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#475 Perioperative Update with Dr. Avital O’Glasser - The Curbsiders Internal Medicine Podcast | Wave AI Podcast Notes

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#475 Perioperative Update with Dr. Avital O’Glasser

The Curbsiders Internal Medicine Podcast

Mon Mar 17 2025

Summary

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Institutional inertia and outdated protocols commonly drive unnecessary testing (such as pre-op coags for cataracts or neurosurgery).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.

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Transcript

Sponsor/Ad Announcer (0:00)

Hey, before we get to the show, I wanted to remind you to check out our patreon@patreon.com curbsiders if you haven't signed up yet, sign up now to get ad free episodes, twice monthly, bonus episodes and a whole bunch of other.

Dr. Matthew Frank Watto (0:12)

Cool stuff@patreon.com curbsiders Paul, I don't have a pun for you. Do you have one?

Dr. Paul Nelson Williams (0:21)

No, not a pun Wado. But I wanted to share an anecdote. I actually I had to go to the urgent care center last week a little bit nerve wracking. I swallowed a whole bunch of Scrabble tiles and the doctor told me that my next trip to the bathroom could spell disaster. Thank you to cheeseburger.com.

Dr. Avital Oglassar (0:43)

The curbsiders podcast is for entertainment, education and information purposes only and the topics discussed should not.

Dr. Paul Nelson Williams (0:47)

Be used solely to diagnose, treat, cure or prevent any diseases or conditions. For the more the views and statements expressed on this podcast are solely those.

Dr. Avital Oglassar (0:51)

Of those and should not be interpreted.

Dr. Paul Nelson Williams (0:52)

Perfect official policy or position of any entity aside from possibly cash like more.

Dr. Avital Oglassar (0:55)

Hospital and affiliate outreach programs, if indeed there are any. In fact there are non pretty much we are responsible. If you screw up.

Dr. Paul Nelson Williams (0:59)

You should always do your own homework.

Dr. Avital Oglassar (1:00)

And let us know when. We're welcome.

Dr. Matthew Frank Watto (1:08)

Welcome back to the curbsiders. I'm Dr. Matthew Frank Waddo, here with my great friend and America's primary care physician, surely the primary care physician, Dr. Paul Nelson Williams.

Dr. Paul Nelson Williams (1:20)

Yep, just sitting in my own shame. Feel real bad. Matt, how are you feeling?

Dr. Matthew Frank Watto (1:26)

Feeling bad because of the pun? Is that what you're saying?

Dr. Paul Nelson Williams (1:28)

Mostly that, yeah, it was a good one.

Dr. Avital Oglassar (10:07)

Yeah, I think the really important thing to emphasize is this is not just a static. You go, I'm doing air quotes on a podcast. You get your H and P within 30 days and then it's a one and done checkbox. Pre op medicine Perioperative medicine is so much more than just a checkbox in the medical record. And part of the reason I love doing this in a dedicated preoperative medicine clinic at an academic institution is that it affords us the opportunity to build relationships and build lines of communication. And I know that that is something that makes this niche within medicine and anesthesiology and other domains sometimes very, very challenging for people who are in private practice or in the community setting. But when you have that opportunity, I would say absolutely, make it a discussion, make it relational rather than transactional and say, hey, just so you know, based on my assessment, thank you for sending this patient to me based on my very granular holistic assessment and the guidelines, and we have brand new guidelines that have been long awaited that came out a few months ago, say the evidence does not support a stress test or they do not have indications for a pre op stress test because X, Y, Z, make it a teachable moment. And maybe if you feel like you're getting ongoing pushback, it's what, five, 30 at night, my time? I'm going to channel Ted Lasso. Finally today, be curious, not judgmental. Maybe say what? What? Is there something that you're worried about that I'm missing? If somebody says, oh, I think this patient needs an echo or this or that, and I can't tell from the chart, I might just say one, try to reassure and also say, hey, is there something that I'm missing? Something that didn't make it into the medical record, it didn't make it into your note. Maybe it was the doorway sign and the patient says, when I first started to have the symptoms in this case of my chola docolithiasis, maybe they did have an urgent care visit or a PCP visit for chest pain, maybe that's lingering in the chart and the surgeon really, really, really wants to make sure it's reconciled before 5:30 in the morning on the day of surgery when everybody's gowned up and about ready to go. There are some things that we really do know and we have mounds of data and really cleverly designed studies to say this is wasteful, it does not change management and cost the healthcare system millions of dollars annually. I'm specifically thinking about the study on routine coags in neurosurgery patients. And if you just eliminated universal coags and neurosurgery patients in this country, we're talking like eight to nine figures annually of savings.

