The Curbsiders Internal Medicine Podcast #475: Perioperative Update with Dr. Avital O’Glasser

Main Theme & Purpose

This lively and in-depth episode brings back perioperative medicine expert Dr. Avital O’Glasser to break down the key updates in the 2024 ACC/AHA perioperative guidelines. The episode arms internists and hospitalists with practical advice on risk stratification, inter-specialty communication, preoperative medication management (including GLP-1s, SGLT2 inhibitors, ACE/ARBs), frailty, appropriateness of testing, biomarkers, perioperative hypertension, NPO guidelines, and the complex art of optimizing patients for surgery. The hosts utilize typical Curbsiders humor amid high-yield clinical pearls and patient-centered wisdom.

Key Discussion Points & Insights

1. The Role of the Preoperative Assessment—"Avoid the C Word"

• The term "clearance" is discouraged; focus instead on a holistic preoperative assessment—not a one-and-done checklist.
• The internist's perioperative role is to quantify and qualify known comorbid conditions (07:10), empower patients, and coordinate optimal care throughout the surgical trajectory.
• Quote [07:10]:

  "The preop assessment... is a chance to learn about a patient, not just generate a risk assessment... but also to empower their perioperative care. It’s the entire spectrum."
  — Dr. Avital O’Glasser

2. Navigating Routine Testing Requests from Surgeons

• The new guidelines (2024 ACC/AHA) reinforce the principle that routine stress tests, EKGs, echos, and PFTs are generally not indicated unless specific clinical indications exist.
• Advocacy is needed to push back on low-value testing, citing evidence and fostering collegial dialogue.
• Institutional inertia and outdated protocols commonly drive unnecessary testing (such as pre-op coags for cataracts or neurosurgery).
• Quote [13:42]:

  “Often those mandated pre-op tests are institutional inertia... Sometimes the best thing to do is just get it done if surgery will be canceled otherwise, but then tackle the system for future patients.”
  — Dr. Avital O’Glasser

3. Communicating Assessment Results: Words Matter!

• Use precise, actionable phrases:
  • “This patient is stable and optimized for this surgery.”
  • “Is further testing needed? Yes/No” and “Is further optimization needed? Yes/No.” (19:34)
  • For complex patients: “risk appropriate” or “risk prohibitive.”
• Quote [19:34]:

  “My preferred charting style is, ‘This patient is, or is not, stable and optimized for this surgery.’”
  — Dr. Avital O’Glasser

4. Risk Calculators: RCRI, MICA/Gupta, and Risk Modifiers

• Know your tool: RCRI, Gupta (MICA), and ACS NSQIP predict different outcomes (MI vs. broader cardiovascular events).
• Prefer MICA/Gupta in the U.S. due to contemporary derivation and more robust databases.
• New ACC/AHA guidelines suggest using Gupta >1% or RCRI >1 (no percentage) as thresholds for further workup (23:57).
• Add risk modifiers: Frailty, severe valve disease, PH, prior coronary revascularization, congenital heart disease, ICDs, recent stroke.
• Quote [25:27]:

  “There are patients who will fall out of the population model and need unique risk consideration... Frailty is one of the modifiers.”
  — Dr. Avital O’Glasser

5. Frailty: Assessment & Implications

• Routine frailty screening now Class II recommendation in guidelines.
• Frailty ≠ comorbidity ≠ disability, but can overlap.
• Tools: Dr. O’Glasser prefers Edmonton Frail Scale, paired with the Mini-Cog for cognitive assessment (32:27).
• Screening for frailty allows for:
  • Prehabilitation.
  • Possible surgical postponement or even cancellation if risks outweigh benefits.
  • Tailoring post-op planning and family involvement.
• Quote [28:16]:

  “Why are we predicting? We’re trying to predict so we can try to prevent.”
  — Dr. Avital O’Glasser

6. OSA and Pulmonary Optimization

• Routine pre-op PFTs rarely indicated—except thoracic surgery or undiagnosed dyspnea.
• OSA recognition is crucial; positive STOP-BANG requires targeted risk mitigation but surgery rarely delayed for formal sleep study (44:13).
• Optimize OSA: Ensure proper use of CPAP, consider level of monitoring, and surgical procedure considerations (e.g., contraindication to CPAP post-op in some cases).

7. Medication Management: ACE/ARBs, SGLT2i, GLP-1s

ACE/ARBs

• Nuanced, individualized. Hold 24 hours prior for non-cardiac, low-risk patients prone to intra-op hypotension (especially if well controlled), but continue in HFrEF (50:08).
• Quote [50:08]:

  “At this juncture, we’re at flip-a-coin... individualized decision-making is key.”
  — Dr. Avital O’Glasser

SGLT2 Inhibitors

• Hold for 3 days before elective surgery due to DKA risk.
• In patients with heart failure (and no DM), weigh the risk of volume overload; may continue up to day of surgery based on patient stability (70:50).

GLP-1 Agonists

• Concern for delayed gastric emptying/aspiration—growing trend to hold for up to 1 week pre-op, but evidence evolving and context-specific (69:18).

8. Perioperative Hypertension: When to Postpone?

• Guidelines advise deferring elective surgery only if BP >180/110 mmHg (consistent with Drs. Merle/Weitz).
• Gather home BP trends; aim for <150 systolic for comfort if time allows, but don’t overtighten control abruptly (57:40).

