERATURE tools, including the Caprini Risk Score.40 At our Preoperative use of opioids for chronic pain is com- institution, we use a modified Caprini system, mon and is recognized as a barrier to adequate

82 • MICHIGAN JOURNAL OF MEDICINE 2016 Arjun P. Meka, BS ET AL perioperative care and a risk factor for adverse • Surgeons should be aware of the potential events. Hyperalgesia, or an increased sensitivity for increased perioperative morbidity in opi- to pain, is a common side effect of chronic opioid oid users. use, and preoperative opioid use consistently pre- dicts increased postoperative opioid utilization.42,43 Obstructive Sleep Apnea Multiple complications are associated with post- LITERATURE operative opioid use, including decreased gastro- Obstructive sleep apnea (OSA) is associated with intestinal functions, which result in longer hospital serious perioperative complications, including stays.44 This combination of impaired pain con- cardiac arrhythmias, myocardial injury, and sud- trol and gastrointestinal dysfunction complicates den death.48 Approximately 20% of adults have postoperative management and delays recovery sleep apnea, with many going undiagnosed, which following major surgery. Additionally, opioid users complicates postsurgical care.49 To attempt to may be at a higher risk for complications, with opi- discover these high-risk­ patients prior to elective oids contributing immunosuppressive effects and surgery, several questionnaires have been devel- infection risk.45,46 oped. The Berlin questionnaire, American Society Interventions aimed at preoperative opioid of Anesthesiologists checklist, STOP-Bang­ ques- weaning and alternative pain management are tionnaire, and Sleep Apnea Clinical Score are all needed. However, opioid cessation in chronic validated tools to screen for OSA.34 Patients who users may be difficult, and given the paucity of test positive for OSA on screening should be data, it is unclear if cessation will improve surgical referred to a sleep medicine specialist for proper outcomes. Treating comorbid mental illness may evaluation and management. Notify anesthe- facilitate opioid cessation, as patients with depres- sia colleagues of patients with known OSA and sion have an increased propensity to use opioids.47 discuss the case prior to surgical intervention. A multidisciplinary approach to preoperative care Altered anesthetic plans, when safe, should be is necessary to wean from opioids and manage considered, including local blocks and spinal chronic pain in this patient population. anesthesia.27 Postoperative airway adjuncts, such as continuous positive airway pressure (CPAP), RECOMMENDATIONS should be employed when patient condition and • Opioid cessation may be beneficial; however, procedure warrants it based on surgeon and it remains unclear whether this will improve anesthesiologist assessment.49 outcomes. • Optimize nonopioid anesthetics and anal- RECOMMENDATIONS gesics in the perioperative period—for­ • Use quick, validated screening devices such example regional anesthesia, gabapentin, as the Berlin questionnaire and STOP-Bang­ and serotonin-­norepinephrine reuptake scoring system. Clinical suspicion should be inhibitors. highest among the elderly and obese. • If preoperative opioid cessation is not pos- • Include anesthesia colleagues in discussion sible, patients should at minimum return to to consider the possible use of regional their preoperative opioid dosing after acute anesthesia over general to minimize OSA pain has resolved. complications, where appropriate. • Comorbid mental illness should be screened • Encourage patients who are prescribed for and addressed, and doing so may facili- CPAP to use their machines throughout the tate opioid cessation. perioperative period.

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Diabetes primary care physician or endocrinologist LITERATURE to develop a plan for preoperative glycemic Proper glycemic control in the perioperative optimization. period is vital in improving surgical outcomes.50 • Glucose should be closely monitored to Patients with diabetes often have serious comor- achieve specific glycemic targets for inpa- bidities, such as cardiovascular disease, obesity, tients postoperatively: and chronic kidney disease—all­ of which sig- ◦ Less than 180 mg/dL in critically ill patients nificantly increase surgical risk.51 Additionally, ◦ Less than 140 mg/dL in stable patients patients with diabetes undergoing surgery are • Discontinue use of oral medications used for more prone to postoperative infectious compli- glycemic control immediately prior to and cations such as pneumonia, surgical site/wound following surgery until condition and diet infection, and sepsis.52 Abnormal HbA1c levels are stabilize. associated with longer hospital length of stays.53 • Patients should use insulin formulations in Optimizing a patient’s blood glucose and HbA1c the perioperative period while they are inpa- levels preoperatively, along with close glucose tients and unable to tolerate a regular diet. monitoring and control perioperatively, improves overall outcomes.52 Postoperatively, optimiza- Conclusion tion can be challenging, given frequent episodes Perioperative care for patients is extremely com- of fasting and changes in metabolic needs. The plex. The objective of this review is to provide specific targets for postoperative glycemic control recommendations for care in clinically relevant include blood glucose levels of less than 140 mg/ and modifiable health domains. Adherence to dL for most postoperative patients and between these recommendations has the potential to 140 and 180 mg/dL for critically ill patients. improve overall cost effectiveness of surgical Patients who utilize oral medications (eg, sulfony- procedures by mitigating complications and lureas, metformin, thiazolidinediones, GLP-1­ ago- decreasing length of stay. While we feel this nists) for glycemic control as outpatients should review presents sufficient data to support the withhold their medications immediately prior to listed recommendations, it is not intended to and following surgery. The perioperative period be entirely comprehensive. The main objective of fasting and inflammatory responses makes of the review is to synthesize the current litera- medication and blood glucose levels less pre- ture into one concise document for easy review dictable. Therefore, oral medications should be by providers. We recognize this review provides withheld while patients are not on a regular diet, general recommendations supported by liter- and sliding-scale­ insulin formulations should pre- ature, and it is not meant to be exhaustive or dominate in the in-­hospital perioperative period.49 entirely comprehensive. Given the large amount Patients should be transitioned to their home oral of literature for each domain, including all data regimen when they are tolerating oral intake and and pertinent studies is beyond the scope and prior to discharge. goal of this review. That being said, readers are encouraged to explore the cited work if they wish RECOMMENDATIONS to delve deeper into certain domains. We hope • Preoperative medication changes should be our work will provide an easily accessible refer- made to improve glycemic control in patients ence for perioperative care and guide the delivery whose HbA1c levels exceed 8%. This should of the highest quality of care to patients through- include close discussion with the patient’s out their surgical experience.

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