Authors: Caroline Evans, Richard Davies

Preoperative anaemia and resultant perioperative allogenic blood transfusion result in significantly poorer surgical outcomes.

This guideline covers early preoperative detection, assessment, optimisation and monitoring of anaemia and specifically iron deficiency as the commonest cause.  This includes strategies to avoid preoperative transfusion where possible including utilisation of iron therapies.

This approach forms the 1st pillar of perioperative patient blood management to improve perioperative outcomes.

Summary and Key Recommendations

• Anaemia and allogenic blood transfusion are associated with poor outcomes for surgical patients.
• The WHO definition of anaemia has been criticized recently. Expert opinion favours a Haemoglobin (Hb) of 130g/l or more, in both males and females.
• Patients should be screened for anaemia and iron deficiency at the earliest opportunity in the surgical care pathway.
• Surgical procedures with a moderate to high risk of blood loss >500ml or a transfusion risk of > 10% are deemed the most suitable.
• Anaemia and iron deficiency are easily treated in the preoperative setting. All patients should be offered iron therapy in line with NICE guidance.
• Patients with absolute iron deficiency and >6 weeks from surgery should be given a trial of oral iron.
• Patients <6 weeks from surgery, identified with Functional Iron deficiency or have a failed oral iron treatment should be offered intravenous iron.
• Strict adherence to preoptimization pathways reduces allogenic transfusion however significant cost benefit realization requires adherence to all of the pillars of Patient Blood Management. 

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Authors: Sneh Shah, Sanooj Soni, Andrew Hartle

It is widely accepted that uncontrolled hypertension is one of the most important preventable risk factors for premature morbidity and mortality.

This guideline provides detailed advice on the pre-operative assessment and management of hypertension aimed at reducing the number of cancellations of elective surgery due to hypertension alone, improving the detection of significant hypertension prior to surgery and reducing the number of patients referred from preoperative assessment clinic back to primary care.

The pre-operative management of anti-hypertensive medication is also summarised.

Summary and Key Recommendations

• The diagnosis and management of hypertension should normally take place within primary care.
• Patients should be referred for elective surgery from primary care if their mean blood pressures in the preceding 12 months are less than 160 mmHg systolic and less than 100 mmHg diastolic.
• Patients may be referred for elective surgery if they remain hypertensive despite optimal antihypertensive treatment or if they decline antihypertensive treatment.
• Pre-operative assessment should focus on the identification of patients at immediate risk to health in the peri-operative period.
• Pre-operative assessment staff should measure the blood pressure of patients who attend clinic without documented evidence of blood pressures less than 160 mmHg systolic and 100 mmHg diastolic by primary care within the preceding 12 months.
• Elective surgery should proceed for patients who attend the pre-operative assessment clinic if their blood pressure is less than180 mmHg systolic and 110 mmHg diastolic when measured in clinic.
• Good communication with primary care should minimise unnecessary investigations and delays to treatment.
• Most antihypertensive agents should be continued pre-operatively with the exception of angiotensin converting enzyme inhibitors and angiotensin 2 receptor blockers which should be withheld 24 hours pre-operatively.
• It has been demonstrated that implementation of the AAGBI/BHS guidelines on the management of hypertension before elective surgery across primary and secondary care results in a reduction in surgical cancellation rates due to peri‐operative hypertension. 

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Authors: Sarah Taylor, Gerard Danjoux

Obstructive Sleep Apnoea (OSA) is common and if untreated is associated with more than doubling the risk of perioperative complications and increased length of hospital stay.

This guideline comprehensively describes patient risk assessment for OSA including use of the STOPBANG screening tool, to facilitate diagnosis and treatment.  It alerts the clinician to the predisposing factors, signs and symptoms associated with increased risk of OSA and explains the associated perioperative risks.

It is recommended that agreed, expedited referral pathways should be established between preoperative assessment clinics and local Sleep Medicine services to minimise delays where significant OSA is suspected. 

Review of current evidence along with expert opinion provides guidance for management in the perioperative period according to severity of OSA.  Day surgery should not be precluded for patients, however, detailed perioperative management & discharge planning should be put into place in advance. 

