The perioperative management of patients using sodium-glucose cotransporter 2 inhibitors (SGLT2is) remains controversial. The US Food and Drug Administration currently recommends stopping SGLT2is for 3-4 days before surgery, irrespective of a diagnosis of diabetes mellitus. Other multisociety recommendations vary significantly in terms of SGLT2i management, perioperative monitoring, and mitigating strategies for euglycaemic diabetic ketoacidosis. This multidisciplinary consensus statement led by the Society for Perioperative Assessment and Quality Improvement (SPAQI) provides updated recommendations based on a modified Delphi process and supported by a systematic review of the literature. The recommendations include a tailored approach to management of SGLT2is perioperatively based on the presence of diabetes mellitus and other comorbidities, surgical and periprocedural dietary considerations, as well as monitoring and prevention strategies for euglycaemic diabetic ketoacidosis.

More than 300 million surgeries are performed annually worldwide. Patients are progressively aging and often have multiple comorbidities that put them at increased cardiovascular risk in the perioperative period. The United States published latest guidelines regarding preoperative cardiac evaluation and risk stratification for patients undergoing non-cardiac surgery in 2014. There are multiple risk stratification tools available that can help guide management. Furthermore, newer laboratory tests, such as preoperative NT-proBNP and high-sensitivity troponin assays, may aid in preventing and diagnosing perioperative myocardial injury.

Functional capacity assessment is important for perioperative risk stratification; however, there are currently limited options for objective and economical functional capacity evaluation. Pedometer functions are now widely available in mobile devices and offer a nonintrusive and objective approach to measuring patient activity level over time. Therefore, we conducted this systematic review to assess the value of pedometer readings in predicting perioperative outcomes. We systematically searched PubMed, EMBASE (Ovid), Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Web of Science Citation Index for studies, which assessed the correlation between perioperative (30 days before to 30 days after surgery) pedometer data and perioperative outcomes. We identified a total of 18 studies for inclusion. Seven of the studies recorded preoperative pedometer data, and 13 studies recorded postoperative pedometer data. Notably, 10 of the studies covered oncologic surgery patients. The included studies consistently reported that preoperative pedometer readings correlated with postoperative complication rates. In addition, in-hospital postoperative pedometer readings correlated with postdischarge complications and readmissions. Perioperative pedometer data demonstrated consistent and biologically plausible association with perioperative outcomes. Further studies are needed to validate the use of pedometer in the perioperative period and to identify the optimal approach for its use to potentially improve patient outcomes.

Background: As patients are discharged from the hospital more quickly, the ability to monitor patient recovery between hospital discharge and the first follow-up clinic visit is becoming increasingly important. Despite substantial increase in both internet use and smartphone ownership over the past 5 years, clinicians have been slow to embrace the use of these devices to capture patient recovery information in the period between hospital discharge and the first clinical follow-up appointment. Objective: This study aims to investigate the generalizability of using a web-based platform to capture patient recovery in a broad surgical patient population and compare response rates for 3 different web-based strategies for delivering recovery surveys over the perioperative period: email, SMS text messaging, and a concurrent mixed approach of using both email and SMS text messaging. Methods: Patients undergoing surgeries managed with an enhanced recovery after surgery pathway were asked to participate in a web-based quality assurance monitoring program at the time of their preoperative surgery appointment. Different follow-up methods were implemented over 3 sequential phases. Patients received Health Insurance Portability and Accountability Act-compliant web-based survey links via email (phase 1), SMS text messaging (phase 2), or concurrently using both email and SMS text messaging (phase 3) using REDCap and Twilio software. Recovery assessments using the established Quality of Recovery-9 instrument were performed 4 days before surgery and at 7 and 30 days postoperatively. Generalizability of the web-based system was examined by comparing characteristics of those who participated versus those who did not. Differences in response rates by the web-based collection method were analyzed using adjusted models. Results: A total of 615 patients were asked to participate, with 526 (85.5%) opting for the follow-up program. Those who opted in were younger, slightly healthier, and more likely to be in a partnership. The concurrent mixed modes method was the most successful for obtaining responses at each time point compared with text or email alone (pre: 119/160, 74.4% vs 116/173, 67.1% vs 56/130, 43.1%, P<.001; 7 days: 115/172, 66.9% vs 82/164, 50.0% vs 59/126, 46.8%, P=.001; 30 days: 152/234, 65.0% vs 52/105, 49.5% vs 53/123, 43.1%, P=.001, respectively). In the adjusted model, the concurrent mixed modes method significantly predicted response compared with using email alone (odds ratio 3.4; P<.001) and SMS text messaging alone (odds ratio 1.9; P<.001). Additional significant predictors of response were race, partnership, and time. Conclusions: For internet users and smartphone owners, electronic capture of recovery surveys appear to be possible through this mechanism. Discrepancies in both inclusion and response rates still exist among certain subgroups of patients, but the concurrent approach of using both email and text messages was the most effective approach to reach the largest number of patients across all subgroups.

