Health Care Guideline:

Perioperative
Sixth Edition
January 2020

Index Table
1. General Preoperative Management

		 Preoperative Health Screening and Assessment
		 Preoperative Testing			Electrocardiogram			

Hemoglobin/Hematocrit Testing

			
			

			
			
			

			

Chest X-ray

Potassium/Sodium Testing

Renal Function (Creatinine) Testing
Pregnancy Testing

Hemostasis (Coagulation) Testing

Glucose Testing in Nondiabetic Patients

		 Sleep Apnea

		 Nicotine Cessation

		 Preparation for Surgery

2. Perioperative Management of Select Conditions
		 Cardiovascular Considerations
		 Prevention of Endocarditis

		Anticoagulants/Antithrombotics
		 Diabetes Mellitus

3. Perioperative Opioid Management

		 Preoperative Opioid Management			

Preoperative Patient Education			Preoperative Opioid Use			Preoperative Opioid Risk Assessment and Mitigation

		 Intraoperative Pain Management

		 Postoperative Opioid Management						

Postoperative Opioid Prescribing
Postoperative Patient Education

		 Perioperative Considerations for Patients with Opioid Use Disorder (OUD)						

Patients on Medication-Assisted Treatment (MAT)

Patients Not on Medication-Assisted Treatment (MAT)

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Table of Contents
Perioperative
Guideline WorkGroup Leader
Mayo Clinic
Nicole Varela, MD
Anesthesiology

Perioperative
Guideline WorkGroup Members
Allina Health
Joshua Mueller, MD
Internal Medicine
Entira Family Clinics(formerly of)
Hannah Degallier, PA-C
Family Medicine
Essentia HealthMark Grimm, MD
Anesthesiology
Fairview HealthServices
Deborah Mielke, MD
Family Medicine
Joan Kane, APNL,
CRNA
Nursing/Anesthesia
HealthPartners
Louis Millman, MD
Internal Medicine
Rebekah Roemer,
PharmD, BCPS
Pharmacy
Mayo Clinic
Adam Jacob, MD
Anesthesiology
Nathaniel Miller, MD
Family Medicine

Perioperative
OpioidManagement
Subgroup
Members
Allina Health
Justin Hora, PharmD
Pharmacy
Entira Family Clinics
David Thorson, MD
Family Medicine/Sports
Medicine
Essentia Health
Joseph Bianco, MD
Internal Medicine
Mark Grimm, MD
Anesthesiology
HealthPartners
Anne Pylkas, MD
Internal Medicine/
Addiction Medicine
Isaac Marsolek, MD
Physical Medicine &Rehabilitation
Rebekah Roemer,
PharmD, BCPS
Pharmacy
Hennepin Healthcare
Charles Reznikoff, MD
Internal Medicine/
Addiction Medicine
Mayo Clinic
Adam Jacob, MD
Anesthesiology

Annotations........................................................................................... 1–59
Index Table.................................................................................................1
Evidence Grading......................................................................................3
Recommendations Table..................................................................... 4–9
Foreword...........................................................................................10–11
Introduction.................................................................................... 10
Scope and Target Population........................................................ 11
Aims................................................................................................. 11
Implementation Recommendations Highlights......................... 11
Related ICSI Scientific Documents.............................................. 11
Definitions....................................................................................... 11
Annotations......................................................................................12–59
Quality Improvement Support....................................................60–63
Aims and Measures............................................................................... 61
Implementation Recommendations.................................................... 62
Implementation Tools and Resources................................................. 62
Implementation Tools and Resources Table....................................... 63
Supporting Evidence........................................................................64–76
References.........................................................................................65–75
Appendix................................................................................................. 76
Appendix A: Literature Search Description................................ 76
Disclosure of Potential Conflicts of Interest.........................77–80
Acknowledgements................................................................................. 81
Document History and Development......................................82–84
Document History................................................................................. 83
ICSI Document Development and Revision Process........................ 84

ICSI
Senka Hadzic, MPH
Facilitator

Nicole Varela, MD
Anesthesiology

Jodie Dvorkin, MD,
MPH
Co-Facilitator

North Memorial Health
Sarah Lippert, MD
General Surgery

Audrey Hansen, MA,
BSN
Co-Facilitator

University of Minnesota(formerly of)Kathleen Harder, PhD
Human Factors

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Evidence Grading
Literature Search
A consistent and defined literature search process is used in the development and revision of ICSI guidelines.
See Appendix A for literature search parameters and search terms. In addition to the literature searches,
articles were obtained by work group members and ICSI staff. Those vetted by the work group were includedin the guideline when appropriate.

Methodology
ICSI utilizes the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology system. GRADE involves systematically evaluating the quality of evidence (high, moderate, low,
very low) and developing a strength of recommendation (strong, weak). For more detailed information on
GRADE, please visit http://www.gradeworkinggroup.org/. In addition, when GRADE methodology could
not be applied, the work group developed consensus recommendations.
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Recommendations Table
The following table is a list of evidence-based recommendations for the Perioperative Guideline based on thereview of primary literature and secondary references (in instances where primary literature was not found).
Topic
Preoperative
HealthScreening andAssessment

Preoperative
Testing

Quality of
Evidence

Recommendation(s)Low

Do not routinely test all patients
undergoing elective, noncardiac
surgery.

Notapplicable

Chest X-ray

Low

Hemoglobin/
Hematocrit
Testing

Low

A preoperative health screening
and assessment that includes
a focused medical history andappropriate physical examination
should be completed for all patients
undergoing a surgical procedure,
regardless of setting (unless theprocedure involves mild sedation,or local/topical anesthesia).

The need for testing should be
guided by individual patient’s
clinical risk factors (based on
medical history and physicalexamination) and the risk of major
adverse cardiac event (morbidity
or mortality) associated with theplanned procedure.
Do not routinely perform chest
X-rays preoperatively unlessindicated by the review of medical
history and physical examination.
Do not routinely test for
hemoglobin preoperatively inhealthy, asymptomatic patients.

Testing for preoperative hemoglobin
level should be considered in:
1.	Patients with a history of anemia
or history suggesting recent
blood loss or anemia and theplanned procedure may leadto significant blood loss or
physiologic stress or
2.	Patients with prior or planned
anticoagulation (expert
consensus).

Strength of
Relevant Resources
Recommendation
Consensus

Fleisher, 2014
(Guideline); Apfelbaum,
2012b (Guideline)

StrongKeay, 2019 (Systematic
Review); Johansson,
2013 (Systematic
Review); Munro, 1997
(Systematic Review)

StrongJohansson, 2013
(Systematic Review);
Joo, 2005 (Systematic
Review)

StrongFowler, 2015 (MetaAnalysis); Johansson,
2013 (Systematic
Review); Munro, 1997
(Systematic Review)

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Recommendations Table
Topic
Potassium/
Sodium Testing

Renal Function(Creatinine
Testing)

Pregnancy
Testing

Quality of
Evidence
Low

Low

Not
Applicable

Recommendation(s)Do not routinely test for potassium
or sodium level preoperatively inhealthy, asymptomatic patients.
Testing may be indicated in:
1.	Patients who are on diuretic
therapy,
2.	Patients with kidney disease(stages 3–5),
3.	Patients on potassium
replacement therapy, or
4.	Patients undergoing bowel
preparation.

Do not routinely test for creatininelevels in healthy, asymptomaticpatients.
Testing may be indicated in patientswith known kidney disease or
patients with a comorbid condition(e.g., diabetes, hypertension) thatcarries increased risk of acutekidney injury or kidney disease.
Do not routinely conduct urine tests
for pregnancy. However, patients ofchildbearing age should be asked if
there is a possibility they might bepregnant.

Pregnancy testing is indicated in:
1.	Patients planning to undergo
surgeries involving theuterus (e.g., hysterectomy,
myomectomy),
2.	Uterine cavity surgery(e.g., dilation and curettage,
endometrial ablation), or
3.	Surgery that impacts blood flow
to the uterus (e.g., endovascularsurgeries that disrupt aortic
blood flow, procedures involving
the uterine arteries).

Strength of
Relevant Resources
Recommendation
StrongJohansson, 2013
(Systematic
Review); Wahr,
1999 (Observational
Study); Munro, 1997
(Systematic Review)

StrongKork, 2015
(Observational Study),
Johansson, 2013
(Systematic Review)

Consensus

ACOG, 2019 (Joint
Statement with ASA);
ASA, 2016 (Statement);
NICE, 2016
(Guideline); Apfelbaum,
2012b (Guideline)

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Recommendations Table
Topic
Hemostasis(Coagulation)
Testing

Glucose Testingin Nondiabetic
Patients

Quality of
Evidence
Low

Not
Applicable

Recommendation(s)Do not routinely perform
coagulation tests before surgery
unless indicated.
Indications for testing may include
the following:
1.	Patients with potential bleeding/clotting problem,
2.	Patients with a known history of
bleeding/clotting abnormalities,
3.	Patients with recent history
suggesting the potential for
bleeding/clotting problems,
4.	Patients who are currently taking
anticoagulant therapy, and5.	Patients who may needpostoperative anticoagulation(where a baseline may beneeded).
Consider glucose testing inpatients with risk factors fordiabetes (as defined by USPSTF
recommendations), or if a primarycare provider feels that diagnosis
of diabetes would alter the plan forsurgery.

Strength of
Relevant Resources
Recommendation
StrongJohansson, 2013
(Systematic Review);
Munro, 1997
(Systematic Review)

Consensus

USPSTF, 2015
(Guideline)

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Recommendations Table
Topic
Sleep Apnea

Nicotine
Cessation

Quality of
Evidence

Recommendation(s)Low

Smoking cessation intervention(brief or intensive) should beinitiated before elective surgery.

Not
applicable

Strength of
Relevant Resources
Recommendation

1.	Clinicians should use a validated Consensus
standardized screening tool toscreen patients for suspected
sleep apnea (risk factors or
patient reporting problems) or
sleep apnea symptoms, andcommunicate to the surgicalteam. Major risk factors forsleep apnea include obesity,
increased neck size (> 37 cm
in men, >35 cm in women),craniofacial abnormalities, older
age and male sex.
2.	Clinicians should remindpatients who have been formallydiagnosed with obstructive sleep
apnea and have an oral applianceor continuous positive airway
pressure equipment to bring
their appliance or equipmentwith them on the operative day
for use during the recovery fromanesthesia or sedation.
3.	Patients with suspected sleep
apnea in the perioperative
period should have a follow-up
evaluation, typically in concert
with the patient’s primary
provider (if one is available),and/or referral to sleep center.
4.	Patients with known sleep apnea
or suspected sleep apnea at apreoperative evaluation shouldhave this communicated to thesurgical and anesthesiology teamand the patient made aware thismay increase the surgical risk.
StrongChung, 2016
(Guideline); Gross,2014 (Guideline)

Bayfield, 2018 (MetaAnalysis); Nolan, 2017
(Observational Study);
Nolan, 2015 (Systematic
Review); Thomsen,
2014 (Systematic
Review)

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Recommendations Table
Topic
HbA1c Testingin Patients with
Diabetes during
Preoperative
Clinic Visit

Quality of
EvidenceNot
applicable

Low
Intraoperative
andPostoperative
Glycemic
Control Targets
for Patients with
Diabetes

Preoperative
Not
Opioid Tapering Applicable

Recommendation(s)Consider obtaining a preoperative
HbA1c test value, if not done in thepast three months, on patients withknown diabetes during preoperative
clinic visit.

Strength of
Relevant Resources
Recommendation
Consensus

Establish a plan for managementof diabetes prior to surgery. The
decision to proceed with surgery
or postpone surgery based on
preoperative HbA1c test value
should be based on individual
patient-centered factors such as
urgency of planned surgery, overallmortality/morbidity risks, risks ofperioperative infections, concerns
for postoperative glucose control,
and patient compliance.

Consider a glycemic target range
Weakbetween 140-180 mg/dL for surgicalpatients with diagnosed diabetes
during the intraoperative andpostoperative periods.
Additional considerations:
1.	For patients with diabetes withglucose levels typically <140, do
not treat to 140.
2.	Consider risk for hypoglycemia
if necessary to treat for glycemic
targets lower than 140.
An individualized approach fortapering in patients who are on
opioids preoperatively (including
patients with chronic opioid use)should be taken.

A decision on whether to taper
preoperatively needs to be madewell in advance of surgery.
However, if a significant medical
concern about opioid use isrecognized closer to the surgery
date that could be made safe with ataper, the patient, the provider andthe surgical team should discuss
whether delaying the surgery
in order to treat the underlying
condition is appropriate.

Consensus

ADA-Diabetes Carein the Hospital,
2019 (Guideline);van den Boom, 2018
(Observational
Study); NICE, 2016
(Guideline); Yang, 2016
(Observational Study);
Gustafsson, 2009
(Observational Study)

Nair, 2016
(Observational Study);
Sathya, 2013 (MetaAnalysis); Buchleitner,
2012 (Systematic
Review); Gandhi,
2007 (Randomized
Controlled Trial); Ata,
2010 (Observational
Study); Ramos, 2008
(Observational Study)
Jain, 2019
(Observational
Study); Nguyen, 2016
(Randomized Controlled
Trial); Hassamal, 2016
(Case Series)

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Recommendations Table
Topic
Postoperative
OpioidPrescribing

Quality of
Evidence

Not
Applicable

Recommendation(s)Strength of
Relevant Resources
Recommendation

The postoperative prescribed opioid Consensus
doses at discharge should be thelowest effective dose of short-acting
opioids.

Hill, 2018
(Observational
Study); Koehler,
2018 (Systematic
Review); Mark, 2018
(Observational Study);
Bicket, 2017 (Systematic
Review); Osmundson,2017 (Observational
Study); Thiels, 2017
(Observational
Study); Ray, 2016
(Observational
Study); Miller, 2015
(Observational
Study); Dhalla, 2009
(Observational Study)

The ICSI Work Group did not review primary literature and instead reviewed the recommendations fromthe relevant societies on the following topics (see specific section for the recommendations and ICSI workgroup’s decision on endorsement):•

Electrocardiogram testing•

Cardiovascular diseases•

Cardiovascular medications•

Preoperative fasting•

Prevention of endocarditis•

Insulin therapy regimens in diabetes mellitus

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Foreword
Introduction

The ICSI Perioperative Guideline has been enhanced to include a new section – Perioperative OpioidManagement – that was developed by a separate subgroup and reviewed and approved by the Perioperative
Guideline work group. The new section addresses the entire continuum of perioperative opioid management(preoperative, intraoperative and postoperative).
The Perioperative Guideline addresses and includes recommendations on the following topics:
Section 1: General Preoperative Management
1. Preoperative Health Screening and Assessment
2. Preoperative Testing (Electrocardiogram, Chest X-ray, Hemoglobin/Hematocrit, Potassium/Sodium,
Creatinine, Pregnancy, Hemostasis, and Glucose in Nondiabetics)
3. Sleep Apnea
4. Nicotine Cessation
5. Preparation for Surgery
Section 2: Perioperative Management of Select Conditions
6. Cardiovascular Considerations: Review of Select Recommendations from American College of
Cardiology/American Heart Association Guidelines
7. Prevention of Endocarditis: Endorsement of Recommendations from American College of Cardiology and American Heart Association Guidelines
8. Anticoagulants/Antithrombotics
9. Diabetes Mellitus
Section 3: Perioperative Opioid Management
10. Preoperative Opioid Management
11. Intraoperative Pain Management
12. Postoperative Opioid Management
13. Perioperative Considerations for Patients with Opioid Use Disorder (OUD)
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Foreword

Scope and Target Population•

Adults (aged 18 years and older) undergoing elective surgery.

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Aims

1. Increase the percentage of surgical patients undergoing elective surgery who have preoperative healthscreening and assessment.
2. Increase the percentage of surgical patients undergoing elective surgery who are smokers who havesmoking addressed prior to surgery.
3. Increase the percentage of surgical patients undergoing elective surgery with any risk factor for
obstructive sleep apnea (OSA) who are screened for OSA prior to surgery.

4. Increase the percentage of surgical patients undergoing elective surgery who have education on preoperative hair removal, bathing, fasting and oral hygiene prior to surgery.
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Implementation Recommendations Highlights

This section highlights general recommendations and tips on setting up organizational infrastructure to
implement the recommendations from this guideline. Refer to the section for more information.
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Related ICSI Scientific Documents•

Pain: Assessment, Non-Opioid Treatment Approaches and Opioid Management

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Definitions

Surgical care team – includes surgeon, anesthesiologist, nursing staff, and opioid prescriber involved inpatient care.
Primary care provider – a provider who performs preoperative health screening and assessment andconducts postoperative follow-up in primary care.
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Annotations
1. General Preoperative Management
Preoperative Health Screening and Assessment
Consensus Recommendation
A preoperative health screening and assessment that includes a focused medical history andappropriate physical examination should be completed for all patients undergoing a surgicalprocedure, regardless of setting (unless the procedure involves mild sedation, or local/topicalanesthesia).

Benefit:
Obtains current information on patient’s medical status to assess for medical conditions that could potentiallylead to adverse perioperative outcomes, and thus mitigate that risk.
Harm:
None.

Benefit-Harms Assessment:
Preoperative health screening and assessment is key to obtaining patient’s current medical status to help
clinicians determine if patient is at risk of adverse perioperative outcomes and to mitigate that risk.
Relevant Resources:
Fleisher, 2014 (Guideline); Apfelbaum, 2012b (Guideline)

Preoperative health screening and assessment should be performed before all surgical procedures unless theprocedure involves mild sedation or a local/topical anesthesia. The goal is to identify and manage medical
conditions that may impact perioperative morbidity and mortality.
Preoperative health screening and assessment should include a focused review of medical history and appropriate physical examination. Additional testing including laboratory, electrocardiogram (ECG) and further
cardiopulmonary evaluation should be based on medical history and physical exam and in consideration ofsurgical procedure risk for adverse cardiac event (see “Preoperative Testing” section for details).
Specifically, focused medical history and physical examination should include (by the expert consensus
of the ICSI work group):• Medical history
Indication for surgical procedure
Allergies and adverse reactions to medications (specify reaction type)
Anesthesia related complications or adverse events (personal and family history)
History of a difficult airway or intubation
Medical history and active medical problems
Surgical history
Current medications, over-the-counter remedies, herbal and dietary supplements
Implantable devices (cardiac devices, spinal stimulator, pain pumps etc.)
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Annotations
Focused review of issues pertinent to the planned anesthesia and procedure:•-

Current status of pertinent known medical issues-

Cardiac status-

Pulmonary status-

The ability to perform four or more METs-

Personal or family history of abnormal bleeding and history/at risk for anemia-

Pregnancy status-

Smoking, alcohol history and illicit drugs-

Risk factors for development of surgical site infection (e.g., smoking, diabetes, obesity, malnutrition, chronic skin disease)-

Risk factors for development of venous thromboembolism (VTE). VTE is a common andpotentially fatal perioperative complication. All surgical patients should undergo risk assessment
for the development of VTE and have appropriate measures taken to prevent both clotting andbleeding abnormalities in the perioperative period.

-

Chronic pain and/or chronic opioid use; plan for postoperative pain management-

Discharge plan following surgery that includes social support-

Need for assistive devices following surgery (e.g., walker, hospital bed)

Physical examination
Weight, height
Vital signs – blood pressure, pulse (rate and regularity), respiratory rate
Cardiovascular exam
Pulmonary exam
Other exams pertinent to surgical procedure and planned anesthesia such as:-

Skin exam for signs of infection-

Neurologic exam-Musculoskeletal-

Airway exam including dentition

Primary care provider communication with the surgical teamThe primary care provider should provide pertinent information to the anesthesiologist and surgeon on resultsof preoperative health screening and assessment in advance of anticipated day of scheduled procedure for all
patients undergoing elective surgery. The report should include a comprehensive assessment, any adjunctive
evaluation and specific recommendations. The ICSI work group acknowledges that regulatory agencies
may have their own requirements for documentation of completion and timing of provision of information.
In instances that a review of the current history and focused physical examination is required on the day ofsurgery prior to the procedure, it may be done by the provider performing the procedure.
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Annotations

Perioperative medication management
Ensure medication reconciliation, preoperatively. Navigating the topic of medications to stop or continue
in the perioperative period can be complicated, especially as new medications come to market frequently.
Working with a pharmacist to help develop and implement perioperative plans regarding medication management (medications to stop or continue) can be beneficial. The pharmacist can also perform medication
reconciliation, guide medications decisions and oversee medication dispensing.
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Preoperative Testing
Recommendation

Quality of Evidence

Do not routinely test all patients undergoing elective noncardiac
surgery.