9. NPO Guidelines & Institutional Inertia

• Strong evidence for clear liquids up until 2 hours before surgery, but most U.S. institutions lag behind due to dogma.
• Hydrated, carbohydrate-replete patients do better; ERAS protocols advocate for liberalized pre-op fluid intake (65:17).

10. Cardiac Biomarkers & Perioperative Surveillance

• BNP/NT-proBNP: Class IIa—can help in intermediate/high cardiac risk and uncertainty about HF status or functional capacity.
• Troponin: Class IIb—routine pre-op troponin for everyone not recommended; more for select high-risk patients.
• Pre-op baselines can distinguish chronic elevations from acute events post-op; more valuable if you’re planning post-op troponin surveillance (74:24, 80:17).
• MENs (Myocardial injury after non-cardiac surgery): Prognostic significance for increased risk of cardiovascular events—ensure patients receive "teachable moment" interventions (statin, ASA in recovery phase, tobacco cessation, etc.)

11. Post-Op Atrial Fibrillation

• Do NOT “forgive” transient post-op AFib—associated with increased long-term risk of AFib and stroke.
• Communicate events clearly to the outpatient team; consider extended ambulatory monitoring, appropriate anticoagulation per guideline risk stratification (89:36).

12. Incidental AFib Discovered Pre-op

• Assess stability, symptoms, and underlying cause (TSH, metabolic panel), and tailor further testing and management to surgical urgency and risk.
• For stable, asymptomatic, rate-controlled patients with low-risk surgery, often proceed with close post-op follow-up.

Notable Quotes & Memorable Moments

• “Perioperative Medicine… is so much more than just a checkbox in the medical record. Make it relational rather than transactional.” (10:07, Dr. O’Glasser)

• “If you walk into the exam room and think, ‘If I sneeze this patient will break a hip’—that’s frailty!” (28:16)

• “Black coffee counts as a clear liquid… if you can read newsprint through it, it counts.” (65:09, Dr. O’Glasser)

• “If you have a STOP-BANG of 7 and AFib… you should be getting a sleep study—but for elective surgery, I almost never delay for it.” (44:13)

• On routine pre-op testing: “We have mounds of data—this is wasteful, does not change management, and costs the healthcare system millions.” (10:07)

• “I use the Edmonton Frail Scale… all of it except the clock draw can be done unassisted. It’s very patient-centered.” (32:27, Dr. O’Glasser)

Timestamps for Key Segments

• 06:00 – Introduction to pre-op approach and avoiding "clearance"
• 09:30 – Discussing and negotiating routine pre-op test requests
• 19:34 – What to write in your operative note (stable, optimized, etc.)
• 21:31 – Strengths and weaknesses of risk calculators (RCRI vs MICA/Gupta/NSQIP)
• 25:27 – The value of risk modifiers including frailty
• 28:16 – Frailty: Measurement and clinical application
• 32:27 – Dr. O’Glasser’s preferred tools for measuring frailty
• 44:13 – OSA management and pulmonary risk assessment
• 48:35 – ACEs/ARBs perioperative management, guideline update
• 56:40 – Perioperative hypertension thresholds and management
• 62:42 – NPO “except meds” dogma and real evidence
• 65:09 – What counts as a “clear liquid”
• 70:31 – GLP-1 and SGLT2i peri-op management
• 74:24 – Cardiac biomarkers and the use of troponins/BNP before surgery
• 82:19 – MENs (Myocardial injury after non-cardiac surgery), implications
• 89:36 – Approach to post-op AFib and evolving recommendations
• 92:28 – How to handle pre-op incidental new-onset AFib
• 96:09 – Take-home pearls: moving toward holistic, patient-centered perioperative care

Take-Home Pearls

• Stop saying “clearance”—ask how you can empower the patient’s safest journey, including pre-, intra-, and post-op phases.
• Don’t order routine pre-op tests unless there’s a clear clinical indication; push back on institutional inertia.
• Use concise, clear, and actionable language in your documentation.
• Choose risk calculators fitting your practice (MICA/Gupta), but always integrate clinical judgment and risk modifiers—especially frailty.
• Screen for frailty; intervene when possible, pause or cancel surgery when appropriate, and involve family/support networks in planning.
• Manage perioperative medications individually—ACE/ARBs, SGLT2i, GLP-1s, and antihypertensives all require nuanced approach based on patient and procedure.
• Liberalize NPO instructions where possible: clear liquids up to 2 hours pre-op is best practice.
• Incorporate biomarker data as adjuncts—be aware of institutional capacity to respond to abnormal results.
• Never “forgive” post-op AFib or MENs—these signal increased long-term risk. Communicate to the outpatient team for risk reduction.
• Zoom out from cardiac risk—pulmonary, hematologic, neuropsychiatric, substance use, and social risk factors profoundly impact perioperative outcomes.

For Further Reference

• Check Figure 1 & 6 of the 2024 ACC/AHA Perioperative Guidelines for stepwise risk stratification and post-op troponin evaluation algorithms.
• The “Things We Do for No Reason” article on NPO after midnight (recommended resource from Dr. O’Glasser).
• Enhanced Recovery After Surgery (ERAS) protocols for guidance on fluids, nutrition, and recovery-acceleration pathways.

Hosts: Dr. Matthew Watto, Dr. Paul Nelson Williams, Dr. Paul Wirtz
Guest: Dr. Avital O’Glasser
Date: March 17, 2025

“Knowledge is empowering, and knowing what I need to learn about you will help on the day of surgery, in the OR, and beyond.”
— Dr. Avital O’Glasser (99:42)

Episode available for CME credit at curbsiders.vcuhealth.org.