Summary and Key Recommendations

• Obstructive Sleep Apnoea (OSA) is common and preoperative assessment should include a risk assessment such as the STOP-BANG screening tool to facilitate diagnosis and treatment.
• A high index of suspicion for OSA should exist in all morbidly obese patients, as the prevalence is substantially higher in this patient group.
• Untreated OSA is associated with more than doubling the risk of perioperative complications and increased hospital length of stay. 
• If OSA is strongly suspected on clinical grounds, or a screening tool, patients should be referred for Sleep Medicine assessment where surgery is non-urgent. 
• If OSA is strongly suspected on clinical grounds, or screening tool, and either sleep studies are not readily available or surgery is urgent, then patients should be treated as if they have a positive diagnosis, and managed accordingly.
• It is recommended that agreed, expedited referral pathways should be established between preoperative assessment clinics and local Sleep Medicine services to minimise delays where significant OSA is suspected. 
• If OSA has been diagnosed or is strongly suspected, the postoperative care provided should include the ability to institute CPAP except in selected minor day-case surgery.
• Patients who have their own treatment devices e.g. CPAP machines, should bring them into hospital on admission.
• OSA should not preclude patients from day case surgery, however, detailed perioperative management & discharge planning should be put into place in advance and central neuraxial techniques or loco-regional anaesthesia used wherever possible. 
• A co-ordinated perioperative management plan should be agreed through the preoperative assessment process. 

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Authors: Brendan Patrick Madden, Nordita Ramos-Bascon

Lung function tests are an essential aspect of pre-operative evaluation.  All pre-assessment units should have easy access to simple spirometry as well as the ability to refer patients for formal lung function testing

This guideline suggests when to perform lung function testing and how to interpret spirometry results.  It also discusses flow volume curves, diffusion capacity (gas transfer) measurement and the potential underlying causes of suboptimal test results. It stresses the importance of prompt referral to appropriate specialists for pre-operative diagnosis and optimisation if significant abnormalities are identified. 

Summary and Key Recommendations

• Lung function tests are an essential aspect of pre-operative evaluation and all pre-assessment units should have easy access to simple spirometry as well as the ability to refer patients for formal lung function testing.
• The FEV1/FVC ratio distinguishes between a predominantly obstructive and predominantly restrictive lung pathology.
• The FEV1 as a percentage of predicted is a measure of the severity of airflow obstruction.
• Patients with severe airflow obstruction or restrictive lung disease are at risk of complications from mechanical ventilation due to high inflation pressures.
• Flow volume curves can reveal reduced small airway calibre and both extra and intra thoracic airway obstruction.
• Measurement of diffusion capacity (gas transfer) gives important information regarding the integrity and size of the alveola/blood membrane.
• Unexplained dyspnea or reduction in gas exchange should prompt consideration of underlying pulmonary embolism or of pulmonary hypertension.
• Prompt referral to appropriate specialists for pre-operative diagnosis and optimisation is indicated if significant abnormalities are identified. 

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Authors: Robert Hill, Mark Tanner

Cardiac implantable electronic devices (CIEDs) are increasingly common in preassessment populations. Indications are wide-ranging and a structured approach is required to avoid patient harm in the perioperative period.

This guidance explains how to preoperatively assess the patient, the underlying cardiac condition and their device and the steps that must be taken prior to surgery.  Perioperative safety strategies that should be employed in the elective and emergency setting are also presented.

Summary and Key Recommendations

• Patients with cardiac implantable electronic devices (CIEDs) must be identified at pre-assessment.
• Efforts should be made to determine the reason for the implant, the type of device and degree of pacemaker-dependency.
• The device should have been checked within the previous 6-12 months depending on the type of device and its age.
• ICDs must have their shock mode temporarily turned off for the duration of the procedure if diathermy is to be used.
• A defibrillator with external pacing facility must be available in the theatre, and pads should be placed on the patient if they are pacemaker dependant.
• Bipolar diathermy should be used whenever possible.
• If monopolar diathermy is essential, the diathermy plate should be placed as far as possible from the device, avoiding the device being between the diathermy forceps and the plate.
• Monopolar diathermy should never be used close to a device.
• Placing a magnet over a pacemaker is NOT recommended.
• In an emergency or if a technician is unavailable, placing a magnet over an ICD will usually turn off the shock function as long as it remains in place. 

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Authors: David Earl, Nicholas Lavies

Transthoracic echocardiography (TTE) is a non-invasive tool for the assessment of cardiac structural and functional abnormality.  

This guideline discusses the indications for preoperative TTE in the context of common cardiac chronic health conditions, the relevant information available and how this can inform perioperative cardiac risk assessment.