Quality of Evidence: Low

The need for testing should be guided by individual patient’s
clinical risk factors (based on medical history and physicalexamination) and the risk of major adverse cardiac event(morbidity or mortality) associated with the planned procedure.

Strength of Recommendation: Strong

Benefit:• Ensures only tests of value for patients who need it are performed.
• Decreases unnecessary perioperative costs for both patients and the health care system.
Harm:• A possibility of missing an important diagnosis.

Benefit-Harms Assessment:
Given the low likelihood that routine testing of healthy, asymptomatic patients will uncover issues that mightlead to adverse outcomes during perioperative period, only those patients who would benefit from additional
testing should undergo it.
Relevant Resources:
Keay, 2019 (Systematic Review); Johansson, 2013 (Systematic Review); Munro, 1997 (Systematic Review)

A 1997 systematic review of case series studies found no evidence to support routine preoperative tests(chest X-ray, electrocardiogram, hemostasis, blood counts, hemoglobin, potassium, creatinine, glucose andurine testing for pregnancy) in healthy, asymptomatic adults. Very few patients went on to have a change
in management of the condition prior to surgery. (Munro, 1997)
A systematic review of three randomized trials and 98 cohort studies found no evidence that preoperative
testing is beneficial in healthy adults undergoing noncardiac surgery. (Johansson, 2013)
Large studies have found no evidence to support routine testing in low risk surgeries such as cataract surgery.
A systematic review of three randomized controlled trials including 21,531 cataract surgery patients foundroutine preoperative medical testing did not reduce the risk of intraoperative or postoperative ocular adverse
events when compared to selective or no testing. (Keay, 2019)
The need for preoperative testing should be guided by preoperative screening and assessment of clinical risk
factors based on patient’s pertinent medical history and physical exam, and in consideration of risk of major
adverse cardiac event (morbidity or mortality) associated with the planned procedure. Consultation withthe surgeon or proceduralist may be necessary to clarify relative procedural risk for the planned procedure.
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Annotations

To help stratify surgical procedure risk, the American College of Cardiology (ACC)/American Heart Association (AHA) estimates the combined surgical and patient characteristics predict a risk of a major adverse
cardiac event (MACE) of death or myocardial infarction of <1% in low-risk surgeries Procedures with arisk of MACE of >=1% are considered elevated risk. (Fleisher, 2014)
There is some evidence that older age may be a factor in increasing the risk of adverse cardiac event during
surgery depending on the type of surgery. An analysis of 2,853 procedures found inpatient mortality rate forhigh-risk procedures in patients 65 years and older was double the rate of patients younger than 65 years.
(Schwarze, 2015)
To guide perioperative mortality risk determination, the 2014 ACC/AHA Guideline on Perioperative
Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery recommends theuse of a validated risk prediction tool to predict the risk of perioperative major adverse cardiac event inpatients undergoing noncardiac surgery. (Fleisher, 2014) Risk calculators may include the Revised Cardiac
Risk Index, American College of Surgeons National Surgical Quality Improvement Program (NSQIP)
Myocardial Infarction and Cardiac Arrest (MICA), and American College of Surgeons NSQIP Surgical
Risk Calculator. (Fleisher, 2014)
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Electrocardiogram
Cardiac arrhythmias and conduction disturbances are common findings in the perioperative period. However,limited evidence does not support routine testing in healthy, asymptomatic individuals. A 1997 systematic
review of case series studies in healthy and asymptomatic adults found routine preoperative electrocardiograms were abnormal in 4.6-31.7% of cases (with the proportion of abnormal tests rising with age andworsening physical status) and led to a change of management in 0-2.2% of patients with unknown effect onpatient outcomes. (Munro, 1997) A literature search by the ICSI Work Group did not find any new studies
on relationship of preoperative electrocardiogram testing to perioperative mortality and morbidity outcomes.
The ICSI work group AGREES with the 2014 ACC/AHA Guideline on Perioperative Cardiovascular
Evaluation and Management of Patients Undergoing Noncardiac Surgery recommendation on preoperative electrocardiogram (ECG). (Fleisher, 2014):• Routine electrocardiogram is not useful for asymptomatic patients undergoing low-risk surgicalprocedures.
•Electrocardiogram is reasonable in patients with known coronary heart disease, significant
arrhythmia, peripheral arterial disease or other structural heart disease, except for those undergoing
low-risk surgery.

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Annotations

Chest X-ray
Recommendation

Quality of Evidence

Do not routinely perform chest X-rays preoperatively unlessindicated by the review of medical history and physicalexamination.

Quality of Evidence: Low

Strength of Recommendation: Strong

Benefit:• Ensures only tests of value for patients who need it are performed.
• Decreases unnecessary perioperative costs for both patients and the health care system.
Harm:• A possibility of missing an important diagnosis.

Benefit-Harms Assessment:
Given the low likelihood that routine testing of healthy, asymptomatic patients will uncover issues that mightlead to adverse outcomes during perioperative period, only those patients who would benefit from additional
testing should undergo it.
Relevant Resources:
Johansson, 2013 (Systematic Review); Joo, 2005 (Systematic Review)

Preoperatively, chest X-rays can help assess status for known chronic medical conditions or to detect previously undiagnosed diseases such as chronic obstructive pulmonary disease (COPD), heart failure, tuberculosis
and lung cancer. (NICE, 2016)
The evidence does not indicate routine use of chest X-rays in healthy, asymptomatic adults. A 2005
systematic review of 14 studies found a highly variable rate of abnormalities (most common ones werecardiomegaly and chronic obstructive pulmonary disease) found on X-rays. The rate of abnormalities varied
from 4-47% and increased with age. Few of these patients had a change in preoperative management. The
rate of postoperative pulmonary complications was similar between patients who had preoperative chest
X-ray and those who did not. (Joo, 2005) Similarly, a 2013 systematic review of two cohort studies foundno significant association between abnormal chest X-ray tests and postoperative pulmonary complicationsin healthy patients undergoing elective, noncardiac surgery. (Johansson, 2013)
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Annotations

Hemoglobin/Hematocrit Testing
Recommendation

Quality of Evidence

Do not routinely test for hemoglobin preoperatively in healthy,
asymptomatic patients.

Quality of Evidence: Low

Testing for preoperative hemoglobin level should be consideredin:
1.	Patients with a history of anemia or history suggesting recent
blood loss or anemia and the planned procedure may lead tosignificant blood loss or physiologic stress, or
2.	Patients with prior or planned anticoagulation (expert
consensus).

Strength of Recommendation: Strong

Benefit:• Ensures only tests of value for patients who need it are performed.
• Decreases unnecessary perioperative costs for both patients and the health care system.
Harm:• A possibility of missing an important diagnosis.

Benefit-Harms Assessment:
Given the low likelihood that routine testing of healthy, asymptomatic patients will uncover issues that mightlead to adverse outcomes during perioperative period, only those patients who would benefit from additional
testing should undergo it.
Relevant Resources:
Fowler, 2015 (Meta-Analysis); Johansson, 2013 (Systematic Review); Munro, 1997 (Systematic Review)

One purpose of the routine preoperative measurement of hemoglobin is to detect anemia as anemia may
impact general anesthesia or patient may be at risk of significant blood loss during procedure.
The evidence does not indicate routine use of hemoglobin tests in healthy, asymptomatic adults. However,
the evidence suggests that it should be considered in patients who have anemia or had a recent blood loss andare at risk for significant blood loss during surgery. The ICSI work group expert consensus is that patientswith prior or planned anticoagulation should also have their hemoglobin levels tested.
The evidence is insufficient to recommend an optimal preoperative hemoglobin levels that would avoid
perioperative complications. The optimal preoperative hemoglobin level (that provides a reserve for unexpected blood loss or cardiorespiratory stress) varies by patient and by type of procedure. The ICSI workgroup expert consensus is that the primary care provider and the surgeon should work together to establish
an individual patient plan for management of hemoglobin levels prior to surgery. It is imperative for the
primary care provider ordering hemoglobin tests to communicate the results to the surgeon; conversely, thesurgeon should communicate to the primary care provider if the procedure could potentially cause significant blood loss.
A 1997 systematic review of case series studies in healthy, asymptomatic adults found that routine preoperative hemoglobin testing level was lower than 10-10.5 g/dl in up to 5% of patients, but rarely lower than 9g/dl with change of preoperative management in only 0.1% to 2.7% of patients. (Munro, 1997)
A 2013 systematic review of 35 cohort studies and four case-control studies found a strong correlation between
low hemoglobin levels and the risk for perioperative and postoperative blood transfusions in patients withpre-existing conditions or signs of anemia during clinical examination and in medical history. (Johansson,2013) A 2015 meta-analysis of 24 observational studies including 371,594 patients with anemia found that
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anemia was associated with increased mortality, acute kidney injury, infection and increased incidence of red
cell transfusion in anemic patients undergoing noncardiac or cardiac surgeries. In cardiac surgery, anemia
was associated with increased risk for stroke but not myocardial infarction. (Fowler, 2015)
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Potassium/Sodium Testing
Recommendation

Quality of Evidence

Do not routinely test for potassium or sodium level
preoperatively in healthy, asymptomatic patients unlessindicated.

Quality of Evidence: Low

Strength of Recommendation: Strong

Testing may be indicated in:
1.	Patients who are on diuretic therapy,
2. Patients with kidney disease (stage 3–5), or
3. Patients on potassium replacement therapy, or
4. Patients undergoing bowel preparation.

Benefit:• Ensures only tests of value for patients who need it are performed.
• Decreases unnecessary perioperative costs for both patients and the health care system.
Harm:• A possibility of missing an important diagnosis.

Benefit-Harms Assessment:
Given the low likelihood that routine testing of healthy, asymptomatic patients will uncover issues that mightlead to adverse outcomes during perioperative period, only those patients who would benefit from additional
testing should undergo it.
Relevant Resources:
Johansson, 2013 (Systematic Review); Wahr, 1999 (Case-Control Study); Munro, 1997 (Systematic Review)

Testing for serum potassium level is important in patients with conditions that may lead to significant hypokalemia or dialysis dependence (e.g., patients taking non-potassium sparing diuretics such as hydrochlorothiazide). Hypokalemia increases the risk of dysrhythmia and makes treatment of dysrhythmias difficult inpatients undergoing general anesthesia. Hyperkalemia may also lead to delays or cancellations of elective
surgeries due to potential for cardiac arrhythmias.
The evidence does not indicate routine use of potassium tests in healthy, asymptomatic adults undergoing
elective surgery. However, the evidence suggests that potassium testing may be indicated in patients withconditions or medical history that put them at risk for cardiac arrhythmia or are undergoing cardiac surgery.
A 1997 systematic review of case series studies in healthy, asymptomatic adults found that in routine
preoperative tests of serum biochemistry, abnormal levels of sodium or potassium are found in up to 1.4%of patients which rarely led to a change in preoperative management. (Munro, 1997) A 2013 systematic
review of five cohort studies found that elevated and low sodium values correlated positively with 30-day
mortality in one study in veterans with ASA physical status of one, two or three undergoing elective surgery;however, the other four studies included in the review found no significant relationship between electrolyte
tests and perioperative complications for patients undergoing elective procedures. (Johansson, 2013) A
1999 case-control study of 2,402 patients undergoing elective coronary artery bypass grafting found significantly increased risk for serious perioperative arrhythmia, intraoperative arrhythmia and postoperative atrial
fibrillation/flutter as well as increased need for CPR in patients with serum potassium level less than 3.5mmol/L. (Wahr, 1999)
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Renal Function (Creatinine) Testing
Recommendation

Quality of Evidence

Do not routinely test for creatinine levels in healthy,
asymptomatic patients unless indicated.

Quality of Evidence: Low

Testing may be indicated in patients with known kidneydisease, or patients with a comorbid condition (e.g., diabetes,
hypertension) that carries increased risk of acute kidney injury
or kidney disease.

Strength of Recommendation: Strong

Benefit:• Ensures only tests of value for patients who need it are performed.
• Decreases unnecessary perioperative costs for both patients and the health care system.
Harm:• A possibility of missing an important diagnosis.

Benefit-Harms Assessment:
Given the low likelihood that routine testing of healthy, asymptomatic patients will uncover issues that mightlead to adverse outcomes during perioperative period, only those patients who would benefit from additional
testing should undergo it.
Relevant Resources:
Kork, 2015 (Observational Study), Johansson, 2013 (Systematic Review)

Acute kidney injury is one of the leading causes for postoperative organ failure, with an estimated incidenceof approximately 1% in noncardiac surgery patients. (Kork, 2015)
The evidence does not indicate routine use of creatinine tests in healthy, asymptomatic adults undergoing
elective surgery. However, the evidence suggests that creatinine testing may be indicated in patients withknown kidney disease or patients who are planning to undergo procedures with increased risk of acute kidney
injury. A baseline creatinine level should be established in these patients. It is the consensus of the ICSI
work group to test potassium levels within 30 days of the planned procedure. If the values are expected tochange or the patient has an acute condition, the levels may be redone closer to the day of the procedure.
A 2013 systematic review of 23 cohort studies on renal tests (creatinine and others) found a positive correlation between pathological renal function tests and the occurrence of complications in 11 studies of patientswith known pre-existing renal disease (the remaining studies either did not provide data or there was no
significant relationship). (Johansson, 2013) A 2015 study of 37,345 noncardiac surgery and 2,024 cardiac
surgery patients found that patients with acute kidney injury had a fivefold higher mortality risk and a fivedays longer hospital length of stay. The study also found that even minor creatinine increases (change increatinine from 25-49% above baseline but < 0.3 mg/dl) not meeting criteria for AKI were associated witha twofold increased risk of death and two-days longer hospital length of stay in all patients. In patients
undergoing noncardiac surgery, minor creatinine increases were associated with a fivefold risk of death anda three-days longer hospital length of stay. (Kork, 2015)
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Pregnancy Testing
Consensus Recommendation
Do not routinely conduct urine tests for pregnancy. However, patients of childbearing age should be
asked if there is a possibility they might be pregnant.
Pregnancy testing is indicated inpatients planning to undergo surgeries involving:
1. The uterus (e.g., hysterectomy, myomectomy),
2. Uterine cavity (e.g., dilation and curettage, endometrial ablation), or
3.	Surgery that impacts blood flow to the uterus (e.g., endovascular surgeries that disrupt aortic blood
flow, procedures involving the uterine arteries).
Benefit:• Ensures only tests of value for patients who need it are performed.
• Decreases unnecessary perioperative costs for both patients and the health care system.
Harm:• A possibility of missing a potential pregnancy.

Benefit-Harms Assessment:
Given the low likelihood that routine pregnancy testing of all female patients will uncover a potential
pregnancy and insufficient evidence on harms of anesthesia in pregnant patients, patients should be asked if
there is a possibility they are pregnant and further test those where there is an indication. Shared decisionmaking discussions can help guide decisions whether to test.
Relevant Resources:
ACOG, 2019 (Joint Statement with ASA); ASA, 2016 (Statement); NICE, 2016 (Guideline); Apfelbaum,
2012b (Guideline)

Elective surgery in pregnant patients is generally avoided unless absolutely necessary due to the concernswith anesthetic teratogenicity and miscarriage during the procedure. (NICE, 2016) The evidence, however,is unclear on the harm of anesthesia to pregnant patients and fetus during surgery.
Literature shows the overall frequency of an incidentally found positive preoperative pregnancy test ranges
from 0.34% to 2.4%. (Maher, 2012) The American Society of Anesthesiologists (ASA) Task Force on
Preanesthesia Evaluation literature review found insufficient evidence on harmful effects of anesthesia on
early pregnancy. (Apfelbaum, 2012b)
The ICSI work group consensus is to not routinely conduct urine test for pregnancy. However, patientsof childbearing age should be asked if there is a possibility they might be pregnant. Pregnancy testing is
indicated in patients planning to undergo surgeries involving the uterus (e.g., hysterectomy, myomectomy),uterine cavity (e.g., dilation and curettage, endometrial ablation), or that impact blood flow to the uterus(e.g., endovascular surgeries that disrupt aortic blood flow, procedures involving the uterine arteries).
Shared decision-making approach can be used to inform patients of the relative risks and benefits of undergoing the planned surgery and anesthesia while pregnant and to determine if pregnancy testing is desiredby the patient. The decisions to test should be guided by the following information:•

No currently used anesthetic agents have been shown to have any teratogenic effects in humans whenusing standard concentrations at any gestational age. (ACOG, 2019)•

Current scientific information is not sufficient to determine whether anesthesia causes harmful effects
during pregnancy. (ASA, 2016)•

Current scientific information is not sufficient to determine whether pre-natal exposure to maternal
anesthetics causes adverse neurodevelopmental effects. (ASA, 2016)

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Hemostasis (Coagulation) Testing
Recommendation

Quality of Evidence

Do not routinely perform coagulation tests before surgery unless Quality of Evidence: Low
indicated.
Strength of Recommendation: Strong
Indications for testing may include the following:
1. Patients with potential bleeding/clotting problem,
2.	Patients with a known history of bleeding/clotting
abnormalities,
3.	Patients with recent history suggesting the potential for
bleeding/clotting problems,
4. Patients who are currently taking anticoagulant therapy, and5.	Patients who may need postoperative anticoagulation (wherea baseline may be needed).
Benefit:• Ensures only tests of value for patients who need it are performed.
• Decreases unnecessary perioperative costs for both patients and the health care system.
Harm:• A possibility of missing an important diagnosis.

