Perioperative medicine training resources: Framework

Abstract
Background: Risk assessment in adults who are about to undergo elective surgery (other than cardiac and thoracic procedures) involves history-taking, physical examination, and ancillary studies performed for individual indications. Further testing beyond the history and physical examination is often of low predictive value for perioperative complications.

Method: This review is based on pertinent articles that were retrieved by a selective search in the Medline and Cochrane Library databases and on the consensus-derived recommendations of the German specialty societies.

Results: The history and physical examination remain the central components of preoperative risk assessment. Advanced age is not, in itself, a reason for ancillary testing. Laboratory testing should be performed only if relevant organ disease is known or suspected, or to assess the potential side effects of pharmacotherapy. Electrocardiography as a screening test seems to add little relevant information, even in patients with stable heart disease. A chest X-ray should be obtained only if a disease is suspected whose detection would have clinical consequences in the perioperative period.

Conclusion: In preoperative risk assessment, the history and physical examination are the strongest predictors of perioperative complications. Ancillary tests are indicated on an individual basis if the history and physical examination reveal that significant disease may be present.

Abstract
Purpose of review: This review summarizes selected recent evidence on issues important for preoperative pain evaluation.

Recent findings: Opioids, though a mainstay of postoperative pain management, are associated with both short and increasingly recognized long-term risks, including persistent opioid use. Risk factors for high levels of acute postoperative pain as well as chronic postsurgical pain may overlap, including psychological factors such as depression, anxiety, and catastrophizing. Tools to predict those at risk for poor postoperative pain outcomes are being studied.

Summary: Preoperative pain and psychological factors can affect postoperative pain outcomes. More work is needed in the future to develop practical interventions in the preoperative period to address these factors.

Abstract
Objective: The aim of this study was to summarize strategies to reduce postsurgical opioid prescribing at discharge.

Summary background data: Current practices for the prescription of opioids at discharge after surgery are highly variable and often excessive. We conducted a systematic review to identify behavioral interventions designed to improve these practices.

Methods: We searched MEDLINE, EMBASE, CINAHL, and PsycINFO until December 14, 2018 to identify studies of behavioral interventions designed to decrease opioid prescribing at discharge among adults undergoing surgery. Behavioral interventions were defined according to the Cochrane Effective Practice and Organisation of Care (EPOC) taxonomy. We assessed the risk of bias of included studies using criteria suggested by Cochrane EPOC and the Newcastle-Ottawa scale.

Results: Of 8048 citations that were screened, 24 studies were included in our review. Six types of behavioral interventions were identified: local consensus-based processes (18 studies), patient-mediated interventions (2 studies), clinical practice guidelines (1 study), educational meetings (1 study), interprofessional education (1 study), and clinician reminder (1 study). All but one study reported a statistically significant decrease in the amount of opioid prescribed at discharge after surgery, and only 2 studies reported evidence of increased pain intensity. Reductions in prescribed opioids ranged from 34.4 to 212.3 mg morphine equivalents. All studies were found to have medium-to-high risks of bias.

Conclusions: We identified 6 types of behavioral strategies to decrease opioid prescription at discharge after surgery. Despite the risk of bias, almost all types of intervention seemed effective in reducing opioid prescriptions at discharge after surgery without negatively impacting pain control.