Preoperative anemia is common, especially in orthopedic, gynecologic, and colorectal surgical patients. (1,2) “The presence of preoperative anemia, even if mild, has been associated with increased risk of red blood cell (RBC) transfusion and increased morbidity and mortality after surgery. In addition, transfusion of RBCs has been consistently associated with worsened clinical outcomes”. (3) Anemia is defined by the WHO as Hgb less than 130 g/L in men and less than 120 g/L in women. Because women are actually at a higher risk of transfusion (lower blood volume), blood management programs advocate for defining preoperative anemia as less than 130 g/L in both men and women.

Screening Tools

Preoperative hemoglobin (Hgb) is recommended to screen for anemia in patients when they are undergoing a procedure that would warrant a group and screen (e.g., revision arthroplasty, large volume prostatectomy, cardiothoracic, hepatobiliary, major spine and major urological procedures). Practitioners may also screen for anemia in patients where index of suspicion is high based on history and medical comorbidities. If a patient is found to be anemic, additional blood work is recommended to delineate the cause. 

Prehabilitation and Optimization Algorithm

Prehabilitation and Optimization Recommendations

Patient Education	Communicate importance of optimizing hemoglobin before surgery to decrease perioperative risks Refer to online patient resources
Consider Delaying Surgery	Consider postponing elective surgery to allow time for further investigation and treatment of anemia to support better surgical outcomes and reduce potential complications. This is particularly relevant when the anemia is unexpected or unexplained. Suggest communication with the surgical team. Patients with a signed refusal for blood products undergoing high blood loss surgeries require special consideration. Consider multidisciplinary discussion and delaying surgery until hemoglobin goal is reached.
Referral to Preoperative Program and/or Primary Care Provider	In addition to treatment of anemia, patients with unexpected or unexplained anemia require further medical  workup for investigation and treatment.  This is particularly critical for patients with unexplained iron deficiency anemia, as they may need further evaluation to rule out serious conditions like gastrointestinal cancers.
Identify Cause of Anemia	Past medical history including bleeding history, medication history, and investigation history. Bloodwork: CBC with differential iron studies (ferritin, transferrin saturation (Tsat), serum iron, total iron binding capacity), GFR, CRP, B12. Which patients require treatment? High blood loss surgeries or operations where group and screen are routinely required, such as: revision/bilateral arthroplasty, large volume prostatectomy and major urological procedures, major gynaecology, open bowel resection/general surgery or hepatobiliary, cardiothoracic, multilevel spine. Other situations where treatment should be considered: Patients with anemia undergoing minor procedures. Patients with iron deficiency with normal hemoglobin, particularly if about to undergo major surgery.
Treat Iron Deficiency Anemia	Criteria: Ferritin < 30 ng/L or Ferritin 30-100 ng/L and transferrin saturation < 0.20 If surgery > 12 weeks away: oral iron (e.g., ferrous fumarate 300 mg PO every other night with 600-1200 mg vitamin C (4)); recheck Hgb after one month If surgery < 12 weeks away or Hgb > 20g/L below goal: IV iron Dosing: Iron deficit can be estimated using the Ganzoni formula Standardized dosing: Iron isomaltoside 1000-1500 mg (1-2 doses) or Iron sucrose 900-1500 mg (3-5 doses)
Follow-up After IV Iron Therapy	Expected duration of iron therapy: Oral iron requires a minimum of 12 weeks to determine effect. IV iron begins to take effect within 10-14 days, with an increase of up to 10g/L per week. Goal: Hgb > 130g/L. This is unachievable in many patients given the timing of surgery and logistics of treatment. Clinical judgement is required as to when maximum benefit has been achieved/when to proceed. ​​​​​​​​​​​​​​​​​​​​​​​​​​​​Follow-up bloodwork should be arranged 3-4 weeks post IV iron and 3 months post oral iron initiative to assess therapy. A preoperative CBC is recommended. Patients undergoing major surgery or those that are iron deficient postoperatively may benefit from oral iron once the surgical period is over and the patient has recovered (oral iron not effective in the context of inflammation, so not recommended immediately postoperatively).
Referral to Hematology, Nephrology, or Internal Medicine	For other causes of anemia (e.g., nutritional deficiencies, bone marrow suppression, chronic kidney disease, anemia of chronic disease/inflammation), or if the patient shows an inadequate response to iron treatment, consider referring the patient to a subspecialist physician for further management.

References

1. Muñoz, M., Laso-Morales, M. J., Gómez-Ramírez, S., Cadellas, M., Núñez-Matas, M. J., & García-Erce, J. A. (2017). Pre-operative haemoglobin levels and iron status in a large multicentre cohort of patients undergoing major elective surgery. Anaesthesia, 72(7), 826–834. https://doi.org/10.1111/anae.13840

2. Baron, D. M., Hochrieser, H., Posch, M., Metnitz, B., Rhodes, A., Moreno, R. P., Pearse, R. M., Metnitz, P., European Surgical Outcomes Study (EuSOS) group for Trials Groups of European Society of Intensive Care Medicine, & European Society of Anaesthesiology (2014). Preoperative anaemia is associated with poor clinical outcome in non-cardiac surgery patients. British journal of anaesthesia, 113(3), 416–423. https://doi.org/10.1093/bja/aeu098

3. Shander, A., Corwin, H. L., Meier, J., Auerbach, M., Bisbe, E., Blitz, J., Erhard, J., Faraoni, D., Farmer, S. L., Frank, S. M., Girelli, D., Hall, T., Hardy, J. F., Hofmann, A., Lee, C. K., Leung, T. W., Ozawa, S., Sathar, J., Spahn, D. R., Torres, R., … Muñoz, M. (2023). Recommendations From the International Consensus Conference on Anemia Management in Surgical Patients (ICCAMS). Annals of surgery, 277(4), 581–590. https://doi.org/10.1097/SLA.0000000000005721

4. BCGuidelines.ca. Iron Deficiency – Diagnosis and Management (2019) Appendix A: Oral Iron Formulations and Adult Doses. https://www2.gov.bc.ca/assets/gov/health/practitioner-pro/bc-guidelines/...

In patients 45 years or older hospitalized for at least one night after elective non-cardiac surgery, the overall 30-day mortality rate in a large multinational study involving more than 40,000 patients was 1.8%, with variations in rate depending on region of the world.  For the 22,447 patients within the study from North America, Europe and Australia, overall 30-day mortality was 1.1% .The 30-day mortality risk for non-elective urgent/emergent surgery  is at least double the risk of elective surgery. (1) 

Many of these deaths are linked to cardiac complications. (1) Myocardial Injury after Noncardiac Surgery (MINS) occurs in 12%-24% of these mortality cases, as indicated by troponin levels exceeding the 99th percentile within 3 days of surgery and presumed to be due to myocardial ischemia,. (2) MINS is associated with a postoperative 30-day mortality rate of 9.8%, compared to 1% for those without it, and increases the risk of major vascular complications, such as myocardial infarction and stroke (3,4,5). Most patients suffering MINS postoperatively are asymptomatic for ischemic features or symptoms. Without postoperative troponin testing, 90% of patients experiencing MINS would remain undetected. (3, 6, 7). 

Screening Tools

The Revised Cardiac Risk Index (RCRI) is a six-question tool used to estimate a patient’s risk of major perioperative cardiac complications after non-cardiac surgery. (8, 9) For patients aged ≥ 65, or for patients aged 45-64 with either significant cardiovascular disease, or an RCRI score ≥ 1, measuring NT-proBNP or BNP before non-cardiac surgery  can improve risk assessment (10). When the postoperative risk of MINS is deemed to be greater than a 5% risk based on NTproBNP or BNP levels, then postoperative MINS Surveillance by way of Troponin testing is indicated (10). 

Revised Cardiac Risk Index (RCRI)

Prehabilitation and Optimization Algorithm

Prehabilitation and Optimization Recommendations 

Order NT-proBNP/BNP	Criteria: overnight admission and one of the following: age >= 65 OR age 45-64 with either RCRI >= 1 or significant cardiovascular disease Threshold values are different for each test (BNP or NTproBNP) for triggering postoperative monitoring with troponin.
Referral for Anesthesia Consult	Perioperative risk discussion and planning If NT-proBNP is unexpectedly high without an obvious cause, consider further evaluation, including a physical exam and echocardiogram. Communicate risk estimates with patient based on RCRI score or elevated NT-proBNP values (8% for 200-1500 pmol/mL, and 16% for > 1500 pmol/mL, risk of death is 1.4% and 4.0% respectively) (8)
Postoperative Monitoring	Obtain EKG and troponin level on the day of surgery once recovery commences Measure Troponin daily x 2-3 days (should not prolong hospitalization for troponin monitoring) If Troponin > 99th percentile, MINS management required (1) Consider in-hospital shared-care management
Communicate with Primary Care Provider for Outpatient Follow-up	Establish follow-up plan for MINS positive patients after discharge from hospital given their increased risk of postoperative mortality.

References

1. Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) Study Investigators, Spence, J., LeManach, Y., Chan, M. T. V., Wang, C. Y., Sigamani, A., Xavier, D., Pearse, R., Alonso-Coello, P., Garutti, I., Srinathan, S. K., Duceppe, E., Walsh, M., Borges, F. K., Malaga, G., Abraham, V., Faruqui, A., Berwanger, O., Biccard, B. M., Villar, J. C., … Devereaux, P. J. (2019). Association between complications and death within 30 days after noncardiac surgery. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne, 191(30), E830–E837. https://doi.org/10.1503/cmaj.190221

2. Smilowitz, N. R., Redel-Traub, G., Hausvater, A., Armanious, A., Nicholson, J., Puelacher, C., & Berger, J. S. (2019). Myocardial Injury After Noncardiac Surgery: A Systematic Review and Meta-Analysis. Cardiology in review, 27(6), 267–273. https://doi.org/10.1097/CRD.0000000000000254

3. Writing Committee for the VISION Study Investigators, Devereaux, P. J., Biccard, B. M., Sigamani, A., Xavier, D., Chan, M. T. V., Srinathan, S. K., Walsh, M., Abraham, V., Pearse, R., Wang, C. Y., Sessler, D. I., Kurz, A., Szczeklik, W., Berwanger, O., Villar, J. C., Malaga, G., Garg, A. X., Chow, C. K., Ackland, G., … Guyatt, G. H. (2017). Association of Postoperative High-Sensitivity Troponin Levels With Myocardial Injury and 30-Day Mortality Among Patients Undergoing Noncardiac Surgery. JAMA, 317(16), 1642–1651. https://doi.org/10.1001/jama.2017.4360

4. Devereaux, P. J., Duceppe, E., Guyatt, G., Tandon, V., Rodseth, R., Biccard, B. M., Xavier, D., Szczeklik, W., Meyhoff, C. S., Vincent, J., Franzosi, M. G., Srinathan, S. K., Erb, J., Magloire, P., Neary, J., Rao, M., Rahate, P. V., Chaudhry, N. K., Mayosi, B., de Nadal, M., … MANAGE Investigators (2018). Dabigatran in patients with myocardial injury after non-cardiac surgery (MANAGE): an international, randomised, placebo-controlled trial. Lancet (London, England), 391(10137), 2325–2334. https://doi.org/10.1016/S0140-6736(18)30832-8

5. Botto, F., Alonso-Coello, P., Chan, M. T., Villar, J. C., Xavier, D., Srinathan, S., Guyatt, G., Cruz, P., Graham, M., Wang, C. Y., Berwanger, O., Pearse, R. M., Biccard, B. M., Abraham, V., Malaga, G., Hillis, G. S., Rodseth, R. N., Cook, D., Polanczyk, C. A., Szczeklik, W., … Vascular events In noncardiac Surgery patIents cOhort evaluatioN VISION Study Investigators (2014). Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes. Anesthesiology, 120(3), 564–578.https://doi.org/10.1097/ALN.0000000000000113

6. Devereaux PJ, Xavier D, Pogue J, Guyatt G, Sigamani A, Garutti I, Leslie K, Rao-Melacini P, Chrolavicius S, Yang H, Macdonald C, Avezum A, Lanthier L, Hu W, Yusuf S; POISE (PeriOperative ISchemic Evaluation) Investigators. Characteristics and short-term prognosis of perioperative myocardial infarction in patients undergoing noncardiac surgery: a cohort study. Ann Intern Med. 2011 Apr 19;154(8):523-8. doi: 10.7326/0003-4819-154-8-201104190-00003. PMID: 21502650.

