Guideline on preoperative optimization of anemia, hyperglycemia and smoking
Canada: A recent study in the Canadian Journal of Surgery reports a clinical practice guideline containing evidence, recommendations, and algorithm for the preoperative optimization of anemia, hyperglycemia, and smoking.
Preoperative optimization has not been explored comprehensively in the surgical literature, as this responsibility has often been divided among surgery, anesthesia, and medicine. The aim of the guideline developed by Joshua A. Greenberg, Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ont., and colleagues is to bring optimization in the preoperative period under the existing umbrella of evidence-based surgical care.
The authors focused on 3 common comorbid conditions seen across surgical specialties — anemia, hyperglycemia, and smoking — as these conditions increase complication rates in patients undergoing major surgery and can be optimized successfully as soon as 6–8 weeks before surgery. With the ability to address these conditions earlier in the patient journey, surgeons can positively affect patient outcomes.
ANEMIA
Recommendations
· Preoperative anemia is associated with adverse surgical outcomes, and all patients undergoing major surgery should be screened for anemia at their first surgical clinic visit and investigated further, as appropriate.
· Complete blood count and ferritin are the most appropriate screening blood tests.
· Patients without evidence of anemia should not be treated with iron supplementation.
· For patients with anemia and a serum ferritin level of 30–100 ng/mL, transferrin saturation index and C-reactive protein tests should be ordered to better determine the presence of iron deficiency.
· Oral iron supplementation is the preferred treatment for patients with IDA and no contraindications (i.e., ≥ 8 wk until surgery, able to tolerate/absorb oral iron formulation, hemoglobin level ≥ 100 g/L).
· Intravenous iron infusions may be appropriate for patients with IDA in certain circumstances (i.e., < 8 wk until surgery, unable to tolerate/absorb oral iron formulation, hemoglobin level < 100 g/L).
· For patients with anemia who have no evidence of IDA or IDA refractory to iron supplementation, referral to a hematologist should be considered for treatment with erythropoietin and intravenous iron infusions.
HYPERGLYCEMIA
Recommendations
· Perioperative hyperglycemia increases the risk of postoperative complications, and all patients undergoing major surgery should be screened for diabetes.
· Measurement of the HbA1c level is the most appropriate screening test for hyperglycemia.
· A preoperative HbA1c level less than 6.0% does not require any further action or preoperative optimization.
· A preoperative HbA1c level of 6.0%–6.9% in a patient with no history of diabetes does not require preoperative optimization. However, it may represent prediabetes or a new diagnosis of diabetes, and the patient should be referred to a family physician, internist or endocrinologist for follow-up and confirmation.
· A preoperative HbA1c level of 7.0%–8.4% requires preoperative optimization, and these patients should be referred to their family physician, an internist or an endocrinologist for optimization to a target blood glucose level of 5–10 mmol/L.
· A preoperative HbA1c level of 8.5% or greater indicates poor glycemic control and requires preoperative optimization, and these patients should be referred to an internist or endocrinologist for preoperative optimization.
· Patients with known diabetes with a preoperative HbA1c level less than 7.0% do not require preoperative optimization.
· All patients (both with and without diabetes) with a preoperative HbA1c level greater than 6.0% should undergo intra- and postoperative blood glucose monitoring, with a target blood glucose level of 6–10 mmol/L, to reduce the risk of postoperative complications.
SMOKING
Recommendations
· Tobacco smoking is associated with increased adverse postoperative outcomes, and all patients undergoing major surgery should have their smoking status identified and documented at every preoperative clinic visit.
· All surgical patients who smoke should be advised to quit smoking preoperatively and have their willingness to quit assessed to guide next steps. Because of the high risk of relapse, those who have quit within the previous 6 months should be treated as active smokers.
· A quit date should be set more than 8 weeks preoperatively to achieve the most substantial improvements in postoperative outcomes; however, outcome benefits may still be seen with cessation as late as the day of surgery.
· In patients who are unwilling to quit smoking, motivational interviewing techniques can be used to increase motivation to quit, thereby increasing quit rates.
· In patients who are unwilling to quit smoking but willing to reduce, clinicians should offer full cessation treatment to support reduction goals.
· All surgical patients who smoke should be offered a combination of counseling and pharmacotherapy preoperatively. When this is not possible, they should still be offered either intervention individually.
· All surgical patients who smoke should be offered combination nicotine replacement therapy (NRT) preoperatively. Prescribers capable of follow-up may consider varenicline as a first-line agent. Second-line options include single-agent NRT and bupropion.
· All surgical patients who smoke should be given brief counseling on the consequences of smoking and the benefits of smoking cessation preoperatively. When possible, counseling should be face to face, frequent, and of sufficient duration, all of which increase cessation rates
· All surgical patients who smoke should be offered clinical follow-up.
Reference:
"Clinical practice guideline: evidence, recommendations and algorithm for the preoperative optimization of anemia, hyperglycemia and smoking," is published in the Canadian Journal of Surgery.
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