Benefit-Harms Assessment:
Given the low likelihood that routine testing of healthy, asymptomatic patients will uncover issues that mightlead to adverse outcomes during perioperative period, only those patients who would benefit from additional
testing should undergo it.
Relevant Resources:
Johansson, 2013 (Systematic Review); Munro, 1997 (Systematic Review)

In the preoperative setting, hemostasis tests (e.g., prothrombin time, activated partial thromboplastin time,
platelet count) are used to establish a baseline for the patient and may be used to plan the use of blood
products and blood salvage techniques in the perioperative period. (NICE, 2016)
The evidence does not indicate routine use of hemostasis tests in healthy, asymptomatic adults undergoing
elective surgery. However, the evidence suggests that hemostasis testing may be indicated in patientswith a potential bleeding/clotting problem, patients with a known history of bleeding/clotting abnormalities, patients with recent history suggesting the potential for bleeding/clotting problems, patients who are
currently taking anticoagulant therapy, and patients who may need postoperative anticoagulation (where abaseline may be needed).
A 1997 systematic review of case series studies in healthy, asymptomatic adults found abnormalities of
bleeding time, prothrombin time and partial thromboplastin time in up to 3.8%, 4.8% and 15.6% of routine
preoperative tests, respectively, which rarely leads to change in the clinical management. (Munro, 1997)
A 2013 systematic review of nine cohort studies found one study that showed a correlation between anabnormal platelet count and an abnormal international normalized ratio test, and the outcomes in adverse
events or morbidity in patients undergoing elective abdominal surgery. Another study in the review found acorrelation between an abnormal prothrombin time and an abnormal platelet count, and mortality in patients
undergoing miscellaneous surgeries. Both of these studies included patients with pre-existing conditions
or who were older adults. The remaining studies in the review did not find valid evidence suggesting thatroutine preoperative hemostasis testing would lead to a change in clinical management or outcome inasymptomatic patients. (Johansson, 2013)
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Glucose Testing in Nondiabetic Patients
There is little evidence around screening for diabetes during the preoperative clinic visit.
The review of evidence shows no clear evidence to determine if diabetes screening in asymptomatic patientsshould be done preoperatively. A prospective study of 120 patients without known diabetes who underwent
major colorectal surgery found that patients with a preoperative HbA1c level over 6.0% had higher mean
postoperative glucose and C-reactive protein levels, and postsurgical complications than patients with anormal HbA1c level. (Gustafsson, 2009) A 1997 systematic review of case series studies found abnormal
levels of glucose in up to 5.2% of healthy or asymptomatic patients undergoing elective surgery. Thesefindings rarely led to change in clinical management. (Munro, 1997) A 2015 systematic review of 22 cohortand case-controlled studies found no data to support routine preoperative testing for blood glucose or HbA1clevels in otherwise healthy adult patients undergoing elective noncardiac surgery. (Bock, 2015)
Given the scarcity of evidence on preoperative HbA1c levels and postoperative outcomes, the 2016 NICE
guidelines recommend against routinely offering HbA1c testing before surgery to people without diagnosed
diabetes.
The U.S. Preventive Services Task Force (USPSTF) recommends screening for abnormal blood glucose
as part of cardiovascular risk assessment in patients aged 40-70 years without obvious diabetes symptoms
who are overweight/obese and seen in primary care settings. According to USPSTF, individuals who havea family history of diabetes, have a history of gestational diabetes or polycystic ovarian syndrome, or are
members of certain racial/ethnic groups (i.e., African Americans, American Indians or Alaskan Natives,
Asian Americans, Hispanics or Latinos, or Native Hawaiians or Pacific Islanders) may be at increased riskfor diabetes at a younger age or at a lower body mass index. Clinicians should consider screening earlier
in individuals with one or more of these characteristics. (USPSTF, 2015)
Given the available information, the consensus of the ICSI work group on glucose testing in nondiabetic patients during preoperative clinic visit is the following: Consider glucose testing in patientswith risk factors for diabetes (as defined by USPSTF recommendation above) or if a primary careprovider feels that diagnosis of diabetes would alter the plan for surgery.
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Sleep Apnea
Consensus Recommendation
1.	Clinicians should use a validated standardized screening tool to screen patients for suspected sleep
apnea (risk factors or patient reporting problems) or sleep apnea symptoms, and communicate
outcomes to the surgical team. Major risk factors for sleep apnea include obesity, increased necksize (> 37 cm in men, > 35 cm in women), craniofacial abnormalities, older age and male sex.  

2.	Clinicians should remind patients who have been formally diagnosed with obstructive sleep apnea
and have an oral appliance or continuous positive airway pressure equipment to bring theirappliance or equipment with them on the operative day for use during the recovery from anesthesia
or sedation.
3.	Patients with suspected sleep apnea in the perioperative period should have a follow-up evaluation,
typically in concert with the patient’s primary provider (if one is available), and/or referral to sleep
center.
4.	Patients with known sleep apnea or suspected sleep apnea at a preoperative evaluation should havethis communicated to the surgical and anesthesiology team, and the patient made aware this may
increase the surgical risk.
Benefit:Targeted screening and identification of at-risk patients can direct therapy that may prevent common
complications associated with perioperative sleep apnea.
Harm:
False-positive screening may lead to unnecessary testing or surgical delay in some patients.

Benefit-Harms Assessment:
The potential to treat the myriad and serious harms associated with untreated perioperative sleep apnea
outweighs the rare harms associated with additional testing.
Relevant Resources:
Chung, 2016 (Guideline); Gross, 2014 (Guideline)

Obstructive sleep apnea has been identified as a perioperative risk factor with increased risks of pulmonary
complications and desaturations, and has been linked to postoperative cardiovascular events, though its effecton perioperative mortality is less clear. (Chung, 2016) Thus, sleep apnea should be considered during the
preoperative evaluation. Validated OSA screening tools in adult surgical patients include the STOP-Bang,
P-SAP, Berlin, and ASA checklist. (Chung, 2016)
Some adult patients may not have a diagnosis of obstructive sleep apnea confirmed by polysomnography
studies but are presumed to have obstructive sleep apnea based on the preoperative history and physicalexamination. Quick and inexpensive surrogates for polysomnography studies are not new and have several
variants. Patients who score high on these indices may need to be treated in the perioperative period asthough they have a formal diagnosis of obstructive sleep apnea. This information should be communicatedto the surgeon and anesthesiologist before the patient undergoes any procedure involving general anesthesia,
monitored anesthesia care, conscious sedation or the administration of narcotics. (Chung, 2016) At this point
evidence does not support delaying surgery to have polysomnography for formal diagnosis. (Chung, 2016)
However, it may be reasonable to delay surgery in certain situations such as patients undergoing surgery
with a very high rate of OSA, e.g., bariatric surgery or where other pulmonary comorbidities are suspected,
e.g., obesity hypoventilation syndrome or severe pulmonary hypertension. (Chung, 2016) Patients withknown sleep apnea or suspected sleep apnea at a preoperative evaluation should have this communicatedto the surgical and anesthesiology team, and the patient made aware this may increase the surgical risk. In
patients with suspected sleep apnea in the perioperative period, follow-up evaluation is recommended inconcert with the patient’s primary provider (if one is available) and/or referral to sleep center.
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Use of PAP for patients with known OSA may reduce postoperative complications. (Chung, 2016) Adult
patients with a diagnosis of obstructive sleep apnea often have oral appliances or continuous positive airway
pressure equipment and should be reminded to bring those appliances or equipment on the operative day, foruse during the recovery from anesthesia or sedation. Additionally, expert recommendations suggest monitoring patients with known or high risk for OSA until they are no longer at risk of perioperative respiratory
depression, though research supporting this practice is minimal. (Gross, 2014)
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Nicotine Cessation
Recommendation

Quality of Evidence

Smoking cessation intervention (brief or intensive) should beinitiated before elective surgery.

Quality of Evidence: Low

Strength of Recommendation: Strong

Benefit:
Smoking cessation may reduce postsurgical complication with the best evidence suggesting reduced surgicalsite infections and pulmonary complications. Additionally, the long-term benefit of smoking cessation issubstantial.
Harm:
Increased patient visits and patient cost when undertaking intensive smoking cessation.

Benefit-Harms Assessment:
The potential benefits of smoking cessation with postsurgical complications and long-term health outcomesoutweigh minimal harms.
Relevant Resources:
Bayfield, 2018 (Meta-Analysis); Nolan, 2017 (Observational Study); Nolan, 2015 (Systematic Review);
Thomsen, 2014 (Systematic Review)

Although smoking cessation should always be encouraged, research suggests that intensive rather than brief
interventions are more effective. A systematic review found that brief interventions reduce the number ofpatients smoking by the day of surgery, but have not consistently shown to decrease postoperative complications, nor is there any long-term reduction in smoking rates. (Thomsen, 2014) Intensive smoking cessation interventions (multisession face-to-face counselling) started greater than four weeks prior to surgery
demonstrated efficacy at reducing smoking by the day of surgery, decreased postoperative wound and overall
complications, and showed a significant reduction in smoking at 12 months. (Thomsen, 2014)
An observational study of smokers undergoing elective surgery found that smoking cessation started the dayof surgery has been linked to lower postoperative surgical site infections. (Nolan, 2017) A meta-analysis
found that cardiac surgery patients who are current smokers at the time of surgery had no increased 30-day
mortality risk compared to ex-smokers, although they were at significantly increased risk of postoperative
pulmonary complications. (Bayfield, 2018) Despite the limited data, this work group agrees that patientsshould be strongly encouraged at all times to abstain from nicotine any time before surgery.
Data regarding nicotine replacement therapy (NRT) is extremely limited, and there is no convincing researchsuggesting NRT is harmful. A systematic review of the topic notes that when NRT is used to help withsmoking cessation, there is a reduction in perioperative complications. (Nolan, 2015) In sum, if patientsare using nicotine replacement therapy prior to surgery, this should be continued preoperatively.
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Preparation for Surgery
Patient Preparation and Education
When providing patient education about their procedure, adequate attention to patients’ reading level, potential visual impairments (if so, large print materials could be provided) and other potential learning barriers
is a critical component for preparing them for surgery.
The components of patient education should include the following:•

Patients and families should be educated on how to manage postoperative pain, when to resume activities of daily living, and how to manage other risk factors such as diabetes, incontinence and impaired
immune status/response.

•

Patients should be educated and informed of fasting requirements sufficiently in advance of the procedure.

•

Patients should be educated on medications that are prescribed at discharge. Medication reconciliation
should be completed and a current medication list sent home with the patient.

•

All patients should be educated on the signs and symptoms of surgical site infection.

•

Patients and families should be provided emergency contact numbers and instructions on whom to call.

•Confirm that discharge instructions have been explained, and patients and family should verbalize
understanding. Because patients may forget verbal instructions, written instructions should be provided.

•

When necessary, it should be verified that the patient will have care assistance for at least 24 hours.

•

Patient and families should be educated on the importance of good hand hygiene in the prevention of
infection. Patients and families managing wound dressings should wash their hands (either soap andwater or waterless hand gels) before and after every contact.

•

Patients and families should receive proper instruction on wound care.

Preoperative Showering/Bathing, Hair Removal and Oral Hygiene
To prevent surgical site infections, patients should be advised to shower/bathe before arriving for theirsurgical procedure. However, there is no evidence that specific wash products with antiseptic solution are
more beneficial than other wash products or soap without antiseptic. The evidence also did not find that hairremoval was beneficial in preventing surgical site infection. If hair removal is necessary, hair clipping was
found to be more effective in preventing surgical site infection than shaving or depilatory cream. Limited
evidence indicates the benefit of perioperative oral hygiene in the reduction of postoperative respiratory
airway infections. Each facility should establish specific guidelines for their patient population and thespecific procedures being performed.
Preoperative Bathing. A 2017 systematic review of eight studies involving 10,655 patients undergoingclean surgeries found soap without antiseptic had the lowest rate of surgical site infection (5.1%) compared
to chlorhexidine bathing (7.1%) or placebo solution (9.1%). There were no significant reductions in theinfection rates in the comparison between patients who had preoperative bathing with 4% chlorhexidine vs.
placebo solution as well as no difference was observed when comparing chlorhexidine bathing with soap.
(Franco, 2017) A 2015 systematic review of seven randomized trials involving 10,157 patients undergoinginvasive surgical procedures found no clear evidence of benefit in preoperative showering or bathing withchlorhexidine over other wash products, to reduce surgical site infection. (Webster, 2015)
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Hair Removal. A 2017 meta-analysis of 14 trials involving 7,278 patients found no significant differences
between shaving, clipping, no hair removal and depilatory cream in the frequency of surgical site infections. The evidence suggests that when it is necessary to remove hair, clipping is more effective in reducing
surgical site infections than shaving or depilatory cream. (Shi, 2017) A 2015 meta-analysis of 19 trials foundno benefit of depilation to prevent surgical site infection, and a higher risk of surgical site infection whenshaving is used for depilation as compared to clipping, chemical depilation or no depilation. The risk ofsurgical site infection seemed to be similar with both chemical depilation and clipping. (Lefebvre, 2015)
Oral hygiene. A 2016 systematic review of six trials and quasi-trials found systematic perioperative oral
hygiene reduces postoperative nosocomial, lower respiratory tract infections and surgical site infections but
not urinary tract infections. (Pedersen, 2016) Systematic perioperative oral hygiene involves mechanicalremoval of dental biofilm or plaques and/or systematic use of mouth rinse performed by patients themselves
or by health care staff.

Preoperative Fasting Recommendations (Clear Liquids, Solids and Nonhuman Milk)
The ICSI work group AGREES with American Society of Anesthesiologists (ASA) recommendations on
preoperative fasting for healthy adult patients undergoing elective procedures. (ASA, 2017):•

Clear liquids-•

Clear liquids may be ingested for up to two hours before procedures requiring general anesthesia,
regional anesthesia, or procedural sedation and analgesia. These liquids should not include
alcohol.

Solids and Nonhuman Milk-

A light meal or nonhuman milk may be ingested for up to six hours before elective procedures
requiring general anesthesia, regional anesthesia, or procedural sedation and analgesia.
•

Additional fasting time (e.g., eight or more hours) may be needed in cases of patient
intake of fried foods, fatty foods, or meat.

The ASA guideline recommendations are further supported by a systematic review of 19 guidelines thatfound strong and consistent evidence exists for the minimization of perioperative fasting, for a two-hour
preoperative fast after clear fluids, and for early recommencement of oral food and fluid intake postoperatively. (Lambert, 2016)
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2. Perioperative Management of Select Conditions
Cardiovascular Considerations
Cardiovascular Diseases
The ICSI work group AGREES with the select ACC/AHA disease-specific perioperative recommendationsin the table below. The select recommendations are from the 2014 ACC/AHA Guideline on Perioperative
Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery (Fleisher, 2014)
and the 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patientswith Coronary Artery Disease. (Levine, 2016) See guidelines for more information.
Coronary Artery Disease

Patients with known or clinic risk for coronary artery disease should be
evaluated according to the ACC/AHA perioperative risk assessment protocol.
(Based on ACC/AHA 2014 guideline)

Elective noncardiac surgery should be delayed at least 60 days after
myocardial infarction in the absence of coronary intervention. (Based on ACC/AHA 2014 guideline)

Revascularization before noncardiac surgery is recommended in circumstancesin which revascularization is indicated according to existing clinical practiceguidelines. (ACC/AHA 2014 guideline recommendation)
It is not recommended that routine coronary revascularization be performed
before noncardiac surgery exclusively to reduce perioperative cardiac events.
(ACC/AHA 2014 guideline recommendation)
Elective noncardiac surgery should not be performed within 14 days ofballoon angioplasty in patients in whom aspirin will need to be discontinued
perioperatively. (ACC/AHA 2014 guideline recommendation)
Elective noncardiac surgery should be delayed 30 days after BMS
implantation and optimally six months after DES implantation. (ACC/AHA
2016 guideline recommendation)

In patients treated with DAPT after coronary stent implantation who must
undergo surgical procedures that mandate the discontinuation of P2Y12
inhibitor therapy, it is recommended that aspirin be continued if possible and
the P2Y12 platelet receptor inhibitor be restarted as soon as possible after
surgery. (ACC/AHA 2016 guideline recommendation)

Elective noncardiac surgery after DES implantation in patients for whom
P2Y12 inhibitor therapy will need to be discontinued may be considered after
three months if the risk of further delay of surgery is greater than the expectedrisk of stent thrombosis. (ACC/AHA 2016 guideline recommendation)
Elective noncardiac surgery should not be performed within 30 days after
BMS implantation or within three months after DES implantation in patientsin whom DAPT will need to be discontinued perioperatively. (ACC/AHA
2016 guideline recommendation)

When noncardiac surgery is required in patients currently taking a P2Y12
inhibitor, a consensus decision among treating clinicians as to the relative risksof surgery and discontinuation or continuation of antiplatelet therapy can be
useful. (ACC/AHA 2016 guideline recommendation)

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LV Function Assessment

It is reasonable for patients with dyspnea of unknown origin to undergo
preoperative evaluation of LV function. (ACC/AHA 2014 guideline
recommendation)

It is reasonable for patients with heart failure with worsening dyspnea or otherchange in clinical status to undergo preoperative evaluation of LV function.
(ACC/AHA 2014 guideline recommendation)
Reassessment of LV function in clinically stable patients with previously
documented LV dysfunction may be considered if there has been noassessment within a year. (ACC/AHA 2014 guideline recommendation)

Routine preoperative evaluation of LV function is not recommended. (ACC/AHA 2014 guideline recommendation)
Cardiomyopathy

Valvular Heart Disease

There is little information on the preoperative evaluation of patientswith specific nonischemic cardiomyopathies before noncardiac surgery.
Preoperative recommendations must be based on a thorough understanding of
the pathophysiology of the cardiomyopathy, assessment and management of
the underlying process, and overall management of the heart failure. (ACC/AHA 2014 guideline statement)

It is recommended that patients with clinically suspected moderate or
greater degrees of valvular stenosis or regurgitation undergo preoperative
echocardiography if there has been either 1) no prior echocardiography within
one year or 2) a significant change in clinical status or physical examination
since the last evaluation. (ACC/AHA 2014 guideline recommendation)
For adults who meet standard indications for valvular intervention(replacement and repair) on the basis of symptoms and severity of stenosis
or regurgitation, valvular intervention before elective noncardiac surgery
is effective in reducing perioperative risk. (ACC/AHA 2014 guideline
recommendation)

Arrhythmias/
Before elective surgery in a patient with a cardiac implantable electronic
Conduction Abnormalities device (CIED), the surgical/procedure team and clinician following the CIED
should communicate in advance to plan perioperative management of the
CIED. (ACC/AHA 2014 guideline recommendation)

Cardiovascular Medications
The ICSI work group reviewed the ACC/AHA medications-specific perioperative recommendations in
the table below. The select recommendations are from the 2014 ACC/AHA Guideline on Perioperative
Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery (Fleisher, 2014)
and the 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patientswith Coronary Artery Disease. (Levine, 2016) See guidelines for more information.
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Beta Blockers Therapy: ICSI Work Group AGREES with the following ACC/AHA Recommendations.
ACC/AHA Recommendation

ICSI Work Group Comment

Beta blockers should be continued in patients undergoing surgery who
have been on beta blockers chronically. (ACC/AHA 2014 guideline
recommendation)

Agree

Beta-blocker therapy should not be started on the day of surgery. (ACC/AHA 2014 guideline recommendation)

Agree

It is reasonable for the management of beta blockers after surgery to be
guided by clinical circumstances, independent of when the agent wasstarted. (ACC/AHA 2014 guideline recommendation)

Agree

Beta Blockers Therapy: ICSI Work Group DISAGREES with the following ACC/AHA Recommendations.
ACC/AHA Recommendation

ICSI Work Group Comment

In patients with intermediate- or high-risk myocardialischemia noted in preoperative risk stratification
tests, it may be reasonable to begin perioperative
beta blockers. (ACC/AHA 2014 guideline
recommendation)

Disagree (due to findings from the 2018 Cochranesystematic review of increased risk of all-cause
mortality and increased risk in stroke rate innoncardiac surgery)In patients with three or more RCRI risk factors(e.g., diabetes mellitus, HF, CAD, renal insufficiency,
cerebrovascular accident), it may be reasonable tobegin beta blockers before surgery. (ACC/AHA 2014
guideline recommendation)
In patients with a compelling long-term indication
for betablocker therapy but no other RCRI risk
factors, initiating beta blockers in the perioperative
setting as an approach to reduce perioperative risk
is of uncertain benefit. (ACC/AHA 2014 guideline
recommendation)

In patients in whom beta-blocker therapy is
initiated, it may be reasonable to begin perioperative
beta blockers long enough in advance to assess
safety and tolerability, preferably more than one
day before surgery. (ACC/AHA 2014 guideline
recommendation)

In the 2014 ACC/AHA Guideline, it was
acknowledged that beginning beta blockers ≤1 day
before surgery is at a minimum ineffective and may
in fact be harmful, and that decision to begin beta
blockers should be influenced by whether a patientis at risk for stroke and whether the patient has otherrelative contraindications. (Fleisher, 2014)

More recent findings from a 2018 Cochranesystematic review (Blessberger, 2018) demonstrated
an association of beta blockers with increased
all-cause mortality in noncardiac surgery. According
to the authors of the review (Blessberger, 2018):•	Data from low risk of bias trials further suggests
an increase in stroke rate with the use of beta
blockers.

•	As the overall quality of evidence is still low
to moderate, more evidence is needed before adefinitive conclusion can be drawn.
•	The substantial reduction in supraventriculararrhythmias and AMI in noncardiac setting
seems to be offset by the potential increase inmortality and stroke.

A 2018 systematic review and meta-analysis of 88 randomized controlled trials (53 trials in cardiac surgery
and 35 trials in noncardiac surgery) on influence of beta blockers on perioperative adverse events had thefollowing findings egarding noncardiac surgery outcomes (the overall quality of evidence was low tomoderate). (Blessberger, 2018)
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Beta blockers significantly increased the risk of all-cause mortality (number needed to treat for an
additional harmful outcome NNTH 167), hypotension (NNTH 16) and bradycardia (NNTH 21).