7. Botto F, Alonso-Coello P, Chan MT, Villar JC, Xavier D, Srinathan S, et al.; Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION) Writing Group, on behalf of The Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION) Investigators; Appendix 1. The Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION) Study Investigators Writing Group; Appendix 2. The Vascular events In noncardiac Surgery patIents cOhort evaluatioN Operations Committee; Vascular events In noncardiac Surgery patIents cOhort evaluatioN VISION Study Investigators. Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes. Anesthesiology. 2014 Mar;120(3):564-78. doi: 10.1097/ALN.0000000000000113. PMID: 24534856.

8. Lee, T. H., Marcantonio, E. R., Mangione, C. M., Thomas, E. J., Polanczyk, C. A., Cook, E. F., Sugarbaker, D. J., Donaldson, M. C., Poss, R., Ho, K. K., Ludwig, L. E., Pedan, A., & Goldman, L. (1999). Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation, 100(10), 1043–1049. https://doi.org/10.1161/01.cir.100.10.1043

9. Ford, M. K., Beattie, W. S., & Wijeysundera, D. N. (2010). Systematic review: prediction of perioperative cardiac complications and mortality by the revised cardiac risk index. Annals of internal medicine, 152(1), 26–35. https://doi.org/10.7326/0003-4819-152-1-201001050-00007

10. Duceppe, E., Parlow, J., MacDonald, P., Lyons, K., McMullen, M., Srinathan, S., Graham, M., Tandon, V., Styles, K., Bessissow, A., Sessler, D. I., Bryson, G., & Devereaux, P. J. (2017). Canadian Cardiovascular Society Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Noncardiac Surgery. The Canadian journal of cardiology, 33(1), 17–32. https://doi.org/10.1016/j.cjca.2016.09.008

 

Postoperative delirium is one of the most common complications following major surgery. While many cases may be preventable, it may affect up to half of older adults and often goes unrecognized. It is associated with increased postoperative complications, length of stay in hospital, non-home discharge, mortality, and healthcare costs, as well as decline in function and cognition. (1-4)

Screening Tools

Identification of patients at increased risk of delirium is an important component of prevention, allowing targeted interventions to reduce postoperative delirium. The strongest risk factors include cognitive impairment, older age, and frailty. Other important risk factors include a history of delirium, visual or hearing impairment, substance dependence, social isolation, severe comorbid illness, and postoperative factors such as infection and medications (e.g., anticholinergics, opioids, and benzodiazepines). (7)

The modified Delirium Elderly At-Risk (mDEAR) tool is recommended as the preferred screening tool because it is the most evidence-supported instrument that can be completed using patient-reported information alone. It assesses cognitive impairment, age, functional dependence, sensory impairment, and chronic substance use, with a score of ≥3 indicating increased risk of postoperative delirium. (8)

Although the evidence supporting the mDEAR remains limited and other validated delirium risk assessment tools are available, these require cognitive testing or other clinician-administered assessments that cannot be incorporated into a standardized patient-completed questionnaire. The mDEAR therefore represents the most practical option for province-wide preoperative screening while recognizing that clinical judgment should always complement screening results when assessing an individual's risk of postoperative delirium.

mDEAR Screening Instrument

Prehabilitation and Optimization Algorithm

Prehabilitation and Optimization Recommendations 

Patient Education	Discuss increase risk of postoperative delirium Review signs and symptoms Non-pharmacological delirium prevention: Regular reorientation and cognitive stimulation Access to natural light and a visible clock Access to usual hearing aids and glasses Early mobilization Family presence, familiar items Sleep hygiene (e.g., avoid daytime napping) Refer to online patient resources
Referral for Comprehensive Geriatric Assessment (CGA)	Studies have shown that CGA can reduce the risk of postoperative delirium. Geriatrician involvement may lead to more accurate identification of delirium and proactive initiation of multimodal delirium risk management in higher risk patients. (6) If specialized CGA is not available in your area, consider referral to virtual provincial geriatrician resources.
Perioperative Strategies	Minimize polypharmacy and deliriogenic medications (e.g., benzodiazepines, zopliclone, anti-cholinergic medications, opioids) Avoid prolonged fasting of fluids Implement regular screening for delirium (e.g., CAM, 3D-CAM (10), 4AT) Oral and nutritional assistance, orienting communication and early mobilization together reduced delirium by 56% and LOS by 2 days in one study (11) Non-pharmacological sleep enhancement protocols (music, noise reduction, sleep aids such as melatonin) Optimize pain management Anesthesic modality has not been shown to impact incidence of delirium (12) Intraoperative dexmedetomidine use may prevent postoperative delirium compared to other anesthetic agents (13) Current evidence that depth of anesthesia monitoring and avoidance of "deep" anesthesia (i.e., BIS target 40-60) is conflicting (14), although the effect likely varies by population Prophylactic dosing and routine treatment with antipsychotic medications does not reduce the incidence or duration of delirium (15).

 References

1. Freter, S. H. (2005). Predicting post-operative delirium in elective orthopaedic patients: The Delirium Elderly At-Risk (DEAR) instrument. Age and Ageing, 34(2), 169–171. https://doi.org/10.1093/ageing/afh245

2. Freter, S., Dunbar, M., Koller, K., MacKnight, C., & Rockwood, K. (2015). Risk of Pre-and Post-Operative Delirium and the Delirium Elderly At Risk (DEAR) Tool in Hip Fracture Patients. Canadian geriatrics journal : CGJ, 18(4), 212–216. https://doi.org/10.5770/cgj.18.185

3. Zywiel, M. G., Hurley, R. T., Perruccio, A. V., Hancock-Howard, R. L., Coyte, P. C., & Rampersaud, Y. R. (2015). Health economic implications of perioperative delirium in older patients after surgery for a fragility hip fracture. The Journal of bone and joint surgery. American volume, 97(10), 829–836. https://doi.org/10.2106/JBJS.N.00724

4. Yan, E., Veitch, M., Saripella, A., Alhamdah, Y., Butris, N., Tang-Wai, D. F., Tartaglia, M. C., Nagappa, M., Englesakis, M., He, D., & Chung, F. (2023). Association between postoperative delirium and adverse outcomes in older surgical patients: A systematic review and meta-analysis. Journal of Clinical Anesthesia, 90, 111221. https://doi.org/10.1016/j.jclinane.2023.111221

5.  Numan, T., van den Boogaard, M., Kamper, A. M., Rood, P. J. T., Peelen, L. M., Slooter, A. J. C., & Dutch Delirium Detection Study Group (2017). Recognition of Delirium in Postoperative Elderly Patients: A Multicenter Study. Journal of the American Geriatrics Society, 65(9), 1932–1938. https://doi.org/10.1111/jgs.14933

6. Lander, H. L., Dick, A. W., Joynt Maddox, K. E., Oldham, M. A., Fleisher, L. A., Mazzeffi, M., Lustik, S. J., Shang, J., Stone, P. W., Gloff, M. S., Nadler, J., Wu, I., Zollo, R., & Glance, L. G. (2025). Postoperative Delirium in Older Adults Undergoing Noncardiac Surgery. JAMA network open, 8(7), e2519467. https://doi.org/10.1001/jamanetworkopen.2025.19467

7. Mahanna-Gabrielli, E., Schenning, K. J., Eriksson, L. I., Browndyke, J. N., Wright, C. B., Culley, D. J., Evered, L., Scott, D. A., Wang, N. Y., Brown, C. H., 4th, Oh, E., Purdon, P., Inouye, S., Berger, M., Whittington, R. A., Price, C. C., & Deiner, S. (2019). State of the clinical science of perioperative brain health: report from the American Society of Anesthesiologists Brain Health Initiative Summit 2018. British journal of anaesthesia, 123(4), 464–478. https://doi.org/10.1016/j.bja.2019.07.004

8. Meehan, A. J., Gabra, J. N., Whyde, C. (2023). Development and validation of a delirium risk prediction model using a modified version of the Delirium Eldery at Risk (mDEAR) screen in hospitalized patients aged 65 and older: A medical record review. Geriatric Nursing, 51, 150-155.https://doi.org/10.1016/j.gerinurse.2023.03.003

9. Jin, Z., Hu, J., & Ma, D. (2020). Postoperative delirium: perioperative assessment, risk reduction, and management. British journal of anaesthesia, 125(4), 492–504. https://doi.org/10.1016/j.bja.2020.06.063

10. Marcantonio, E. R., Ngo, L. H., O'Connor, M., Jones, R. N., Crane, P. K., Metzger, E. D., & Inouye, S. K. (2014). 3D-CAM: derivation and validation of a 3-minute diagnostic interview for CAM-defined delirium: a cross-sectional diagnostic test study. Annals of internal medicine, 161(8), 554–561. https://doi.org/10.7326/M14-0865

11. Chen, C. C., Li, H. C., Liang, J. T., Lai, I. R., Purnomo, J. D. T., Yang, Y. T., Lin, B. R., Huang, J., Yang, C. Y., Tien, Y. W., Chen, C. N., Lin, M. T., Huang, G. H., & Inouye, S. K. (2017). Effect of a Modified Hospital Elder Life Program on Delirium and Length of Hospital Stay in Patients Undergoing Abdominal Surgery: A Cluster Randomized Clinical Trial. JAMA surgery, 152(9), 827–834. https://doi.org/10.1001/jamasurg.2017.1083

12. Fan, G., Zhong, M., Su, W., An, Z., Zhu, Y., Chen, C., Dong, L., Wu, L., & Zhang, X. (2024). Effect of different anesthetic modalities on postoperative delirium in elderly hip fractures: A meta-analysis. Medicine, 103(23), e38418. https://doi.org/10.1097/MD.0000000000038418

13. Huang, J. X., Zhang, S. S., Wang, S. X., Xi, D. S., Luo, F. R., Liu, C. J., & Li, H. (2024). The role of perioperative sedative anesthetics in preventing postoperative delirium: a systematic review and network-meta analysis including 6679 patients. BMC cardiovascular disorders, 24(1), 147. https://doi.org/10.1186/s12872-024-03783-5

14. Deschamps, A., Ben Abdallah, A., Jacobsohn, E., Saha, T., Djaiani, G., El-Gabalawy, R., Overbeek, C., Palermo, J., Courbe, A., Cloutier, I., Tanzola, R., Kronzer, A., Fritz, B. A., Schmitt, E. M., Inouye, S. K., Avidan, M. S., & Canadian Perioperative Anesthesia Clinical Trials Group (2024). Electroencephalography-Guided Anesthesia and Delirium in Older Adults After Cardiac Surgery: The ENGAGES-Canada Randomized Clinical Trial. JAMA, 332(2), 112–123. https://doi.org/10.1001/jama.2024.8144

15. Nikooie, R., Neufeld, K. J., Oh, E. S., Wilson, L. M., Zhang, A., Robinson, K. A., & Needham, D. M. (2019). Antipsychotics for Treating Delirium in Hospitalized Adults: A Systematic Review. Annals of internal medicine, 171(7), 485–495. https://doi.org/10.7326/M19-1860

 

Frailty is a clinical state of increased vulnerability due to age-associated decline in physiological reserve, resulting in compromised ability to cope with external everyday or acute stressors. (1) Preoperative frailty is associated with increased postoperative complications, mortality, and longer-term negative outcomes, including falls, lower quality of life, non-home discharge, and prolonged length of stay. (2,3)

Screening Tools

The FRAIL Scale is a validated preoperative screening tool for frailty and predictor of mortality and postoperative complications that can be completed entirely by the patient, making it well suited for standardized preoperative screening. (4) Many geriatricians find assessment of ADLs and IADLs to be a useful adjunct. 

