Surgical Prehabilitation Toolkit for Healthcare Providers

Prehabilitation and optimization are crucial strategies for enhancing patient health before surgery, thereby reducing the risk of postoperative complications. The presurgical period represents a window of opportunity to boost and optimize the health of an individual, providing a compensatory buffer for the imminent reduction in physiological reserve post-surgery.

Prehabilitation is a proactive approach that focuses on improving patients' physical and psychological resilience through interventions such as exercise, nutrition, and psychological preparation. Optimization centers on improving patients’ medical conditions prior to surgery such as managing comorbidities, adjusting medications, and conducting health screenings. Both strategies are vital for expediting recovery, improving patient experiences and outcomes, and reducing healthcare system costs.

Surgical Patient Optimization Collaborative

Following on the success of the 2015-16 Enhanced Recovery After Surgery (ERAS) Collaborative, the Surgical Patient Optimization Collaborative (SPOC) launched in 2019 with 14 sites and expanded with another 13 sites in 2022, to include a total of 27 sites. The collaboratives provided system change strategies, funding support, and shared learning to interdisciplinary teams. Through SPOC 1.0 and 2.0, prehabilitation programs have been established in more than 50% of hospitals performing surgery in BC, demonstrating the benefits of prehabilitation to surgical patients, providers, and the healthcare system within the BC surgical landscape.

The Surgical Prehabilitation Toolkit

The Surgical Prehabilitation Toolkit was originally created in 2019 by the BC Surgical Optimization Working Group and vetted by 15 provincial sites involved in the Surgical Patient Optimization Collaborative (SPOC). Through 2024, the BC Prehabilitation Working Group reviewed and updated the toolkit, adding clinical context, actionable recommendations and screening tool recommendations based on current evidence-based guidelines. 

The updates reflect valuable feedback from clinicians within the collaborative and insights from field experts, aimed at enhancing the usability of clinical component pathways. These revisions focus on making the pathways more actionable and practical for providers, while also adding new components that address emerging needs and best practices identified through ongoing engagement around prehabilitation. 

The toolkit includes clinical context for each clinical component and actionable recommendations for prehabilitation and optimization that may prove useful for health care providers looking to prehabilitate patients before surgery. This toolkit is not meant to dictate the practice of clinicians, rather to provide options that are available to both providers and patients throughout British Columbia. Clinicians are encouraged to use the toolkit at their own discretion based on the best interest of the patient.

A pdf version of the toolkit can be accessed by clicking on the image below or each component can be explored through the menu options to the left or below.

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Perioperative Care Alignment and Digital Screening (PCADS)

While SPOC and other research has demonstrated the positive impact of prehabilitation and optimization, typical pre-surgical journeys offer limited opportunity for prehab in the time leading up to surgery due to tight timelines and limited resources. A digital pre-surgical screening workflow has been identified as a critical piece to support prehabilitation and optimization workflows to improve the surgical system of care.

The Perioperative Care Alignment and Digital Screening (PCADS) project (2023-2024), developed a standardized Pre-Surgical Risk Assessment and Triage Tool (PRATT) to identify high-risk patients early in their preoperative wait time and provide standardized evidence-based recommendations for timely interventions like prehabilitation and optimization.

The PRATT is designed to collect patient health information and provide tailored recommendations in a streamlined manner early in the surgical timeline, allowing more time for patients to receive prehabilitation and optimization to improve their health prior to surgery. The clinical output includes:

The PRATT currently exists as a database of patient questions and clinical output logic designed to be implemented digitally and integrate seamlessly with the recommendations included in the prehabilitation toolkit. The full PCADS report including the PRATT clinical content is available to any practitioners in British Columbia to incorporate into their prehabilitation workflows via the link below.

PCADS Final Report with PRATT Clinical Content

For a full list of contributors to the Prehabilitation Toolkit and PRATT, please click HERE.

Legal Disclaimer

We try very hard to keep this information accurate and up-to-date, but we cannot guarantee this. This information is intended as a resource and general guidance and is not meant to dictate the practice of clinicians. Clinicians are encourage to use the information at their own discretion based on the best interest of the patient. It cannot be used for any commercial or business purpose. Although we make reasonable efforts to ensure the accuracy of the information in these resources, we make no representations, warranties or guarantees, whether express or implied, that the information is accurate, complete or up to date. We do not exclude or limit in any way our liability to you where it would be unlawful to do so.