Dr. Avital Oglassar (13:42)

Yeah, and that is such a high yield example. I feel like I hear practically weekly from colleagues all over the country that they're having these challenges. And I'll say my number one response to that is often those mandated pre op tests are institutional inertia. It may not be a specific surgeon saying please do this, but it may be a department, it may be a freestanding surgery center that has a policy. It may be someone well intentioned who digs up a letter from 10, 15, 20 years ago and applies it to the wrong surgery. So somebody who's having a cataract extraction, which I can actually agree it can be life saving, can be very safety promoting for someone with vision loss. There's some really cool data coming out for patients with dementia and cataract restoring vision, but maybe we continue anticoagulants and antiplatelets for patients having cataract extractions. Coags are not going to change anything about that. Again, I'm in a position where I can see that pattern recognition and say, oh gosh, I've now heard about three patients who are coming to our eye hospital at Catchlak Northwest and they're coming in with all this paperwork from their pcp, including a type and screen and a chest X ray and ekg. And, and I can go to the A group and say, hey, by the way, we're noticing this really low value testing requirement. Again, be curious, where is this coming from? Can we, can I bring to you all the data, all the evidence that we have saying this is low value and not indicated? And sometimes also for if you have an individual patient whose surgery is about to get canceled and they're about to have to wait another eight to nine months to get it rescheduled, sometimes the best thing to do might be just get it done and then continue to have the discussions. The analogy I want to use is antimicrobial stewardship. And yes, giving inappropriate antibiotics to one patient might actually create a slippery slope of antibiotic resistance and whatnot and complications and C Diff and all those lovely, lovely things. But sometimes if you have a patient right in front of you and that surgery is not going to proceed without coags in that moment, a couple hundred bucks to just get this patient into their surgery and then let's tackle the system is patient centered care.

Dr. Avital Oglassar (21:31)

There is a lot of discussion and debate about the recalibration of the rcri, which I think happened shortly before the start of the pandemic. I feel like it's been at least five or six years, but don't cite me on that. And what happened is the model. So this is a great lesson in that any risk calculator you use, you should know. Data in, data out, like, where was derived from, what is it supposed to predict? So the different risk calculators, cardiac risk calculators in the periops setting do predict different things. The RCRI revised cardiac risk index predicts at least a half a dozen, and I can't even rattle them all off my head. Different types of cardiovascular complications, including mi, including, I think, heart failure, like, decompensated heart failure, malignant arrhythmia. The Gupta, which we all affectionately call it the Gupta, is actually officially the MICA predicts easy to remember. Myocardial infarction, cardiac arrest, mica. When you get into the pulmonary risk calculators, there is a whole plethora and they also predict different things. Some predict respiratory failure, some predict pneumonia, some predict any respiratory complications very broadly, which may include transient hypoxia, atelectasis, bronchospasm. So I think that's one thing to remember first, that risk calculators are not a one size fits all model. I think getting comfortable with it, getting comfortable with the ins and outs and the nuances and some have strength and weaknesses is also a really good lesson in general for medicine. But a couple of years ago, the RCRI model online was recalibrated to try to capture the min so myocardial injury after non cardiac surgery. Background prevalence rate that we are seeing from studies like the vision study that was added to the model. But the original derivation model for the RCRI was not designed to capture that. It's not one of the things it predicts. So the model got thrown off. Some of the best guru advice I've heard from it says, start thinking about it like a D dimer. A negative D dimer has very, very good negative predictive value. So an RCRI of 0 is as low as you can get because you're right, like the RCRI makes it very hard to say like, oh, your risk of a cardiac event is predicted to be over or under 1% there. I also have preferentially been using the MICA or the GUPTA for several years now. It's a larger derivation model. It's a contemporary United States surgical cohort. So the RCRI was derived from several thousand patients. The MICA is derived, I think the derivation cohort was a quarter million and the validation cohort was another quarter million. The ACS American College of Surgeons Nescip calculator, which predicts a lot of different things, is a real time, living, breathing NESQIP national database. It was derived from over 1.4 million patients and they are always adding to it. So now there are even geriatric risk modifiers that you can add to it. So I preferentially don't use the RCRI because I like the GUPTA for many reasons. And the new guidelines have also picked up on the recalibration. I think they're very diplomatic and professional with how they call that out. What they say is if you go through the flow sheet now the line in the sand to consider any potential ischemic evaluation. Is Gupta predicting risk more than 1% or an RCRI score? Of more than 1, they took out the percentage from the RCRI.

Dr. Avital Oglassar (28:16)

And that all really, really valid points in such a great introduction to this. And one of the things I say when I'm teaching about perioperative medicine is why are we predicting? We're not just predicting to get a static statement of risk, a percentage on the chart into the medical setting. We're trying to predict so we can try to prevent. We're trying to predict what a patient is at risk for so that if we proceed with surgery we can be as proactive as possible rather than have to be reactive. Like I'd much rather, as an example, have someone whose volume status in I's and O's is very, very closely monitored. If they have fragile heart failure from post op day zero onward, including instructions on discharge, then it'd be post OP Day 4. The goal was to discharge that day. But there's a rapid response being called for, hypoxia and new oxygen requirement, and they're indeed compensated heart failure. But why are we assessing frailty? Why do we have a new cardiology guideline saying that There's a Class 2 recommendation to screen for frailty? If we're not going to do anything with that, and the answer is we are going to do something with that. It may be cancellation of surgery. It may be cancellation of surgery permanently because the surgery is so risk prohibitive. There's that phrase again, that ultimately the risk benefit is not in favor of proceeding with surgery. Maybe it's a postponement of surgery because there is more and more data coming out that we can reverse or risk mitigate frailty. Maybe there's things that we can do especially to optimize a patient, or we maybe even say, and there are a lot of surgery groups that I work with who use frailty assessments to help triage patients to invasive or less invasive. Classic example is TAVR patients. Frailty is one of the reasons where someone may be risk prohibitive for an open a surgical aortic valve replacement, but they're an excellent candidate for a tavr, which is lower risk. So frailty is a syndrome of decreased physiologic reserve. It is different, but over. You can imagine the Venn diagram here. It is different than comorbidity. So you can have a lot of medical conditions and not be frail. It's different than disability. But you can also have two or all three at the same time in a patient. And the images that we use to what is frailty? What is decreased physiologic reserves or a syndrome of decreased physiologic reserve? This graphic is decades old at this point and like the original citation has been buried. But there's an image of a narrowing precipice where you start off with a very wide like platform and then just gets narrower and narrower and narrower. And if you are not frail, if you have physiologic reserves, you can withstand more physiologic insults. So I remember like from med school, the classic example was a 20 year old, very, very healthy, robust patient who's in hemorrhagic shock is going to look pretty good until they can't maintain their stroke volume. But if you are walking a very, very narrow tightrope, think of like you walk in an exam room and you're like, if I sneeze, this patient's going to break a hip. That's frailty. There are better, better validated tools to measure frailty. But that's my eyeball. That's my doorway test for frailty. So the patient, the 90 year old with dementia who is inpatient for four days with a UTI, has far fewer physiologic reserves than a non frail patient.