Summary and Key Recommendations

• TTE is most commonly requested to assess left ventricular function and valvular pathology.
• There is no place for routine TTE in preoperative cardiac risk assessment.
• Preoperative TTE is warranted if there are new clinical signs of cardiac failure.
• Repeat TTE is not required in chronic stable cardiac failure. 
• Ejection fraction is poorly correlated with postoperative outcome.
• Aortic stenosis is a significant risk factor which is often asymptomatic.
• Preoperative TTE is indicated in a new finding of systolic murmur in those aged over 60 and in any patient if in addition the ECG is abnormal or there are cardiac symptoms.
• Preoperative TTE is indicated in the assessment of known moderate or severe aortic stenosis  if the valve has not been imaged within the last 1-2 years.
• Preoperative TTE is indicated in the diagnosis and assessment of pulmonary hypertension.
• Bedside focussed TTE shows promise in addressing availability when surgery is urgent. 

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Authors: Kiran Rait, Lui G Forni

This guideline aims to support avoidance of postoperative acute kidney injury (PO-AKI) in the perioperative period.  PO-AKI is associated with substantially increased patient morbidity, mortality and system costs, even when mild. 

Risk scoring systems to preoperatively identify at risk patients are discussed alongside perioperative strategies to avoid PO-AKI development are presented.

Guidance is also provided on early postoperative detection and assessment of PO-AKI to aiming to limit severity when it occurs.

Summary and Key Recommendations

• Avoidance of acute kidney injury (AKI) should translate into a reduction in perioperative morbidity and mortality as well as resulting in significant economic savings. Therefore, it should be considered as standard care of the pre-operative management for every patient.
• Perioperative AKI should be defined by the KDIGO criteria.
• Determine the risk of perioperative AKI by selecting an appropriate scoring system such as the “any-stage AKI score”.
• In the preoperative period there is no need to stop statins, ACE inhibitors or A2RBs unless additional factors predisposing to AKI are likely e.g. the use of other nephrotoxins.
• Consider using peri and post-operative goal-directed fluid therapy and avoid systolic hypotension.
• Assess for risk factors for AKI including CKD and optimise where possible. 
• In the event of post-operative AKI developing ensure a timely nephrology referral where the aetiology is not clear.
• Consider the use of biomarkers for AKI if available.  

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Authors: Pallavi Dasannacharya, Lenny Ng, Wolfgang Bauer

Antiplatelet therapies are common in patient presenting for major non-cardiac surgery, frequently within 12 months of coronary stenting.  Patients face the competing risks of perioperative myocardial events when antiplatelet therapies are interrupted and increased perioperative blood loss when they are continued. These must be balanced against surgical considerations.

This guideline reviews the commonly utilised antiplatelet agents and their indications for use. Approaches are presented to assess both cardiovascular thrombosis risk and risk of intraoperatively blood loss.  A stepwise approach to decision making around management of antiplatelet agents including several specific clinical contexts is provided summarising the best available evidence.

Summary and Key Recommendations

• The risk for perioperative cardiac events is increasing as the prevalence of ischaemic heart disease and coronary stents rises in the surgical patient population.
• The presence of coronary artery stents makes the perioperative management of antiplatelet therapy essential.
• Preoperative discontinuation of aspirin taken for secondary prevention is associated with increased risk of adverse cardiac events. This risk is highest for patients with coronary stents.
• Most routine operations can be undertaken without interrupting aspirin unless there is a risk of bleeding into an enclosed space. This also applies to dipyridamole.
• When clopidogrel is used as monotherapy, and discontinuation considered essential, low-dose aspirin should be substituted (unless contra-indicated).
• In situations of high thrombotic risk, when the patient is on dual antiplatelet therapy, elective surgery should generally be delayed until clopidogrel can be safely stopped.
• When surgery cannot be delayed and thrombotic risk is high, the continuation of both aspirin and clopidogrel should be a discussion between surgeon, anesthetist, and cardiologist.
• At present there is a lack of evidence about the bleeding risks with newer antiplatelet agents (prasugel, ticagrelor, cangrelor).
• Recent advances in stent technology support a shorter period of DAPT (Dual Antiplatelet Therapy) coverage. 

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Authors: Adrian Wong, Serene Ho

The use of herbal/traditional/complementary remedies amongst patients is variable and probably underreported. These substances may interact with prescribed and administered conventional medication and may have serious side effects.  Although regulation has been improved, there remain concerns over the efficacy, pharmacodynamics and pharmacokinetics of these agents

Patients should be asked specifically about their use of herbs, vitamins, supplements, or other natural or alternative products.