•

Beta blockers use had a potential increase in the risk of cerebrovascular events when all studies
were analyzed; however, when only the studies with low risk of bias were analyzed, the risk wassignificantly increased (NNTH 265).

•

Beta blockers significantly reduced the risk of AMI (NNTB 76), myocardial ischemia (NNTB 9)
and supraventricular arrhythmias (NNTB 112).

•

There was no clear evidence of an effect on ventricular arrhythmias, congestive heart failure andlength of hospital stay.

ACE Inhibitors and ARB Therapy
ACC/AHA Recommendation

ICSI Work Group Comment

Continuation of angiotensin-converting enzyme(ACE) inhibitors or angiotensin-receptor blockers(ARBs) perioperatively is reasonable. (ACC/AHA
2014 guideline recommendation)

Agree with qualification

If ACE inhibitors or ARBs are held before surgery,
it is reasonable to restart as soon as clinicallyfeasible postoperatively. (ACC/AHA 2014 guideline
recommendation)

Recent evidence suggests the risk for intraoperative
hypotension morbidity is significantly higher if
continued the morning of surgery, with unclear effecton mortality and morbidity.

The consensus of the ICSI work group is foranesthesiology team to be cautious about therisk for intraoperative hypotension in patientschronically receiving ACEIs/ARBs who are on it
the day of surgery, and should know how to treat it
effectively. The risks and benefits of continuing these
medications should be weighed against patients’ risk
factors.

ACEI/ARB medications reduce the activity of the renin–angiotensin–aldosterone system, ultimately
decreasing peripheral vascular tone and increasing perfusion. (Fleisher, 2014) Patients who use these
medications are prone to developing side effects like hypotension and even refractory hypotension during
anesthesia use, and whether ACEIs/ARBs should be continued or discontinued perioperatively in suchpatients remains debatable.
Though the 2014 ACC/AHA guideline recommends ACEI and ARB medications can be taken perioperatively, more recent evidence shows the risk for intraoperative hypotension morbidity is significantly higher
if continued the morning of surgery with unclear effect on mortality and morbidity (Fleisher, 2014). The
consensus of the ICSI work group is for anesthetists to be cautious about the risk for intraoperative hypotension in patients chronically receiving ACEIs/ARBs and are on it the day of surgery, and should know
how to treat it effectively. The risks and benefits of continuing these medications should be weighed against
patients’ risk factors.
A 2018 systematic review and meta-analysis of 13 studies reporting on the incidences of intraoperative
hypotension between patients who continued receiving ACEIs/ARBs and those who did not on the day of
their surgical procedure found that hypotension during anesthesia was more likely to develop in patients
who continued to take ACEIs/ARBs when compared to those who did not. However, no significant differences between these groups of patients were found with regards to postoperative complications including
ST-T abnormalities, myocardial injury, myocardial infarction, stroke, major adverse cardiac events, acutekidney injury or death. (Ling, 2018)
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Another 2018 systematic review and meta-analysis of nine studies (five RCTs and four cohort studies) witha total of 6,022 patients on chronic ACEI/ARB therapy before noncardiac surgery found that while withholding ACEI/ARB therapy on the morning of surgery was associated with significantly less intraoperative
hypotension, withholding ACEI/ ARB therapy was not associated with a difference in the mortality risk orrisk of major adverse cardiac event vs. those who continued these medications on the morning of surgery.
(Hollmann, 2018)
Calcium Channel Blocker Therapy
ACC/AHA Recommendation

ICSI Work Group Comment

No specific recommendation.

A 2003 systematic review of 11 studies with
1,007 patients found calcium channel blockers
significantly reduced ischemia and supraventriculartachyarrhythmia in the setting of noncardiac surgery.
(Wijeysundera, 2003)
While ACC/AHA guidelines do not provide specificrecommendations, it is the consensus of the ICSI
work group that it may be reasonable to continue
calcium channel blocker therapy perioperatively.

Diuretic Therapy
ACC/AHA Recommendation

ICSI Work Group Comment

No specific recommendation.

Thiazide and loop diuretic medications arecommonly prescribed for treatment of hypertension
as well as congestive heart failure.

While ACC/AHA guidelines do not provide specificrecommendations, it is the consensus of the ICSI
work group that diuretic therapy should be held on
the morning of surgery in most cases. Continuing
diuretic therapy on the morning of surgery may bereasonable for patients with congestive heart failure.

Alpha-2 Agonists
ACC/AHA Recommendation

ICSI Work Group Comment

Alpha-2 agonists for prevention of cardiac events are
not recommended in patients who are undergoing
noncardiac surgery. (ACC/AHA 2014 guideline
recommendation)

Agree

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Statins
ACC/AHA Recommendation

ICSI Work Group Comment

Statins should be continued in patients currently
taking statins and scheduled for noncardiac surgery.
(ACC/AHA 2014 guideline recommendation)

Agree

Perioperative initiation of statin use is reasonable inpatients undergoing vascular surgery. (ACC/AHA
2014 guideline recommendation)

Perioperative initiation of statins may be consideredin patients with clinical indications according to
GDMT who are undergoing elevated-risk procedures.
(ACC/AHA 2014 guideline recommendation)

Antiplatelet Therapy
ACC/AHA Recommendation

ICSI Work Group Comment

In patients undergoing urgent noncardiac surgery
during the first four to six weeks after BMS or DES
implantation, DAPT should be continued unless therelative risk of bleeding outweighs the benefit of theprevention of stent thrombosis. (ACC/AHA 2014
guideline recommendation)

Agree

When noncardiac surgery is required in patientscurrently taking a P2Y12 inhibitor, a consensus
decision among treating clinicians as to the relative
risks of surgery and discontinuation or continuationof antiplatelet therapy can be useful. (ACC/AHA
2016 guideline recommendation)

Agree

In patients who have received coronary stents andmust undergo surgical procedures that mandate thediscontinuation of P2Y12 platelet receptor–inhibitor
therapy, it is recommended that aspirin be continued
if possible and the P2Y12 platelet receptor–inhibitor
be restarted as soon as possible after surgery. (ACC/AHA 2016 guideline recommendation)

In patients undergoing nonemergency/nonurgent
noncardiac surgery who have not had previous
coronary stenting, it may be reasonable to continue
aspirin when the risk of potential increased cardiac
events outweighs the risk of increased bleeding.
(ACC/AHA 2014 guideline recommendation)

Agree

Initiation or continuation of aspirin is not beneficial
Agreein patients undergoing elective noncardiac noncarotid
surgery who have not had previous coronary stenting,unless the risk of ischemic events outweighs the riskof surgical bleeding. (ACC/AHA 2014 guideline
recommendation)

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Prevention of Endocarditis

The ICSI work group did not find any new literature regarding antibiotic prophylaxis for prevention of
endocarditis and agrees with the recommendations from the following guidelines:•

The 2007 American Heart Association (AHA) Guideline on Prevention of Infective Endocarditis(Wilson, 2007)•

The 2017 American Heart Association (AHA)/American College of Cardiology (ACC) Focused
Update of the 2017 AHA/ACC Guideline for the Management of Patients with Valvular Heart
Disease (Nishimura, 2017)

Summary of Recommendations:
1. Increased Lifetime Risk of Acquisition of Infective Endocarditis
The 2007 AHA Guideline on Prevention of Infective Endocarditis (IE) does not recommend IE
prophylaxis based solely on an increased lifetime risk of acquisition of IE. (Wilson, 2007)
2. Dental Procedures
Both the 2007 AHA Guideline on Prevention of Infective Endocarditis and the 2017 AHA/ACC
Focused Update of the 2017 AHA/ACC Guideline for the Management of Patients with Valvular
Heart Disease recommend IE prophylaxis for certain cardiac conditions* associated with the highest
risk of adverse outcome from endocarditis for patients undergoing dental procedures. (Nishimura,
2017; Wilson, 2007)*Specifically, prophylaxis against IE is reasonable before dental procedures that involve manipulationof gingival tissue, manipulation of the periapical region of teeth or perforation of the oral mucosa
in patients with the following:
1. Prosthetic cardiac valves, including transcatheter implanted prostheses and homografts.
2. Prosthetic material used for cardiac valve repair, such as annuloplasty rings and chords.
3. Previous IE.
4. Unrepaired cyanotic congenital heart disease or repaired congenital heart disease, with residual
shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch orprosthetic device.
5. Cardiac transplant with valve regurgitation due to a structurally abnormal valve.
3. Gastrointestinal/Genitourinary Procedures
Both guidelines found no evidence for infective endocarditis prophylaxis in gastrointestinal procedures or genitourinary procedures, absent known active infection. (Nishimura, 2017; Wilson, 2007)
4. Respiratory Tract/Infected Skin/Skin Structure/Musculoskeletal Tissue
The 2007 AHA guideline found antibiotic prophylaxis to be reasonable for procedures on respiratory
tract or infected skin, skin structure, or musculoskeletal tissue only for patients with underlying cardiac
conditions (listed above) associated with the highest risk of adverse outcome from IE. (Wilson, 2007)
5. Invasive Procedures
The 2007 AHA guideline stated that it did not find published data that demonstrates convincingly thatthe administration of prophylactic antibiotics prevents IE associated with bacteremia from an invasive
procedure. However, the possibility that there may be an exceedingly small number of cases of IE
that could be prevented by prophylactic antibiotics in patients who undergo an invasive procedure
could not be excluded. Such therapy should be restricted to those patients with the highest risk ofadverse outcome and who would derive the greatest benefit from prevention of IE. (Wilson, 2007)
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For information on prophylaxis on infective endocarditis, refer to resources such as the Sanford Guide for
Antimicrobial Therapy or Micromedex.
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Anticoagulants/Antithrombotics

The evidence on anticoagulant bridging and reversal tends to be specific to individual procedure and clinicalindication. The ICSI work group consensus is to take into consideration the following for perioperative
management of anticoagulants/antithrombotics to potentially prevent or reduce risk of adverse events:
Preoperative
As part of the preoperative assessment, patients taking any medication that can affect hemostasis or may
require antithrombotic therapy postoperatively should undergo the following workup:•

Estimate thrombotic risk and bleed risk (in consultation with the surgeon) in order to determine
whether or not chronic therapy should be interrupted, or to determine choice of new antithrombotic
therapy postoperatively (at surgeon discretion).
-

Timing of interruption of anti-thrombotic therapy can differ greatly among agents that affecthemostasis (e.g., non-steroidal anti-inflammatory drug (NSAID) vs. vitamin K antagonist vs.
direct oral anticoagulant (DOAC) vs. antiplatelet)•

Determine whether or not patient requires bridging therapy if anticoagulation is interrupted.

•

Determine a tentative plan for antithrombotic initiation or resumption postoperatively.

•

Perioperative anticoagulation plan should be developed in conjunction with surgeon.

Intraoperative (Day of Surgery)• Surgery may be delayed or cancelled if perioperative plan is not in place for patients taking certain
anticoagulant medications (reversal of anticoagulants would be necessary in the setting of urgent/
emergent procedures).
•

Risk of epidural hematoma is increased with epidural placement/removal and concurrent use ofsome types of anticoagulation therapy. Ensure anesthesia team is aware of anticoagulation plan.

•

Assess risk for development of perioperative VTE; weigh risk vs. benefit of mechanical vs. pharmacological VTE prophylaxis.

Postoperative• Communicate with anesthesia team regarding anticoagulation management in the setting of neuraxial(epidural, spinal, paravertebral) anesthesia and analgesia.
•

Implement postoperative anticoagulation plan as appropriate.

•

Provide patient education surrounding anticoagulation management.

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Diabetes Mellitus
HbA1c Testing in Patients with Diabetes during Preoperative Clinic Visit
Consensus Recommendation
Consider obtaining a preoperative HbA1c test value, if not done in the past three months, on patientswith known diabetes during preoperative clinic visit.
Establish a plan for management of diabetes prior to surgery. The decision to proceed with surgery
or postpone surgery based on preoperative HbA1c test value should be based on individual patient
centered factors such as urgency of planned surgery, overall mortality/morbidity risks, risks ofperioperative infections, concerns for postoperative glucose control, and patient compliance.

Benefit:
HbA1c and especially glucose levels affect patient outcomes during surgery. It is beneficial to test
preoperatively to understand the baseline and provide this information to surgeons. This would help
surgeons guide and individualize their decision-making regarding whether to go ahead or delay surgery basedon this information in conjunction with other risk factors.
Harm:
The evidence is not established on an optimal way to test for hyperglycemia during the preoperative phase insurgical patients. The patient may undergo multiple tests, which increases patient visits and cost.
Benefit-Harms Assessment:
Potential to prevent harm to patients by testing (using either HbA1c or glucose values) is greater than theharms of increased visits and cost. Therefore, testing should be pursued.

Relevant Resources:
ADA-Diabetes Care in the Hospital, 2019 (Guideline); van den Boom, 2018 (Observational Study); NICE,
2016 (Guideline); Yang, 2016 (Observational Study); Gustafsson, 2009 (Observational Study)

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Intraoperative and Postoperative Glycemic Control Targets for Patients with Diabetes
Recommendation

Quality of Evidence

Consider a glycemic target range between 140-180 mg/
dL for surgical patients with diagnosed diabetes during theintraoperative and postoperative periods.

Quality of Evidence: Low

Strength of Recommendation: Weak

Additional considerations:
1.	For patients with diabetes with glucose levels typically <140,
do not treat to 140.
2.	Consider risk for hypoglycemia if necessary to treat for
glycemic targets lower than 140.

Benefit:
Elevated postoperative glucose has been associated with several adverse outcomes including wound
infection, pneumonia, sepsis and cardiovascular events
Harm:
Individual patients may need different targets, depending on their medical comorbidities.

Benefit-Harms Assessment:
While it is critical to always individualize targets to each patient, the ICSI work group believes that 140-180
mg/dL reflects a reasonable target range that avoids the potential for hypoglycemia but also will mitigate
adverse postoperative outcomes related to glycemic control.

Relevant Resources:
Nair, 2016 (Observational Study); Sathya, 2013 (Meta-Analysis); Buchleitner, 2012 (Systematic Review);
Gandhi, 2007 (Randomized Controlled Trial); Ata, 2010 (Observational Study); Ramos, 2008 (Observational
Study)

Preoperative Testing during Clinic Visit
In the preoperative setting, the HbA1c test value may be used to alter diabetes management, with the aimof reducing postoperative morbidity and mortality. However, there is uncertainty regarding the optimal
timing of the test in individuals known to have diabetes. (NICE, 2016)
Studies have shown a positive association between preoperative HbA1c and postoperative glucose levels.
(Yang, 2016; Gustafsson, 2009) Evidence on how HbA1c directly affects outcomes such as mortality isless clear.
A retrospective analysis of 6,684 noncardiac and 6,393 cardiac surgeries in patients with diabetes foundthat although A1c was positively associated with perioperative glucose, it was not associated with increased
30-day mortality after controlling for glucose. Perioperative glucose predicted 30-day mortality, linearly innoncardiac and nonlinearly in cardiac procedures. (van den Boom, 2018) However, there have been a few
low-quality retrospective studies that found an association between poorly controlled HbA1c (>7%) andpostoperative complications such as infections and mortality. (NICE, 2016)
While not specific to perioperative patients, the ADA recommendation on patients admitted to the hospital
is to perform an HbA1c test on all patients with diabetes or hyperglycemia (blood glucose >140 mg/dL)
admitted to the hospital if not performed in the prior three months. Specific to patients undergoing surgery,the 2016 NICE guideline recommends that people with diabetes who are being referred for surgical consultation from primary care should have their most recent HbA1c test results included in their referral informationand to offer HbA1c testing to people with diabetes having surgery if they have not been tested in the last
three months. (NICE, 2016)
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The consensus of the ICSI work group is to consider obtaining a preoperative HbA1c, if not done in
the past three months, on patients with known diabetes during a preoperative clinic visit.
Establish a plan for management of diabetes prior to surgery. The decision to proceed with surgery
or postpone surgery based on preoperative HbA1c test value should be based on individual patientcentered factors such as urgency of planned surgery, overall mortality/morbidity risks, risks of perioperative infections, concerns for postoperative glucose control, and patient compliance.
Intraoperative and Postoperative Glycemic Control
The consensus of the ICSI work group is to consider a glycemic target range between 140-180 mg/dL
for surgical patients with diagnosed diabetes during the intraoperative and postoperative periods.
Additionally, given the complexities and wide variety of methodologies employed to achieve glycemic
control, individual patient evaluation and instruction are required prior to surgery to avoid extremes inglucose levels. Therefore, the following additional considerations should be taken: 1) for patients withdiabetes with glucose levels typically <140, do not treat to 140, and 2) consider risk for hypoglycemia ifnecessary to treat for glycemic targets lower than 140.
Hyperglycemia in the perioperative period is associated with several adverse outcomes including wound
infection, pneumonia, sepsis, and cardiovascular events. (Kwon, 2013) In evaluating glucose control, thereis evidence that evaluates the perioperative period as a whole while other evidence specifically looks at the
intraoperative and postoperative periods, respectively. The lack of robust, high-quality evidence, includinginconsistently defined populations and varied methodology, make it challenging to understand if intraoperative glycemic goals should be different from postoperative glycemic goals.
Perioperative period in general
The evidence shows that although an optimal target glucose range remains unknown for patients withdiabetes, there is general consensus that adequate glycemic control, without hypoglycemia and excessive
hyperglycemia, results in a better surgical outcome.
•A 2013 meta-analysis of six randomized trials and cohort studies found that in patients with diabetes, amoderate perioperative glycemic target (150-200mg/dl) is associated with reduction in postoperative
mortality and stroke compared with a liberal target (>200mg/dl), whereas no significant additional
benefit was found with more strict glycemic control (<150mg/dl). (Sathya, 2013)•

A 2012 systematic review of 12 randomized trials looking at perioperative glucose management indiabetic patients undergoing surgery found no significant difference in infectious complications,
renal failure, cardiovascular events, and all-cause mortality between intensive glucose control andconventional glucose control groups (as defined by individual authors). It found that intensive
glycemic control was associated with an increased risk of hypoglycemic episodes. (Buchleitner,
2012)