Dr. Avital Oglassar (34:54)

So for this patient also, I would say, what is life like for you now, both subjectively and then get Some objective data. How different was it before you were admitted with the cholidochthiasis? If this was a nonagenarian who was going to the gym three times a week, still volunteering at a community center. So keeping the body sharp, the brain sharp, and you know, is back feeling at 90% of baseline after their hospitalization, that's going to be a reassuring data point. Or if they say, you know, I really felt like that hospital stay drained me, I haven't gotten back to the gym yet. I'm feeling like I lost a ton of muscle mass. Maybe this is short term and to be able to say like, hey, like I know what you're capable of. What can we do to kind of get you as close back to that best recent baseline before your surgery with nutritional optimization? I'm going to start using the term optimization a lot here. Maybe it's really emphasizing protein intake and high quality sleep and rebuilding strength and stamina through some sort of exercise program, be it through physical therapy or self directed. And I've had plenty of patients where well intentioned. They were told, oh, you know, just, just take it easy. You know, we're going to discharge you, your surgery's going to be in a few weeks. Just go home and take it easy. And it's like, no, I actually don't want you to take it easy. I want you to P yourself because I need to get you back into another physiologically stressful setting. And maybe this is a patient who was also who was frail going into their hospital stay for cholidocolithiasis and they've only gotten more frail. And the data that we have in the best guidance is to think of frailty as multidimensional, multimodal. And there's even discussions of kind of the different phenotypes of frailty. Is it physical frailty? Is it kind of more psychosocial frailty? Surgery is stressful even if you are younger and healthy, like you need support to recover from surgery. So I think that's just a good pause point. In general, what resources can this patient rally to empower them for the smoothest course in the hospital going home. So maybe it's that, you know, go walk around the block. You already walk around the block once a night, do it twice a day between now and surgery. Who's going to help you at home? Maybe if someone really is screening as frail or screening as someone is, you worry that they're high risk for delirium. This is the patient. I will do that. Anticipatory coaching Say I want you to think, I want you to actually do guided imagery. You are going to get out of bed after your surgery either with the nursing staff, with your family. You know, I don't want you to get up and fall. Maybe it's a formal physical therapy assessment in the hospital, but like I need you to be mentally prepared to not just sit in bed after surgery. I will do guided imagery with patients to say, I'm going to teach you the term out of bed to chair like, and enlist their family and say like, you know what, the thing that's going to help you recover from this surgery as smoothly and expediently as possible is early ambulation. This, that, other risk mitigation strategies. So sometimes it's that anticipatory counseling. I said early on in this recording. It's not just is this patient going to get into the hour, not be canceled, it's really thinking through this spectrum.

Dr. Avital Oglassar (44:13)