Although the Clinical Frailty Scale (CFS) is the preferred tool for clinical frailty assessment, it requires clinician judgment and is therefore not appropriate for patient-completed screening. Patients identified as at risk using the FRAIL Scale should undergo further clinical assessment, with the CFS used where appropriate to confirm frailty and inform perioperative planning. (5–7)

 

Prehabilitation and Optimization Algorithm

Prehabilitation and Optimization Recommendations

Patient Education	Refer to online patient resources for frailty-specific physical prehab and nutrition resources, including information on how to access physiotherapy for patients with frailty
Preoperative Risk Discussion	Assess goals of care and advance care plan (e.g., complete MOST form) Identify substitute decision maker Assess for cognitive impairment and ability to provide consent for surgery (e.g., Clinical Frailty Scale, Mini-Cog or MMSE) Refer to online provider resources for assessment tools
Referral for Comprehensive Geriatric Assessment (CGA)	Referral to geriatrician can be useful prior to moderate/highly invasive surgery If no local specialist, refer to provider online resources for telehealth consultation options

References

1. Fried, L. P., Tangen, C. M., Walston, J., Newman, A. B., Hirsch, C., Gottdiener, J., Seeman, T., Tracy, R., Kop, W. J., Burke, G., McBurnie, M. A., & Cardiovascular Health Study Collaborative Research Group (2001). Frailty in older adults: evidence for a phenotype. The journals of gerontology. Series A, Biological sciences and medical sciences, 56(3), M146–M156. https://doi.org/10.1093/gerona/56.3.m146

2. Lin, H. S., Watts, J. N., Peel, N. M., & Hubbard, R. E. (2016). Frailty and post-operative outcomes in older surgical patients: a systematic review. BMC geriatrics, 16(1), 157. https://doi.org/10.1186/s12877-016-0329-8

3. McIsaac, D. I., Aucoin, S. D., Bryson, G. L., Hamilton, G. M., & Lalu, M. M. (2021). Complications as a Mediator of the Perioperative Frailty–Mortality Association. Anesthesiology, 134(4), 577–587. https://doi.org/10.1097/ALN.0000000000003699

4. Gong, S., Qian, D., Riazi, S., Chung, F., Englesakis, M., Li, Q., Huszti, E., & Wong, J. (2023). Association Between the FRAIL Scale and Postoperative Complications in Older Surgical Patients: A Systematic Review and Meta-Analysis. Anesthesia and analgesia, 136(2), 251–261. https://doi.org/10.1213/ANE.0000000000006272

5. Sieber, F., McIsaac, D. I., Deiner, S., Azefor, T., Berger, M. et al. (2025). 2025 American Society of Anesthesiologists practice advisory for perioperative care of older adults scheduled for inpatient surgery. Anesthesiology. 142:22-51.

6. Aucoin, S. D., Hao, M., Sohi, R., Shaw, J., Bentov, I. et al. (2020). Accuracy and feasibility of clinically applied frailty instruments before surgery. Anesthesiology. 133:78-95.

7. McIsaac, D. I., Harris, E. P., Hladkowicz, E., Moloo, H., Lalu, M. M. et al. (2020). Prospective comparison of preoperative predictive performance between 3 leading frailty instruments. Anesth Analg. 131(1):263-272.

 

Studies have reported an association between hyperglycemia and adverse infectious and cardiovascular outcomes after cardiac and noncardiac surgery. (1-5) Many studies recommend delaying elective surgery until hemoglobin A1c (HbA1c) levels are below 8.5, recognizing that this may not be feasible for all patients and that such a cutoff is not currently supported by robust evidence. (6-10)

Screening Tools

Glycemic Control Screening Questions extrapolated from BC Guidelines for Diabetes Care (11). The CANRISK questionnaire is a validated risk tool for patients to self-assess their diabetes risk. (11)

Prehabilitation and Optimization Algorithm

Prehabilitation and Optimization Recommendations

Patient Education	Reinforce general goal of A1c less than 7 (12) Explain perioperative risks of hyperglycemia Refer to online patient resources If no previous diabetes diagnosis: HbA1c 6.0-6.4 (or fasting glucose 6.1-6.9 mmol/L): prediabetes likely HbA1c > 6.5 (of fasting glucose >= 7.0 mol/L: diabetes likely
Referral for Diabetes Diagnoses and Management (No Pre-Existing Diabetes)	Encourage follow-up with primary care provider for confirmation of diabetes diagnosis and initiation of management Refer to online provider resources for referral templates
Referral for Glycemic Optimization (Known Diabetes)	Request re-evaluation from physician directing diabetes care with the goal of improving blood glucose control prior to surgery, if feasible GLP-1 receptor agonists may increase the risk of pulmonary aspiration during anesthesia due to delayed gastric emptying. Evidence and institutional practices are evolving - some centres continue GLP-1 agents up to surgery, while others recommend holding for 3-5 half lives or pausing dose escalations preoperatively. Contact your local surgical or anesthesia department for site-specific guidance before advising patients. Refer to online provider resources for telehealth consultation options and referral templates
Consider Delaying for Glycemic Optimization	Discuss concerns, including potential benefits and risk of delaying surgery, with surgical team, particularly for total joint arthroplasty, vascular surgery, and spine surgery with instrumentation Refer to local diabetes expert or online provider resources for telehealth consultation options

References

1. Gustafsson, U. O., Thorell, A., Soop, M., Ljungqvist, O., & Nygren, J. (2009). Haemoglobin A1c as a predictor of postoperative hyperglycaemia and complications after major colorectal surgery. The British journal of surgery, 96(11), 1358–1364. https://doi.org/10.1002/bjs.6724

2. Dronge, A. S., Perkal, M. F., Kancir, S., Concato, J., Aslan, M., & Rosenthal, R. A. (2006). Long-term glycemic control and postoperative infectious complications. Archives of surgery (Chicago, Ill. : 1960), 141(4), 375–380. https://doi.org/10.1001/archsurg.141.4.375

3. Han, H. S., & Kang, S. B. (2013). Relations between long-term glycemic control and postoperative wound and infectious complications after total knee arthroplasty in type 2 diabetics. Clinics in orthopedic surgery, 5(2), 118–123. https://doi.org/10.4055/cios.2013.5.2.118

4. Kwon, S., Thompson, R., Dellinger, P., Yanez, D., Farrohki, E., & Flum, D. (2013). Importance of perioperative glycemic control in general surgery: a report from the Surgical Care and Outcomes Assessment Program. Annals of surgery, 257(1), 8–14. https://doi.org/10.1097/SLA.0b013e31827b6bbc

5. Noordzij, P. G., Boersma, E., Schreiner, F., Kertai, M. D., Feringa, H. H., Dunkelgrun, M., Bax, J. J., Klein, J., & Poldermans, D. (2007). Increased preoperative glucose levels are associated with perioperative mortality in patients undergoing noncardiac, nonvascular surgery. European journal of endocrinology, 156(1), 137–142. https://doi.org/10.1530/eje.1.02321

6. ElSayed, N. A., Aleppo, G., Aroda, V. R., Bannuru, R. R., Brown, F. M., Bruemmer, D., Collins, B. S., Hilliard, M. E., Isaacs, D., Johnson, E. L., Kahan, S., Khunti, K., Leon, J., Lyons, S. K., Perry, M. L., Prahalad, P., Pratley, R. E., Seley, J. J., Stanton, R. C., Gabbay, R. A., … on behalf of the American Diabetes Association (2023). 16. Diabetes Care in the Hospital: Standards of Care in Diabetes-2023. Diabetes care, 46(Suppl 1), S267–S278. https://doi.org/10.2337/dc23-S016

7. Membership of the Working Party, Barker, P., Creasey, P. E., Dhatariya, K., Levy, N., Lipp, A., Nathanson, M. H., Penfold, N., Watson, B., & Woodcock, T. (2015). Peri-operative management of the surgical patient with diabetes 2015: Association of Anaesthetists of Great Britain and Ireland. Anaesthesia, 70(12), 1427–1440. https://doi.org/10.1111/anae.13233

8. Halvorsen, S., Mehilli, J., Cassese, S., Hall, T. S., Abdelhamid, M., Barbato, E., De Hert, S., de Laval, I., Geisler, T., Hinterbuchner, L., Ibanez, B., Lenarczyk, R., Mansmann, U. R., McGreavy, P., Mueller, C., Muneretto, C., Niessner, A., Potpara, T. S., Ristić, A., Sade, L. E., Schirmer, H., Schüpke, S., Sillesen, H., Skulstad, H., Torracca, L., Tutarel, O., Van Der Meer, P., Wojakowski, W., Zacharowski, K., ESC Scientific Document Group. (2022). 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. European heart journal, 43(39), 3826–3924. https://doi.org/10.1093/eurheartj/ehac270

9. Rajan, N., Duggan, E. W., Abdelmalak, B. B., Butz, S., Rodriguez, L. V., Vann, M. A., & Joshi, G. P. (2024). Society for Ambulatory Anesthesia Updated Consensus Statement on Perioperative Blood Glucose Management in Adult Patients With Diabetes Mellitus Undergoing Ambulatory Surgery. Anesthesia and analgesia, 139(3), 459–477. https://doi.org/10.1213/ANE.0000000000006791

10. Giori, N. J., Ellerbe, L. S., Bowe, T., Gupta, S., & Harris, A. H. (2014). Many diabetic total joint arthroplasty candidates are unable to achieve a preoperative hemoglobin A1c goal of 7% or less. The Journal of bone and joint surgery. American volume, 96(6), 500–504. https://doi.org/10.2106/JBJS.L.01631

11. Guidelines and Protocols Advisory Committee. (2021). Diabetes Care. British Columbia Medical Services Commission. https://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-guidelines/diabetes

12. Diabetes Canada. (n.d.). Individualizing your patient’s A1C target. Retrieved October 27, 2024, from https://guidelines.diabetes.ca/reduce-complications/a1ctarget

One in three high-risk patients choosing surgery will experience serious medical complications leading to long-term decline in health and quality of life. Often patients do not receive the information they need to make an informed decision about surgery. (1)

Essential communication regarding goals of care is essential for aligning surgical interventions with patient values, preferences, and clinical realities. Shared decision making is a collaborative process between clinicians and patients, which aims to select the most suitable treatment option based on best available evidence and informed patient preferences. (1)

Screening Tools

• Do you have an advanced care plan - a list of instructions to help guide a trusted person to make health care treatment decisions on your behalf if required?
• Have you identified a substitute decision maker - someone you trust to make health care treatment decisions on your behalf if you are unable to do it yourself?
• Is the patient at higher risk of perioperative complications? (e.g., advanced age, frailty, poor functional capacity, moderate/highly invasive surgery, multiple comorbidities)

Optimization is recommended for patients that answer No to question 1 or 2, or Yes to question 3.