There is insufficient data on many of these herbal remedies to provide robust scientific recommendations however this guideline summarises the pragmatic advice for management of herbal remedies pre-operatively.  It also provides an outline of  the pharmacological effects and preoperative considerations for individual selected herbal remedies.

Summary and Key Recommendations

• The use of herbal/traditional/complementary remedies amongst patients is variable and probably underreported.
• Patients should be asked specifically about their use of herbs, vitamins, supplements, or other natural or alternative products.
• Although regulation has been improved, there remain concerns over the efficacy, pharmacodynamics and pharmacokinetics of these agents.
• There is insufficient data on many of these herbal remedies to provide robust scientific recommendations on when to stop them before surgery. However a pragmatic recommendation of 7 days will be sufficient for the commonly used remedies.
• Cannabinoids and marijuana should be discontinued 72 hrs before general anaesthesia.
• It is recommended that departments provide consistent advice on the perioperative management of herbal remedies and that this is regularly reviewed.  

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Authors: Kimme Hyrich

Over the past 2 decades, new drug development for autoimmune inflammatory diseases including rheumatoid arthritis and related conditions, psoriasis and inflammatory bowel disease has been rapid. 

Many of these drugs, in particular biologic and targeted synthetic DMARDs, are associated with an increased risk of infection although whether this extends to post-operative infections is less clear.  Data to support evidence-based decision making regarding the peri-operative management of DMARDs are limited and largely of low quality.  

Recommendations are given for management of conventional DMARDs and biologic and targeted synthetic DMARDs based on expert opinion and observational data.

Ideally an individualised risk assessment should take place based on the patient and the planned procedure and where possible, consultation with the DMARD prescriber.

Summary and Key Recommendations

Over the past 2 decades, new drug development for autoimmune inflammatory diseases including rheumatoid arthritis and related conditions, psoriasis and inflammatory bowel disease has been rapid. Many of these drugs, in particular biologic and targeted synthetic DMARDs, are associated with an increased risk of infection although whether this extends to post-operative infections including prosthetic joint infections is less clear. Data to support evidence-based decision making regarding the peri-operative management of DMARDs are limited and largely of low quality.

• It is advised to ensure a full drug history, including hospital prescribed injections and infusions, is taken from all patients as most new biologic DMARDs will not appear on GP prescription records. This should include all drugs received in the past 6 months where possible.
• It is currently recommended that patients can continue conventional DMARDs throughout surgery but should pause all biologic DMARDs at least 1 dosing interval prior to surgery. For some drugs this can be up to 3-6 months although most are dosed more frequently.
• Patients receiving new JAK inhibitors, a daily targeted synthetic DMARD, should hold this medication at least 1 week prior to surgery.
• Biologic DMARDs and JAK inhibitors can be restarted a minimum of 14 days after surgery once it is confirmed that there are no issues with wound healing and staples and sutures have been removed. They should NOT be administered in the setting of infection. 

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Author: Lyn Owens

Hazardous drinking (>14 units per week) is common in UK surgical populations and associated with multisystem perioperative complications. Reduction in preoperative consumption can reduced perioperative morbidity and mortality and requires a multidisciplinary approach in the preoperative period.

This guidance presents screening strategies for hazardous drinking and the provision of brief preoperative advice to control intake. Approaches and tools for detection and support of serious alcohol use disorders requiring more intensive preoperative support are also presented.

Summary and Key Recommendations

• “Make every contact count” Use the preoperative assessment clinic as an opportunity to identify patients at risk due to their drinking.
• Alcohol presents hidden harms to individuals that both patient and clinician may be unaware of.
• Alcohol consumption prior to surgery has been shown to increase risk of a number of often life threatening post-operative complications.
• Use alcohol assessment to identify preoperative interventions to improve postoperative outcomes.
• Plan surgery to coincide with achievement of alcohol treatment goals.
• Provide support for alcohol reduction or cessation: utilising local services and protocols. 

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Authors: GF Singleton, Judith Tomlinson, Ramani Moonesinghe 

Risk prediction tools should be used to guide multi-disciplinary decision-making, the allocation of appropriate resources and communication with patients and their families.  These tools can be divided into risk prediction scores (providing a numerical scale of risk) and models (providing a percentage estimate of risk).

This guideline describes how to evaluate risk prediction tools and looks individually at a range of tools available to assist the clinician in pre-operative risk assessment. 

It suggests that the SORT is easy to use requiring readily available preoperative data and has better calibration and discrimination than P-POSSUM and SRS. 