Sure. I'm going to knock PFTs off the to do list very quickly. And say outside of thoracic surgeries, there's no data to say patients should have PFTs before surgery. I would just say if somebody is undergoing an evaluation for dyspnea of unknown etiology and because of the cardiac evaluation is reassuring. If you would get PFTs in the outpatient's primary care setting, it's probably prudent to get those done before an elective surgery. But outside of a patient having thoracic surgery like a wedge resection or a lung reduction surgery where the thoracic surgeon has already ordered it to determine if the patient meets surgical Criteria. I honestly cannot remember ever ordering PFTs. Maybe once in the last 15 years for someone who had unexplained dyspnea. Sleep apnea though, that is another hot topic. We've had guidance for over. I've been in pre op clinic for almost 15 years, believe it or not. So I'm like over under a decade. Over under 15 years. We've had guidance for that long to say this is a perioperis factor. And in the last decade we've learned so much more about pulmonary hypertension as a giant perioperis factor, especially once it's more advanced, that there are a lot more eyes on sleep apnea. This is one of the things. If I had a magic wand and could and unlimited cash flow and no issues with insurance barriers and appointments. Anyone who had a stop bang that was elevated ideally would be getting some type of sleep study or home sleep study. We just don't have the resources for that in this country. You know, if somebody has a stop bang of seven and they have daytime fatigue and they have afib, you know they have, they should be getting a sleep study. It is very rare just with the health system in this country for me to delay or postpone or cancel a surgery for a sleep study because that's just the reality of the situation. Do I still risk assess so that I can risk, modify and act proactively? And I pull this from the data that says if you have untreated sleep apnea, you may still proceed with surgery in the appropriate setting. So like frailty, maybe it's saying you should not be done at an ambulatory surgery center and get sent home the same day. Maybe you should be done in the hospital setting. Maybe you should be done in the hospital setting with preparation to be admitted overnight for monitoring and observation. So get that. How are we going to risk, modify on the back end of surgery? There are some surgeries where CPAP might also be contraindicated immediately afterwards. I think about patients who have endoscopic, transtenoidal, like pituitary mass resections. Pretty sure their surgeon doesn't want positive pressure blowing up their nasal passages into that fresh surgical bed. I know patients who have a Nissen, they don't want positive pressure and potentially blowing down the esophagus right after the surgery. Sinus surgery. I can't imagine wearing a CPAP machine right after sinus surgery. And I know patients who maybe sometimes have that sinus surgery and that's because they have a septal deviation and their nasal congestion is actually contributing to their sleep apnea physiology. So there are things we can do to risk modify patients and risk mitigate. Patients outside of CPAP sleep with the head of the bed elevated. So if you're like, if you think about the patient who has mild sleep apnea and they don't need cpap, maybe it's sleep on your side, maybe it's sew the tennis ball into the back of your pajamas, maybe it's prop up on a few pillows. So I will counsel patients that as well. You know, I want you to sleep propped upright. I want you to go low and go slow and be very cautious with your opioid dosing before bedtime. So you know, if you're feeling and I'll even say like maybe just take half the dose that you've been doing through the day and do acetaminophen and you know, the lowest dose of your range or half dose of your range of prescribed opioids before bed and I'll counsel them about that.

Dr. Avital Oglassar (49:08)

Take care. Well, that is one of our other million dollar questions in perioperative medicine. And I think if you're going to find anything that elicits a very, very strong reaction on either side of the discussion, it's arbs and aces and GLB ones and SGLT 2. I'm just shooting my blood pressure up just saying those words out loud because they are, it's not, it's not black or white. It's a very nuanced patient centered discussion which, you know, sometimes makes that medical decision making challenging, especially if you don't have, you don't know who your anesthesiology colleagues are in an institution and you can't haven't been afforded the opportunity to have those institution level discussions about Culture and best practice. And this is really an area where, if anything, it's getting more and more nuanced and complicated. But, but that's gonna be the right thing for patients. And that applies to a lot of the medications we manage. What's the concern? The concern is that the with the ACES and arbs is that they're vasodilatory medications. And with general anesthesia, the risk of blood pressure drops and sustained hypotension under anesthesia is there. So that, you know, do I continue, do I hold these medications? How will it change? Interop management is a really, really important question. The reason this gets even more nuanced and complicated is it's been a long time coming, having really good prospective RCTs. And the way that the earliest studies were designed, you may have had metrics of decreased prolonged hypotension in the or, but did it translate to post op aki, post op cardiac complications, increased lengths of stay, or was it just the anesthesiologist needed to give pressors and more fluids in the or? So again it's what did we study, what did we measure, what did we capture? The more recent studies to come out, there have been several, including the Stop or Not trial that came out in the last year. And I'm forgetting the wonderfully witty name of was it space trial that came out the year before. Honestly, at this juncture, we're at flip a coin. It takes the same. It really is. It takes the same. I told you it was getting more and more nuanced. It takes the same number of patients continuing their meds and holding their meds to have both hypertension and hypotension. And really it needs to be patient centered. One of the studies that I really like to reference came out of University of Nebraska before I'm like over under on the start of the pandemic, before the start of the pandemic. And it kind of looked like the number needed to treat, the number needed to harm by withholding or continuing therapy was the same. And then the risk was hypertension of meds weren't resumed. So I think that's also a really great lesson if you think about how the healthcare system functions on the inpatient setting. I'm sure we've all been in a position where it's 9:15 in the morning and we're starting internal medicine rounds on a patient and we have a discussion. And the morning labs finally came back and the creatinine bumped a little bit and oh my gosh, morning Med pass just happened and they just got their arm or they just got their ACE or they just got their loop diuretic. I always like to say like make it on the post op side of things. Make it an individualized day by day discussion. On the pre op side of things. I'm going to read from the 2024 ACC HA guidelines. They really do like how they discuss it. So for starters, there's a two way recommendation that if a patient is on chronic renin angiotensin aldosterone system inhibitors for chronic systolic heart failure so that afterload reduction perioperative continuation is reasonable. And that's something that I've been doing for a long time too. If you were on 2.5 of lisinopril bid for your EF of 25%, I actually want you to have that hemodynamic support on board. And let's assume that the surgery is risk appropriate for that patient. Maybe someone who's listed for heart transplant needs a biopsy to exclude malignancy to stay listed for transplant. Like they really do need to get the surgery done. The new guidelines now have a Class 2B recommendation and it kind of reads like a double negative. So you got to like twist yourself do like upside down and backwards on this in select patients. And the little star is patients with controlled blood pressure and undergoing elevated risk surgical procedures. Patients on chronic RASI for hypertension omission 24 hours before surgery may be beneficial to limit interop hypotension. Omission might be beneficial. It doesn't say to hold them, it says maybe you want to hold them. And it's like wait, what? But I think this has actually given us a lot of room as well as the like. Is there any line in the sand that says this blood pressure needs to have a surgery canceled? And that's a whole other topic of discussion. But let's say you have someone who has very very well controlled primary hypertension on 10 of lisinopril and they are coming in for a long surgery where the risk of intra op hypotension is real and it's high. So an eight hour scoliosis surgery, those patients are going to be hypotensive and getting fluids and getting blood products. If that patient's baseline is 115 over 60 on their therapy, I'm going to feel very comfortable having them hold it. Their risk of inter op hypotension has met my threshold. If I have someone who is on three or four drugs for antihypertensive therapy and they still are riding at like 150 systolics. And they're having a day surgery with general if they're having carpal tunnel release with local and some anxiolytics, because regional anesthesia options for surgery beyond general anesthesia are really, really, really expanding. So if I know that this patient is going to have deep sedation and local, I'm going to continue their meds. They're not at risk for interop hypotension because they're not getting a lot of vasodilatory drugs as part of the anesthesia cocktail. Maybe someone is having a hour long inguinal hernia repair with general anesthesia. So not a big risk of interoperable hypotension, inherently not a risk of fluid shifts, not a risk of blood loss. And they are on Amlodipine 10 and Hydrochlorothiazide 25 and Losartan 50 or Sartin 25. Let's make it 25. And they're running 150 to 160 on those agents. I might actually continue that patient's ARB because I know what their baseline is. I know what the risk of shooting up afterwards is. Or if somebody maybe runs runs high and they take it at night, I'm going to have them take it the night before. Or if they're running low, I might have them skip the night before. So I look at all the other medications they're on and you know, again, is that quantify and qualify? I said early in the beginning, you can't just say this patient's hypertension. You need to actually learn about that patient's baseline hypertension management and control and make an individualized decision.