Prehabilitation and Optimization Recommendations

Patient Education	Encourage patients to think about what matters most for their health. Provide Advance Care Planning Guide and What Matters Most to Me Worksheet Refer to online patient resources
Preoperative Goals of Care Discussion	Lead with "What should I know about you as a person to help me take the best care of you that I can?" Intended to open a patient-centred, narrative conversation that goes beyond symptoms and diagnoses. Ask the following questions: What worries or concerns do you have about your upcoming surgery? Can you share what you understand about your current health? How do you hope that this surgery will help you? Are there any outcomes from this surgery that you would consider unacceptable? Use the best-case scenario /  worst-case scenario framework (2,3), a narrative and visual decision-support tool designed for high-stakes conversations. Refer to online provider resources.
Referral for Comprehensive Geriatric Assessment (CGA)	Consider preoperative assessment by Geriatrics to delineate risk

References

1. Centre for Perioperative Care. (n.d.). Shared decision making for clinicians. Retrieved October 21, 2024, from https://www.cpoc.org.uk/guidelines-resources-resources/shared-decision-making-clinicians

2. Kruser, J. M., Nabozny, M. J., Steffens, N. M., Brasel, K. J., Campbell, T. C., Gaines, M. E., & Schwarze, M. L. (2015). "Best Case/Worst Case": Qualitative Evaluation of a Novel Communication Tool for Difficult in-the-Moment Surgical Decisions. Journal of the American Geriatrics Society, 63(9), 1805–1811. https://doi.org/10.1111/jgs.13615

3. Taylor, L.J., Naboznym, M.J., Steffens, N.M., Tucholka, J.L., Brasel, K.J., Johnson, S.K., Zelenski, A., Rathouz, P.J., Zhao, Q., Kwekkeboom, K.L., Campbell, T.C., Schwarze, M.L. A Framework to Improve Surgeon Communication in High-Stakes Surgical Decisions: Best Case/Worst Case. JAMA Surg. 152(6), 531-538. https://doi.org/10.1001/jamasurg.2016.5674

Significant anxiety and depression are associated with increased postoperative pain, prolonged hospital length of stay, and hospital readmission, as well as many other postoperative complications (1,2). Preoperative education and expectation setting can help reduce postoperative anxiety, depression, and length of stay, and improve patient experiences and outcomes. (3,4)

Screening Tools

The Patient Health Questionnaire-2 (PHQ-2) is an initial screening tool for depression, comprising the first two questions of the Patient Health Questionnaire-9 (PHQ-9). A PHQ-2 score of 3 or more warrants completion of the PHQ-9. (5,6)

The General Anxiety Disorder-2 (GAD-2) is an initial screening tool for generalized anxiety disorder (GAD), comprising the first two questions of the General Anxiety Disorder-7 (GAD-7). A GAD-2 score of 3 or more warrants completion of the GAD-7 scale. (7)

While no scale is diagnostic, these tools are intended to help identify pre-surgical patients who may be experiencing more significant symptoms, who may benefit from targeted pre-surgical intervention.

Patient Health Questionnaire-9 (PHQ-9)

Generalized Anxiety Disorder-7 (GAD-7) Questionnaire

Prehabilitation and Optimization Algorithm

Prehabilitation and Optimization Recommendations

Clinician tips on Reframing Benefits vs Emphasizing Risk	The language clincians choose can meaningfully shape patient experience. During informed consent or risk discussions, framing recommendations in terms of benefits - rather than focusing solely on risks - can foster reassurance and engagement. Risk-focused framing: "Your history of anxiety/depression increases your risk of greater pain, longer hospital stay, readmission, and other complications." Benefit-focused framing: "Your answers to the screening questions show me that you've been feeling some worry and/or low mood. Many people feel this way before surgery. Taking care of your mental wellbeing can help you to feel more calm, comfortable, and in control. It can help you to heal more quickly and more easily." To explore how language and suggestion can influence patient health - positively or negatively - consider these resources: Podcast (35 min): Arizona Center for Integrative Medicine – Episode 35 with Dr. Steve Bierman   Book: Healing – Beyond Pills and Potions by Dr. Steve Bierman (recommended in audiobook format for its focus on cadence and emphasis) healingbeyondpills.com
Patient Education	Set patient expectations for postoperative depression and anxiety management Refer to online patient resources
Self-Referral Options	Encourage patient to seek help from at least one of the following options: Primary care appointment to discuss mental health (provide patient with their PHQ-9 and GAD-7 scores) Help Starts Here or 211 for online/telephone access to local supports and resources 310-6789 BC mental health and crisis response line 988 national suicide crisis helpline BounceBack BC - a free, online skill building program to manage low mood, mild to moderate depression, anxiety, stress, or worry (ages 13+)
Physician-Referral Options	Mild to Moderate symptoms PHQ-9 score 5-18 and NO thoughts of self-harm GAD-7 score 5-15 Mind Space Referral (mind-space.ca) Patients require an active primary care provider. Referral can come from PCP or perioperative clinician as long as patient has a PCP. Severe symptoms PHQ-9 score >= 19 or YES to thoughts of self-harm GAD-7 score >= 15 Assess immediacy of risk, urgent referral to psych via ER if necessary Otherwise, urgent referral to Primary Care for assessment/psychiatry referral

References

1. Browne, J. A., Sandberg, B. F., D'Apuzzo, M. R., & Novicoff, W. M. (2014). Depression is associated with early postoperative outcomes following total joint arthroplasty: a nationwide database study. The Journal of arthroplasty, 29(3), 481–483. https://doi.org/10.1016/j.arth.2013.08.025

2. Geoffrion, R., Koenig, N. A., Zheng, M., Sinclair, N., Brotto, L. A., Lee, T., & Larouche, M. (2021). Preoperative depression and anxiety impact on inpatient surgery outcomes: A prospective cohort study. Annals of Surgery Open, 1(e049). https://doi.org/10.1097/AS9.0000000000000049

3. 10. Li, L., Li, S., Sun, Y., Zhang, S., Zhang, X., & Qu, H. (2021). Personalized Preoperative Education Reduces Perioperative Anxiety in Old Men with Benign Prostatic Hyperplasia: A Retrospective Cohort Study. Gerontology, 67(2), 177–183. https://doi.org/10.1159/000511913

4. Ng, S. X., Wang, W., Shen, Q., Toh, Z. A., & He, H. G. (2022). The effectiveness of preoperative education interventions on improving perioperative outcomes of adult patients undergoing cardiac surgery: a systematic review and meta-analysis. European journal of cardiovascular nursing, 21(6), 521–536. https://doi.org/10.1093/eurjcn/zvab123

5. El Khoudary SR, Greendale G, Crawford SL, Avis NE, Brooks MM, Thurston RC, Karvonen-Gutierrez C, Waetjen LE, Matthews K. The menopause transition and women’s health at midlife: a progress report from the Study of Women’s Health Across the Nation (SWAN). Menopause. 2019;26:1213–1227. doi: 10.1097/GME.0000000000001424

6. Bromberger JT, Epperson CN. Depression during and after the perimenopause: impact of hormones, genetics, and environmental determinants of disease. Obstet Gynecol Clin North Am. 2018;45:663–678. doi: 10.1016/j.ogc.2018.07.007

7. Behrman S, Crockett C. Severe mental illness and the perimenopause. BJPsych Bulletin. 2024;48(6):364-370. doi:10.1192/bjb.2023.89

8. Canadian Menopause Society Pocket Guide Menopause Management: A practical tool for healthcare professionals. Retrieved March 6, 2026, from https://www.canadianmenopausesociety.org/professionals/publications/

9. Instructions for Patient Health Questionnaire (PHQ) and GAD-7 Measures. (n.d.). Retrieved August 26, 2024, from https://www.phqscreeners.com/images/sites/g/files/g10016261/f/201412/instructions.pdf

10. Kroenke, K., Spitzer, R. L., & Williams, J. B. (2003). The Patient Health Questionnaire-2: validity of a two-item depression screener. Medical care, 41(11), 1284–1292. https://doi.org/10.1097/01.MLR.0000093487.78664.3C

11. Plummer, F., Manea, L., Trepel, D., & McMillan, D. (2016). Screening for anxiety disorders with the GAD-7 and GAD-2: A systematic review and diagnostic meta-analysis. General Hospital Psychiatry, 39, 24-31. https://doi.org/10.1016/j.genhosppsych.2015.11.005
 

Malnutrition is present in approximately 45% of patients at time of admission to hospital. It is often underrecognized and is associated with increased postoperative complications and in-hospital and 30-day mortality. Nutrition risk is also associated with increased length of stay, readmission, and hospital costs. (1-5) Preoperative & early postoperative nutritional intervention are associated with improvements in postoperative complications and mortality. (6)

Screening Tools

The Canadian Nutrition Screening Tool (CNST) is a valid and reliable screening tool to identify those patients at risk of malnutrition in the adult acute care environment. (1)

Prehabilitation and Optimization Algorithm

Prehabilitation and Optimization Recommendations

Patient Education

Patients with a CNST score of 2 are at high risk for malnutrition and require dietician assessment. It is essential that the patient is able to meet their carbohydrate and protein needs prior to surgery. For 2-4 weeks prior to surgery an increase in dietary protein (aiming for 1.2-2 g/kg/day) may be recommended. (9) If individual is malnourished, total protein increases to 1.5-2.0 g/kg/day (10). Refer to online patient resources

Referral for Nutrition Counseling

Dietician to assess for malnutrition and provide a plan to optimize nutrition before surgery Refer to online provider resources for dietician resources and referral templates

References

1. Laporte, M., Keller, H. H., Payette, H., Allard, J. P., Duerksen, D. R., Bernier, P., Jeejeebhoy, K., Gramlich, L., Davidson, B., Vesnaver, E., & Teterina, A. (2015). Validity and reliability of the new Canadian Nutrition Screening Tool in the 'real-world' hospital setting. European journal of clinical nutrition, 69(5), 558–564. https://doi.org/10.1038/ejcn.2014.270

2. Wong, H. M. K., Qi, D., Ma, B. H. M., Hou, P. Y., Kwong, C. K. W., Lee, A., & Prehab Study Group (2024). Multidisciplinary prehabilitation to improve frailty and functional capacity in high-risk elective surgical patients: a retrospective pilot study. Perioperative medicine (London, England), 13(1), 6. https://doi.org/10.1186/s13741-024-00359-x