© 2025 Specialists Services Committee
This information may be copied for the purpose of producing information materials. Please quote this original source. If you wish to use part of this information in another publication, suitable acknowledgement must be given and the logos, branding, images, and icons removed. For more information, please contact us at sscbc@doctorsofbc.ca.

SSC. (2025). BC Surgical Prehabilitation Toolkit. https://sscbc.ca/surgical-prehab-toolkit

Anemia

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)

Screening Tools

Preoperative hemoglobin (Hgb) is recommended for screening based on patient co-morbidities and surgical invasiveness, as per site specific protocols. (3) If a patient is found to be anemic, basic screening for iron deficiency anemia as well as other causes (e.g., chronic kidney disease) is recommended.

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
  • For cases of anemia with an unclear cause or iron deficiency anemia that is not related to the reason for surgery, consider postponing elective surgery to allow time for further investigation and treatment of the anemia to support better surgical outcomes and reduce potential complications. Suggest communication with surgical team.
  • Patients undergoing high blood loss surgeries who would decline transfusion require special consideration. Consider multidisciplinary discussion and delaying surgery until hemoglobin goal is reached.
Communication with Primary Care Provider
  • If a patient is found to have anemia before surgery and does not meet the criteria for perioperative optimization, it is important to inform the patient and request their primary care provider investigate and treat the underlying cause of the anemia. This is particularly crucial 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
  • Population for optimization: surgeries with expected blood loss >= 500 mL or patients with severe anemia
  • Example high blood loss surgeries include*: redo/bilateral joints, multilevel spine, open gynecology, open bowel resection/general surgery, major urology cases, all cardiac, open thoracics, radical prostatectomies
    *full list of high and low blood loss surgeries for Vancouver General Hospital available via online provider resources
  • Recommend performing basic screening to identify possible underlying causes of anemia. This should include taking a detailed bleeding history, reviewing the patient's medication history, and testing (e.g., iron studies, renal function)
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: IV iron dose can be based on the Ganzoni formula or standardized dosing (e.g., iron isomaltoside 1000 mg x 1 dose or iron sucrose 300 mg x 3 doses)
Follow-up After IV Iron Therapy
  • IV iron takes 10-14 days for full effect, expect increase of up to 10 g/L/week
  • Follow-up bloodwork should be arranged for 10-14 days post iron infusion and flagged for anesthesia review
  • Ensure CBC is re-done within 30 days of surgical procedure
  • After administering iron supplementation, the goal is to treat anemia so that hemoglobin levels reach above 130 g/L. If this target is not met before the scheduled surgery, clinical judgment should be used to decide whether to delay the surgery until the goal is achieve
  • May recommend postoperative oral iron for patients having major surgery as it has been shown to speed recovery.
Referral to Hematology, Nephrology, or Internal Medicine
  • If there are other potential causes of anemia besides iron deficiency  (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.

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/...

Cardiac Risk

In patients hospitalized for at least one night after non-cardiac surgery, the overall 30-day mortality rate is 1.8% with urgent/emergent surgery being associated with at lease double the risk of elective surgery. (1)

Many of these deaths are linked to cardiac complications (1). Myocardial Injury after Noncardiac Surgery (MINS), indicated by troponin levels exceeding the 99th percentile due to myocardial schema without ischemic features, occurs in 12-24% of cases (2). MINS is associated with a post-operative 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).

Screening Tools

The Revised Cardiac Risk Index (RCRI) includes six factors, each worth 1 point (6). A review of 792,740 patients showed that the RCRI has moderate ability to predict major perioperative cardiac complications (7). For patients aged 65 or older, those aged 45-64 with significant cardiovascular disease, or those with an RCRI score ≥ 1, measure NT-proBNP or BNP before noncardiac surgery to improve risk assessment (8).

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: RCRI >= 1, age >= 65, or age 45-64 with 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
  • Measure Troponin daily x 2-3 days (should not prolong hospitalization for troponin monitoring)
  • If Troponin > 99th percentile, MINS management required (1)
  • Obtain EKG and troponin level in PACU
  • 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. 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