Dr. Avital Oglassar (58:46)

I'm trying to be humble. I've memorized the 101 page document entirely, including where the asterisks are. So class 2 a recommendation in most astrac patients with hypertension plan for elective non cardiac surgery. It is reasonable to continue medical therapy for hypertension. Okay. That's what we just talked about. So if you have hypertension, you should take your antihypertensives going into surgery unless we need to individualize your H and R plan. Got it. Okay. To be or not to be recommendation in patients who have cardiovascular risk factors. So our patient, for example, has known cardiac disease or risk factors for periop complications. Add a history of poorly controlled hypertension and they define that. The guidelines define that it's greater than or equal to 110. Sorry, 180 systolic or greater than or equal to 110 diastolic, which is really high. Deferring surgery may be considered to reduce the risk of complications. And I'm like, wow, they went that generous. And that's where the consult guys have what they have used as well. In the pre op clinic though, I'm sort of straddling the. Is this okay, enough for surgery. Is this where you should be long term for health maintenance? And am I thinking like your primary care or not? I don't necessarily want people as tight if they're not controlled. I don't necessarily want to get them as tightly controlled as I would if I've seen them in the primary care setting because I don't want them to bottom out. I don't want them to have complications from going too low too quickly. I am personally, this is my expert opinion. I am perfectly thrilled to see someone sitting in the 130s, 140s in pre op clinic. And if they say, you know, at home in the morning, I'm 120s, beautiful, fantastic. If they're like 160 in pre op clinic and they say I'm always high at visits, I was running late, the parking lot was a mess, I went to the wrong location and I look at like all their other recent office visits and they're 135 and they're 130 at home. Like, I'm really happy with that. I will document as such. I will include that in my medical decision making. But if someone is, is running 180, 190, 200 recently, and maybe again it's that Ted Lasso, be curious. Maybe they ran out of refills. Maybe you know, something has changed or maybe they just haven't been able to get in for primary care. I like to start having a discussion about adding or up titrating antihypertensives if we are really routinely seeing numbers above 150 to 160 systolic. Because I think that's also best for the patient in the long term. And what I'll also do, unless I have clear data that this is their established trend, I want to say, like, go to the pharmacy, buy a blood pressure cuff if you don't already have one, and get numbers and send me a portal message in, in a week if I have that time, or three days and let me know what your numbers are at home. And most of the time patients are actually absolutely fine at home. They're riding the one teens to 120s to 130s. Maybe they have a lone bump to the 140s or 150s. But if I can really say like you are running consistently less than 150systolic, I'm very happy about that before surgery.

Dr. Avital Oglassar (66:16)

And this is also a great example of necessity being the mother of invention or are finally breaking dogma and inertia. We have finally been able to really make progress in shifting this narrative and discussion since the IV fluid crisis started several months, about five, six months ago at this point. Interesting. So everyone's like, how does climate change affect perioperative medicine? I said, you have no idea. We at Catchlak Northwest and many, many institutions around the country started to liberalize from that strict NPO after midnight to, you know what? Now we are really going to say we need to get comfortable with the uncertainty of saying, yeah, clear liquids and hope the patients, you know, follow directions accurately. And the other things I was hearing was like, well, you know, maybe their last case of the afternoon and even if they wake up at five in the morning and have a light breakfast, that somebody's going to get canceled and they're going to get bumped up and we won't be able to start the case till three in the afternoon. Like that never happens. But we have liberalized fluid after midnight instructions for patients so that they come in more hydrated. And there are also a lot of surgery protocols. So the ERAs protocol, we're not talking about the residency match and we're not talking about Taylor Swift's ERAS tour, which I constantly called ERAS tour. The ERAS protocol is enhanced recovery after surgery. It's trademarked. Started in Britain over a decade ago, but looked at ways to basically fast track patients recoveries. We know that hydrated patients and patients who have access to carbohydrates do better with surgery. And there are a lot of surgery protocols that with institutional agreements and buy in and support, we're having patients come in npo. Except for clears, there are protocols. So like Cashel Act Northwest, like hepatobiliary program. If you're coming in for a Whipple, you may actually be asked to chug a sports drink with a couple teaspoon tablespoons of sugar in it right before your surgery. And then with the IV fluid crisis, it was like, wait, we have institutional memory with patients not being strict NPO and having better outcomes. So it's actually exciting. Like there was this crisis and we all went, you know what, let's finally lean into this data that we are all nervous to really put into action.

