Perioperative medicine: Overview

Abstract
Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are widely used for the treatment of type 2 diabetes and/or obesity. The physiological actions of endogenous GLP-1, and synthetic GLP-1RAs include inhibition of gastric emptying. This has peri-procedural implications due to the potential increased risk of retained gastric contents which may result in pulmonary aspiration. There is a need for local evidence-based guidelines to best manage patients on GLP-1RAs and dual GLP-1 and glucose-dependent insulinotropic polypeptide receptor co-agonists (GLP-1/GIPRAs) presenting for surgical and medical procedures requiring sedation or anaesthesia. A panel of experts was formed to consider the peri-procedural implications of GLP-1RA and GLP-1/GIPRA use and establish best practice recommendations based on the current evidence.We recommend that all patients should be asked about glucagon-like peptide-1 receptor agonist (GLP-1RA) and dual GLP-1 and glucose-dependent insulinotropic polypeptide receptor co-agonist (GLP-1/GIPRA) use prior to anaesthesia or sedation for surgical and endoscopic procedures and be informed of the benefits and risks. We also recommend that GLP-1RAs and GLP-1/GIPRAs be continued in the peri-procedural period. Preprocedural diet modification with a 24-h clear fluid diet, followed by standard 6-h fasting, should be recommended for all patients receiving GLP-1RAs or GLP-1/GIPRAs. In patients who have not completed or are unable to have a 24-h liquid diet, risk stratification using gastric ultrasound or minimally sedated gastroscopy to assess gastric contents is recommended, as is the use of intravenous erythromycin. We cannot currently recommend using the absence of gastrointestinal symptoms for risk stratification, nor can we recommend an adequate cessation period for GLP-1RAs and GLP-1/GIPRAs to ensure gastric emptying has returned to baseline levels. This clinical guideline, developed by multiple professional bodies, outlines current best practice recommendations for patients taking GLP-1RAs and combined GLP-1/GIPRAs who require general anaesthesia, sedation and/or endoscopic procedures. The guide provides a structure for Australian and New Zealand primary health practitioners, gastroenterologists, surgeons, endocrinologists, anaesthetists and perioperative physicians to support clinical decisions in these patients.

Abstract
Introduction: Pre-operative group sessions incorporating patient education and behaviour change interventions, known as 'surgery schools', are becoming increasingly common before major elective surgery across the world. However, there is a lack of conclusive evidence regarding the effectiveness of surgery schools, and the development and delivery of these complex interventions lacks standardisation.

Methods: In collaboration with the Perioperative Quality Initiative, we aimed to develop evidence- and expertise-based consensus statements and recommendations regarding the definition, design, content, and outcomes of surgery schools. Thirty-two international multidisciplinary experts in surgery school and pre-operative preparation attended a series of virtual meetings based on a modified Delphi methodology. A systematic review and additional targeted literature searches were used to propose statements for the definition, design, content and outcomes of surgery schools. Statements and recommendations were discussed iteratively and refined in multiple rounds, until agreement was reached.

Results: Consensus was reached on a definition of surgery school, as well as three statements and 18 recommendations in relation to: scope; outcomes; intervention development; delivery; inclusivity; and educational content of surgery schools. Seventeen areas were highlighted as priorities for future research.

Discussion: These consensus statements and recommendations are intended to help clinicians and service managers who plan to develop and implement surgery schools. They may improve the quality of those programmes and help to standardise their content. We also hope that this work will influence government strategy and policy in relation to the design, delivery and funding of peri-operative optimisation pathways.

Abstract
Background: Surgery-related adverse events are among the most common adverse events in-hospital. However, no comprehensive, multidisciplinary perioperative guidelines exist at the European level. The aim of this study is to describe the process and results in achieving European multidisciplinary consensus on perioperative patient safety recommendations.

Methods: This multimethod study included: (1) a systematic review of guidelines; (2) selection and synthesis of recommendations; and (3) a two-round modified Delphi technique including a 2-day face-to-face consensus conference. We recruited a panel of two expert groups balanced in terms of gender, geographical origin, and professional background, with meaningful participation from patient representatives. Consensus was defined as at least 70% of the panel rating a recommendation 7-9 on a 9-point Likert scale for importance to patient safety and feasibility of implementation.

Results: The systematic review included 267 guidelines, from which 4666 patient safety recommendations were identified and extracted. After four synthesis rounds, 99 recommendations were presented for the Delphi survey, detailing their strength of recommendation, level of evidence, and methodological quality of the cited guidelines. An expert group, composed of 66 multidisciplinary experts from 19 European countries, participated with a response rate of 80.3%. After the two Delphi rounds and the consensus conference, the panel agreed on a final set of 101 recommended perioperative patient safety practices.

Conclusions: A set of 101 comprehensive, evidence-based, patient-centred perioperative patient safety practices was developed through a European consensus process to improve the quality of care in healthcare facilities across Europe and beyond.