Purpose of review Patients presenting for non-operating room procedures are often ‘too sick’ for surgery and require specific anesthesia care in remote areas with logistical and scheduling challenges. Recent findings Increased complexity and scope of minimally invasive procedures have expanded this practice. In addition, the concept of therapeutic options other than conventional surgery is gaining traction. Summary Our review of recent literature confirms the complexity and supports the safety of providing care in non-operating room anesthesia locations. Standard preanesthesia assessments and principles apply to these areas.

Purpose of review Psychiatric illness is common in patients presenting for surgery. Overall health and surgical outcomes are adversely affected by the presence of psychiatric comorbidities. Recent findings As new treatment modalities become available, their perioperative implications need to be evaluated. These implications include drug–drug interactions, hemodynamic effects, bleeding risk, and factors affecting perioperative exacerbation of the underlying psychiatric illness. Summary From our review of the recent literature we continue to support the continuation of psychoactive agents in the perioperative period, taking into consideration the effects these agents have on concomitant drug use in the perioperative period; and the risks of withholding them at a high-stress time.

BACKGROUND As patients are being discharged from the hospital earlier, the ability to monitor patient recovery between hospital discharge and the first follow-up clinic visit is becoming increasingly important. Despite substantial increases in both internet use and smartphone ownership over the past 5 years, clinicians have been slow to embrace the use of these devices to capture patient recovery information in the period between hospital discharge and the first clinical follow-up appointment. OBJECTIVE To investigate the generalizability of using a web-based platform to capture patient recovery in a broad surgical patient population, and compare response rates for three different web-based strategies for delivering recovery surveys over the perioperative time-period: email, short message service (SMS) text messaging, and a concurrent mixed approach of using both email and SMS text messaging. METHODS Patients undergoing surgeries managed with an Enhanced Recovery After Surgery (ERAS) pathway program were asked to participate in the web-based quality assurance monitoring program at the time of their pre-operative surgery appointment. Different follow-up methods were implemented over three sequential phases. Patients received HIPAA compliant web-based survey links by either email (phase 1), SMS text (phase 2), or concurrently using both email and SMS text (phase 3) using RedCap® and Twillio® software. Recovery assessments using the established Quality of Recovery-9 (QOR-9) tool were measured 4 days prior to surgery, and at 7 and 30 days postoperatively. Generalizability of the web-based system was examined by comparing demographic and clinical characteristics of those who participated vs. those that did not. Differences in response rates by web-based collection method were analyzed in adjusted models. RESULTS A total of 615 patients asked to participate, with 526 (85.53%) opting in to the follow-up program. Those who opted in were younger, slightly healthier, and more likely to be in a partnership. The concurrent mixed modes (CMM) was the most successful method for obtaining responses at every time point compared to text or email alone (pre: 74% vs. 67% vs 43%, P <.001; 7 day: 67% vs. 50% vs. 47%, P = .001; 30 day: 65% vs. 50% vs. 43%, P = .001, respectively). In the adjusted model, the CMM method of contact significantly predicted response compared to using email alone (Odds Ratio (OR) =3.4, P <.0001), and SMS text alone (OR=1.9, P =.0003). Additional significant predictors of response were race, partnership and time. CONCLUSIONS For internet users and smartphone owners, electronic capture of recovery surveys appears to be possible through this HIPAA compliant resource friendly mechanism. Discrepancies in both inclusion and response rates still exist among certain subgroups of patients, but the concurrent approach of using both email and text messages was the most effective approach to reach the largest number of patients across all subgroups.

Smokers are at increased risk for surgical complications. Despite the known benefits of smoking cessation, many perioperative health care providers do not routinely provide smoking cessation interventions. The variation in delivery of perioperative smoking cessation interventions may be due to limited high-level evidence for whether smoking cessation interventions used in the general population are effective and feasible in the surgical population, as well as the challenges and barriers to implementation of interventions. Yet smoking is a potentially modifiable risk factor for improving short- and long-term patient outcomes. The purpose of the Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement on Perioperative Smoking Cessation is to present recommendations based on current scientific evidence in surgical patients. These statements address questions regarding the timing and intensity of interventions, roles of perioperative health care providers, and behavioral and pharmacological interventions. Barriers and strategies to overcome challenges surrounding implementation of interventions and future areas of research are identified. These statements are based on the current state of knowledge and its interpretation by a multidisciplinary group of experts at the time of publication.

aDepartment of Medicine, the Renaissance School of Medicine at Stony Brook, Stony Brook NY bDepartment of Anesthesiology, the Renaissance School of Medicine at Stony Brook, Stony Brook NY Address Correspondence to: Paul S. Richman, MD, HSC-17040, Stony Brook University Medical Center, 100 Nicolls Rd, Stony Brook, NY 11794. E-mail: [email protected]

