Update in Perioperative Medicine: What the Past Year Taught Us

Every year, the perioperative medicine update at Converge gives hospitalists a reason to recalibrate, and the Nashville session (anchored, fittingly, around an 84-year-old woman with the kind of comorbid stack that makes even seasoned consultants squint) hit most of the questions we actually field at the bedside. What follows is the working clinician’s version of what changed, what didn’t, and where the evidence is genuinely useful.

Self-Reported Metabolic Equivalents of Task (METs) Still Earn Their Keep

Valadkhani and colleagues followed 27,472 patients undergoing elective noncardiac surgery in Sweden and tied self-reported MET categories to both 30-day and 365-day mortality, plus days alive at home.¹ The dose-response was clean: adjusted absolute mortality risk at one year ranged from 0.2%, at MET 6 to 8, to 7.2% at MET 1. Twenty-eight percent of patients had missing MET data, and the categorization is subjective, but the take-home is that asking the patient (and corroborating with family, since our case patient and her daughter disagreed sharply) actually predicts something. MET 1 is not a number to gloss over in a preoperative note—it carries a real signal about whether someone goes home again.

Short-Duration Smoking Cessation Is Helpful, Full Stop

The 1989 Mayo paper that gave us the “stopping right before surgery makes things worse” mythology has finally been put to bed. Tang and colleagues reviewed 55 studies and found that even two weeks or more of cessation reduced pulmonary complications by 27% versus active smokers, with the benefit growing with duration (37% at six weeks or more).² Wound complications dropped 33% at four weeks or more; mortality dropped 14%. So, when the patient asks for one last cigarette before going to the operating room, the answer your colleague half-remembers from training is wrong. Any cessation is better than none.

For End-Stage Renal Disease, (AUB)-HAS2 Outperforms RCRI

A retrospective analysis of 32,337 end-stage renal disease patients in the National Surgical Quality Improvement Program showed the American University of Beirut (AUB)-HAS2 Cardiovascular Risk Index outperformed the Revised Cardiac Risk Index (RCRI) for both mortality (area under the curve, 0.68 versus 0.62) and the composite of death, myocardial infarction, or stroke.³ The unique HAS2 elements, namely anemia, vascular surgery, and active symptoms, appear to do the lifting that RCRI misses in this population. RCRI’s well-known underperformance in renal failure now has a published alternative worth using.

SGLT2 Inhibitors: Probably Keep Them On

The TriNetX propensity-matched analysis of 98,118 pairs found that type 2 diabetes mellitus patients on SGLT2 inhibitors within 90 days of surgery had lower 30-day all-cause mortality (0.68% versus 1.12%), major adverse cardiovascular events, acute kidney injury, and even ketoacidosis compared to nonusers.⁴ This contradicts the U.S. Food and Drug Administration’s three-to-four-day hold guidance, and while ICD-10–based diabetic ketoacidosis capture is a real limitation, the signal goes in the opposite direction of what the warning predicts. Reasonable practice: proceed and monitor glucose,  basic metabolic panel, and ketones every six hours for 24 hours, especially during prolonged fasting.

Functional Improvement Trajectories After Surgery Cohort Reframes What We Measure

Wijeysundera and colleagues followed 2,007 Canadians 65 years of age and older undergoing major noncardiac surgery.⁵ By six months, 16.5% had significant new disability or death; by 12 months, 20.7%. One in four did not return home without specialized support. Preop signals, such as cognitive impairment (odds ratio (OR), 1.41), frailty (OR, 1.88), tobacco use (OR, 1.44), open surgery (OR, 1.66), or unmet social support needs (OR, 1.30), were modifiable or at least addressable. Older patients fear nursing-home placement more than death, and survival alone is the wrong outcome to be marketing. The framework of “screen, discuss, frame” (best case-worst case) co-management is the right scaffold for these conversations.

Multidisciplinary Pre-Op Discussions Change Management

A Dutch multicenter observational study of 225 high-risk patients across nine hospitals showed that 32% did not proceed to surgery after multidisciplinary team review, and 81% of those who did had at least one management modification—anesthetic technique, surgical approach, optimization, or risk recommunication.⁶ The role of the perioperative hospitalist in these meetings is conspicuously underdescribed; this is a space we should be filling.