Intraoperative period
Intraoperative hyperglycemia has been found to be associated with adverse surgical outcomes, but the benefitsof intensive glucose control during this period are uncertain. (Simha, 2019) A cohort study of adult surgery
patients (both diabetic and nondiabetic) who required intraoperative glucose management found that a higher
intraoperative glucose level is associated with a higher postoperative glucose level. Initiating insulin infusion
when intraoperative glucose level exceeds 140 mg/dL to prevent hyperglycemia is associated with lower
postoperative glucose levels and fewer incidences of postoperative hyperglycemia. However, patient- andprocedure-specific variable interactions also play a role and may impact the relationship between intraoperative and postoperative glucose levels. (Nair, 2016) Specific to glucose control ranges, a 2007 randomized
trial of intensive insulin infusion therapy to maintain blood glucose in the normal range of 80 to 100 mg/ dL
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in patients with and without diabetes undergoing cardiac surgery was not found to favorably influence
postoperative complications and may be associated with greater harm. (Gandhi, 2007)
Postoperative period
A retrospective study of 995 patients (with and without diabetes) who had undergone general andvascular surgery that evaluated the association of perioperative hyperglycemia and postoperative infections
found that postoperative hyperglycemia increased the risk of infections by 30% with every 40-point increase
from normoglycemia (<110 mg/dL). Longer hospitalization for patients with postoperative glucose levels
from 110 to 200 mg/dL and >200 mg/dL was also observed. (Ramos, 2008) Furthermore, a retrospective
medical record review of 2,090 general and vascular surgery patients with and without diabetes found that
postoperative hyperglycemia may be the most important risk factor for surgical site infections. (Ata, 2010)
Medications
Oral hypoglycemics
This ICSI work group agrees with the American Society of Anesthesia (ASA) recommendations on
perioperative management of oral hypoglycemics with qualifications. These recommendations are from
Perioperative Hyperglycemia Management: An Update. (Duggan, 2017)
Oral Medication Use the Day Before and the Day of Surgery
Of note, ASA gives two separate recommendations for the day of surgery. The first recommendation applies
to patients with reduced postoperative oral intake or extensive surgery with anticipated hemodynamic changes
and/or fluid shifts. We believe this will apply to a majority of surgeries. The second recommendation is if
normal intake is anticipated the same day and it is a minimally invasive surgery.
Secretagogues:
1. Day before surgery: take
2. Day of surgery if reduced postoperative oral intake or extensive surgery with anticipated HD(hemodynamic) changes and/or fluid shifts: hold
3. Day of surgery if normal oral intake anticipated same day and minimally invasive surgery: hold
SGLT-2 Inhibitors:
1. Day before surgery: hold
2. Day of surgery if reduced postperative oral intake or extensive surgery with anticipated HD (hemodynamic) changes and/or fluid shifts: hold
3. Day of surgery if normal oral intake anticipated same day and minimally invasive surgery: holdThiazolidinediones
1. Day before surgery: take
2. Day of surgery if reduced postoperative oral intake or extensive surgery with anticipated HD(hemodynamic) changes and/or fluid shifts: hold
3. Day of surgery if normal oral intake anticipated same day and minimally invasive surgery: take
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Metformin
1. Day before surgery: take (hold if patient having a procedure with IV contrast dye administration,
particularly in those with GFR<45 milliliters/minute)
2. Day of surgery if reduced postoperative oral intake or extensive surgery with anticipated HD(hemodynamic) changes and/or fluid shifts: hold
3. Day of surgery if normal oral intake anticipated same day and minimally invasive surgery: take(hold in patient having a procedure with IV contrast dye administration, particularly in those with
GFR<45 milliliters/minute)
DPP-4 Inhibitors
1. Day Before Surgery: take
2. Day of surgery if reduced postoperative oral intake or extensive surgery with anticipated HD(hemodynamic) changes and/or fluid shifts: take
3. Day of surgery if normal oral intake anticipated same day and minimally invasive surgery: take
Insulin Therapy
For surgical patients with type 2 diabetes managed at home by diet, oral hypoglycemics or very low-dose
insulin (less than or equal to 0.4 units/kg), in-hospital management with a basal-bolus regimen has beenshown to be more effective than supplemental correction sliding-scale insulin alone. A randomized trialof 211 patients with type 2 diabetes undergoing general surgery found basal-bolus treatment with glargine
once-daily plus glulisine before meals improved glycemic control and reduced hospital complications
compared with sliding scale insulin. (Umpierrez, 2011) An observational study of 150 diabetic patientsusing a once-daily evening insulin glargine regimen found that the percent of normal insulin dose given
the evening before surgery directly impacts perioperative glucose levels. More specifically, patients taking
60%-87% of their usual dose the evening before surgery were likely to arrive in target blood glucose range
with decreased risk for hypoglycemia with the optimal dose around 75% of normal dose. (Demma, 2017)
Both studies looked at the perioperative period.
This ICSI work group agrees with the American Society of Anesthesia (ASA) recommendations on
how to adjust insulin regimens the day prior and the day of surgery for patients on insulin at homeprior to surgery. These recommendations are from Perioperative Hyperglycemia Management: An Update.
(Duggan, 2017)Day before surgery insulin regimens
Glargine or detemir• Normal diet until midnight (includes those permitted clear liquids until two hours prior to surgery):usual dose for AM dose, 80% of Usual dose for PM dose.
•

Bowel Prep (and/or clear liquids only 12-24 hours prior to surgery): usual dose for AM dose, 80%
of usual dose for PM dose.

NPH or 70/30 insulin• Normal diet until midnight (includes those permitted clear liquids until two hours prior to surgery):
80% of usual dose for AM dose, 80% of usual dose for PM dose.
•

Bowel prep (and/or clear liquids only 12-24 hours prior to surgery): 80% of usual dose for AM
dose, 80% of usual dose for PM dose.

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Lispro, aspart, glulisine, regular• Normal diet until midnight (includes those permitted clear liquids until two hours prior to surgery):usual dose for AM dose, usual dose for PM dose.
•

Bowel prep (and/or clear liquids only 12-24 hours prior to surgery): usual dose for AM dose, usual
dose for PM dose.

Noninsulin Injectables• Normal diet until midnight (includes those permitted clear liquids until two hours prior to surgery):
Usual dose for AM dose, usual dose for PM dose.
•

Bowel prep (and/or clear liquids only 12-24 hours prior to surgery): Hold when starting clear liquid
diet/bowel prep for AM dose, hold when starting clear liquid diet/bowel prep for PM dose.

Day of surgery insulin regimens
Glargine or detemir• 80% of usual dose if patient uses twice-daily basal therapy
NPH or 70/30 insulin• 50% of usual dose if BG 120mg/dL; hold for blood glucose (BG) < 120mg/dL
Lispro, aspart, glulisine, regular: holdNoninsulin injectables: hold

3. Perioperative Opioid Management
Preoperative Opioid Management
Preoperative Patient Education
Preoperatively, patients should receive education about pain and opioids before the surgical procedure. The education should include multimodal pain management options, including opioids, andconsistent messaging that the pain is an anticipated part of the postoperative course. Additionally,
patient care goals and expectations in regard to pain during surgery should be understood to manage their
expectations for surgical outcomes. Unrealistic goals jeopardize the patients’ participation in their care andcould lead to disengagement. Any common misconceptions that patients may have about opioids should
be understood and addressed.
To support the discussion between provider and patient on care goals and expectations, shared decisionmaking process may be used (See ICSI Shared Decision-Making Model for more information on how tohave these discussions). This approach takes into consideration patients’ role in creating goals for pain andsurgical outcomes, allows patients to have a clear understanding of their individual risk profile, and the risks
and benefits associated with potential of opioid use during surgery, as well as exploration of their values andpreferences. Additionally, within this process, patients should be well aware of the recommended guidelines
for opioid prescribing in regard to duration and dosage.
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Preoperative Opioid Risk Assessment and Mitigation
Providers performing preoperative health screening and assessment should be aware of the following tohelp optimize the management of perioperative pain in their patients:•

Have a standard approach or checklist to assess for risk of adverse events (including risk for chronic
opioid use and opioid use disorder) in patients for whom opioids are considered for pain control
perioperatively.

•

Assess preoperatively for appropriateness of nonopioid modalities for the treatment of perioperative
pain.

•

For complex patients (e.g., patients with chronic pain, long-term opioid use, or opioid use disorder),a multidisciplinary team that includes the primary care provider, pain management specialist, andsurgical team (including postoperative opioid prescriber) may be needed prior to surgery to coordinate a plan of care. This approach incorporates biopsychosocial effects of the medical condition(Gatchel, 2014; Gatchel, 2007) and has shown to reduce pain severity, improve mood and overall
quality of life for patients with chronic pain. (Oslund, 2009; Gatchel, 2007; Gatchel, 2006)•

Communication regarding opioids is needed among the primary care provider, surgical team(including postoperative opioid prescriber), pain specialist and hospitalist.

It is critical that the results of preoperative exam are documented in the chart.
To mitigate the risk of adverse effects due to opioid use perioperatively, it is important that a provider
doing preoperative health screening and assessment performs and documents these findings on the
preoperative exam:•

Directed physical examination•

Directed pain history•

Any patient care goals and preferences regarding pain control•

Review of PMP*

*Prescription Monitoring Program (PMP) provides information about the patient’s exposure to opioids and othercontrolled substances, as well as whether patients receive
opioids from other prescribers. A PMP query may affectthe surgical team’s decision-making on postoperative
opioid prescribing. In a study looking at opioid prescribing
behavior before and after a PMP query, a high proportionof prescribing decisions were changed in light of the information the PMP query provided. (Gugelmann, 2011) It is
helpful to document the results of the PMP in the medical
record, both to demonstrate the diligence in decisionmaking, and to capture outside information in the medical
chart for future review.

Risk Assessment and Mitigation
Opioid problems
Psychiatric comorbidities
Elimination of drug
Respiratory compromise
Adverse reactions
Trouble (high-risk) medications
Early mobility and falls
Delirium

Prior to surgery, all patients should have an individualized assessment of risk(s) of adverse events of opioid
use and risk(s) to be mitigated. This will help to more realistically counsel the patient, may guide choice of
opioids and may improve the outcome(s) of surgery.
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Opioid Problems

What is the risk that a patient develops a new opioid use disorder (addiction) after surgery?
Opioid use disorder (OUD) should be recognized, diagnosed and charted in a timely manner. OUD carries
great morbidity and mortality but also has effective treatments. (Pierce, 2016; Volkow, 2014) It is challenging
to discuss OUD with patients. Counseling patients on possible outcomes of opioid prescriptions requiresthat the provider him or herself review the diagnostic criteria of OUD. (Hasin, 2013) OUD is also a challenging outcome to study. A recent study attempted to measure OUD in opioid-naïve patients exposed to
opioids after surgery. The incidence of OUD was 0.2% postoperatively. The most important risk for OUD
was duration of opioids; with each additional week of opioids, the risk of OUD increased 20%. (Brat, 2018)
Preexisting substance use and mental health disorders also increased the risk of OUD. A timely discontinuation of postoperative opioids is the most likely way to mitigate risk of OUD.
Standard risk tools such as the Opioid Risk Tool (ORT) are used to predict opioid misuse, but poorly predict
OUD itself. (Klimas, 2019; Volkow, 2016) Risk assessment tools should not be used to determine the indication or dose of opioids; rather, these tools inform the intensity of monitoring required. Risk tools may
also facilitate shared decision-making with the patient. Note that the prevalence of OUD in the community
is 1%, and it is often not disclosed or recognized in the preoperative visit. (Han, 2018) The TAPS tool for
diagnosis of OUD may help recognize it in an outpatient setting. (McNeely, 2016)
How do I predict if my patient will overdose from opioids?
Past overdose is powerful predictor of future overdoses. Many patients who are hospitalized with a nonfatal
overdose resume opioids, and this puts them at elevated risk of fatal overdose and increased all-cause mortality.
(Olfson, 2018; Larochelle, 2016) A new screening tool to predict opioid overdose may prove useful. The
Risk Index for Overdose or Serious Opioid-induced Respiratory Depression, or RIOSORD, accounts for
medical and psychiatric comorbidities and prescription characteristics to generate a risk score that predicts
chance of overdose. (Zedler, 2018) This tool can be incorporated into the preoperative assessment withprescription recommendations to avoid adding further risk. An additional safeguard is provision of a naloxone
rescue kit to the patient with instructions; however, state laws governing naloxone prescriptions vary.
How do I prepare my patients with an established diagnosis of opioid use disorder for surgery?
Patients with OUD have a wide spectrum of clinical stability; they may be stable and in long-term remission, possibly on medication, or may be unstable and actively using intravenous drugs. This difference may
affect the postoperative use of opioids. It is important to first ascertain if the patient is in treatment. Obtaina release of information and contact the treatment provider. Medications are an important component ofrecovery in OUD and should be carefully managed in the perioperative period. (Alford, 2006) Consider
obtaining a urine drug screen, or reviewing the urine drug screen record with the addiction provider. It is
critical to assess for recent IV drug use in OUD patients in the preoperative interview. Active IV drug use
may require the surgery to be postponed. A focused addiction consultation may help assess the preoperativerisk of drug use, and may help manage postoperative opioid use. See the “Perioperative Considerations forPatients with Opioid Use Disorder” section for more detailed information on medications and risk mitigation for these patients.
What is the patient’s risk of continuing on opioids long-term after a surgery?
Opioid-naïve patients who receive opioid prescriptions after a cataract removal remain on opioids one year
later 7.7% of the time; patients receiving an opioid prescription within seven days of surgery were 44%
more likely to become long-term opioid users within one year compared with those who received no suchprescription. (Alam, 2012) Healthy adolescents prescribed opioids for minor procedures, such as dental
extractions, have a 30% increased relative risk of misusing opioids. (Miech, 2015) The presence of unused
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opioids in the home is itself a risk factor for someone in the household using opioids illicitly. (Seamans,
2018) Many patients have unused opioids after surgery. (Bedard, 2018; Bates, 2011) Therefore, in any
instance where opioids are not routinely needed after a surgery, they should not be prescribed.
Postoperative short-term prescriptions may lead to chronic opioid use in patients who were opioid naive
prior to the surgery. These patients do not meet criteria for opioid addiction. The likelihood of chronic
opioid use after an acute pain episode is linearly dose-dependent on the opioid exposure. (Shah, 2017) The
opioid exposure that predicts chronic use is the sum of the total opioids in the course of acute pain treatment (called total morphine milligram equivalent [MME]). Mental health comorbidities increase the riskof ongoing opioid use: depression and anxiety, use of antidepressants and benzodiazepines, substance use
disorders, tobacco use. Average rates of ongoing opioid use after surgery is 6% at three months after thesurgery and 1.5% one year after the surgery. (Brummett, 2017; Sun, 2016; Carroll, 2012) An article by Sun
et al, 2016 provides relative risks associated with ongoing opioid use that can be used to individualize an
assessment and incorporated in the preoperative evaluation (e.g., the relative risk for ongoing opioid use is
1.8 for patients also prescribed benzodiazepine). (Sun, 2016)
Psychiatric Comorbidities
Providers need to be aware of any psychiatric comorbidities that could affect pain management and of any
medications patients are currently taking. If conditions are under poor control, therapies should be initiatedprior to surgery if possible.
Certain mental health disorders pose a higher risk when initiating opioids. (Davis, 2017; Volkow, 2016)
Patients with post-traumatic stress disorder or adverse childhood experiences are at very high risk for opioid
misuse and addiction. Patients with eating disorders and obsessive-compulsive disorders are similarly athigh risk but less studied.
Elimination
Renal impairment is an important limiting factor when choosing an opioid. Most opioids are cleared atleast in part by the kidneys. In anyone other than young healthy patients, providers should have a recent
measurement of renal function before prescribing an opioid. If the glomerular filtration rate is less than 60,
consult a pharmacist before deciding on an opioid. (Dean, 2004)
Respiratory Compromise (and Immunocompromise)
Opioids suppress dyspnea, decrease ventilation, relax the muscles of the upper airway and reduce the gag
reflex, and therefore cause a number of respiratory effects important in the perioperative period. Opioids
in an opioid-naïve patient will worsen sleep apnea, hypoventilation syndromes and oxygenation in any
patient predisposed to these issues. (Mador, 2014) Unrecognized obstructive sleep apnea increases therisk of death and heart failure after noncardiac surgeries, possibly related to opioid exposure. (Chan, 2019)
Observation in the postoperative period may reveal apneic episodes in patients without an establishedsleep apnea diagnosis. Initiating opioids in an opioid-naïve patient with COPD doubles the mortality from
pulmonary causes. (Levine, 2017; Vozoris, 2016) Opioids are associated with an increased risk of pneumonia, including invasive pneumococcal disease, and opioid prescriptions are overrepresented in deaths
from pneumonia. (Wiese, 2018; Hall, 2018) The cause of the increase in pneumonia risk is not known but
may be due to immunosuppression or aspiration. (Wiese, 2019) Patients hospitalized after a surgery caneasily be observed for respiratory complications. However, outpatient surgeries for opioid-naïve patientswith a respiratory illness may require educating the patient and family, and provision of a naloxone kit. It
should be emphasized that the relative risks of respiratory events due to postoperative opioids may be large,
but the absolute risk remains small.
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Adverse Reactions
Urinary retention is a common and underestimated adverse effect of opioids, especially given the riskof urinary tract infection postoperatively and the importance of minimizing unneeded urinary catheters.
(Benyamin, 2008) Patients with preexisting urinary retention may particularly struggle.
Opioid-induced constipation results from decreased bowel motility and decreased mucosal secretions.
Colace or fiber is not adequate treatment or prevention of opioid induced constipation. Senna may help
situate the bowel but is often not sufficient if the stool is dry. Polyethylene glycol is a good agent to treat
opioid-induced constipation. (Swegle, 2006)
Patients will often become nauseated when receiving opioids. This can be easily diagnosed and treated withtraditional antiemetics as long as the provider is aware. (Swegle, 2006)
Patients will often develop pruritis on opioids. Antihistamines may reduce the pruritus, but some antihistamines have an anticholinergic effect that may interact with the sedating effect of the opioids. (Ganesh, 2007)
Consider loratadine or cetirizine or fexofenadine before agents such as diphenhydramine. (Swegle, 2006)
It is important to distinguish true allergic reaction from adverse reaction when choosing opioid therapy forpatients. If a true, IgE-mediated allergic reaction (hives, anaphylaxis) is documented, patients might tolerate
opioid therapy from a different structural class. (Powell, 2019) Expected adverse reactions to opioids arecommon and can be managed with a variety of medications.
Trouble (High Risk) Medications: Tramadol, Meperidine, Methadone, Codeine, Long Acting Opioids
and Benzodiazepines
Tramadol, tapentadol and meperidine lower seizure threshold. (Manninen, 1997) This epileptogenic effectis exaggerated in renal failure (Pham, 2017) and for those with preexisting seizure disorder. (Boostani,2012) In such patients these medications should be avoided. Postoperatively, tramadol carries an increased
risk of ongoing opioid use compared to other opioids. (Thiels, 2019) There is a black box warning against
use of tramadol in children under 12 years of age and in breastfeeding women (https://www.fda.gov/drugs/
drug-safety-and-availability/fda-drug-safety-communication-fda-restricts-use-prescription-codeine-pain-andcough-medicines-and). Meperidine may increase the risk of serotonin syndrome according to case reports.
(Tissot, 2003) The Food and Drug Administration (FDA) released a statement in 2016 about several safetyissues regarding the entire class of opioid medications, including the risk of serotonin syndrome. (FDA, 2016)
Many opioids prolong the QT interval, and in some instances, arrhythmias result. Methadone, even at low
doses, has a high risk of QT prolongation. Oxycodone and tramadol show intermediate risk, but otheropioids such as morphine and buprenorphine are considered low risk. (Behzadi, 2018) QT prolongation
is multifactorial, typically resulting from other medications, electrolyte abnormalities, bradycardia, andindividual susceptibility. (Behzadi, 2018) For patients with a long QT interval, consult with a pharmacist
before initiating opioids, to avoid exacerbating the risk. (Tisdale, 2016)
The Food and Drug Administration has issued a black box warning against using codeine in children of any age
after surgery, specifically after tonsillectomy and/or adenoidectomy, and against use in breastfeeding women.
(FDA, 2018) This is due to the fact that many people are ultra rapid metabolizers of codeine, leading to the rapid
buildup of the active metabolite, and therefore unexpected respiratory suppression. This effect is not uniqueto children; any patient may have respiratory suppression from codeine from this mechanism. (Dean, 2012)
Long-acting opioids should not be initiated for acute pain. Even in chronic pain, long-acting opioids areassociated with increased mortality, including increased cardiovascular and pulmonary mortality. (Ray, 2016)
Benzodiazepines add risk of overdose, addiction, and ongoing use, and should be used sparingly andcautiously in combination with opioids in the postoperative period. (Hozack, 2019)
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Early Mobility and Falls
Opioids are associated with a 4.5-fold increase risk of falls and double the mortality in elderly patientcompared to NSAIDs. (Solomon, 2010) Generally, for elderly patients, for the first two weeks after initiating
opioid therapy, but not thereafter, short-acting opioids are associated with a greater risk of fracture than are
long-acting opioids. (Miller, 2011) The highest risk opioid to cause falls is codeine; the lowest risk opioid
to cause falls is tramadol. (Buckeridge, 2010)
Early mobilization is critical. For hospitalized patients, a physical therapist should be able to assess safety
and should do so aware of the relationship of the assessment to the most recent opioid dose; the patient’s
safety assessment my change after he or she has taken an opioid. For outpatient surgeries, careful explanation of the risk of falls is important, and planning to minimize fall risk could help.
Delirium
Delirium is a possible outcome after any surgery and is usually multifactorial. Postoperative delirium occurs
in 16-35% of patients. (Leung, 2009; Morrison, 2003) Pain can be an important contributor to delirium;
patients receiving very low doses of opioids after hip replacement are at significant increased risk of delirium.
Yet opioids themselves also contribute to delirium. (Swart, 2017; Clegg, 2010; Morrison, 2003) Meperidine
and tramadol may be more associated with postoperative delirium than other opioids. (Swart, 2017) To
further minimize the risk of delirium, polypharmacy and excessive sedation should be avoided, particularly
by not starting benzodiazepines or not using anticholinergic antihistamines. (Clegg, 2010) Medical causesof delirium should be ruled out. Postoperative delirium will never be completely eliminated. However, bytreating pain prudently, while minimizing unneeded opioids, avoiding benzodiazepines and anticholinergic
medications, the risk and severity of postoperative delirium may be reduced.
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Preoperative Opioid Use
When looking at evidence in the postoperative outcomes of patients on preoperative opioids, the definitionof preoperative opioid use varied across studies. The definitions ranged from any documented opioid use
prior to surgery to more specific time frames defined by each study. Because of this broad definition ofpreoperative opioid use, it is hard to draw definitive conclusions. Additionally, there is variation amongstudies on inclusion of medical and mental health comorbidities (mood, anxiety), personality disorders,trauma and substance use disorders comorbidities (some studies looked at impact of this and others did not).
In general, available systematic review and observational studies, mostly comprising of patients undergoingorthopedic surgeries (e.g., primary total knee or hip arthroplasty), show that compared to opioid-naïve patients,
patients with preoperative opioid use have worse postoperative outcomes. Those outcomes include physicaland mental health outcomes including higher pain and function scores, higher likelihood of long-term opioiduse, increased discharges to rehabilitation facility vs. home, greater length of stay, higher readmission rates,
and higher rates of surgical site infections and revisions. (Blevins Peratikos, 2019; Bonner, 2019; Goplen,
2019; Berglund, 2018; Bell, 2018; Politzer, 2018; Rozell, 2017; Zarling, 2017) The results remained true
after controlling for certain medical and mental health comorbidities.
Studies of other types of orthopedic surgery (spine, lumber fusion and cervical fusion) followed similar
outcomes as did studies of abdominal surgery. (Cron, 2017; Faour, 2017; Tye, 2017; Waljee, 2017; Issa,
2014; Lee, 2014)
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Chronic Opioid Use
Studies that specifically looked at outcomes for patients with preoperative chronic opioid use differedon the definition of chronic opioid use. Also, the total body of literature is smaller compared to generalpreoperative opioid use and comprised mostly patients undergoing orthopedic surgeries such as total knee,shoulder arthroplasty, cervical spine fusion and lumbar spine fusion. None of the studies included patientswith opioid addiction. Overall, these drawbacks limit the conclusions that may be drawn on patients onchronic opioids preoperatively.
Evidence shows that compared to patients who are opioid-naïve or not chronic opioid users, those who arechronic opioid users preoperatively have higher likelihood of long-term opioid use postoperatively, increased
risk of complications (e.g., wounds, infections and constipation), ED visits, and revision surgery. (Kalakoti,
2019; Jain, 2018a; Jain, 2018b) Other findings show longer length of stay, continued and persistent chronic
opioid use postoperatively, and higher MED consumption in chronic opioid users. (Kim, 2019; Kim, 2018;
Cheah, 2017; Aasvang, 2016; Zarling, 2016) These studies have also found that patients with medical andmental health comorbidities (e.g., mood, anxiety) are more likely to be chronic opioid users preoperatively.
The studies varied on which comorbidities were included.
Preoperative Opioid Tapering
Consensus Recommendation
An individualized approach for tapering in patients who are on opioids preoperatively (including
patients with chronic opioid use) should be taken.
A decision on whether to taper preoperatively needs to be made well in advance of surgery. However,
if a significant medical concern about opioid use is recognized closer to the surgery date which could bemade safe with a taper, the patient, the provider and the surgical team should discuss whether delaying
the surgery in order to treat the underlying condition is appropriate.
Benefit:
Small body of available evidence shows that postoperative outcomes (reduced risk of adverse events,
reduced likelihood of revision surgery, reduced morphine equivalent dose (MED), and improved pain scoresand patient-reported scores on physical and mental health outcomes) in tapered patients are comparable tothe outcomes for opioid-naïve patients.
Harm:
Given that evidence on harms of tapering is not available and harms are unknown, there is a potential riskthat a patient could experience adverse effects from opioid tapering.

