Health Care Guideline: Perioperative Index Table Sixth Edition January 2020 1. General Preoperative Management Preoperative Health Screening and Assessment Preoperative Testing Electrocardiogram Chest X-ray Hemoglobin/Hematocrit Testing Potassium/Sodium Testing Renal Function (Creatinine) Testing Pregnancy Testing Hemostasis (Coagulation) Testing Glucose Testing in Nondiabetic Patients Sleep Apnea Nicotine Cessation Preparation for Surgery 2. Perioperative Management of Select Conditions Cardiovascular Considerations Prevention of Endocarditis Anticoagulants/Antithrombotics Diabetes Mellitus 3. Perioperative Opioid Management Preoperative Opioid Management Preoperative Patient Education Preoperative Opioid Risk Assessment and Mitigation Preoperative Opioid Use Intraoperative Pain Management Postoperative Opioid Management Postoperative Opioid Prescribing Postoperative Patient Education Perioperative Considerations for Patients with Opioid Use Disorder (OUD) Patients on Medication-Assisted Treatment (MAT) Patients Not on Medication-Assisted Treatment (MAT) Return to Table of Contents www.icsi.org Copyright © 2020 by Institute for Clinical Systems Improvement 1 Perioperative Sixth Edition /January 2020 Table of Contents Perioperative Perioperative Annotations ..........................................................................................1–59 Guideline Work Opioid Index Table ................................................................................................1 Group Leader Management Evidence Grading .....................................................................................3 Mayo Clinic Subgroup Nicole Varela, MD Members Recommendations Table .................................................................... 4–9 Anesthesiology Allina Health Foreword ..........................................................................................10–11 Justin Hora, PharmD Introduction ................................................................................... 10 Perioperative Pharmacy Guideline Work Scope and Target Population ....................................................... 11 Group Members Entira Family Clinics David Thorson, MD Aims ................................................................................................ 11 Allina Health Family Medicine/Sports Implementation Recommendations Highlights ........................ 11 Joshua Mueller, MD Medicine Internal Medicine Related ICSI Scientific Documents ............................................. 11 Essentia Health Definitions ...................................................................................... 11 Entira Family Clinics Joseph Bianco, MD (formerly of) Internal Medicine Annotations .....................................................................................12–59 Hannah Degallier, PA-C Mark Grimm, MD Quality Improvement Support ...................................................60–63 Family Medicine Anesthesiology Aims and Measures............................................................................... 61 Essentia Health Mark Grimm, MD HealthPartners Implementation Recommendations ................................................... 62 Anne Pylkas, MD Anesthesiology Internal Medicine/ Implementation Tools and Resources ................................................ 62 Fairview Health Addiction Medicine Implementation Tools and Resources Table ...................................... 63 Services Isaac Marsolek, MD Supporting Evidence .......................................................................64–76 Deborah Mielke, MD Physical Medicine & Family Medicine Rehabilitation References ........................................................................................65–75 Joan Kane, APNL, Rebekah Roemer, Appendix ................................................................................................ 76 CRNA PharmD, BCPS Appendix A: Literature Search Description ............................... 76 Nursing/Anesthesia Pharmacy Disclosure of Potential Conflicts of Interest ........................77–80 HealthPartners Hennepin Healthcare Acknowledgements ................................................................................ 81 Louis Millman, MD Charles Reznikoff, MD Internal Medicine Internal Medicine/ Document History and Development .....................................82–84 Rebekah Roemer, Addiction Medicine Document History ................................................................................ 83 PharmD, BCPS Pharmacy Mayo Clinic ICSI Document Development and Revision Process ....................... 