3. Duerksen, D. R., Keller, H. H., Vesnaver, E., Laporte, M., Jeejeebhoy, K., Payette, H., Gramlich, L., Bernier, P., & Allard, J. P. (2016). Nurses' Perceptions Regarding the Prevalence, Detection, and Causes of Malnutrition in Canadian Hospitals: Results of a Canadian Malnutrition Task Force Survey. JPEN. Journal of parenteral and enteral nutrition, 40(1), 100–106. https://doi.org/10.1177/0148607114548227

4. Duerksen, D. R., Keller, H. H., Vesnaver, E., Allard, J. P., Bernier, P., Gramlich, L., Payette, H., Laporte, M., & Jeejeebhoy, K. (2015). Physicians' perceptions regarding the detection and management of malnutrition in Canadian hospitals: results of a Canadian Malnutrition Task Force survey. JPEN. Journal of parenteral and enteral nutrition, 39(4), 410–417. https://doi.org/10.1177/0148607114534731

5. Allard, J. P., Keller, H., Jeejeebhoy, K. N., Laporte, M., Duerksen, D. R., Gramlich, L., Payette, H., Bernier, P., Vesnaver, E., Davidson, B., Teterina, A., & Lou, W. (2016). Malnutrition at Hospital Admission-Contributors and Effect on Length of Stay: A Prospective Cohort Study From the Canadian Malnutrition Task Force. JPEN. Journal of parenteral and enteral nutrition, 40(4), 487–497. https://doi.org/10.1177/0148607114567902

6. Impact of malnutrition on early outcomes after cancer surgery: an international, multicentre, prospective cohort study

7. Martínez-Ortega, A. J., Piñar-Gutiérrez, A., Serrano-Aguayo, P., González-Navarro, I., Remón-Ruíz, P. J., Pereira-Cunill, J. L., & García-Luna, P. P. (2022). Perioperative Nutritional Support: A Review of Current Literature. Nutrients, 14(8), 1601. https://doi.org/10.3390/nu14081601

8. Gillis, C. and Weimann, A. (2025). Prehabilitation in surgery - an update with a focus on nutrition. Curr Opin Clin Nutr Metab Care. 28(3), 224-234.

9. Gillis, C. and Wischmeyer, P.E. (2019). Pre-operative nutrition and the elective surgical patient: why, how and what? Anesthesia, 74(Suppl.1), 27-35.

10. Durrand J., Singh, SJ., Danjoux, G., (2019). Prehabilitation. Clin Med (Lond). 19(6), 458-464.

Obesity is a chronic medical condition that may increase perioperative risk. It is additionally linked to several other conditions, such as type II diabetes and obstructive sleep apnea, that may further enhance risk beyond elevated BMI. (1-4)

For patients with class 1* obesity (BMI: 30–34.9), increased perioperative complications mainly relate to venous thromboembolism. In class 2* & 3* obesity (BMI: 35 or higher), there is a modest increase in the risk of postoperative pulmonary complications, wound infections, longer hospital stays, increased blood loss, longer surgeries, and renal failure. (5-8)

Although high BMI is associated with higher perioperative risks, there is limited research on the effects of preoperative weight loss through diet and limited evidence to suggest delaying surgery based on BMI. (9)

*Classification is based on Caucasian populations. Lower cutoffs have been recommended for other ethnicities. (10)

Screening Tools

Although BMI is easy to obtain and therefore used to identify and categorize severity of obesity, integrating other indices (e.g., waist to hip ratio, waist circumference, and percent body fat) may improve predictions of metabolic health, comorbid conditions, and perioperative risk stratification. (1-3)

Prehabilitation and Optimization Algorithm

Prehabilitation and Optimization Recommendations

Patient Education	Counsel patients on obesity-related perioperative risks, recognizing that stigma and bias can worsen morbidity and mortality. Ask permission to measure and discuss weight as it impacts surgical risk "Would it be okay if we discussed your weight today as it impacts your anesthetic and surgical care?” Refer to online provider resources for information on communicating and treating obese patients
Screen for Comorbid Disease	Obstructive Sleep Apnea (OSA) Refer to sleep apnea section Obesity Hypoventilation Syndrome (OHS) See below Diabetes Refer to glycemic control section Cardiovascular disease risk stratification Refer to cardiac section Kidney disease
Obesity Hypoventilation Syndrome (OHS)	Initial Screen for OHS Complete Room air ABG if BMI >= 50 or BMI >= 35 and STOP-Bang >= 6 and HC03 >= 27 For patients with BMI < 50, a serum HCO3 < 27 effectively rules out OHS. Room air PaCO2 >= 45 mmHg suggests OHS, but other potential causes of hypercapnia need to be ruled out for a definitive diagnosis. If OHS suspected: Referral for Anesthesia consult Referral to Sleep Medicine Preoperative investigations Chest X-ray Echocardiogram Spirometry
Referral for Anesthesia Consult	To allow for assessment of and planning for the perioperative management of comorbid conditions (e.g.,OSA, OHS) and other factors such as airway management, vascular access, and patient positioning. (11)
Consider Referral to Obesity Medicine	Recommended for patients with significant comorbid disease Refer to online provider resources for obesity medicine providers

References

1. Wharton, S., Lau, D. C. W., Vallis, M., Sharma, A. M., Biertho, L., Campbell-Scherer, D., Adamo, K., Alberga, A., Bell, R., Boulé, N., Boyling, E., Brown, J., Calam, B., Clarke, C., Crowshoe, L., Divalentino, D., Forhan, M., Freedhoff, Y., Gagner, M., Glazer, S., … Wicklum, S. (2020). Obesity in adults: a clinical practice guideline. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne, 192(31), E875–E891. https://doi.org/10.1503/cmaj.191707

2. Gurunathan, U., & Myles, P. S. (2016). Limitations of body mass index as an obesity measure of perioperative risk. British journal of anaesthesia, 116(3), 319–321. https://doi.org/10.1093/bja/aev541

3. Ledford, C. K., Ruberte Thiele, R. A., Appleton, J. S., Jr, Butler, R. J., Wellman, S. S., Attarian, D. E., Queen, R. M., & Bolognesi, M. P. (2014). Percent body fat more associated with perioperative risks after total joint arthroplasty than body mass index. The Journal of arthroplasty, 29(9 Suppl), 150–154. https://doi.org/10.1016/j.arth.2013.12.036

4. Chan, W. K., Chuah, K. H., Rajaram, R. B., Lim, L. L., Ratnasingam, J., & Vethakkan, S. R. (2023). Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD): A State-of-the-Art Review. Journal of obesity & metabolic syndrome, 32(3), 197–213. https://doi.org/10.7570/jomes23052

5. Dindo, D., Muller, M. K., Weber, M., & Clavien, P. A. (2003). Obesity in general elective surgery. Lancet (London, England), 361(9374), 2032–2035. https://doi.org/10.1016/S0140-6736(03)13640-9

6. De Oliveira, G. S., Jr, McCarthy, R. J., Davignon, K., Chen, H., Panaro, H., & Cioffi, W. G. (2017). Predictors of 30-Day Pulmonary Complications after Outpatient Surgery: Relative Importance of Body Mass Index Weight Classifications in Risk Assessment. Journal of the American College of Surgeons, 225(2), 312–323.e7. https://doi.org/10.1016/j.jamcollsurg.2017.04.013

7. Madsen, H. J., Gillette, R. A., Colborn, K. L., Henderson, W. G., Dyas, A. R., Bronsert, M. R., Lambert-Kerzner, A., & Meguid, R. A. (2023). The association between obesity and postoperative outcomes in a broad surgical population: A 7-year American College of Surgeons National Surgical Quality Improvement analysis. Surgery, 173(5), 1213–1219. https://doi.org/10.1016/j.surg.2023.02.001

8. Kassahun, W. T., Mehdorn, M., & Babel, J. (2022). The impact of obesity on surgical outcomes in patients undergoing emergency laparotomy for high-risk abdominal emergencies. BMC surgery, 22(1), 15. https://doi.org/10.1186/s12893-022-01466-6

9. Pavlovic, N., Boland, R. A., Brady, B., Genel, F., Harris, I. A., Flood, V. M., & Naylor, J. M. (2021). Effect of weight-loss diets prior to elective surgery on postoperative outcomes in obesity: A systematic review and meta-analysis. Clinical obesity, 11(6), e12485. https://doi.org/10.1111/cob.12485

10. Li, Z., Daniel, S., Fujioka, K., & Umashanker, D. (2023). Obesity among Asian American people in the United States: A review. Obesity (Silver Spring, Md.), 31(2), 316–328. https://doi.org/10.1002/oby.23639

11. Chau, E. H., Lam, D., Wong, J., Mokhlesi, B., & Chung, F. (2012). Obesity hypoventilation syndrome: a review of epidemiology, pathophysiology, and perioperative considerations. Anesthesiology, 117(1), 188–205. https://doi.org/10.1097/ALN.0b013e31825add60

Obstructive sleep apnea (OSA) is a chronic medical condition that is commonly undiagnosed. The most common form of sleep-disordered breathing, it is characterized by recurring transient obstructions of airflow that occur exclusively during sleep. OSA is associated with increased risk of perioperative complications, including postoperative respiratory failure, cardiac events, and ICU transfer, and should be identified and treated as early as possible to help reduce this risk. (1-7)

Screening Tools

The STOP-Bang questionnaire is a validated tool for preoperative screening for OSA, assessing the likelihood of moderate to severe OSA. Scores of 5 or higher indicate a high probability of moderate to severe OSA. (8)

While the STOP-Bang questionnaire is a useful screening tool, clinical judgment remains essential because the STOP-Bang may underestimate OSA risk in populations with atypical presentations or additional risk factors. Clinicians should consider a lower threshold for screening or referral in individuals with factors not fully captured by screening tools—including women (particularly those who are pregnant or postmenopausal), transgender men receiving testosterone therapy, individuals with a strong family history, craniofacial or neuromuscular disorders, PTSD, and habitual alcohol use. (9-12)

Prehabilitation and Optimization Algorithm

 

Prehabilitation and Optimization Recommendations 

Patient Education	Counsel patients on the perioperative and long-term risks of untreated moderate or severe obstructive sleep apnea. For pre-existing OSA diagnosis: Instruct patient to continue using their treatment device (e.g., CPAP, BPAP, or dental device) until their surgery, and bring it to hospital, including for daycare surgery. Request sleep study results from primary care provider if not available on electronic health record. If patient is not using their treatment device as prescribed, emphasize the importance of its use in the postoperative period and suggest they follow up with their sleep clinic to discuss barriers to use and potential solutions.
Referral for Diagnostic Testing	Home Sleep Apnea Test (HSAT) (without Sleep Disorder Physician consultation) See Form A for inclusion and exclusion criteria. This testing should be ordered by a physician who is responsible for the longitudinal care of a diagnosis of sleep apnea. Sleep Disorder Consultation Referral Sleep physicians will determine the appropriate testing modality and follow for therapy. Use for patients that are not appropriate for HSAT See online provider resources for referral templates
Referral for Anesthesia Consult	Consider referral in patients coming for moderate to severely invasive surgery, airway surgery, or those with severe OSA not compliant with CPAP. To plan for postoperative management & monitoring to minimize OSA related perioperative complications.
Screening for Comorbid Disease	Obesity Hypoventilation Syndrome (see Obesity) Diabetes Cardiovascular / Respiratory complications
Consider delaying for further treatment of OSA	Made on a case by case basis taking into consideration: Patient's overall health Urgency of the surgery Potential impact of untreated OSA on the surgical outcome In the vast majority of cases there is insufficient evidence to support delaying surgery for testing/treatment unless there is evidence of significant or uncontrolled systemic disease or additional problems with ventilation or gas exchange. Continuation with surgery is reasonable if the patient is managed perioperatively as though they have untreated moderate to severe OSA. (9)