Dr. Avital Oglassar (70:50)

Yeah, and that has gotten, that's a fascinating area. Like just real quick, the history of that evolution of knowledge is fascinating. We had data for euglycemic DKA attributable to the SGLT2 inhibitors in the periop setting within a year of them being approved by the FDA in 2016. And it showed up first in the bariatric surgery patient population. So patients who have very significant changes in carb intake and fluid status post op. And then it is expanded to like we have data for other surgical populations. The challenge now is the expansion of indications to patients with heart failure or CKD without diabetes. There are a small number of case reports that have been published in the peer reviewed literature that patients without diabetes, and I think maybe even without glucose intolerance or pre diabetes but on these medications for heart failure do have the potential to enter a euglycemic DKA state. Small number. In my discussions with heart failure cardiologists and other cardiology colleagues, they are genuinely concerned about patients risk of decompensated heart failure if they're holding a medication that is functionally acting as a diuretic. I mean it is, it's a diuretic, it causes an osmotic diuresis and has other cardiovascular benefits. That's why these meds are so exciting. So we are in. If you have heart failure with or without diabetes, my expert advice is to individualize those discussions. Again, it's ask the patient enough information to make individualized decisions. So if someone has very, very fragile heart failure and they have a history of frequent exacerbations and their weight kind of, you know, they, their weight oscillates, they always kind of feel like they're running a little bit above their dry weight, they're on a high dose loop diuretic, they do, you know, their A1C is 5. I am much more inclined to engage in shared decision making that says we are continuing this medication until the morning of surgery itself. If someone has well controlled diabetes and their A1C is 6.36 and their heart failure is really, really well controlled. And they are on a PRN low dose loop diuretic that they end up taking only maybe once or twice a month. I have a much different threshold to say, you know what, I feel very comfortable holding your SGLT2 for three days and, you know, monitor your weights, monitor your symptoms. If you need to reach for that PRN loop diuretic in that three day hold window, that's what it's there for.

Dr. Avital Oglassar (74:32)

I'm not touching that part of the case. Yeah, biomarkers. This is one of the things that we were all betting on showing up in the guidelines and with good reasons because there was so much data that emerged or was published and explored since 2014. They are crux a big part of the Canadian perioperative guidelines. A lot of the research has come out of Canada as well. This is one of those things that it really, really, really at this in late winter 2025. I think in large part depends on your institutional preparedness to respond to post op troponin elevations. And I always say that with a pit in my stomach because we like, we should be doing the best thing for patients all the time, no matter what. But I think before anyone implements a routine post op, and I know you asked about pre op, but post op troponin surveillance, I'd say make it a conversation with your cardiology Colleagues, especially those who may be asked to consult on post op troponin elevations. But getting back to the pre op, again, we're trying to predict so we can try to prevent one of the predictions. One of the best cases to say check a pre op high sensitivity troponin before surgery is that if you know that you're going to be checking or you're going to have a very low threshold to check post op troponins, especially with these high sensitivity ones, having a pre op baseline can be very, very helpful to determine is this just a chronic troponin elevation? Maybe this person has chronic diastolic heart failure and they have end stage renal disease on dialysis and they always have a little bit of myocardial stretch and impaired troponin clearance. I'm using the C word in a renal sense, not a pre op sense. Call myself there. And having a pre op baseline can be very, very helpful. At the pre op clinic at Cash Black Northwest, based on my expert opinion, I don't know that I've ever checked a pre op troponin in a resting asymptomatic patient to guide post op or to determine if they should get any ischemic testing before surgery. Because I just, I don't feel like I have a very good mechanism on what to do if in an asymptomatic risk appropriate patient that high sensitivity troponin comes back with an isolated high. What am I going to do for them before surgery? Like I am still working through that challenge myself and it's A2B recommendation for troponins, but it's A2A recommendation for BNP or NT Pro BNP. I actually like having the NT pro BNP or the BNP in my back pocket in the pre op setting. And I've had that sense for years. Not quite how the guidelines currently introduce it, but as one of the tools in my tool belt as an internal medicine physician to engage in clinical reasoning about a patient and their baseline and their baseline symptomatology and sometimes saying like, oh, you know, like when you were admitted, you know, so let's say this patient came in and they're septic with their acute cholecysitis because of their symptoms. They got a chest and they got a ct and in the lung cuts of, you know, the upper cuffs of this abdominal ct, you see bilateral pleural effusions. I don't know if that's from sepsis. I don't know if that's from third spacing Maybe they do have heart failure. So as I'm prepping to see patients, I will look for those context clues and say, hey, if I got a BNP or an NT pro BNP on this patient, what am I going to do if it comes back normal, elevated or in that kind of like indeterminate range? If someone has had one done for any reason, I will certainly like, oh, hey, by the way, you went to your primary care for like the non specific edema edema or non specific dyspnea evaluation and you had a stone cold normal BNP as part of that evaluation and it was really felt like it was attributed to like uramlovapine. I'm still five months after the guidelines have been updated. I'm still trying to build the muscle memory of what does it look like to use the BNP as the step between, hey, this patient is at elevated risk of cardiac complications of mace. Should I get a stress test? Because that's what the flow sheet is now showing. It is an intermediary step between excellent functional capacity risk less than 1% or RCRI less than 1 and do they need ischemic testing and do I have enough other things to say they should be getting ischemic testing? Maybe they've already had a stress test in the last year. I'm not going to repeat it. So the BNP is not going to change my management. So that's a very long convoluted way of saying I'm still scratching my head about the biomarkers and I think a lot of people are as well.