The conclusion is that further research should focus on the development of tools to predict other patient-centred outcomes (such as longer-term survival and health related quality of life) and on measuring the impact that the use of risk prediction tools may have on surgical outcome.  

Summary and Key Recommendations

• Risk prediction tools should be used to guide multi-disciplinary decision-making, the allocation of appropriate resources and communication with patients and their families.
• The ideal risk prediction tool incorporates information on patient health and fitness, and surgical magnitude and urgency. 
• Evidence from national audits suggests that formal assessment and documentation of risk is poorly and infrequently performed by clinicians in the pre-operative setting. Where risks are documented patients are more likely to receive care that meets standards.
• There are a number of tools available to assist the clinician in pre-operative risk assessment.  These can be divided into risk prediction scores (providing a numerical scale of risk) and models (providing a percentage estimate of risk).
• No tool is without limitations and all should be used alongside clinical judgment. Inter-hospital variation of the structure and process of care delivery may account for some performance limitation.
• The SORT is easy to use requiring readily available preoperative data and has better calibration and discrimination than P-POSSUM and SRS. A version of the SORT which incorporates clinical judgement could be used by MDTs and/or experienced perioperative clinicians, and the original SORT by other colleagues. 
• Further research should focus on the clinical effectiveness of risk prediction tool implementation (i.e. does using risk assessment tools actually improve patient outcomes) and on predicting other patient-centred outcomes such as longer-term survival and health related quality of life. 

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Authors: Emma Plunkett, Surrah Leifer

Preassessment services have a key role in the process of perioperative informed consent and facilitating shared decision-making.

This guideline provides practical support for services to assist the gaining of valid consent for surgery and anaesthesia including assessment of capacity, frameworks for discussion of risk and  provision of preoperative information.  Specific situations discussed include the patient assessed to lack capacity, advance directives and refusal of consent.

Summary and Key Recommendations

• Consent should be informed, voluntary and from a person who has capacity.
• Consent is a process and should involve shared decision making principles and / or frameworks.
• Pre-assessment clinics have an important role in the consent process by:
• Providing patients with key information related to the procedure and anaesthetic, especially written information.
• Identifying patient specific factors which may impact on the “material risks” to a particular patient.
• Pre-assessment staff should be with familiar with how to recognise if a patient does not have capacity and how to manage this situation in their organisation.
• A consent form for an elective surgical procedure should usually have been signed prior to the patient attending for nurse-led pre-assessment. 
• It is not necessary to take separate written consent for anaesthesia which is performed to facilitate a surgical procedure. 

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Authors: James Durrand, Gerard Danjoux

The association between poor exercise capacity morbidity and mortality has led to the introduction of objective functional capacity assessment within comprehensive preoperative assessment for major surgery.  Preoperative improvement in physical fitness through increased physical acitivty and structured exercise training is a potential route to improved surgical outcomes.

This guideline provides an overview of current evidence for preoperative exercise, a patient centred framework for exercise prescription in the context of a multimodal prehabilitation approach and strategies to support preoperative behaviour change.

Summary and Key Recommendations

• Prolonged physical inactivity leads to reduced aerobic capacity and loss of muscle mass (sarcopenia). This compromises the body’s ability to withstand the physiological demand of major surgery increasing risk of adverse perioperative outcomes.  Inactivity also promotes chronic health conditions that further elevate risk.
• Baseline activity levels, and objectively measured functional capacity, should be assessed prior to major surgery to help guide individual patient management.
• Preoperative exercise training has the potential to offset poor physical fitness resulting from chronic inactivity, or the effect of neoadjuvant cancer therapies, and improve perioperative outcomes.  
• Surgery presents a ‘teachable moment’ to facilitate lifestyle change.  Enhanced patient motivation in the preoperative period requires structured support to provide the opportunity and capability to make change.
• Combined programmes incorporating aerobic, resistance and inspiratory muscle training may yield the greatest benefits.  An ‘exercise prescription’ approach may be most effective.
• Patient and perioperative team education is critical to success and compliance. Consistent messaging across the entire perioperative pathway by all team members is key.
• Provision of preoperative structured exercise training is a collaborative effort between patients, primary care, secondary care and public health services to ensure available resources are appropriately allocated to patients most likely to benefit.
• A ‘menu’ of exercise support options will engage the widest number of surgical patients, one size cannot fit all.
• Exercise can be considered as one component of a multimodal prehabilitation approach to improve patient ‘readiness’ for surgery. 

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