References

1. Roesslein, M., & Chung, F. (2018). Obstructive sleep apnoea in adults: peri-operative considerations: A narrative review. European journal of anaesthesiology, 35(4), 245–255. https://doi.org/10.1097/EJA.0000000000000765

2. Mutter, T. C., Chateau, D., Moffatt, M., Ramsey, C., Roos, L. L., & Kryger, M. (2014). A matched cohort study of postoperative outcomes in obstructive sleep apnea: could preoperative diagnosis and treatment prevent complications? Anesthesiology, 121(4), 707–718. https://doi.org/10.1097/ALN.0000000000000407

3. Abdelsattar, Z. M., Hendren, S., Wong, S. L., Campbell, D. A., Jr, & Ramachandran, S. K. (2015). The Impact of Untreated Obstructive Sleep Apnea on Cardiopulmonary Complications in General and Vascular Surgery: A Cohort Study. Sleep, 38(8), 1205–1210. https://doi.org/10.5665/sleep.4892

4. Patel, D., Tsang, J., Saripella, A., Nagappa, M., Islam, S., Englesakis, M., & Chung, F. (2022). Validation of the STOP questionnaire as a screening tool for OSA among different populations: a systematic review and meta-regression analysis. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine, 18(5), 1441–1453. https://doi.org/10.5664/jcsm.9820

5. Melesse, D. Y., Mekonnen, Z. A., Kassahun, H. G., & Chekol, W. B. (2020). Evidence based perioperative optimization of patients with obstructive sleep apnea in Resource Limited Areas: A systematic review. International Journal of Surgery Open, 23, 23–34. https://doi.org/10.1016/j.ijso.2020.02.002

6. Cozowicz, C., & Memtsoudis, S. G. (2021). Perioperative Management of the Patient With Obstructive Sleep Apnea: A Narrative Review. Anesthesia and analgesia, 132(5), 1231–1243. https://doi.org/10.1213/ANE.0000000000005444

7. Chaudhry, R. A., Zarmer, L., West, K., & Chung, F. (2024). Obstructive Sleep Apnea and Risk of Postoperative Complications after Non-Cardiac Surgery. Journal of clinical medicine, 13(9), 2538. https://doi.org/10.3390/jcm13092538

8. Hwang, M., Nagappa, M., Guluzade, N., Saripella, A., Englesakis, M., & Chung, F. (2022). Validation of the STOP-Bang questionnaire as a preoperative screening tool for obstructive sleep apnea: a systematic review and meta-analysis. BMC anesthesiology, 22(1), 366. https://doi.org/10.1186/s12871-022-01912-1

9. Chung, F., Memtsoudis, S. G., Ramachandran, S. K., Nagappa, M., Opperer, M., Cozowicz, C., Patrawala, S., Lam, D., Kumar, A., Joshi, G. P., Fleetham, J., Ayas, N., Collop, N., Doufas, A. G., Eikermann, M., Englesakis, M., Gali, B., Gay, P., Hernandez, A. V., Kaw, R., … Auckley, D. (2016). Society of Anesthesia and Sleep Medicine Guidelines on Preoperative Screening and Assessment of Adult Patients With Obstructive Sleep Apnea. Anesthesia and analgesia, 123(2), 452–473. https://doi.org/10.1213/ANE.0000000000001416

10 Perioperative Management of OSA in Adults. 2025. Center for Perioperative Care. Royal College of Anesthesiologists.

Significant acute postoperative pain is common, even among those on an established pain management protocol (1). Pain after surgery is associated with increased risk of postoperative readmission to hospital, emergency department visits, myocardial injury, delirium, and chronic pain (2-7). Postoperative pain control may be improved by addressing modifiable patient risk factors such as sleep, BMI, depression, anxiety, and preoperative pain (8).

Screening Tools

The Perioperative Opioid Quality Improvement (POQI) score is a screening tool being developed at St. Paul's Hospital to identify patients at increased risk of significant postoperative pain and long-term opioid use. While the POQI score is not yet validated, it was selected to support postoperative pain risk stratification based on clinical experience using this tool in British Columbia. 

Preoperatively, it screens patients for common variables associated with an increased risk for developing postoperative pain. Postoperatively, inpatient consumption of > 90 morphine milligram equivalents per day is used as a surrogate marker for assessing performance of the preoperative screening tool (9).  Patients with a POQI score >= 7 (out of a possible total of 35) are considered to be at ‘increased risk’ of significant postoperative pain and long-term opioid use and should receive a personalized care plan to help reduce their initial exposure to opioids. (9)

Perioperative Opioid Quality Improvement (POQI) Assessment

Prehabilitation and Optimization Algorithm

Prehabilitation and Optimization Recommendations

Patient Education	Set patient expectations for postoperative pain management "Achieving zero pain is not realistic. The goal is to achieve a level of pain that allows patients to breathe deeply and cough, get up and move, do exercises or physio, and rest or sleep when it is time to do so. There are many ways to achieve this."
Self-Referral Options	Refer to online patient resources including access to the following: Managing Pain Before and After Surgery (PainBC): A free self-paced online program for people having surgery and their families to better manage pain after surgery and decrease complications. Coaching for Health (PainBC): A free one-on-one telephone coaching program designed to help people living with chronic pain learn self-management skills, regain function, and improve well-being Empowered Relief (Pain Canada) - a free 2 hour CBT module for managing pain Power Over Pain Portal - a national hub for pain resources Gentle Movement at Home video series
Referral for Anesthesia Consult	To develop effective pain management strategies and explore options for anesthesia and postoperative pain control, especially in moderate to severely invasive surgery
Physician-Referral Options	Mind-space.ca - MSP-funded virtual group medical visits for mental wellbeing, anxiety, depression. *All patients referred to Mind Space must have a current primary care provider. Referral to Transitional Pain Clinic Transitional pain clinics are short-term outpatient services that manage pain before and after surgery to prevent acute pain from becoming chronic. Currently available at Vancouver Coastal Health and Providence Health sites. Referral to Chronic Pain Clinic - find local clinics on Pathways BC.

References

1. Sommer, M., de Rijke, J. M., van Kleef, M., Kessels, A. G., Peters, M. L., Geurts, J. W., Gramke, H. F., & Marcus, M. A. (2008). The prevalence of postoperative pain in a sample of 1490 surgical inpatients. European journal of anaesthesiology, 25(4), 267–274. https://doi.org/10.1017/S0265021507003031

2. Katz, J., Jackson, M., Kavanagh, B. P., & Sandler, A. N. (1996). Acute pain after thoracic surgery predicts long-term post-thoracotomy pain. The Clinical journal of pain, 12(1), 50–55. https://doi.org/10.1097/00002508-199603000-00009

3. Hernandez-Boussard, T., Graham, L. A., Desai, K., Wahl, T. S., Aucoin, E., Richman, J. S., Morris, M. S., Itani, K. M., Telford, G. L., & Hawn, M. T. (2017). The fifth vital sign: Postoperative pain predicts 30-day readmissions and subsequent emergency department visits. Annals of Surgery, 266(3), 516–524. https://doi.org/10.1097/SLA.0000000000002372

4. Dubljanin Raspopović, E., Meissner, W., Zaslansky, R., Kadija, M., Tomanović Vujadinović, S., & Tulić, G. (2021). Associations between early postoperative pain outcome measures and late functional outcomes in patients after knee arthroplasty. PLOS ONE, 16(7), e0253147. https://doi.org/10.1371/journal.pone.0253147

5. Buvanendran, A., Della Valle, C. J., Kroin, J. S., Shah, M., Moric, M., Tuman, K. J., & McCarthy, R. J. (2019). Acute postoperative pain is an independent predictor of chronic postsurgical pain following total knee arthroplasty at 6 months: A prospective cohort study. Regional Anesthesia & Pain Medicine, 44(3), e100036. https://doi.org/10.1136/rapm-2018-100036

6. Turan, A., Leung, S., Bajracharya, G. R., Babazade, R., Barnes, T., Schacham, Y. N., Mao, G., Zimmerman, N., Ruetzler, K., Maheshwari, K., Esa, W. A. S., & Sessler, D. I. (2020). Acute Postoperative Pain Is Associated With Myocardial Injury After Noncardiac Surgery. Anesthesia & Analgesia, 131(3), 822–829. https://doi.org/10.1213/ANE.0000000000005033

7. Khaled, M., Sabac, D., Fuda, M., Koubaesh, C., Gallab, J., Qu, M., Lo Bianco, G., Shanthanna, H., Paul, J., Thabane, L., & Marcucci, M. (2024). Postoperative pain and neurocognitive outcomes after noncardiac surgery: a systematic review and dose-response meta-analysis. British journal of anaesthesia, S0007-0912(24)00550-6. Advance online publication. https://doi.org/10.1016/j.bja.2024.08.032

8. Yang, M. M. H., Hartley, R. L., Leung, A. A., Ronksley, P. E., Jetté, N., Casha, S., & Riva-Cambrin, J. (2019). Preoperative predictors of poor acute postoperative pain control: a systematic review and meta-analysis. BMJ open,9(4), e025091. https://doi.org/10.1136/bmjopen-2018-025091

9. Görges, M., Sujan, J., West, N. C., Sreepada, R. S., Wood, M. D., Payne, B. A., Shetty, S., Gelinas, J. P., & Sutherland, A. M. (2024). Postsurgical Pain Risk Stratification to Enhance Pain Management Workflow in Adult Patients: Design, Implementation, and Pilot Evaluation. JMIR perioperative medicine, 7, e54926. https://doi.org/10.2196/54926

Poor functional capacity and physical fitness are associated with poor surgical outcomes including prolonged hospital length of stay and increased risk of postoperative complications. Increasing physical fitness can improve resilience and recovery after surgery. (1,2)

Screening Tools

The Physical Activity Vital Sign (PAVS) Calculator is a quick and easy way to flag sedentary patients for referral and counseling.

Prehabilitation and Optimization Algorithm

Prehabilitation and Optimization Recommendations

Patient Education

Emphasize the importance of muscle- and bone-strengthening activities at least 2 days per week to increase strength and functional capacity prior to surgery (e.g., STABLE Exercises). (5) Recommend at least 150 min of moderate- to vigorous-intensity aerobic physical activity per week, in bouts of 10 minutes or more. Moderate intensity activity: you can talk but not sing (e.g., brisk walk or riding a bicycle) Vigorous intensity activity: you are out of breath and can talk but don’t want to (e.g., jogging or swimming) Refer to the FREE Choose to Move program for personalized physical activity coaching and support. Participants set goals, build a tailored physical activity plan, and connect with peers while receiving information on health and wellness. In-person and online programs available.