Aging is associated with normal and abnormal brain structural and neuropsychological changes. Due to the expected increase in older adults requiring surgery, perioperative clinicians will be increasingly encountering patients with neurodegenerative disease. To help perioperative clinicians understand signs of abnormal behaviors that may mark an undiagnosed neurodegenerative disorder and alert additional patient monitoring, the Society for Perioperative Assessment and Quality Improvement (SPAQI) worked with experts in dementia, neuropsychology, geriatric medicine, neurology, and anesthesiology to provide a summary of cognitive and behavioral considerations for patients with common neurodegenerative disorders being evaluated at preoperative centers. Patients with neurodegenerative disorders are at high risk for delirium due to known neurochemical disruptions, medication interactions, associated frailty, or vascular risk profiles presenting risk for repeat strokes. We provide basic information on the expected cognitive changes with aging, most common neurodegenerative disorders, and a list of behavioral features and considerations to help differentiate neurodegenerative disorders. Finally, we propose screening recommendations intended for a multidisciplinary team in the perioperative setting.

Frailty is an age-related, multi-dimensional state of decreased physiologic reserve that results in diminished resiliency and increased vulnerability to stressors. It has proven to be an excellent predictor of unfavorable health outcomes in the older surgical population. There is agreement in recommending that a frailty evaluation should be part of the preoperative assessment in the elderly. However, the consensus is still building with regards to how it should affect perioperative care. The Society for Perioperative Assessment and Quality Improvement (SPAQI) convened experts in the fields of gerontology, anesthesiology and preoperative assessment to outline practical steps for clinicians to assess and address frailty in elderly patients who require elective intermediate or high risk surgery. These recommendations summarize evidence-based principles of measuring and screening for frailty, as well as basic interventions that can help improve patient outcomes.

Cardiac risk stratification before surgery informs consent, may advise optimization interventions, and guides intraoperative and postoperative management and monitoring. Published guidelines provide an outline for risk stratification but are only updated every 5 to 10 years; hence, cardiology expert opinion is often needed. Preoperative cardiovascular evaluation starts with an excellent history and physical examination. Accurate assessment of exercise tolerance is paramount in defining risk and determining the need for further testing. Risk/benefit ratio needs to be assessed and reviewed with all stakeholders, which pertains to deciding on cardiac intervention before surgery and bleeding versus thrombosis risk when managing medications.

Technology is the prominent feature of the twenty-first century, including in medicine. There are very few organs that cannot be stimulated, shocked, or infused. With more and more implantable devices being approved for clinical use, anesthesiologists have to regularly take care of patients who have these devices. An understanding of the devices, the associated comorbidities, and the perioperative risks is crucial for safe management of these patients. Cardiac devices are discussed in some detail; neurostimulators and other implantable devices are briefly described. The principles of assessment and management are similar for all patients with implanted devices.

There are more than 29 million people in the United States with diabetes; it is estimated that by 2050, one in 3 individuals will have the disease. At least 50% of patients with diabetes are expected to undergo surgery in their lifetime. Complications from uncontrolled diabetes can impact multiple organ systems and affect perioperative risk. In this review, the authors discuss principles in diabetes management that will assist the perioperative clinician in caring for patients with diabetes.

23 Background: Chronic liver disease is prevalent, but is frequently overlooked as a perioperative risk factor. Treatment modalities have improved, leading to increasing numbers of patients with chronic liver disease and cirrhosis present-ing for elective surgeries. It is known that patients with liver disease who require surgery are at greater risk 1 for perioperative complications compared to those with healthy livers because of the stress of surgery and effects of anesthesia. Purpose: Identifi cation of surgical risk is imperative for therapeutic decision-making and informed treatment choices. Patients are often screened preopera- tively by midlevel practitioners who need guidance for appropriate evaluation. Description: We have introduced a simple algorithm for evaluation and management of patients with known or suspected liver disease to guide midlevel practitioners, nurses, and physicians in the preoperative clinic. The algorithm includes history, physical, and laboratory fi ndings, 2 as well as the use of the vali-dated Child-Pugh score. 3 More detailed explanatory information is appended by footnotes. Results: Early use of the tool has led to increased recognition, improved his-tory and physical examination skills, and appropriate laboratory test interpreta- tion. As severe liver cirrhosis is rare, we are not able to demonstrate globally improved outcomes, but we are able to show institutional improvements in perioperative management. Conclusions: A well-designed protocol, aided by clinical pathways, improves screening effi ciency and outcomes. We present our algorithm for the preopera- tive evaluation of the patient with liver disease.

Ambulatory surgery currently represents more than two thirds of surgeries performed. It is considered low-risk surgery and patients expect to be discharged home safely and comfortably the same day. More than 30 years of evidence supports the idea that preoperative assessment is best done by a focused history and physical, and only minimal, selective, further laboratory investigations. Costs are optimized by this approach and outcomes have not been shown to be adversely affected, possibly even improved, with less harm inflicted by additional testing. This article focuses on what is appropriate testing for ambulatory surgery patients.