Dr. Avital Oglassar (82:43)

Oh my God. Can I quote you on that one? I'm giving a pre op lecture at ACP in two months. It is a marker, it is a biomarker of some type of physiologic stress on your myocardium without an alternative explanation. If you were septic and if this patient with acute cholecysitis, let's say they get in there, it's gangrenous, it's perforated, and this guy is like septic and hemodynamically unstable in the. Or, you know, maybe there's an alternative explanation. Or if you have a massive PE and there's another indication for, you know, right heart strain, troponin elevation. But as an indicator of strain on the myocardium, it is, it is a very legitimate eye opening risk factor for worse post OP outcomes at 30, 90, and I think even out to a year. I think when we first started to gain recognition that this was a thing about a decade ago from the vision studies and that group of researchers out of Canada, I think there are a lot of people said, oh, it must be a type 2 event. These are patients who are not going to have obstructive coronary disease. Maybe it's microvascular dysfunction or it's some stress in the myocardial cells. And as we gained more and more experience with it, drilling down into what we are seeing in patients, the data is actually really, really eye opening. A lot of patients do have obstructive lesions or they have advanced underlying coronary disease. And I forget off the top of my head which study it is, but there is a study that came out at least eight or 10, 10 years ago that said of patients who develop men's, the percentage of them who are not on guidelines, directed therapy or have an opportunity for risk reduction counseling is embarrassingly low. Like patients were not getting tobacco cessation counseling, patients were not getting put on statins. I think this one study maybe also looked at aces and arbs. But other, like if you have coronary disease, best practice would say you should be on this should be part of your care package. So for me it is, when I see it in a patient, it is a teachable moment, it's a reachable moment. Does the primary care also get the information about it. It's the same thing for post op afib. Did the primary care get the warm handoff that this happened to this patient and they need to be able to have appropriate outpatient follow up? Maybe it is a stress test afterwards, maybe it is referral to cardiology, maybe it's the coronary cta. Because we're doing different types of population primary care type interventions for atherosclerotic heart disease. The managed trial is the only randomized prospective trial to look at a treatment for men's that has been done yet. And it did show that dabigatran improved outcomes. But we're not seeing a lot of patients on post op being initiated on dabigatran post op. There are caveats and there's a word of caution with the study. I want to give all the kudos to the researchers because this is a really big question. They are the leaders in this field and they were the first to do an RCT on it. The way it was powered and the way that the composite outcome was developed, I think there was a, or like a protocol change into the data collection. It was statistically significant for the primary composite outcome, which included arterial and venous thromboembolic events. And it was not statistically significant if you looked at just recurrent MI alone, if I'm recalling it correctly. So there was a lot of saying like, yeah, it reached statistical significance, but you prevented VT elite because you prescribed a bigotryn for patients. We need more research. But if I see that there's a. Somebody has had men's, I absolutely want to make sure they have the opportunity for appropriate care outside of the post op setting.

Dr. Avital Oglassar (89:36)

Not so much. I think we've covered what there is to be said about post ophib. The one thing I'll also add is there were some lovely studies. There were several studies that came out in the last year that looked at like, what does it mean to like, appropriately surveil or appropriately manage someone with lone post op afib or isolated post op afib. There's one study, I forget where it was published, that said, I think it was like the length of ambulatory monitoring for recurrence of post OP needs to be longer than like the two weeks you might do in the outpatient setting. So just like, you know, you're right, it's not a free pass. And if you have afib, maybe this person should really, really have a very, you know, Is it a 30 day monitor? We are gaining technological advances that meet patients where they are every year, including certain wearable devices that are FDA approved for detection of afib. So honestly, if I had a patient who had a run of AFIB and converted to sinus rhythm post op, it's an elevated bleeding wrist surgery. So I don't want to start a DOAC before they're discharged. Their heart rate, their blood pressure is great. I'm sending them back out, including to their primary care. And I even set them up for a two week monitor on discharge and the monitor shows no afib. If they say, hey doc, I have this wearable device, should I turn on the AFIB detection setting? I would say absolutely, because it might take us another month or two months to capture that you're in afib. And if your wearable device is signaling this, get, get appropriate medical care. The, the newest guidelines also talk about, you know, if a patient is rate controlled before surgery, what do you do? If they're not rate controlled, it's treat the underlying triggers or potential triggers. And I actually really like. It's a Class 1 recommendation. In patients with new onset AFIB identified in the setting of non cardiac surgery outpatient follow up for thromboembolic wrist stratification modification and AFIB surveillance is recommended given high risk of AFIB recurrence. That's just like a mic drop statement. It's basically as you summarize, it doesn't go away. It's something to know about, it's something that can cause harm to patients down the line and we can't forget about it.

