The latest perioperative medicine update highlighted several findings that could reshape routine pre‑operative assessment and postoperative care for hospitalists.
Functional capacity and mortality risk
A Swedish cohort of 27,472 patients undergoing elective non‑cardiac surgery linked self‑reported metabolic equivalents of task (METs) to both 30‑day and 1‑year mortality. Researchers found a clear dose‑response: patients reporting MET 6‑8 had an adjusted one‑year mortality of 0.2%, while those at MET 1 faced a risk of 7.2%.
Even though 28% of participants lacked MET data and the measure is subjective, the study suggests that a simple question about functional capacity still predicts outcomes. They recommend confirming patient reports with family members when possible.
Smoking cessation before surgery
Contrary to older teaching, a systematic review of 55 studies showed that stopping smoking at least two weeks before an operation cuts pulmonary complications by 27% compared with continued smokers. The benefit increases with longer abstinence, reaching a 37% reduction after six weeks.
Wound complications fell 33% after four weeks of cessation, and overall mortality decreased by 14%. The evidence supports encouraging any duration of pre‑operative smoking cessation rather than allowing a “last cigarette” before the procedure.
These data reinforce that lifestyle changes, even when brief, can have measurable effects on surgical risk.
Risk assessment for patients with end‑stage renal disease
A retrospective analysis of 32,337 end‑stage renal disease patients in the National Surgical Quality Improvement Program compared the American University of Beirut HAS2 index with the Revised Cardiac Risk Index (RCRI). The HAS2 model performed better for predicting mortality (AUC 0.68 vs. 0.62) and the composite of death, myocardial infarction, or stroke.
The improvement stemmed from HAS2’s inclusion of anemia, vascular surgery, and active symptoms—variables that RCRI omits. Clinicians may consider adopting the HAS2 score when evaluating renal‑failure patients for non‑cardiac surgery.
SGLT2 inhibitors and postoperative outcomes
In a propensity‑matched study of 98,118 type 2 diabetes patients, those who continued SGLT2 inhibitors within 90 days of surgery experienced lower 30‑day all‑cause mortality (0.68% vs. 1.12%) and fewer major cardiovascular events, acute kidney injury, and ketoacidosis. This finding runs counter to the FDA’s three‑to‑four‑day hold recommendation for these drugs.
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While the study relied on ICD‑10 codes for ketoacidosis, the overall trend suggests that continuing SGLT2 inhibitors may be safe when glucose, electrolytes, and ketones are monitored every six hours for the first 24 hours post‑operatively.
Functional decline after major surgery in older adults
Researchers followed 2,007 Canadians aged 65 and older undergoing major non‑cardiac surgery. By six months, 16.5% had either new disability or had died; the figure rose to 20.7% at one year.
Pre‑operative factors such as cognitive impairment (OR 1.41), frailty (OR 1.88), tobacco use (OR 1.44), open surgical approach (OR 1.66), and unmet social support (OR 1.30) were linked to worse outcomes. These variables are often modifiable, emphasizing the importance of thorough pre‑operative screening and shared decision‑making that includes discussions of best‑case and worst‑case scenarios.
Understanding that many older patients fear institutionalization more than death helps clinicians prioritize functional outcomes over survival alone.
Multidisciplinary pre‑operative reviews
A Dutch multicenter observational study of 225 high‑risk patients found that 32% did not proceed to surgery after a multidisciplinary team review. Among those who did operate, 81% experienced at least one change in management—ranging from anesthetic technique to surgical approach or optimization of comorbidities.
The peri‑operative hospitalist’s role in these discussions remains under‑described, suggesting an opportunity for greater involvement.
Blood management and iron supplementation
The TOP trial randomized 1,424 high‑cardiac‑risk patients to liberal (hemoglobin < 10 g/dL) versus restrictive (hemoglobin < 7 g/dL) postoperative transfusion thresholds. While the primary composite outcome at 90 days showed no difference, the liberal group had fewer non‑myocardial‑infarction cardiac complications (5.9% vs. 9.9%), driven mainly by reduced arrhythmias and heart‑failure events.
A meta‑analysis of 12 randomized trials demonstrated that intravenous iron administered within 30 days after surgery raised hemoglobin by roughly 0.45 g/dL, whereas oral iron showed no measurable effect. The benefit was most pronounced after orthopedic procedures, indicating that IV iron may be the preferred strategy for patients with low ferritin and ongoing blood loss.
Overall, the update showed that basic variables—functional capacity, smoking status, frailty, social support, and iron stores—continue to drive postoperative outcomes more than many newer interventions.