Two Negative Trials Worth

PERI-CRIT randomized 2,101 patients to perioperative ivabradine versus placebo; there were modest hazard-ratio reductions, no impact on myocardial injury after non-cardiac surgery, and the trial was otherwise stopped early for futility.⁷ In cogPOISE-3, trial investigators and study groups compared hypotension-avoidance (mean arterial pressure [MAP] of at least 80) versus hypertension-avoidance (MAP  of at least 60) strategies in 2,603 patients and found no difference in delirium, Montreal Cognitive Assessment decline, or digit symbol substitution test decline at one year.⁸ The realized between-group MAP difference postoperatively was only 1 to 1.5 mmHg, which probably explains a lot. Continuing angiotensin-converting enzyme inhibitors or angiotensin receptor blockers perioperatively appears acceptable in patients with marginal preoperative pressures and without a large blood-loss risk.

Transfusion in High Cardiac Risk: The TOP Trial

Kougias and colleagues randomized 1,424 high-cardiac-risk patients to liberal (under 10 g/dL) versus restrictive (under 7 g/dL) postop transfusion.⁹ There were no differences in the primary composite at 90 days, but the liberal group had significantly fewer non-myocardial-infarction cardiac complications (5.9% versus 9.9%), driven by arrhythmias and heart failure. Restrictive remains defensible; trends and hemodynamics matter more than crossing a number.

Postop IV Iron Works; Oral Doesn’t

A meta-analysis of 12 RCTs found IV iron within 30 days postop raised hemoglobin by approximately 0.45 g/dL; oral iron did nothing measurable.¹⁰ The greatest benefit was in orthopedic surgery; cardiac surgery showed no signal. For our case patient, ferritin of 4 and declining transfusion, IV iron is the move.

The through-line from Nashville: the unglamorous variables of function, frailty, cognition, social support, smoking, and iron stores keep outperforming the flashier interventions. Keep doing the basics and do them earlier. 

Dr. Migliore is an assistant professor of medicine at Columbia University College of Physicians and Surgeons and director of general medicine consult and perioperative services, as well as a medicine attending physician at Columbia University Medical Center, both in New York.

References

1. Valadkhani A, et al. Impact of preoperative functional capacity on postoperative mortality and morbidity: a prospective cohort study. Anesthesiology. 2026;144(3):525-534. doi:10.1097/ALN.0000000000005779.
2. Tang E, et al. Impact of short duration smoking cessation on post-operative complications: a systematic review and meta-analysis. J Clin Anesth. 2025;106:111967. doi:10.1016/j.jclinane.2025.111967.
3. Patel R, et al. Comparing Revised Cardiac Risk Index and American University of Beirut HAS2 in end-stage renal disease patients undergoing noncardiac surgery: a retrospective analysis of the National Surgical Quality Improvement Program database. Nephron. 2025;149(11):653-660. doi:10.1159/000546927.
4. Wu HL, et al. Association between pre-operative sodium-glucose cotransporter-2 inhibitor use and postoperative outcomes: a propensity score-matched analysis of the TriNetX database. Anaesthesia. 2026;81(3):351-361. doi:10.1111/anae.70024.
5. Wijeysundera DN, et al. Significant new disability after major non-cardiac surgery in older adults aged 65 years and older in Canada: a multicentre prospective cohort study. Lancet Healthy Longev. 2025;6(11):100789. doi:10.1016/j.lanhl.2025.100789.
6. Vernooij JEM, et al. Characteristics and outcome of preoperative multidisciplinary team discussions for high-risk noncardiac surgical patients in the Netherlands: a multicentre prospective observational study. Br J Anaesth. 2025;135(2):449-458. doi:10.1016/j.bja.2025.05.004.
7. Szczeklik W, et al. Ivabradine for prevention of myocardial injury after noncardiac surgery (PREVENT-MINS trial): study protocol for a randomized controlled trial. Trials. 2025;26(1):533. doi:10.1186/s13063-025-09087-z.
8. Marcucci M, et al. Effects of a hypotension-avoidance versus a hypertension-avoidance strategy on neurocognitive outcomes after noncardiac surgery. Ann Intern Med. 2025;178(7):909-920. doi:10.7326/ANNALS-24-02841.
9. Kougias P, et al. Liberal or restrictive postoperative transfusion in patients at high cardiac risk: the TOP randomized clinical trial. JAMA. 2025;334(24):2197-2207. doi:10.1001/jama.2025.20841.
10. Lim J, et al. The use of iron after surgery: a systematic review and meta-analysis. Anaesthesia. 2025;80(8):988-996. doi:10.1111/anae.16605.