84 Adam Jacob, MD Mayo Clinic Anesthesiology Adam Jacob, MD Anesthesiology ICSI Senka Hadzic, MPH Nathaniel Miller, MD Facilitator Family Medicine Jodie Dvorkin, MD, Nicole Varela, MD MPH Anesthesiology Co-Facilitator North Memorial Health Audrey Hansen, MA, Sarah Lippert, MD BSN General Surgery Co-Facilitator University of Minnesota (formerly of) Kathleen Harder, PhD Human Factors www.icsi.org Institute for Clinical Systems Improvement 2 Perioperative Sixth Edition /January 2020 Evidence Grading Literature Search A consistent and defined literature search process is used in the development and revision of ICSI guidelines. See Appendix A for literature search parameters and search terms. In addition to the literature searches, articles were obtained by work group members and ICSI staff. Those vetted by the work group were included in the guideline when appropriate. Methodology ICSI utilizes the Grading of Recommendations Assessment, Development and Evaluation (GRADE) meth- odology system. GRADE involves systematically evaluating the quality of evidence (high, moderate, low, very low) and developing a strength of recommendation (strong, weak). For more detailed information on GRADE, please visit http://www.gradeworkinggroup.org/. In addition, when GRADE methodology could not be applied, the work group developed consensus recommendations. Return to Table of Contents www.icsi.org Institute for Clinical Systems Improvement 3 Perioperative Sixth Edition /January 2020 Recommendations Table The following table is a list of evidence-based recommendations for the Perioperative Guideline based on the review of primary literature and secondary references (in instances where primary literature was not found). Topic Quality of Recommendation(s) Strength of Relevant Resources Evidence Recommendation Preoperative Not A preoperative health screening Consensus Fleisher, 2014 Health applicable and assessment that includes (Guideline); Apfelbaum, Screening and a focused medical history and 2012b (Guideline) Assessment appropriate physical examination should be completed for all patients undergoing a surgical procedure, regardless of setting (unless the procedure involves mild sedation, or local/topical anesthesia). Preoperative Low Do not routinely test all patients Strong Keay, 2019 (Systematic Testing undergoing elective, noncardiac Review); Johansson, surgery. 2013 (Systematic Review); Munro, 1997 The need for testing should be (Systematic Review) guided by individual patient’s clinical risk factors (based on medical history and physical examination) and the risk of major adverse cardiac event (morbidity or mortality) associated with the planned procedure. Chest X-ray Low Do not routinely perform chest Strong Johansson, 2013 X-rays preoperatively unless (Systematic Review); indicated by the review of medical Joo, 2005 (Systematic history and physical examination. Review) Hemoglobin/ Low Do not routinely test for Strong Fowler, 2015 (Meta- Hematocrit hemoglobin preoperatively in Analysis); Johansson, Testing healthy, asymptomatic patients. 2013 (Systematic Review); Munro, 1997 Testing for preoperative hemoglobin (Systematic Review) level should be considered in: 1. Patients with a history of anemia or history suggesting recent blood loss or anemia and the planned procedure may lead to significant blood loss or physiologic stress or 2. Patients with prior or planned anticoagulation (expert consensus). Return to Table of Contents www.icsi.org Institute for Clinical Systems Improvement 4 Perioperative Recommendations Table Sixth Edition /January 2020 Topic Quality of Recommendation(s) Strength of Relevant Resources Evidence Recommendation Potassium/ Low Do not routinely test for potassium Strong Johansson, 2013 Sodium Testing or sodium level preoperatively in (Systematic healthy, asymptomatic patients. Review); Wahr, 1999 (Observational Testing may be indicated in: Study); Munro, 1997 1. Patients who are on diuretic (Systematic Review) therapy, 2. Patients with kidney disease (stages 3–5), 3. Patients on potassium replacement therapy, or 4. Patients undergoing bowel preparation. Renal Function Low Do not routinely test for creatinine Strong Kork, 2015 (Creatinine levels in healthy, asymptomatic (Observational Study), Testing) patients. Johansson, 2013 (Systematic Review) Testing may be indicated in patients with known kidney disease or patients with a comorbid condition (e.g., diabetes, hypertension) that carries increased risk of acute kidney injury or kidney disease. Pregnancy Not Do not routinely conduct urine tests Consensus ACOG, 2019 (Joint Testing Applicable for pregnancy. However, patients of Statement with ASA); childbearing age should be asked if ASA, 2016 (Statement); there is a possibility they might be NICE, 2016 pregnant. (Guideline); Apfelbaum, 2012b (Guideline) Pregnancy testing is indicated in: 1. Patients planning to undergo surgeries involving the uterus