7. 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

8. 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

Delirium

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

The Delirium Elderly At-Risk (DEAR) instrument has been used to predict postoperative delirium in elective and emergency orthopedic patients based on cognitive impairment, age, functional dependence, sensory impairment, and chronic substance use. “Among arthroplasty patients, having two or more risk factors was associated with an eight-fold increase in the incidence of delirium.” (1) The modified DEAR (mDEAR) uses routinely collected medical record data to assess cognitive impairment instead of the MMSE utilized in the DEAR and attributes 2 points to cognitive impairment and 1 point to each other factor. A patient scoring 3 or more indicates a higher risk of developing delirium. (5)

mDEAR Screening Instrument

Prehabilitation and Optimization Algorithm

Prehabilitation and Optimization Recommendations 

Patient Education
  • Discuss perioperative risk of delirium
  • Non-pharmacological delirium prevention:
    • Reorientation
    • Access to natural light and a visible clock
    • Bring hearing aids and glasses and put them on in the daytime
    • Early mobilization
    • Family presence
    • Refer to online patient resources
Referral for Comprehensive Geriatric Assessment (CGA)
  • Several studies have shown that CGA-based care can reduce the risk of postoperative delirium. This is attributed to better identification of delirium risk factors and proactive initiation of multimodal delirium risk management in higher risk patients. (6)
  • Refer to online provider resources for provincial geriatrician resources and telehealth consultation options
Perioperative Strategies
  • Minimize polypharmacy
  • Avoid prolonged fasting of fluids

 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. 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

6. 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

Frailty

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 has been validated as a preoperative screening tool for frailty and as a predictor of mortality and postoperative complication. (4) Many geriatricians find ADLs and IADLs as a useful adjunct to a screening tool.

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
  • Refer to online provider resources for assessment tools (e.g., Mini-Cog or MMSE)
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

Glycemic Control

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 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: likely prediabeti
    • HbA1c > 6.5: likely diabetic
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
  • If holding GLP-1 agonist for a prolonged duration, adding other antihyperglycemic medication may be required.
  • 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

Goals of Care

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)

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
  • Refer to online patient resources
Preoperative Goals of Care Discussion
  • Use the best-case scenario /  worst-case scenario framework (2)
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

Mental Wellbeing

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

Patient Education
  • Set patient expectations for postoperative anxiety management
  • "Based on your responses, it sounds like you might be feeling anxious or experiencing low moods at times. Your mental wellbeing affects your ability to recover well after surgery. Other patients have found these resources to be helpful in the past.”
  • 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
Physician-Referral Options
  • Mild to Moderate symptoms (PHQ-9 score: < 15): refer to mind-space.ca
  • Severe symptoms (PHQ-9 score: >= 15): refer to Psychiatry or Primary Care

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. 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

6. 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

7. 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

Nutrition

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 that are at high risk for malnutrition (CNST 2) require dietician assessment. It is essential that the patient is able to meet their energy, 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.
  • Refer to online patient resources
Referral for Nutrition Counseling
  • Dietician to confirm diagnosis of malnutrition and advise dietary plan for optimized 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. 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

Obesity

Obesity is linked to several conditions, such as type II diabetes and obstructive sleep apnea, that may increase perioperative risks. Comorbidities may outweigh BMI in assessing these risks. (1-4)

For patients with class 1* obesity (BMI: 30–34.9), perioperative risks are mainly limited to venous thromboembolism. In class 2* obesity (BMI: 35–39.9) and higher, there is a modest increase in risks, including 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

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)

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 family doctor or device vendor 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

Pain Management

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 an algorithm being developed at St. Paul's Hospital. It aims to identify patients at increased risk of significant postoperative pain and long-term opioid use, so that their care plans may be tailored with the intent of helping reduce initial opioid consumption. (9) It incorporates several variables associated with increased risk for developing postoperative pain and uses consumption of > 90 morphine milligram equivalents per day while inpatient after surgery as a surrogate marker for assessing performance (9). While the POQI score is not validated, it was selected to support postoperative pain risk stratification based on local BC experience with the tool. A POQI score >= 7 is considered to be ‘increased risk.’

Perioperative Opioid Quality Improvement (POQI) Assessment

Prehabilitation and Optimization Algorithm

Prehabilitation and Optimization Recommendations

Patient Education
  • Set patient expectations for postoperative pain management
  • "Given your risk factors, managing post-surgery pain might be challenging. There are many ways we can work together before and after surgery to decrease 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
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 - Mindfulness teaching virtually
  • 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

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

Physical Activity

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
  • 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: brisk walk or riding a bicycle; you can talk but not sing
    • Vigorous intensity activity: jogging or swimming; you are out of breath and can talk but don’t want to
  • Recommend muscle- and bone-strengthening activities at least 2 days per week.
  • Refer to online patient resources for preoperative exercise program.
  • 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

Smoking Cessation

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

Substance Use - Alcohol

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 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

Substance Use - Cannabis

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 - Illicit Substances

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

Support After Surgery

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