Referral for Tailored Prehabilitation

Consider referral to physiotherapy for tailored preoperative exercise guidance for patients with medical limitations such as: Frailty (See frailty) Symptomatic cardiorespiratory disease Chronic pain Inflammatory arthritis Neurological conditions Refer to online provider resources for physiotherapy resources, referral templates, and information on who can access physio for free in BC

References

1. Barberan-Garcia, A., Ubré, M., Roca, J., Lacy, A. M., Burgos, F., Risco, R., Momblán, D., Balust, J., Blanco, I., & Martínez-Pallí, G. (2018). Personalised Prehabilitation in High-risk Patients Undergoing Elective Major Abdominal Surgery: A Randomized Blinded Controlled Trial. Annals of surgery, 267(1), 50–56. https://doi.org/10.1097/SLA.0000000000002293

2. Gillis, C., Ljungqvist, O., & Carli, F. (2022). Prehabilitation, enhanced recovery after surgery, or both? A narrative review. British journal of anaesthesia, 128(3), 434–448. https://doi.org/10.1016/j.bja.2021.12.007

3. Ball, T. J., Joy, E. A., Gren, L. H., & Shaw, J. M. (2016). Concurrent Validity of a Self-Reported Physical Activity "Vital Sign" Questionnaire With Adult Primary Care Patients. Preventing Chronic Disease. 13, E16. https://doi.org/10.5888/pcd13.150228

4. Mather, J, Wu, Y, Carr, L. et al. (2024). PHYSICAL ACTIVITY AS A VITAL SIGN: ASSOCIATION OF SELF-REPORTED PHYSICAL ACTIVITY LEVELS WITH CARDIOMETABOLIC RISK PROFILE IN A LARGE HEALTHCARE SYSTEM. JACC. 83 (13_Supplement) 1695. https://doi.org/10.1016/S0735-1097(24)03685-4

5 Izquierdo, M., de Souto Barreto, P., Arai, H., Bischoff-Ferrari, H. A., Cadore, E. L., Cesari, M., Chen, L-K., Coen, P. M., Courneya,K. S., Duque, G., Ferrucci, L., Fielding, R. A., García-Hermoso, A., Gutiérrez-Robledo, L. M., Harridge, S.D.R., Kirk, B., Kritchevsky, S., Landi, F., Lazarus, N., Liu-Ambrose, T., Marzetti, E., Merchant, R. A., Morley, J. E., Pitkälä, K. H., Ramírez-Vélez, R., Rodriguez-Mañas, L., Rolland, Y., Ruiz, J. G., Sáez de Asteasu, M. L., Villareal, D. T., Waters, D. L., Won, C.W., Vellas, B., Fiatarone Singh, M. A. (2025). Global consensus on optimal exercise recommendations for enhancing healthy longevity in older adults (ICFSR), The Journal of nutrition, health and aging, 29(1), 1-58.  https://doi.org/10.1016/j.jnha.2024.100401

Cigarette smoking is a risk factor for perioperative pulmonary, cardiovascular, bleeding and wound healing complications. (1,2) There is some evidence that vaping (or the use of e-cigarettes) is also associated with these complications. (3) The likelihood that quit-motivated patients can abstain from smoking is increased by use of nicotine replacement therapy (NRT). (4)

Screening Tools

Screening Questions:

• Do you currently use products that contain tobacco or nicotine? (e.g., smoking cigarettes or e-cigarettes, vaping nicotine, or chewing tobacco)
• If Yes, what type of tobacco/nicotine product?
• If cigarettes, how many packs/day? If other, how much & how often?

Prehabilitation and Optimization Algorithm

Prehabilitation and Optimization Recommendations

Patient Education

5 A’s Algorithm for Smoking Cessation (5). ASK about tobacco/nicotine use See screening questions ADVISE to quit Strongly urge all tobacco users to quit in a clear, strong, personalized manner. "It is extremely important for you to quit smoking before surgery. Smoking and vaping have a huge impact on your heart and lung health and increase the risk of complications after surgery. Quitting or cutting back on smoking before surgery can: lower your risk of getting pneumonia after surgery, reduce your risk of having a heart attack during/after surgery, speed up your healing after surgery, which reduces your risk of infection." ASSESS readiness to make a quit attempt “Are you willing to try to quit before surgery?” ASSIST with the quit attempt “Stopping smoking is not solely about willpower. Your body may be addicted to or dependent on nicotine and quitting can be difficult.” Quit Plan: Encourage patients to set a quit date, tell family/friends, remove tobacco products from the environment, plan for withdrawal symptoms and cravings Recommend pharmacotherapies (6):  Medications & Nicotine Replacement Therapy can increase smoking cessation success and reduce withdrawal symptoms (e.g., patch, gum, sprays, or oral medication). Family doctors or pharmacists are able to arrange therapies and ensure these therapies are covered financially through PharmaCare. Refer to online patient resources for covered therapies. Provide resources for quitting: (6) Quit Now Healthlink or *211 to access support through live chats, telephone and connection with local smoking cessation resources. Online patient resources ARRANGE follow-up care See referral for follow-up below

Referral for Follow-up

Outpatient follow-up: Encourage patients to schedule follow-up with their primary care provider for 2 weeks time to discuss progress. Day of Surgery - revisit smoking cessation: If still smoking: Normalize that lapses are very common and reassure that stopping smoking is not solely about willpower. Many people require more than one attempt. Reinforce the benefits of smoking cessation postoperatively, and offer further resources if appropriate (such as pharmacotherapy if it was not utilized with last quit attempt).

References

1. Eliasen, M., Grønkjær, M., Skov-Ettrup, L. S., Mikkelsen, S. S., Becker, U., Tolstrup, J. S., & Flensborg-Madsen, T. (2013). Preoperative alcohol consumption and postoperative complications: a systematic review and meta-analysis. Annals of surgery, 258(6), 930–942. https://doi.org/10.1097/SLA.0b013e3182988d59

2. Turan, A., Mascha, E., Roberman, D., Turner, P. L., You, J., Kurz, A., Sessler, D. I., Saager, L. (2011). Smoking and Perioperative Outcomes. Anesthesiology, 114(4), 837-846. https://doi.org/10.1098/ALN.0b013e318210f560

3. Rusy, D., Honkanen, A., Landrigan-Ossar, M. F., Chatterjee, D., Schwartz, L., Lalwani, K., Dollar, J., Clark, R., Diaz, C. D., Deutsch, N., Warner, D. O., Soriano, S. G., (2021). Vaping and E-Cigarette Use in Children and Adolescents: Implications on Perioperative Care from the American Society of Anesthesiologists Committee on Pediatric Anesthesia, Society for Pediatric Anesthesia, and American Academy of Pediatrics Section on Anesthesiology and Pain Medicine. Anesthesia & Analgesia, 133(3), 562-568. https://doi.org/10.1213/ANE.0000000000005519

4. Bush, K., Kivlahan, D. R., McDonell, M. B., Fihn, S. D., & Bradley, K. A. (1998). The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Archives of internal medicine, 158(16), 1789–1795. https://doi.org/10.1001/archinte.158.16.1789

5. Fiore, M. C., Jaén, C. R., Baker, T. B., et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. U.S. Department of Health and Human Services, Public Health Service. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/clinicians-providers/guidelines-recommendations/tobacco/clinicians/update/treating_tobacco_use08.pdf

6. Government of British Columbia (n.d.). Smoking Cessation Program – information for health professionals. Retrieved October 18, 2024, from https://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/pharmacare/pharmacies/smoking-cessation-program-for-health-professionals

Preoperative alcohol use is associated with an increased risk of postoperative morbidity, infections, wound complications, pulmonary complications, prolonged hospital length of stay, and admission to intensive care. (1) Screening for alcohol misuse prior to elective surgery allows for further screening for health complications, planning for those at risk of complicated withdrawal, and offering resources for safe tapering preoperatively in those patients who are motivated to do so.

Screening Tools

The Alcohol Use Disorder Identification Test (AUDIT-C) is an effective and validated 3-question screen for severity of alcohol misuse that is based on the 10-question AUDIT questionnaire. (2)

AUDIT-C Questionnaire

Prehabilitation and Optimization Algorithm

Prehabilitation and Optimization Recommendations

Patient Education for Lower Risk Patients (AUDIT-C < 5)	“Frequent alcohol use before surgery can affect how your body responds to medications. It also decreases your body's ability to fight infection and heal properly. There are many ways that your healthcare team can help you to safely cut down or stop using alcohol. It is important to not use alcohol for at least 24 hours prior to surgery.” Discuss Canadian Low Risk Drinking Guidelines: “Research shows that no amount or kind of alcohol is good for your health. It doesn’t matter what kind of alcohol it is—wine, beer, cider or spirits. Drinking alcohol, even a small amount, is damaging to everyone, regardless of age, sex, gender, ethnicity, tolerance for alcohol or lifestyle. That’s why if you drink, it’s better to drink less.” Canada's Low Risk Drinking Guide suggests that: 0 drinks per week has benefits such as better health and better sleep.  1 to 2 standard drinks per week: You will likely avoid alcohol-related consequences for yourself and others. Refer to online patient resources for information on safe alcohol consumption and reduction Telephone service: 24-hour BC Alcohol and Drug Information and Referral Service toll-free from anywhere in B.C. at 1-800-663-1441
Patient Education for Higher Risk Patients (AUDIT-C >= 5)	“Frequent alcohol use before surgery can affect how your body responds to medications. It also decreases your body's ability to fight infection and heal properly. There are many ways that your healthcare team can help you to safely cut down or stop using alcohol. It is important to not use alcohol for at least 24 hours prior to surgery, however, if you use alcohol daily you could be physically dependent. That means it can be dangerous to stop drinking overnight or cold turkey.” Advise patients that elective surgical procedures will be delayed if they are acutely intoxicated Patient resources: Make an appointment to see your primary care provider (e.g., family doctor) Call 811 to speak to a healthcare navigator who can find resources near you to help you slowly and safely reduce your alcohol use prior to surgery Refer to online patient resources
Referral for Safe Tapering	Primary care or Addiction Medicine for management suggestions
Preoperative Investigations	Screening for complications of alcohol use: CBC INR/PTT Albumin ALP ALT GGT
Referral for Anesthesia Consult	Especially if inpatient stay required
PAWSS Score	To assess risk of complicated withdrawal PAWSS score >= 4 indicates high risk of complicated withdrawal
Postoperative Withdrawal Management for Inpatients	Consider involving Addiction Medicine in hospital, especially if PAWSS >= 4 Alcohol withdrawal management postoperative orders (CIWA)

References

1. Eliasen, M., Grønkjær, M., Skov-Ettrup, L. S., Mikkelsen, S. S., Becker, U., Tolstrup, J. S., & Flensborg-Madsen, T. (2013). Preoperative alcohol consumption and postoperative complications: a systematic review and meta-analysis. Annals of surgery, 258(6), 930–942. https://doi.org/10.1097/SLA.0b013e3182988d59

2. Bush, K., Kivlahan, D. R., McDonell, M. B., Fihn, S. D., & Bradley, K. A. (1998). The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Archives of internal medicine, 158(16), 1789–1795. https://doi.org/10.1001/archinte.158.16.1789

Cannabis (marijuana) use may lead to increased anesthetic requirements, postoperative pain, opioid use after surgery, and nausea and vomiting. (1-3) Smoking cannabis increases the risk of pulmonary complications, cardiovascular complications (including postoperative myocardial infarction), and in-hospital mortality; it may also increase airway irritation, carboxyhemoglobin, and reduce oxygen-carrying capacity, similar to conventional cigarette smoking. (3-5)

Screening Tools

Cannabis Screening Questions:

Do you use Cannabis? If Yes:

• How often?
• How much do you use?
• How are you using it? (e.g., smoking, vaping, tincture/oil, edibles, cream)
• Have you ever had symptoms like headaches, anxiety, poor sleep, or stomach pain when you stopped using cannabis for a day or two (Cannabis Withdrawal Syndrome)?