Benefit-Harms Assessment:
Given the small body of evidence on perioperative outcomes for patients who are tapered from opioids
preoperatively and unknown harms from it, primary care providers performing preoperative health screening
and assessment should take an individualized approach to tapering as stated in the recommendation.
Relevant Resources:
Jain, 2019 (Observational Study); Nguyen, 2016 (Randomized Controlled Trial); Hassamal, 2016 (Case
Series)There is only a small body of emerging evidence on tapering opioids prior to surgery. The largest study(n=58,082) found that stopping opioids three months before surgery for patients on opioids longer thansix months reduced the risk of pain-related ED visits, readmissions, infections and revision surgery within
one year, particularly in patients undergoing hip surgery and lumbar fusion. (Jain, 2019) One study of 41
patients who regularly used opioids and successfully tapered their morphine equivalent dose by 50% prior toa total knee or hip arthroplasty had greater improvements in physical health outcomes than patients who did
not taper. Outcomes in the tapered group were also comparable to those of opioid-naïve patients. (Nguyen,2016) A case series study of six spine surgery patients who underwent preoperative opioid reduction
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program for about six to eight weeks found a decrease in daily morphine equivalent dose (MED), and in painscore in five patients, and a surgery-related complication in one patient. All six patients had improvements
in mental health outcomes such as depression, anxiety and fatigue. Most patients had improved physicalfunctioning, disturbances in sleep and satisfaction with participation in social roles. (Hassamal, 2016) The
tapering protocols varied between the studies. None of these studies identified potential harms from stopping opioids or tapering.
Given the lack of uniformity in the literature on the standard definitions of preoperative or chronic opioid
use and lack of more expansive literature looking at efficacy and/or harms of tapering prior to surgery, the
ICSI Perioperative Opioid Management Subgroup consensus is to take an individualized approachfor tapering in patients on opioids preoperatively. A decision on whether to taper preoperatively needs
to be made well in advance of surgery. However, if a significant medical concern about opioid use is recognized closer to the surgery date which could be made safe with a taper, the patient, the provider and surgicalteam should discuss whether delaying the surgery in order to treat the underlying condition is appropriate.
The individualized approach should take into consideration the following:•

Individual patient risk factors for adverse events of continued opioid use post surgery•

Individual patient risk factors for adverse events due stopping or tapering opioids prior to surgery•

Shared decision-making discussions between providers and patients on the risks of continued opioid
use preoperatively, which include patient education on postoperative pain expectations•

Multidisciplinary approach that focuses on opioid management and communication between primarycare providers and the surgical team both preoperatively and postoperatively•

Goals of an opioid taper (how much to taper and over what period of time) prior to surgery•

Follow-up and support for patients managing pain and changes to their medication regimens

Links to additional resources that provide specific guidance on opioid tapering (MN Health Collaborative
Demystifying Opioids and U.S. Department of Health and Human Services guide on tapering) are available
in “Implementation Tools and Resource Table” section of this guideline.
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Intraoperative Pain Management

An intraoperative plan of care should incorporate the results of preoperative health screening and assessment,
optimize periprocedural regional analgesia/anesthesia techniques to reduce the need for opioid use postoperatively where possible. Additionally, the plan should emphasize use of multimodal analgesia (e.g., NSAIDs,
Cox-2 inhibitors (COXIBs), or acetaminophen) when possible. This approach provides superior pain relief
and decreases the need for supplemental opioid use compared to an unimodal analgesia approach, which inturn means that patients may only require nonpharmacologic modalities postoperatively. (Apfelbaum, 2012a)
The following table provides a summary of intraoperative approaches prior to incision vs. postincision
during the surgical procedure. It is informed by the American Society of Anesthesiologists Task Forceon Acute Pain Management Practice Guidelines for Acute Pain Management in the Perioperative Setting.
(Apfelbaum, 2012a)
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Pre-Incision Medications and Techniques

Post-Incision Medications and Techniques

Acetaminophen*
NSAIDs (COX-2 inhibitor)
Gabapentinoids (gabapentin, pregabalin)
Regional anesthesia• Neuraxial blockade		 - Continuous epidural analgesia
			Single-injection spinal opiates
		- Paravertebral•	Peripheral nerve blockade (single injection orcontinuous)		- Upper extremity				• Interscalene block				• Suprascapular nerve block				• Supraclavicular block				• Infraclavicular block				• Axillary block		- Lower extremity				•	Lumbar plexus/fascia iliaca block				• Femoral nerve block				• Distal femoral triangle block				• Adductor canal block				• Sciatic nerve block				• Popliteal (sciatic) nerve block				• Selective tibial nerve block				• Ankle block				• iPACK block•	Truncal/fascial plane blockade (single injection orcontinuous)		 - Erector spinae plane (ESP) block		 - PECS I, II blocks
		 - Serratus plane block		- TAP block		 - Rectus sheath block		 - Quadratus lumborum block

Acetaminophen*
NSAIDS (ketorolac, ibuprofen)
Dexamethasone
Regional/local anesthesia• See pre-incision regional techniques• Surgeon-administered incision infiltration• Surgeon-administered fascial plane blocks
Lidocaine, bolus plus infusion
Ketamine, bolus plus infusion
Dexmedetomidine, bolus plus infusion
Magnesium infusion*A note on acetaminophen: There is some early evidence showing positive preventive effect of acetaminophen
given within one hour of anesthesia vs. postincision; however, more evidence is needed to draw definitive
conclusions. A 2015 systematic review and meta-analysis of seven randomized controlled trials with 544
patients aged 16 years and older including all types of surgeries looked at the relationship between acetaminophen as preventive analgesia and postoperative outcomes. Acetaminophen given preventively (defined
as within one hour before induction of anesthesia) was compared to acetaminophen given after incision(any time between postincision and within 30 minutes from the end of surgery). The review found a reduction in 24-hour opioid consumption, lower pain scores at one hour and two hours, and a lower incidence of
postoperative vomiting in the preventive acetaminophen group. (Doleman, 2015)
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Postoperative Opioid Management
Postoperative Opioid Prescribing
In general, multimodal pain management strategies that include use of medications from multiple therapeutic classes prioritizing nonopioid medications before administering opioid medications should be usedwhenever appropriate. These include, a scheduled regimen of NSAIDs, COXIBs or acetaminophen, whenappropriate, and regional blockade with local anesthetics, when appropriate. (Apfelbaum, 2012a) These
modalities may reduce pain enough to save opioids for extreme or break-through pain.
The surgical team should consider reviewing the following when determining individual patient postdischarge
pain management plan with the goal of improving function and control pain:•

The results of preoperative health screening and assessment to understand the patient’s history withpain management and medications•

Any plan of care that was set by a patient and the provider

If considering opioid prescribing postoperatively, review:•

Individual patient factors such as age, prior exposure to opioids, mental status, and pain management history•

Patient’s pre-existing health conditions that increase the risk of adverse effects and addiction due
to opioid use (see “Preoperative Opioid Risk Assessment and Mitigation”)•-

This information should be available from preoperative health screening and assessment. If
not available, the surgical team (including postoperative opioid prescribers) should assess.

-

Findings should have been documented during the preoperative exam. If this was notdone, the surgical team should query because it provides information about the patients’
exposure to opioids and other controlled substances, as well as whether patients receive
opioids from other prescribers.

PMP

Consensus Recommendation
The postoperative prescribed opioid doses at discharge should be the lowest effective dose of shortacting opioids.
Benefit:•	Provides optimal pain control, reduces potential for unused opioids in the community and maintains
patient satisfaction.
• Initiation of long-acting opioids can harm the patient by increasing the risk of overdose or death.
Harm:• Risks include overdose and death.

Benefit-Harms Assessment:
Opioids carry the risk of potential overdose and death. In order to mitigate for this risk, it is important that
if opioids are prescribed postoperatively at discharge that the lowest effective dose of short-acting opioidis prescribed.

Relevant Resources:
Hill, 2018 (Observational Study); Koehler, 2018 (Systematic Review); Mark, 2018 (Observational Study); Bicket,2017 (Systematic Review); Osmundson, 2017 (Observational Study); Thiels, 2017 (Observational Study); Ray,2016 (Observational Study); Miller, 2015 (Observational Study); Dhalla, 2009 (Observational Study)

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The higher total morphine milligram equivalent (MME) dose and a longer duration of opioids prescribedpostoperatively during the inpatient stay are associated with many undesirable outcomes: longer hospital
stays, increased readmission rate, mortality rate, chance of health care facility disposition and total cost ofcare. (Shafi, 2018) There is growing body of literature looking at patterns of opioid use postoperatively todetermine the amount needed on discharge, if any at all. (Hill, 2018; Mark, 2018) Each patient is unique,and there is growing evidence that using a procedure-specific, patient-centered approach to guide the use of
postoperative opioids provides optimal pain control, reduces unused opioids in the community, and maintains
patient satisfaction. (Bicket, 2017; Osmundson, 2017; Thiels, 2017) Studies have also found that more than
80% of patients report unused opioids and 42-71% of pills dispensed went unused after surgery. (Feinberg,
2018; Tan, 2018; Batemen, 2017; Bates, 2011; Bicket, 2017; Osmundson, 2017)
Given the available evidence, it is the consensus of this work group that the postoperative prescribed
opioid doses at discharge should be the lowest effective dose of short-acting opioids.
Other considerations for postoperative opioid prescribing at discharge for all patients include:•

Prescribed opioid doses should be individualized based on the risk of adverse events due to opioid
use to each patient. It is out of scope of this document to address procedure-specific dosing. For
information on procedure specific postoperative opioid prescribing at discharge, refer to the MN
Health Collaborative Call to Action on standards for opioid prescribing based on the type of surgery.

•

Avoid long-acting opioids. Initiation of long-acting opioids can harm the patient by increasing therisk of overdose or death. (Ray, 2016; Miller, 2015; Dhalla, 2009)•

Provide following information to patients on:-

Expectations on length of time they would be on opioids for surgical-related pain-

Risks of overdose and death (including the risk if opioids are taken with alcohol or illicit
drugs)-The potential risk to other person/child, or pet, specifically if taken with alcohol or illegal
drugs

-

Safe storage of the medications, preferably in a lockbox and with safe disposal instructions-

Information on opioids and driving-

Naloxone kit to high-risk surgical patients and/or their close contacts (e.g., family, friends,
caretaker)

Additional considerations for patients with chronic opioid use preoperatively:•

Preoperatively, the patient should be educated that any new higher dosing of opioids for postoperative pain is not the new normal. The objective is to treat surgical-related pain, not chronic pain.

•

Patients may not need their preoperative opioid dose after surgical healing, particularly if the surgery
was done to help improve the issue for which opioids were initially prescribed.

•

The surgical team and primary opioid prescriber should have clear communication on who is theactive opioid prescriber at all times.

•

Patients on chronic opioids preoperatively may be enrolled in a controlled substance agreement withthe provider who prescribes their chronic opioids. While this should not preclude another provider
from prescribing opioids in an acute setting, good communication is needed between care teams
and with the patient.

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Postoperative Patient Education

For patients who are prescribed opioids postoperatively, include information on potential of adverse effects
of opioids and what to do if experiencing any adverse effects. Refer to “Preoperative Opioid Risk Assessment and Mitigation” section for detail on adverse effects.
For patients who are prescribed opioids postoperatively, PRN instructions on opioid prescriptions may not
be sufficient for patients to understand when they should take opioids. Therefore, the providers may wantto consider including clear prescription instructions on all opioid prescriptions for patients on how and when
to decrease dose and to increase the interval between doses as pain subsides.
Naloxone
Naloxone is a medication that can reverse the sedating effects of opioids. Serious side effects from naloxone
use are rare, but benefits during an overdose far exceed the risks. The reversal effect of naloxone may notoutlast the sedating effect of many opioids, so it is recommended to activate the emergency services whenever it is used. (CDC, 2018; Hooten, 2017)
Administration can be intranasally, intramuscularly or subcutaneously. Anyone can administer it if received
education on how to do it (free online or community training course are available; check for availability inyour area).
Opioids Storage and Disposal
Proper storage and disposal of opioids can reduce diversion, accidental misuse and overdose. (Hooten, 2017)
All patients should be instructed to store their opioids in a location, ideally locked, that is unreachable byfamily or house guests. Patients should be instructed to dispose of their unused medications promptly atthe end of a pain episode.
Disposal options in the order of preferred method (see the “Implementation Resources Table” for more
information):•

Medication take-back is the preferred method per the FDA. The U.S. DEA may periodically hostprescription take-back events at temporary collection sites. Authorized collection sites in the community are also available and include local law enforcement facilities, retail pharmacies, hospital or clinic
pharmacies.

•

The second preferred option (if no take-back programs are available) is pharmaceutical disposal
bags with activated charcoal, which can be purchased for at-home disposal.

•

The third preferred method is flushing down the toilet. The FDA and DEA allow for opioids to be
flushed down the toilet; however, this method is not endorsed by the EPA.

Opioids and Driving
The sedating effects of opioids may impair one’s ability to operate a motor vehicle or carry out tasks that
require wakefulness and reaction time. (Hooten, 2017). Therefore, it is important to warn patients about therisk to themselves and others while performing potentially dangerous tasks while on opioids.
Nontolerant opioid users will likely experience greater impairment. (Hooten, 2017) Alcohol and other
CNS depressants may increase these effects and should be avoided while a patient is on opioid medications. (Hooten, 2017) When a patient has developed tolerance to the sedating effects of opioids, patients
may safely operate a motor vehicle. (Hooten, 2017) Determining when the patient has developed enoughtolerance is a judgment call, and prescribers should err on the side of caution.
There may also be legal implications for patients who drive while taking opioids, which can vary state tostate. Local law may vary on what meets the definition of “driving under the influence” of a controlled
substance, and prescribers should understand and follow local laws.
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Annotations

Perioperative Considerations for Patients with Opioid Use Disorder (OUD)
Patients on Medication-Assisted Treatment (MAT)
Patients with opioid use disorder (OUD) are at high risk of opioid overdose and relapse if using opioids for
management of acute pain. (SAMHSA, 2018) Thus, these patients may be at risk of having their acute pain
underestimated or undertreated. (Mehta, 2006) Patients who are on medication-assisted therapy (MAT)should be carefully managed i.n the perioperative period if opioids are prescribed to manage acute pain.
(Alford, 2006)
There is a lack of high-quality evidence on perioperative opioid management of patients with OUD on MAT.
The evidence consists mostly of low-quality studies including case studies, retrospective studies and expert
opinion. The specific protocols for perioperative MAT and acute pain management with opioids vary in theliterature based on different expert consensus groups.
Given the complexities of acute pain management with opioids in OUD patients on MAT, the patient’s
provider and surgical team may consider a consult with addiction medicine and/or pharmacist to
provide guidance on MAT and opioid management perioperatively.
Currently, three agents are used for MAT in OUD:
Methadone: A synthetic, long-acting opioid, approved for treatment of OUD in 1972. The dose generally ranges from 60-120 mg and is available for treatment of OUD only via methadone clinic.
Buprenorphine: A partial mu agonist, kappa antagonist and long acting. It was approved for officebased treatment of OUD in 2002.
Naltrexone: Opioid antagonist with a 28-day extended release formulation. Also available in PO
formulation.
Patient Education
In addition to information in the “Preoperative Patient Education” section, a few additional considerations forpatients with OUD who are currently on MAT undergoing surgery should include:•

Discussion of expectations of pain from surgery and expectations about opioids for pain from surgery•

Reassurance to patients regarding pain expectations and more specifically, their addiction history will
not prevent adequate pain management. (Alford, 2006) Discuss and document previous experiences
and utilize shared decision-making in discussions regarding decisions for opioids for pain management.