Dr. Avital Oglassar (92:28)

Oh, that is another one of the million dollar questions and one that definitely leads me and my colleagues to lose some sleep at night and I'm going to go back to the quantify and qualify. Get that really nuanced cardiopulmonary review of systems from a patient. Are they having any symptoms or not? Are they having any sensations of at least tachycardia and rapid rvr or are they really running rate controlled? Maybe they say on their wearable device like my heart rate's always in the 60s and 70s and they're asymptomatic, their functional capacity is great and there's a lot of there's not great guidance like does this patient need their surgery postponed or canceled? I don't think of AFIB as a herald for ischemic heart disease. So I do not go AFIB distress test in the pre op setting unless there's something else that says, oh, like you should, like you have chest pain when your heart rate's above 100. Am I going to throw add on a TSH? I've gotten appropriately evidence based high value resource utilization. I've gotten a basic metabolic and a CBC on a patient. If I see someone with incidental or lone AFIB in the pre op setting, I'm going to initiate some diagnostic evaluation. I'm going to initiate an attempt to start working through a differential diagnosis. So maybe I've already collected their BMP and CBC because that's appropriate for the surgery. If I can add on a tsh, I'm going to add on a tsh. This may be a patient I'm already calculating a stop bang score on, but I should relate to their primary care. Like hey, they have new onset afib, they're rate controlled, they're asymptomatic, it's a time sensitive surgery. Let's proceed. But please make sure that they can get in to see you as soon as possible to talk about an evaluation. If someone has low functional capacity or cardiopulmonary symptoms, I'm going to start actively thinking like do I want to get an echo to look for structural heart disease rather than ischemic heart disease? Will that change management before surgery? If someone has lone afib, their heart rate is 60 beats per minute and it's again that carpal tunnel release with local and some sedation or a cataract extraction with just less topical. And they're not even going to take an anxiolytic. I'm much more comfortable with them proceeding in a risk appropriate way as opposed to if this is a patient who's coming in for that 8 hour scoliosis surgery where they're going to be hemodynamically unstable assumed in the case. And anticoagulation management is going to get even more complicated with that giant surgical bed. So again, it's, it's, it's the patient, it's the company it keeps, it's the surgery they're scheduled for.

Dr. Avital Oglassar (96:09)

And they are, they are literally zooming right now. And if you hear any background noise, it's my two labradoodles. But thank you. Yeah, so take home. I know we started off earlier on. We talked about how holistic and thoughtful and really broad focused the new guidelines are. And again, I really do appreciate how they leaned into things that things that are not just part of the cardiovascular system, like frailty and anemia is on there as well. And just to zoom out even further, there is so much attention on cardiac stuff in the pre op setting. We spent most of this episode alone talking about different cardiac conditions. It's just the tip of the iceberg in periop. And this is one of the reasons I love, I really do love practicing this niche, interdisciplinary field as an internal medicine trained, board certified practicing physician. So many times you hear, you get the question, is this patient. I'm doing air quotes cleared for surgery. That is code word for does this patient have cardiac clearance in air quotes. And that's code word for does this patient need a stress test. We have so much data and we have old data that pulmonary complications are more common and more costly than cardiac complications. And that is even data before we started to really start capturing the onus on pulmonary hypertension and obesity hypoventilation in the post op setting. So that data I'm sure if we reran it. The cardiac stuff is sometimes the lowest concern for my When I have concerns about a patient being risk prohibitive for a surgery I mentioned frailty is often a big reason to say a patient is risk prohibitive for surgery or not risk appropriate yet. But I literally think through every organ system on a patient any given day and I want those who are not in dedicated pre op clinics to feel empowered to do that as well. So being able to slow down, say oh, there's cirrhosis, maybe they're driving periop risk factor. You know, that child's b approaching child cirrhosis. Maybe that's why they should not be thinking about this surgery. How can we measure this, calculate a risk, have a patient centered discussion? Maybe it's not risk prohibitive, but it needs very, very nuanced planning, interdisciplinary planning. So that patient with von Willebrand's disease, that patients with sickle cell anemia, that patient with hemophilia, how are we going to meet their individual care needs? We haven't even scratched the surface of neuropsychiatric conditions. You know, how do you support a patient with severe PTSD through the periops setting? How do you support patients who are neurodivergent and maybe very, very uncomfortable and unfamiliar surroundings in the periops setting? How are you supporting patients on mat or an addiction recovery through the perioperative setting? There is so much to make space for, to hold space for in a patient centered way and to be able to look a patient in the eye and they're like wow. Like wow. We really did fill the fill the hour appointment and say like we gotcha. Like we have again, we have quantified and qualified. I don't know to say that to a patient, but like knowledge is empowering and knowing what I need to learn about you, I guarantee you is going to help on the day of surgery. It's going to help in the operating room, it's going to help outside the operating room.