Prehabilitation and Optimization Algorithm

Prehabilitation and Optimization Recommendations

Patient Education	Advise patients on perioperative risks of cannabis use (1,2) "Cannabis use puts you at higher risk of heart attacks and lung complications, as well as nausea and vomiting and increased pain after surgery.” “It is best to stop using cannabis for at least 72 hours before surgery. This does not apply to creams.” Advise patients that elective surgical procedures will be delayed if they are acutely intoxicated Discuss Canada's Lower Risk Cannabis Use Guidelines (6): Choose low-strength products, such as those with a lower THC content or a higher ratio of CBD to THC. Avoid using synthetic cannabis products. Smoking cannabis (for example, smoking a joint) is the most harmful way of using cannabis because it directly affects your lungs. Refer to online patient resources
Recommend Self Taper	Lower amount every day over 7 days with total cessation 72 hours prior to surgery “If you use a lot of cannabis on a daily basis you should slowly decrease the amount you use every day until you can stop for 72 hours without feeling unwell.” Slow taper if experiencing symptoms of Cannabis Withdrawal Syndrome (CWS)
Referral for Supported Taper	Consider tapering to a goal of less than the recommended preoperative maximum (rather than complete cessation 72 hours preop) Consider primary care, Addiction Medicine, or RACE line support
Referral for Anesthesia Consult	To develop effective pain management strategies and explore options for anesthesia and postoperative pain control, especially in moderate to severely invasive surgery
Provide Education on Cannabis Withdrawal Syndrome	Usually begins 1-2 days after cessation and lasts up to 3 weeks Symptoms include: headaches, anxiety, poor sleep, stomach pain Treatment: Supportive counseling and psychoeducation Consider referral for supported taper or suggest slower taper (10% reduction per day) No medications are approved for medically assisted withdrawal, though some are used ‘off‐label’ in clinical practice.

References

1. Ladha, K. S., McLaren-Blades, A., Goel, A., Buys, M. J., Farquhar-Smith, P., Haroutounian, S., Kotteeswaran, Y., Kwofie, K., Le Foll, B., Lightfoot, N. J., Loiselle, J., Mace, H., Nicholls, J., Regev, A., Rosseland, L. A., Shanthanna, H., Sinha, A., Sutherland, A., Tanguay, R., Yafai, S., … Clarke, H. (2021). Perioperative Pain and Addiction Interdisciplinary Network (PAIN): consensus recommendations for perioperative management of cannabis and cannabinoid-based medicine users by a modified Delphi process. British journal of anaesthesia, 126(1), 304–318. https://doi.org/10.1016/j.bja.2020.09.026

2. Shah, S., Schwenk, E. S., Sondekoppam, R. V., Clarke, H., Zakowski, M., Rzasa-Lynn, R. S., Yeung, B., Nicholson, K., Schwartz, G., Hooten, W. M., Wallace, M., Viscusi, E. R., & Narouze, S. (2023). ASRA Pain Medicine consensus guidelines on the management of the perioperative patient on cannabis and cannabinoids. Regional anesthesia and pain medicine, 48(3), 97–117. https://doi.org/10.1136/rapm-2022-104013

3. Echeverria-Villalobos, M., Todeschini, A. B., Stoicea, N., Fiorda-Diaz, J., Weaver, T., & Bergese, S. D. (2019). Perioperative care of cannabis users: A comprehensive review of pharmacological and anesthetic considerations. Journal of clinical anesthesia, 57, 41–49. https://doi.org/10.1016/j.jclinane.2019.03.011

4. Tetrault, J. M., Crothers, K., Moore, B. A., Mehra, R., Concato, J., & Fiellin, D. A. (2007). Effects of marijuana smoking on pulmonary function and respiratory complications: a systematic review. Archives of internal medicine, 167(3), 221–228. https://doi.org/10.1001/archinte.167.3.221

5. Jeffers, A. M., Glantz, S., Byers, A. L., & Keyhani, S. (2024). Association of Cannabis Use With Cardiovascular Outcomes Among US Adults. Journal of the American Heart Association, 13(5), e030178. https://doi.org/10.1161/JAHA.123.030178

6. The Centre for Addiction and Mental Health. (2017). 10 Ways to Reduce Risks to Your Health When Using Cannabis. https://www.camh.ca/-/media/files/pdfs---reports-and-books---research/canadas-lower-risk-guidelines-cannabis-pdf.pdf

Substance use is associated with increased postoperative complications, prolonged hospital length of stay, and increased healthcare costs. (1-4) Acute intoxication and chronic use have implications for perioperative care. (5)

Additional challenges depend on the severity and type of substance(s) used, as well as other factors that may be associated with substance use, including experiencing homelessness or mental illness. Collaboration with community providers is important, especially for patients being treated for opioid use disorder.

Screening Tools

Screening Questions:

• In the last 12 months, have you used drugs other than those required for medical reasons? (not including alcohol or cannabis)
• If yes, characterize drug use (drug, dose, frequency, and route of administration)

The Drug Abuse Screening Test (DAST-10) is a validated 10-item brief screening tool that assesses drug use (excluding alcohol and tobacco), in the past 12 months and gives a score of the degree of problems related to drug use and misuse. (6,7) This allows preoperative interventions to target those patients with substantial or severe problems related to drug abuse.

Drug Abuse Screening Test (DAST-10)

Prehabilitation and Optimization Algorithm

Prehabilitation and Optimization Recommendations

Patient Education	Advise patients on the perioperative risks of substance use. (8) Advise patients that elective surgical procedures will be delayed if they are acutely intoxicated. (8) Recommend support services: Encourage patients to see their healthcare provider for safe ways to decrease substance use before surgery. Online services: available at Help Starts Here Telephone service: 24-hour BC Alcohol and Drug Information and Referral Service toll-free from anywhere in B.C. at 1-800-663-1441
Referral for Safe Tapering Support	Addiction Medicine or Primary Care with/without RACE line support
Screen for Comorbid Disease	CBC EKG HIV Hep B Hep C
Referral for Anesthesia Consult	To develop effective pain management strategies and explore options for anesthesia and postoperative pain control, especially in moderate to severely invasive surgery
Postoperative Care for Inpatients	Referral to Addiction Medicine consultative services to avoid complicated withdrawal and facilitate discharge planning and supports

References

1. Kulshrestha, S., Bunn, C., Gonzalez, R., Afshar, M., Luchette, F. A., & Baker, M. S. (2021). Unhealthy alcohol and drug use is associated with an increased length of stay and hospital cost in patients undergoing major upper gastrointestinal and pancreatic oncologic resections. Surgery, 169(3), 636–643. https://doi.org/10.1016/j.surg.2020.07.059

2. Venishetty, N., Nguyen, I., Sohn, G., Bhalla, S., Mounasamy, V., & Sambandam, S. (2023). The effect of cocaine on patients undergoing total hip arthroplasty. Journal of orthopaedics, 43, 64–68. https://doi.org/10.1016/j.jor.2023.07.029

3. Best, M. J., Buller, L. T., Klika, A. K., & Barsoum, W. K. (2015). Outcomes Following Primary Total Hip or Knee Arthroplasty in Substance Misusers. The Journal of arthroplasty, 30(7), 1137–1141. https://doi.org/10.1016/j.arth.2015.01.052

4. Raso, J., Althoff, A., Brunette, C., Kamalapathy, P., Arney, M., & Werner, B. C. (2023). Preoperative Substance Use Disorder Is Associated With an Increase in 90-Day Postoperative Complications, 1-Year Revisions and Conversion to Arthroplasty Following Arthroscopic Rotator Cuff Repair: Substance Use Disorder on the Rise. Arthroscopy : the journal of arthroscopic & related surgery: official publication of the Arthroscopy Association of North America and the International Arthroscopy Association, 39(6), 1386–1393.e4. https://doi.org/10.1016/j.arthro.2022.12.026

5. Jimenez Ruiz, F., Warner, N. S., Acampora, G., Coleman, J. R., & Kohan, L. (2023). Substance Use Disorders: Basic Overview for the Anesthesiologist. Anesthesia and analgesia, 137(3), 508–520. https://doi.org/10.1213/ANE.0000000000006281

6. Yudko, E., Lozhkina, O., & Fouts, A. (2007). A comprehensive review of the psychometric properties of the Drug Abuse Screening Test. Journal of substance abuse treatment, 32(2), 189–198. https://doi.org/10.1016/j.jsat.2006.08.002

7. Gavin, D. R., Ross, H. E., & Skinner, H. A. (1989). Diagnostic validity of the drug abuse screening test in the assessment of DSM-III drug disorders. British journal of addiction, 84(3), 301–307. https://doi.org/10.1111/j.1360-0443.1989.tb03463.x

8. Gould, R., Lindenbaum, L., & Rogers, K., (2024). Anesthesia for patients with substance use disorder or acute intoxication. UpToDate. Retrieved Aug 24, 2024, from  https://www.uptodate.com/contents/anesthesia-for-patients-with-substance-use-disorder-or-acute-intoxication

Making arrangements in advance to have adequate support at home can help patients return home after surgery as soon as it is appropriate and avoid delays to discharge. (1,2) Traditional criteria for discharge following day surgery includes the presence of a capable adult care-giver for 24 hours postoperatively.

Screening Tools

Screening Questions:

• Do you have someone that can help you during your recovery after surgery if necessary?
• Do you have someone who can take over your caregiving responsibilities while you recover from surgery (e.g.,vulnerable adults, children, or pets)?

Prehabilitation and Optimization Algorithm

Prehabilitation and Optimization Recommendations

Patient Education	Advise patients on the importance of post-surgery support and set clear expectations for their recovery. "Depending on what type of surgery you are having you may need to have someone help you for a while. If the plan is for you to go home the same day (daycare surgery), it is critical that you have someone to assist you on the way home as well as a responsible adult to spend the night with you."
Provide resources for those with no support	*211 or gov.bc.ca - telephone or online resource to find local home and community care services Refer to local social worker

References

1. Kay, A. B., Ponzio, D. Y., Bell, C. D., Orozco, F., Post, Z. D., Duque, A., & Ong, A. C. (2022). Predictors of Successful Early Discharge for Total Hip and Knee Arthroplasty in Octogenarians. HSS journal : the musculoskeletal journal of Hospital for Special Surgery, 18(3), 393–398. https://doi.org/10.1177/15563316211030631

2. Zhang, Z., & Tumin, D. (2019). Expected social support and recovery of functional status after heart surgery. Disability and rehabilitation, 42(8), 1167–1172. https://doi.org/10.1080/09638288.2018.1518492