•

Discussion of risk of relapse•

Discussion of risk of overdose•

Discussion of identifying triggers/cravings•

Discussion of availability and access to naloxone to patients and/or family members and training•

Discussion of storage/disposal/lockbox

Perioperative Pain Management
In general, pain management should use strategies that both provide effective analgesia and prevent withdrawal symptoms, with those being two separate goals. (Quinlan, 2017) Therefore, initially the goal is
to maximize nonpharmacological options and nonopioid pharmacology. (Quinlan, 2017; Mehta, 2006)
However, opioids may still be prescribed as part of multimodal pain management because OUD patients
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are likely to be opioid tolerant, but are often pain intolerant. (Harrison, 2018) If opioids are prescribed,
there should be careful considerations for preoperative and postoperative management of MAT. The next
section includes more specific considerations for each MAT agent.
Additional considerations include:•

Using regional anesthesia (Quinlan, 2017)•

Early recognition and treatment of symptoms and behavioral changes that might indicate withdrawal(Quinlan, 2017)•

Avoid use of mixed agonist and antagonist opioids because they may precipitate an acute withdrawal
syndrome (Alford, 2006)•

Avoiding prescribing benzodiazepines and carisoprodol (Quinlan, 2017)•

Using tamper-proof and secure analgesia administration procedures•

Notifying the patient’s MAT provider regarding the patient’s discharge and confirming the time andamount of the last maintenance opioid dose (Alford, 2006)

Risk mitigation of adverse effects of postoperative opioid use in patients with OUD on MAT (regardlessof agent) should include:•

Implementing risk mitigation rules: high frequency visits to closely monitor use of postoperative
opioids, pill counts, checking of PMP, urine drug screening for alcohol/drug use•

No early refills•

No replacement of lost prescriptions•

Prescription only with visit•

Verifying availability of naloxone at home and patient/family member training on how to administerit

If Opioids are Prescribed, Specific Considerations by Each MAT Agent:
Methadone
Preoperative Management•

Verify patients’ outpatient methadone dose with their methadone clinic.

•

Verify availability of naloxone in hospital/at home.

•

Continue daily dose preoperatively, understanding this dose is not adequate to treat postoperative,
acute pain. (Harrison, 2018)•-

Example: Think of methadone as patients’ basal needs, like basal insulin, and short-acting
opioids as their acute needs, like mealtime insulin.

-

If unable to take PO, give IV and reduce dose by one-half to two-thirds and split three times aday (TID). (Harrison, 2018)

Patients with OUD are more likely to exhibit hypersensitivity symptoms and high tolerance. (Jamison
et al., 2000; Barry 2009)-

Hypersensitivity and pain intolerance are common among those with OUD. This means thatthey feel pain more intensely and may require higher doses of opioids to feel the same relief.

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Relapse risk is high and worse with inadequate pain control. (Ti, 2015; Voon 2018)-

The risk of in-hospital illicit opioid use is higher among patients with OUD and inadequate
pain control, especially if they are denied pain medication. (Ti, 2015)-

Focus groups involving 83 self-identified drug using patients, illustrated how restrictive policies regarding use of opioid pain medications for acute pain, serve as a risk factor for drug use.
(Voon, 2018)•

Be aware of pharmacological properties. Avoid partial agonists (butorphanol, buprenorphine,
nalbuphine). Giving a partial agonist with a full agonist (methadone) has the potential to displace
the full agonist and cause precipitated withdrawal. (Walsh, 2003; Clark, 2002; Strain, 1995; Walsh,
1995; Strain, 1993)•

Communicate following information to methadone clinic:-

Inform them the patient will undergo a procedure, and the hospital will administer methadone
until discharge, and potential discharge date.

-If patients are not hospitalized or in a TCU, they will need to get their methadone from themethadone clinic. The methadone clinic decides if the patient is eligible for take-home doses.

Postoperative Management•

Continue the daily dose throughout perioperative period, understanding this dose may not be adequate
to treat postoperative, acute pain. (Harrison, 2018)•

Discuss postoperative opioid management plans with support person or OTP.

•

Beware of high frequency visits/prescriptions (closely monitor use of postoperative opioids).

•

Taper postoperative opioids in similar time frame for opioid-naïve patients. (Expert Consensus)

Buprenorphine
Preoperative Management
In general, the preferred method is to either continue patient’s current dose of buprenorphine or continue alowered dose prior to surgery. (Harrison, 2018, Quaye, 2018) Discontinuation is not preferred due to highrisk of inadequate pain relief, relapse and overdose. (Lembke, 2018; Quaye, 2018; Sen, 2016; Bentzley,
2015; Sigmon, 2013; Volpe, 2011; Ling, 2009; Breen, 2003)
1. Continuing current dose buprenorphine (preferred method)•

The most prominent risk is inadequate pain relief. Buprenorphine is a partial mu agonist with highaffinity, meaning it will block most other opioids from accessing the receptor. To overcome thatblockade, higher doses and/or higher potency opioids may be needed. (Expert Consensus)•

The risk of relapse with this method would be related to undertreated pain. If pain is undertreated,
the risk of relapse increases (Ti, 2015; Voon, 2018) because patients are likely to seek illicit sources
to treat pain.

•

Overdose risk is low with the combination of buprenorphine and short-acting opioids in a controlled
and appropriate fashion.

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Annotations
2. Continue lowered-dose buprenorphine (preferred method)•

The risk of inadequate pain relief is lessened with this method, because as the dose of buprenorphine
is lowered, the receptor availability is increased, and therefore the patient can feel the effects ofshort-acting opioids. (Greenwald, 2014; Greenwald, 2007)•

The risk of relapse may be increased with a lowered dose of buprenorphine (Expert Consensus)
given that maintenance buprenorphine doses are titrated to cravings, but there is evidence thatpain control is manageable when the buprenorphine is continued. (Vilkins, 2017; Hansen, 2016;
Macintyre, 2013; Kornfeld, 2010; Meyer, 2010; Jones, 2009)

Continuing current dose vs. lowering dose
Whether to continue the patient’s current dose of buprenorphine or taper to a lower dose but notoff, to provide more mu receptor availability, has not been studied. (Lembke, 2018) The decisionof whether to continue the current dose of buprenorphine versus decreasing the dose of buprenorphine should be a shared decision between the provider and the patient that takes into consideration
preoperative buprenorphine dose, previous patient experiences and OUD relapse risk.
*See table at the end of buprenorphine section for an example of buprenorphine perioperative
management plan.
3. Discontinuation of buprenorphine (not preferred method)•A high risk of inadequate pain relief. Buprenorphine has a very high potency; 1 mg morphine isequivalent to 15-35 mcg of buprenorphine, so patients usually have a very high opioid tolerance.
Attempting to treat their baseline opioid needs plus their acute pain needs requires astronomicaldoses of regular opioids. (Volpe, 2011)-

Example: A patient on 8 mg buprenorphine, which is the equivalent of about 600 mg morphine,or 400 mg oxycodone, which is just their baseline need and wouldn’t treat their acute pain.

•

A very high risk of relapse. Because the patient is no longer on buprenorphine, he or she has noblockade of mu opioid receptors and thus can feel the full effects of all opioids. Discontinuation
has been associated with increased risk of illicit opioid use. (Quaye, 2018; Sen, 2016; Bentzley,
2015; Sigmon, 2013; Ling, 2009; Breen, 2003)•

Because the risk of relapse is higher, the risk of overdose is also higher. (Lembke, 2018)

Postoperative Management
1. If continued current dose buprenorphine (Expert Consensus):•

Use higher potency opioids, e.g., oxycodone as opposed to hydrocodone.
-

If the initial dose set by the surgeon is not controlling the pain, it may be because the buprenorphineis blocking the effect of the opioid. Options:i.

Increase the dose of the opioid or change to a higher potency opioid.

ii.

Decrease the dose of the buprenorphine, to increase receptor availability.

iii. Increase and split the dose of the buprenorphine to TID, to achieve better pain relief.
The peak pain relief of buprenorphine is at about 8 hours. (Alford, 2006)•

Taper postoperative opioids in similar time frame as for opioid-naïve.

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If cravings or illicit opioid use occurs:-

If undertreated pain is the cause, consider the above options.

-

Alternatively, if buprenorphine was lowered postoperatively, return to previous dose, or increase
dose to TID.
iv. Attempt to treat the postoperative pain with only buprenorphine.

2. If continued lowered-dose buprenorphine (Expert Consensus):•

Use higher potency opioids, e.g., oxycodone as opposed to hydrocodone-

If the initial dose set by the surgeon is not controlling the pain, it may be because the buprenorphineis blocking the effect of the opioid. Options:i.

Increase the dose of the opioid or change to a higher potency opioid.

ii.

Decrease the dose of the buprenorphine to increase receptor availability.

iii. Increase and split the dose of the buprenorphine to TID, to achieve better pain relief.
The peak pain relief of buprenorphine is at about eight hours. (Alford, 2006)•

Taper postoperative opioids in similar time frame as for opioid-naïve.
-•While tapering off the postoperative opioids, simultaneously increase the buprenorphine back to
the previous dose.

If cravings or illicit opioid use occurs:-

If undertreated pain is the cause, consider the above options.

-

Alternatively, increase to previous buprenorphine dose, or higher and to TID.
iv. Attempt to treat the postoperative pain with only buprenorphine.

3. If discontinued buprenorphine (Expert Consensus):•

Will likely need higher potency opioids because the patient will have a high tolerance, but the pain
management will likely be incredibly difficult•

Attempt to taper the postoperative opioids in a similar time frame as opioid-naïve.
-This will likely be difficult because the patient is not used to being on zero opioids and, he or she
has a baseline tolerance, so getting to zero is very difficult.

•After the postoperative opioids are completed, the patients still needs to get back on their buprenorphine,which requires a re-induction. They need to come completely off all opioids for a period of 12-24
hours (SAMHSA, 2019), depending on the opioid, to restart the buprenorphine to prevent precipitatedwithdrawal. This is incredibly difficult for most patients.

•

If severe cravings or illicit opioid use occurs, stop all postoperative opioids for 12-24 hours (SAMHSA,2019), re-induct on buprenorphine and attempt to treat as above (see 1 and 2).

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Annotations*Buprenorphine Perioperative Management Plan Example (Adapted from Quaye, 2018)
Low Pain Level
Pre-opContinue current
Management dose buprenorphine

Post-op
ConsiderManagement buprenorphine
dividing dose to TID
Consider very shortterm postop opioids

Moderate–Severe
Pain Level + <8mg
Buprenorphine

Continue current dosebuprenorphine

Moderate–Severe Pain Moderate–Severe
Level + 9mg–15mg
Pain Level + >16mg
Buprenorphine
Buprenorphine
Consider taperingbuprenorphine to 8mg
over 1-4 weeks

Taper to <16mg over
1-4 weeks, then to 8 theday prior to surgery

Discuss relapse risk
with patient; if high,continue current doseand use higher potency
or higher dose opioids
postop

Discuss relapse risk
with patient; if high,continue current doseand use higher potency
or higher dose opioids
postop, ideally get to 16
mg or less

Consider buprenorphine Consider buprenorphine Consider buprenorphine
dividing dose to TID
dividing dose to TID
dividing dose to TID
Postop opioids- L ength same as
opioid-naïve
- N
 eed higher potency
opioidPostop opioids- L ength same as
opioid-naïve
- N
 eed higher potency
opioidPostop opioids- L ength same as
opioid-naïve
- N
 eed higher potency
opioidNaltrexone IM/PO
Preoperative Management
1. Planned procedures: able to discontinue IM naltrexone >4 weeks prior to surgery (48-72 hours for PO)(Expert Consensus)•

Naltrexone works by antagonizing the opioid receptor, so it must be stopped and metabolized/
eliminated before opioids will be fully able to access the opioid receptors. However, the patient
still has an opioid use disorder, the “safety net” is being removed and a drug of choice given after
the surgery; therefore, the risk of relapse and accidental overdose is high.

•Because patients still have OUD, they likely still have pain intolerance and hypersensitivity (Jamison,
2000) and may require higher doses or potency opioids. However, depending on how long it has
been since they stopped using illicit opioids, they do not have the same tolerance to the respiratory
depressant effects of opioids that they once had, so while they may not feel the pain relief, theirrisk of respiratory depression and overdose is back to baseline.

2. Unplanned procedures: Unable to discontinue naltrexone (Expert Consensus)•

Naltrexone works by antagonizing the opioid receptor, so it must be stopped and metabolized/
eliminated before opioids will be fully able to access the opioid receptors.

•

The naltrexone will need to be stopped as soon as possible and “override” the blockade with very
potent and higher doses opioids.

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Annotations•

For PO naltrexone, elimination half-life is about 13-14 hours, so to fully remove the drug from thesystem requires 50-60 hours. (SAMHSA, 2009)•For IM naltrexone, depending on when the injection occurred, it may take weeks for elimination.

•

If high potency and high dose opioids are used to “override” the blockade, as the naltrexone iseliminated, the blockade will become less and less powerful and the opioids may become too potent,
causing respiratory depression/overdose.

•

The risk of inadequate pain relief is therefore very high, and thus the risk of illicit opioid use is veryhigh. The patient may try to overcome the blockade with illicit opioids. (Ti, 2015; Kunoe, 2010;
Vickers, 2006)•

Plan on using nonopioid medications aggressively; involve pain and/or addiction medicine consult
teams.

Postoperative Management
1. For planned procedures where naltrexone was discontinued (Expert Consensus):•

Naltrexone works by antagonizing the opioid receptor, so a patient cannot be on both an opioid
agonist and an opioid antagonist (naltrexone) at the same time.

•

Attempt to taper the postoperative opioids in a similar time frame as opioid-naïve.

•Restart the IM or PO naltrexone after 7-10 days off all opioids (naltrexone medication package
insert).

•If illicit opioid use is suspected, consider options with patient:-

Discontinue all opioids and restart naltrexone as soon as possible.

-

Consider buprenorphine induction; follow instructions above for postoperative pain
management on buprenorphine.

2. For unplanned procedures where naltrexone was not discontinued. (Expert Consensus) Do this incoordination with addiction specialist and/or pharmacist.
•

Naltrexone works by antagonizing the opioid receptor, so a patient cannot be on both an opioid
agonist and an opioid antagonist (naltrexone) at the same time.

•

Pain management in this situation is very difficult; involve addiction medicine or pain consultants
or pharmacy whenever possible.

•

If high potency and high dose opioids are used to “override” the blockade, as the naltrexone iseliminated, the blockade will become less and less powerful and the opioids may become too potent,
causing respiratory depression/overdose.

•-This occurs after 50-60 hours with PO naltrexone and 1-4 weeks with IM naltrexone.
(SAMHSA, 2009)-

The provider will need to know when the patient had their last injection, to understandwhen the injection will start to wear off.

-

Start to wean opioids to less potent/lower doses as the date the injection wears off
approaches.

Attempt to taper the postoperative opioids in a similar time frame as opioid-naïve.

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Restart the IM or PO naltrexone after 7-10 days off all opioids (naltrexone medication package insert).

•

If illicit opioid use is suspected, consider these options with patient:-

Discontinue all opioids and restart PO naltrexone as soon as possible. (If IM, and injection is still active, discontinue just opioids.)-

Consider buprenorphine induction, follow instructions above for postoperative pain
management on buprenorphine.

Patients Not on Medication-Assisted Treatment (MAT)
Patients with opioid use disorder currently using opioids should not undergo a procedure unless it is urgent
or emergent. Treatment of the substance use disorder should take priority. Once the patient is on MAT, theprocedure can take place.
If a procedure is urgent or emergent, every effort should be made to start MAT before the procedure takes
place. A consult with an addiction medicine or pain specialist is recommended.
If that is not possible, the management plan should include maximizing nonpharmacological intervention,
maximizing nonopioid pharmacology, and a consultation with an addiction medicine or pain specialist assoon as possible to initiate MAT after the surgical procedure. Opioid management of the acute pain may
still be needed, but should be monitored carefully. Refer to the MN Health Collaborative Algorithm for
Screening and Treatment of Opioid Use Disorder (OUD) for more information on how to address patientswith OUD and not on MAT.
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Institute for Clinical Systems Improvement59Quality Improvement Support:

Perioperative

The intent of this section is to provide resources, strategies and measurement to help
close the gap between current clinical practice and the recommendations set forth in
the guideline.
Measurement is one of the key components of quality improvement. It evaluates theimpact of clinical evidence-based recommendations on current clinical practice, andcan assure that new practices are being implemented. The measures are recommended
by each guideline workgroup and confirmed through consensus. ICSI’s Committee
for Evidence-Based Practice provides oversight and final approval for the measures
as part of the guideline revision process.
As part of the process, local and national resources for measures are searched andrelevant measures are included if aligned with the workgroup recommendations.
These resources include: National Quality Forum (NQF), Joint Commission, National
Committee for Quality Assurance (NCQA), MN Community Measurement (MNCM),
CMS MACRA-MIPS measures and resources specific to the guideline topic.
ICSI work groups focus on quality improvement measures, not measures foraccountability. Our goal is to help organization understand how closely practicemirrors guideline recommendations and monitor this over time as quality improvementchanges are implemented.
Types of measures included are measures of process, experience, and outcomes; eachmeasure is labeled accordingly. Measurement data should be tracked and comparedover time to help gain insight into effectiveness of interventions. Measurement
definitions and data collection frequency need to be consistent to ensure validity ofdata comparisons over time.
The subdivisions of this section are:
• Aims and Measures• Implementation Recommendations• Implementation Tools and Resources
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Aims and Measures
These are suggested aims and measures by the work group. These do not include measurement specifications.
1. Increase the percentage of surgical patients undergoing elective surgery who have preoperative healthscreening and assessment.
Measure for accomplishing this aim:a.

Percent of patients undergoing elective surgery who have preoperative health screening and assessment.

2. Increase the percentage of surgical patients undergoing elective surgery who are smokers who havesmoking addressed prior to surgery.
Measures for accomplishing this aim:a.

The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day ofelective surgery or procedure. (ASA) (MACRA-MIPS)

3. Increase the percentage of surgical patients undergoing elective surgery who have risk factors for
obstructive sleep apnea (OSA) who are screened for OSA prior to surgery.
Measures for accomplishing this aim:a.

Percentage of surgical patients undergoing elective surgery with risk factors for OSA who arescreened for OSA prior to surgery.

4. Increase the percentage of surgical patients undergoing elective surgery who have education on preoperative hair removal, bathing, fasting and oral hygiene prior to surgery.
Measure for accomplishing this aim:a.

Percentage of patients with education on preoperative hair removal, bathing, fasting and oral hygiene
prior to surgery.

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Implementation Recommendations
Prior to implementation, it is important to consider current organizational infrastructure that addresses thefollowing:•

Develop a reliable, standardized system to obtain complete preoperative basic health assessments
and appropriate preoperative testing to eliminate unwarranted variation•

Establish a reliable, standardized system to communicate completed preoperative basic healthassessments and associated test results to surgical team prior to procedure.

•Develop a comprehensive patient-centered approach to education and appropriate procedure preparation.

•

Establish a reliable, standardized system for the surgical team to communicate pertinent postoperative information to primary care to help guide postoperative assessment and management.

•

Develop consistent messaging about pain and opioids for patients and family, and educate all staff
and providers on the value of its use.

•

Assure that workflows and electronic records are up to date and support desired improvements.

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Implementation Tools and Resources
Criteria for Selecting Resources
The following tools and resources specific to the topic of the guideline were selected by the work group.
Each item was reviewed thoroughly by at least one work group member. It is expected that users of thesetools will establish the proper copyright prior to their use. The types of criteria the work group used are:•

The content supports the clinical and the implementation recommendations.

•

Where possible, the content is supported by evidence-based research.

•

The author, source and revision dates for the content are included where possible.

•

The content is clear about potential biases, and conflicts of interests and/or disclaimers are noted.

