Perioperative Management

Anticoagulation should be discontinued in patients undergoing elective surgery with a low‐to‐moderate thromboembolic risk at least 48 hours before surgery and resumed within 12 to 24 hours after surgery. For patients at high risk of thromboembolism, such as those with coronary artery stents or mechanical heart valves, the risk of death due to thrombosis may outweigh the risk of surgical bleeding. The decision to discontinue anticoagulation therapy should be individualized and involve a multidisciplinary team. For patients with stents, factors to consider include the type of stent (bare or drug-eluting), time since placement, type of surgery, and whether an elective procedure can be postponed until periods of increased risk have passed (1).

bridging therapy2).

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warfarin (56, 7).

Because it takes up to 5 days for warfarin to achieve therapeutic anticoagulation, it can be started the day of or after surgery unless the risk of postoperative bleeding is high. Patients should receive bridging anticoagulation until the INR has reached the therapeutic target.

In patients receiving anticoagulant therapy, the decision to use regional anesthesia should be made on a case‐by‐case basis, taking into account the risks of bleeding and thrombosis. Epidural catheters should not be removed until at least 12 hours after the last dose of a DOAC.

Most medications taken to control chronic disorders, especially cardiovascular medications (including antihypertensives), should be continued throughout the perioperative period. Most oral medications can be given with a small sip of water on the day of surgery. Other medications may have to be given parenterally or delayed until after surgery. Anticonvulsant levels should be measured preoperatively in patients with a seizure disorder.

On the day of surgery, patients with insulininsulininsulin regimen is not restarted until patients resume their regular diet. Oral hypoglycemic agents are usually restarted when the patient is discharged from the hospital.

Patients with known coronary artery disease or heart failure should undergo preoperative evaluation and risk stratification by their cardiologist. If patients are not medically optimized, they should undergo additional testing before elective surgery.

Preoperative pulmonary function tests can help quantify the degree of obstructive, restrictive, or reactive airway disease. Pulmonary function should be optimized by carefully adjusting the use and doses of inhalers, other medications, and airway clearance techniques.

Patients who smoke cigarettes are advised to stop smoking as early as possible before any procedure involving the chest or abdomen. Several weeks of smoking cessation are required for ciliary mechanisms to recover. An incentive inspirometer should be used before and after surgery.

For patients with frequent or heavy use of cannabinoids, American Society of Regional Anesthesia and Pain Medicine guidelines recommend counseling about potential risks (eg, increased postoperative nausea and vomiting, myocardial infarction) of continued use during the perioperative period, postponing elective surgery in patients with altered mental status or impaired decision‐making capacity due to acute cannabis intoxication, and delaying nonemergent surgery for a minimum of 2 hours after smoking or ingesting cannabis because of increased risk of myocardial infarction (8).

Patients who are dependent on illicit drugs or alcohol may experience withdrawal during the perioperative period. Patients with alcohol use disorderopioid use disorder

1. 1. Fleisher LA, Fleischmann KE, Auerbach AD, et al: 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol 64(22):e77-e137, 2014. doi:10.1016/j.jacc.2014.07.944

2. 2. Douketis JD, Healey JS, Brueckmann M, et al: Perioperative bridging anticoagulation during dabigatran or warfarin interruption among patients who had an elective surgery or procedure. Substudy of the RE-LY trial. Thromb Haemost 113(3):625-632, 2015. doi:10.1160/TH14-04-0305

3. 3. Schulman S, Carrier M, Lee AY, et al: Perioperative management of dabigatran: a prospective cohort study. Circulation 132(3):167-173, 2015. doi:10.1161/CIRCULATIONAHA.115.015688

4. 4. Pollack CV Jr, Reilly PA, van Ryn J, et al: Idarucizumab for dabigatran reversal - full cohort analysis. N Engl J Med 377(5):431-441, 2017. doi:10.1056/NEJMoa1707278

5. 5. Keeling D, Baglin T, Tait C, et al: Guidelines on oral anticoagulation with warfarin - fourth edition. Br J Haematol 154(3):311-324, 2011. doi:10.1111/j.1365-2141.2011.08753.x

6. 6. Kuo HC, Liu FL, Chen JT, et al: Thromboembolic and bleeding risk of periprocedural bridging anticoagulation: A systematic review and meta-analysis. Clin Cardiol 43(5):441-449, 2020. doi:10.1002/clc.23336

7. 7. Douketis JD, Spyropoulos AC, Kaatz S, et al: Perioperative bridging anticoagulation in patients with atrial fibrillation. N Engl J Med 373(9):823-833, 2015. doi:10.1056/NEJMoa1501035

8. 8. Goel A, McGuinness B, Jivraj NK, et al: Cannabis use disorder and perioperative outcomes in major elective surgeries: a retrospective cohort analysis. Anesthesiology 132(4):625-635, 2020. doi:10.1097/ALN.0000000000003067

The American Society of Anesthesiologists (ASA) recommendations regarding oral intake are as follows (1):

• 8 hours preoperatively: Stop intake of meat or fried or fatty foods

• 6 hours: Limit intake to a light meal (eg, toast and a clear liquid), then only clear liquids allowed

• 2 hours: Stop all oral intake, including food, liquids, and medications

For certain gastrointestinal procedures, cleansing enemas or oral antibiotic bowel preparations must be started 1 to 2 days before surgery.

In the United States, the Joint Commission Universal Protocol providing preprocedure operating room guidance was developed with the goal of preventing surgical errors involving the wrong patient, procedure, or part of the body. Part of the protocol is holding a preprocedure time out during which the team confirms several important factors:

• Patient identity

• Verification of correct procedure and location and side of the operative site

• Availability of all needed equipment

• Verification of administration of indicated prophylaxis (eg, antibiotics, anticoagulants, beta-blockers)

1. 1. Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures: An Updated Report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. Anesthesiology. 2017;126(3):376-393. doi:10.1097/ALN.0000000000001452