#475 Perioperative Update with Dr. Avital O’Glasser
Mar 17, 2025
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In this episode, Dr. Avital O’Glasser, a hospitalist and expert in perioperative medicine at Oregon Health and Science University, shares cutting-edge insights into the latest 2024 ACC/AHA guidelines. She discusses when to hold ACE inhibitors, the complexities of managing obstructive sleep apnea before surgery, and why the traditional 'NPO after midnight' rule is outdated. Listeners will appreciate her take on personalized patient care, balancing cardiac risks, and the importance of effective communication in surgical environments.
The 2024 ACC/AHA guidelines emphasize the importance of cardiac biomarker testing to manage preoperative cardiovascular risks effectively.
Effective preoperative assessment goes beyond clearance for surgery by incorporating risk stratification and identifying potential postoperative complications.
Managing medications like GLP-1 agonists and SGLT2 inhibitors pre-surgery requires careful consideration due to their effects on anesthesia and metabolic risks.
Deep dives
Importance of Perioperative Assessment
The preoperative assessment is crucial for ensuring patient safety and optimizing surgical outcomes. It involves a comprehensive evaluation of a patient's medical history, functional capacity, and current medication management, particularly for those with complex medical backgrounds. Understanding the full scope of a patient's health status goes beyond just ensuring they are 'cleared' for surgery; it encompasses risk stratification and the identification of potential postoperative complications. Effective preoperative reviews allow healthcare providers to tailor surgical plans and manage patients more effectively through the surgical continuum.
Latest Updates to ACC AHA Guidelines
The 2024 ACC AHA guidelines introduce new recommendations, including the use of cardiac biomarkers like proBNP and troponin in the perioperative setting. A two-way recommendation suggests proBNP testing for elevated risk patients, improving clinicians' ability to identify and manage cardiovascular risks preoperatively. Additionally, the guidelines refine the utility of stress testing by incorporating individual patient assessments to determine the necessity of further testing based on the patient's functional capacity and comorbidities. These updates emphasize a more preventive approach towards managing risks associated with surgery.
Role of GLP-1 Agonists and SGLT2 Inhibitors
The use of GLP-1 agonists, such as terzepatide, raises specific concerns regarding gastric emptying and possible aspiration risks during surgery. These medications slow gastrointestinal motility, which could complicate anesthesia management if not appropriately addressed prior to the procedure. Meanwhile, SGLT2 inhibitors are recommended to be held at least three days before surgery due to the risk of euglycemic DKA, especially in patients without a prior history of diabetes. Continued learning about the interaction and monitoring required for these medications is essential for optimal perioperative care.
Managing AFib in the Perioperative Setting
New onset atrial fibrillation (AFib) identified in the preoperative setting necessitates careful evaluation of the patient's clinical status before proceeding with surgery. It is crucial to assess the patient's symptoms, functional capacity, and any underlying conditions that may impact surgical outcomes. Guidelines stress the importance of outpatient follow-up for patients experiencing new AFib to address thromboembolic risk and ensure proper management post-surgery. This represents a shift from previously assuming that transient AFib could be overlooked, highlighting the need for vigilant assessment and management.
Insights on MINS and Postoperative Care
Myocardial injury after non-cardiac surgery (MINS) is now recognized as a significant risk factor for adverse outcomes, necessitating increased awareness among healthcare providers. Elevated troponin levels postoperatively can indicate a myocardial insult, prompting further evaluation and intervention to manage cardiovascular risk. The guidelines advocate for a proactive approach to patient management, where clinicians should work to communicate these findings and secure outpatient follow-up. Providing patients with individualized recommendations based on their specific risk factors enhances their postoperative care and prevents potential complications.
Holistic View in Perioperative Medicine
A comprehensive understanding of perioperative medicine requires addressing multifaceted issues affecting surgical patients, including frailty, anesthesia considerations, and chronic illnesses. Providers should recognize that a holistic evaluation encompasses the entire patient experience, from the preoperative assessment through to postoperative recovery. Being mindful of psychosocial factors, coexisting conditions, and the patient's overall well-being is essential for enhancing surgical outcomes. By promoting interdisciplinary communication among care teams, a more patient-centered approach can be fostered, ultimately leading to improved results.
2024 ACC/AHA guideline update, including biomarker testing, MINS, and other consulting tips
Master perioperative medicine! Learn when to hold ACE inhibitors, how to manage OSA without delaying surgery, and why "NPO after midnight" is outdated. We’re joined by Dr. Avital O’Glasser, our Chief of Perioperative Medicine!
Written and produced, show notes, cover art, CME, and infographics: Paul Wurtz MD.
Hosts: Matthew Watto MD, FACP; Paul Williams MD, FACP
Reviewer: Molly Heublein MD
Showrunners: Matthew Watto MD, FACP; Paul Williams MD, FACP
Technical Production: PodPaste
Guest: Avital O’Glasser MD
Disclosures
Dr. O’Glasser reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
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