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Implementation Tools and Resources Table
Author/Organization

Title/Description

Audience

Web Site

The MN Health
Collaborative Call to
Action: Adult Opioid
Postoperative Prescribing

Standards on postoperative
opioid prescribing at
discharge by procedure
type

Health Care

https://www.icsi.org/programs/mn-healthcollaborative/

The MN Health
Collaborative:
Demystifying Opioids
Package

Guidance on
Opioid Use Disorder
Algorithms & Tapering
Frequently Asked
Questions (FAQs)

Health Care

https://www.icsi.org/programs/mn-healthcollaborative/

Health Care

https://www.icsi.org/programs/mn-healthcollaborative/

The MN Health
Collaborative Call to
Action: Opioid Disposal

Guidance on Appropriate
Disposal of Unused
Opioids

ICSI Shared DecisionMaking Model

Health Care
A guide for health careproviders on conducting
collaborative conversations
with patients

https://www.icsi.org/guideline/perioperativeguideline/

U.S. Department of Healthand Human Services

HHS Guide for Clinicianson the Appropriate
Dosage Reduction or
Discontinuation of LongTerm Opioid Analgesics

Health Care

https://www.hhs.gov/about/news/2019/10/10/
hhs-announces-guide-appropriate-tapering-ordiscontinuation-long-term-opioid-use.html

Health Care

https://www.fda.gov/drugs/safe-disposal-medicines/
disposal-unused-medicines-what-you-should-know

U.S. Drug Enforcement
Search engine for finding
Agency: Diversion Control public locations to dispose
Divisionof unused controlled
substances. Other
information also available.

Health Care

https://www.dea.gov/diversion-control-division

U.S. Food and Drug
Administration (FDA):
Disposal of Unused
Medicines: What You
Should Know

FDA Information on
Disposal of Unused
Controlled SubstancesThis resource link may beprovided to patients by ahealth care provider.

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63Supporting Evidence:

Perioperative

The subdivisions of this section are:• References• Appendix

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References
Aasvang EK, Lunn TH, Hansen TB. Chronic pre-operative opioid use and acute pain after fast-track
total knee arthroplasty. Acta Anaesthesiol Scand. 2016 Apr;60(4):529-36.
Alam A, Gomes T, Zheng H, et al. Long-term analgesic use after low-risk surgery: a retrospective cohort
study. Arch Intern Med. 2012 Mar 12;172(5):425-30.
Alford DP, Compton P, Samet JH. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Ann Intern Med. 2006 Jan 17;144(2):127-34.
American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 775. Nonobstetricsurgery during pregnancy. Obstet Gynecol 2019;133:e285–6.
American Diabetes Association. 15. Diabetes Care in the Hospital: Standards of Medical Care in
Diabetes—2019. Diabetes Care 2019 Jan; 42(Supplement 1): S173-S181.
American Society of Anesthesiologists. Pregnancy Testing Prior to Anesthesia and Surgery. October
26, 2016.
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outcomes in patients with diabetes: a meta-analysis. Diabetes Res Clin Pract. 2013 Oct;102(1):8-15.
Schwarze ML, Barnato AE, Rathouz PJ, et al. Development of a list of high-risk operations for patients
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Appendix A: Literature Search Description
Search Terms: Perioperative
Preoperative screening; perioperative care; perioperative period; perioperative care; elective surgery; preoperative medical evaluation; preoperative clearance; preoperative health assessments; preoperative testing;diagnostic tests routine; electrocardiogram; hemoglobin; creatinine; potassium; chest X-ray; pregnancy
test; preoperative management of medical conditions; cardiovascular disease (Beta blockers, statin therapy,
anticoagulation and blood disorders); sleep apnea; diabetes; diabetes mellitus; nondiabetic patient; blood
glucose; glucose levels; glycemic control; A1c; HbA1c; diabetes management and glycemic control; glucose
levels; glycemic control for nondiabetic patients; glucose levels; prevention of endocarditis; management ofpatients with coronary stents; preoperative nicotine cessation; preoperative showering/shaving; preoperative
fasting recommendations; coagulation studies; antiplatelets for patients with ischemic stroke disease, heart
failure, arrhythmia, heart valve disease (outside of stents and ischemic cardiac disease); when to stop ACE
inhibitors in patients with ischemic cardiac disease, ischemic stroke, heart failure, arrhythmia, heart valve
disease; when to stop antithrombotics and anticoagulants prior to surgery; when to resume antithrombotics
and anticoagulants after surgery; when to bridge anticoagulants prior to surgery; when to resume anticoagulants after surgery; anticoagulant reversal in surgery only.
Search Terms: Perioperative Opioid
Perioperative opioid managment; preoperative and postoperative opioid management; perioperative chronic
opioid management; preoperative and postoperative chronic opioid management; analgesics, opioid/
administration and dosage; analgesics, opioid; chronic opioid use; preoperative care; perioperative care;postoperative care; postoperative pain management; postoperative complications; chronic opioid disorders;
opioid-related disorders; analgesic, patient controlled; pain, postoperative/drug therapy.
Age group:
Patients 18 years of age and older
Inclusions:
Routine and elective procedures only
Exclusions:
Emergency and urgent proceduresTime period:
Jan. 1, 2014–April 30, 2019 (Jan. 31, 2019 for perioperative opioid)
Types of studies:
Systematic review/meta-analysis
Randomized controlled trials
Observational studies (cohort, case-control and cross-sectional)
Human studies: English
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Disclosure of Potential Conflicts of Interest:

Perioperative

ICSI has long had a policy of transparency in declaring potential conflicting
and competing interests of all individuals who participate in the development,
revision and approval of ICSI guidelines and protocols.
In 2010, the ICSI Conflict of Interest Review Committee was established by
the Board of Directors to review all disclosures and make recommendations tothe board when steps should be taken to mitigate potential conflicts of interest,
including recommendations regarding removal of work group members. This
committee has adopted the Institute of Medicine Conflict of Interest standards
as outlined in the report, Clinical Practice Guidelines We Can Trust (2011).
Where there are work group members with identified potential conflicts, theseare disclosed and discussed at the initial work group meeting. These members
are expected to recuse themselves from related discussions or authorship ofrelated recommendations, as directed by the Conflict of Interest committee orrequested by the work group.
The complete ICSI policy regarding Conflicts of Interest is available at
http://bit.ly/ICSICOI.
Funding Source
The Institute for Clinical Systems Improvement provided the funding for thisprotocol revision. ICSI is a not-for-profit, quality improvement organization
based in Bloomington, Minnesota. ICSI’s work is funded by the annual duesof the member medical groups. Individuals on the work group are not paid by
ICSI but are supported by their medical group for this work.
ICSI facilitates and coordinates the guideline development and revision process.
ICSI members review and provide feedback but do not have editorial control
over the work group. All recommendations are based on the work group’s
independent evaluation of the evidence.
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77Perioperative

Sixth Edition /January 2020

Disclosure of Potential Conflicts of Interest
Perioperative Guideline Work Group

Nicole Varela, MD (Work Group Leader and Member)Anesthesiology; Mayo Clinic
Guideline-Related Activities: None
Programmatic Relationships: None
Financial/Non-Financial: None
Hannah Degallier, PA-C (Work Group Member)
Family Medicine; Entira Family Clinics (formerly of)
Guideline-Related Activities: None
Programmatic Relationships: None
Financial/Non-Financial: None
Mark Grimm, MD (Work Group Member)Anesthesiology; Essentia Health
Guideline-Related Activities: None
Programmatic Relationships: None
Financial/Non-Financial: Advisory Council, Member of Epic’s Adult Anesthesia Steering Committee
Kathleen Harder, PhD (Work Group Member)
Human Factors; University of Minnesota (formerly of)
Guideline-Related Activities: None
Programmatic Relationships: None
Financial/Non-Financial Conflicts of Interest: None
Adam Jacob, MD (Work Group Member)Anesthesiology; Mayo Clinic
Guideline-Related Activities: None
Programmatic Relationships: None
Financial/Non-Financial Conflicts of Interest: None
Joan Kane, APNL, CRNA (Work Group Member)
Nursing, Anesthesia; Fairview Health Services
Guideline-Related Activities: None
Programmatic Relationships: None
Financial/Non-Financial: None
Sarah Lippert, MD (Work Group Member)
General Surgery; North Memorial Health
Guideline-Related Activities: None
Programmatic Relationships: None
Financial/Non-Financial: None
Deborah Mielke, MD (Work Group Member)
Family Medicine; Fairview Health Services
Guideline-Related Activities: None
Programmatic Relationships: None
Financial/Non-Financial: None
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78Disclosure of Potential Conflicts of Interest

Perioperative

Sixth Edition /January 2020

Nathaniel Miller, MD (Work Group Member)
Family Medicine; Mayo Clinic
Guideline-Related Activities: None
Programmatic Relationships: None
Financial/Non-Financial: None
Louis Millman, MD (Work Group Member)Internal Medicine; HealthPartners
Guideline-Related Activities: None
Programmatic Relationships: None
Financial/Non-Financial: None
Joshua Mueller, MD (Work Group Member)Internal Medicine; Allina Health
Guideline-Related Activities: None
Programmatic Relationships: None
Financial/Non-Financial: None
Rebekah Roemer, PharmD, BCPS (Work Group Member)Pharmacy; HealthPartners
Guideline-Related Activities: None
Programmatic Relationships: None
Financial/Non-Financial: None

Perioperative Opioid Management Subgroup

Joseph Bianco, MD (Subgroup Member)Internal Medicine; Essentia Health
Guideline-Related Activities: None
Programmatic Relationships: None
Financial/Non-Financial: Rural Communities Opioid Response HRSA Grant
Mark Grim, MD (Subgroup Member)Anesthesiology; Essentia Health
Guideline-Related Activities: None
Programmatic Relationships: None
Financial/Non-Financial: Advisory Council, Member of Epic’s Adult Anesthesia Steering Committee
Justin Hora, PharmD (Subgroup Member)Pharmacy; Allina Health
Guideline-Related Activities: None
Programmatic Relationships: None
Financial/Non-Financial: None
Adam Jacob, MD (Subgroup Member)Anesthesiology; Mayo Clinic
Guideline-Related Activities: None
Programmatic Relationships: None
Financial/Non-Financial: None
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79Disclosure of Potential Conflicts of Interest

Perioperative

Sixth Edition /January 2020

Isaac Marsolek, MD (Subgroup Member)
Physical Medicine, Rehabilitation; HealthPartners
Guideline-Related Activities: None
Programmatic Relationships: None
Financial/Non-Financial: None
Anne Pylkas, MD (Subgroup Member)Internal Medicine, Addiction Medicine; HealthPartners
Guideline-Related Activities: None
Programmatic Relationships: None
Financial/Non-Financial: Member, American Board of Addiction Medicine; Secretary, MN Board of Addiction Medicine; Secretary, Steve Rummler Hope Network
Charles Reznikoff, MD (Subgroup Member)Internal Medicine, Addiction Medicine; Hennepin Healthcare
Guideline-Related Activities: None
Programmatic Relationships: None
Financial/Non-Financial: Expert Testimony; Member, Governor’s Task Force on Medical Cannabis; Member,
MN DHS Opioid Prescribing Work Group; Member, AMA Pain Task Force
Rebekah Roemer, PharmD, BCPS (Subgroup Member)Pharmacy; HealthPartners
Guideline-Related Activities: None
Programmatic Relationships: None
Financial/Non-Financial: NoneDavid Thorson, MD (Subgroup Member)
Family Medicine, Sports Medicine; Entira Family Clinics
Guideline-Related Activities: None
Programmatic Relationships: None
Financial/Non-Financial: None
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Institute for Clinical Systems Improvement80Acknowledgements:

Perioperative

ICSI seeks review from members and the public during the revision process.
Member Review
All ICSI documents are available for member review at two points
in the ICSI revision process. The ICSI Response Report is sent tomembers at the beginning of a document revision. The goal of thisreport is to solicit feedback about the guideline, including but notlimited to the algorithm, content, recommendations and implementation. Members are also welcome to participate in the public comment
period (see below).
The work group would like to thank the following member organizations for reviewing the ICSI Perioperative Guideline in the publiccomment period:• M Health Fairview• Sanford HealthPublic Comment
ICSI makes a draft of the guideline available to the public on the
ICSI website. The public is invited to comment in an effort to get
feedback prior to its finalization. All comments will be reviewed by
the ICSI facilitator and work group members as needed. ICSI workgroup may or may not make changes to the guideline based on publiccomment responses.
The work group would like to thank all who reviewed the draft andsubmitted comments for the ICSI Perioperative Guideline.
Invited Reviewers
For some guidelines, ICSI invites experts in the community tocomment on a guideline draft prior to finalization. This is done during
the public comment period.
The work group would like to thank following individuals who
reviewed the draft and submitted comments for the ICSI Perioperative Guideline:• Michael Hooten, MD; Mayo Clinic• Halena Gazelka, MD; Mayo Clinic
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Copyright © 2020 by Institute for Clinical Systems Improvement81Document History and Development:

Perioperative
Document Drafted
April 2008
Critical Review
Sep–Nov 2008
First Edition
Feb 2009
Second Edition
Oct 2009
Third Edition
Nov 2010
Fourth Edition
Dec 2012
Fifth Edition
Apr 2014
Public Comment
Sep 2019

Sixth Edition
January 2020

The next revision will be no later than November 2024.

Sophia Anaya, RN
Surgery
Hennepin Count Medical CenterPeter Argenta, MD
Gynecologic Oncology
University of Minnesota Physicians
Greg Beilman, MD
General Surgery, Work Group Leader
Fairview Health Services
Chuck Boback, MD
Family Practice
Stillwater Medical Center
Mike Cannon, RN
Nursing
Methodist HospitalJane Erickson, RN
Facilitator
ICSI
Joann Foreman, RN
Facilitator
ICSI
Jane Gendron
Measurement Advisor
ICSI
Carol L. Hamlin, RN, MS
Surgery
University of Minnesota
Medical Center-Fairview
Betty Hanna, RN
Nursing
HealthPartners
Kathleen Harder, PhD
Human Factors Content Consultant
University of Minnesota
Nancy Jaeckels
Measurement and Implementation Advisor
ICSI

Original Work Group Members
Janet Jorgenson-Rathke, PT
Measurement and Implementation Advisor
ICSI

John Robrock, MD
Family Practice
HealthSystem Minnesota

Krissa Klotzle, PharmD, BCPS
Pharmacy
HealthPartners Medical Group andRegions Hospital

Rebekah Roemer, PharmD
Pharmacy
Park Nicollet Health Services

Paul Kosmatka, MD
Orthopedic Surgery
St. Mary's/ Duluth Clinic Health System
Stephanie Lach, MSN, MBA, RN
Patient Safety and Quality
HealthPartners Medical Group andRegions Hospital
Dana M. Langness, RN, BSN
Surgery
HealthPartners Medical Group andRegions HospitalJames Maresh, MD
General Surgery
Sanford HealthMary Matteson, RN
Surgery
Gillette Children's Specialty Healthcare
Debbie McAdams
Buyers Health Care Action Group
Representative
Pillsbury Company
Laurie McNamara, RN
Nursing
Fairview Ridges Hospital
Ruth Moes, MD
Anesthesiology
Winona HealthPeter Rothe, MD
Internal Medicine, Work Group Leader
HealthPartners
Thomas Schmidt, MD
Patient Safety and Quality
Park Nicollet Health Services
Gwen E. Schuller-Bebus, RN, BA
Surgery
Gillette Children's Specialty Healthcare
Cheryl Swanson
Patient Safety and Quality
Gillette Children's Specialty Healthcare
Marc F. Swiontkowski, MD
Orthopedic Surgery
Fairview Health Services
Ann Tarnowski
Health Education
HealthPartners
Cally Vinz, RN
Facilitator
ICSIJohn Weigelt, MD
Surgery
HealthPartners
J. Karr Wolfe, MD
Pediatrics
HealthPartners

Brad Narr, MD
Anesthesiology
Mayo Clinic

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Contact ICSI at:
8009 34th Avenue South, Suite 1200 | Bloomington, MN 55425 | (952) 814-7060 | (952) 858-9675 fax
Online at http://www.icsi.org
Copyright © 2020 by Institute for Clinical Systems Improvement

82Perioperative

Sixth Edition /January 2020

Document History
In 2005-2007, ICSI hospital members championed patient safety activities aimed at advancing efficientsurgical process flow and creating safe and reliable practices that reduced the number of adverse events insurgery. In collaboration with its members, ICSI developed standardized surgical protocols for safe sitemarking, and the reduction of surgical site infection and retained foreign objects. This work resulted in thecreation of three specific safety protocols:
Safe Site Protocol for All Invasive, High-Risk or Surgical Procedures; Prevention of Unintentionally Retained
Foreign Objects in Surgery; and Prevention of Surgical Site Infection.
In 2007-2008, ICSI facilitated a Reliability Centered Surgical Care Redesign Collaborative, which provided
a collaborative learning environment for participants to become knowledgeable in reliability theory andprinciples. This collaborative provided an opportunity for participants to share their learnings as they worked
to implement these and other surgical-related protocols.
Recognizing that these surgical processes are part of the comprehensive perioperative experience, these three
distinct protocols were merged in 2008 to create one comprehensive Perioperative Guideline consistent withthe requirements established by The Joint Commission National Patient Safety Goals.
In 2013-2014, the Preoperative Guideline and Perioperative Protocol were merged into one document.
The 2019 revision included the following updates:•

The guideline name changed from Perioperative Protocol to Perioperative Guideline.

•

A new section on perioperative opioid management has been added. It was developed by a separate
subgroup and reviewed by the Perioperative Guideline work group.

•

Since an extensive revision was done on the clinical content of this guideline, the work group members
recruited for this revision were primarily from content areas related to recommendations addressedin this revision. Work group members were not recruited to review and update the “Surgical Care
Protocol (Human Factors)” section; thus, that section was not addressed in this version.

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83Perioperative

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ICSI Document Development and Revision Process
Overview
Since 1993, the Institute for Clinical Systems Improvement (ICSI) has developed more than 60 evidence-based
health care documents that support best practices for the prevention, diagnosis, treatment or management of agiven symptom, disease or condition for patients.

Audience and Intended Use
The information contained in this ICSI Health Care Guideline is intended primarily for health professionals andother expert audiences.

This ICSI Health Care Guideline should not be construed as medical advice or medical opinion related to any
specific facts or circumstances. Patients and families are urged to consult a health care professional regarding theirown situation and any specific medical questions they may have. In addition, they should seek assistance from ahealth care professional in interpreting this ICSI Health Care Guideline and applying it in their individual case.

This ICSI Health Care Guideline is designed to assist clinicians by providing an analytical framework for theevaluation and treatment of patients, and is not intended either to replace a clinician’s judgment or to establish a
guideline for all patients with a particular condition.

Document Development and Revision Process
The development process is based on a number of long-proven approaches and is continually being revised
based on changing community standards. The ICSI staff, in consultation with the work group and a medical
librarian, conduct a literature search to identify systematic reviews, randomized clinical trials, meta-analysis, otherprotocols, regulatory statements and other pertinent literature. This literature is evaluated based on the GRADE
methodology by work group members. When needed, an outside methodologist is consulted.
The work group uses this information to develop or revise clinical flows and algorithms, write recommendations,and identify gaps in the literature. The work group gives consideration to the importance of many issues as they
develop the protocol. These considerations include the systems of care in our community and how resources
vary, the balance between benefits and harms of interventions, patient and community values, the autonomy ofclinicians and patients and more. All decisions made by the work group are done using a consensus process.
ICSI’s members review each guideline as part of the revision process. They provide comment on the scientificcontent, recommendations, implementation strategies and barriers to implementation. This feedback is used byand responded to by the work group as part of their revision work. Final review and approval of the guideline isdone by ICSI’s Committee on Evidence-Based Practice. This committee is made up of practicing clinicians andnurses, drawn from ICSI member medical groups.

Implementation Recommendations and Measures
These are provided to assist medical groups and others to implement the recommendations in the protocols. Where
possible, implementation strategies are included that have been formally evaluated and tested. Measures areincluded that may be used for quality improvement as well as for outcome reporting. When available, regulatoryor publicly reported measures are included.

Document Revision Cycle
Scientific documents are revised every 2-5 years as indicated by changes in clinical practice and literature. ICSI
staff monitors major peer-reviewed journals every month for the guidelines for which they are responsible. Work
group members are also asked to provide any pertinent literature through check-ins with the work group midcycle
and annually to determine if there have been changes in the evidence significant enough to warrant document
revision earlier than scheduled. This process complements the exhaustive literature search that is done on thesubject prior to development of the first version of a guideline.

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