Updated October 2025

Perioperative Medicine

Perioperative Risk Assessment and Optimization

Evidence-based framework to stratify perioperative risk, identify modifiable factors, and deliver targeted prehabilitation and optimization to reduce complications, LOS, and readmissions. Integrates cardiac, pulmonary, hematologic, metabolic, functional, and procedural risks, mapped to pragmatic interventions and Enhanced Recovery principles.

Clinical question

How should clinicians systematically assess and optimize perioperative risk to improve surgical outcomes across noncardiac procedures?

Preoperative EvaluationCardiac RiskPrehabilitationAnemiaGlycemic ControlERASShared Decision-Making

Key points

Start with procedural risk + patient risk

Combine surgery-specific risk and patient comorbidity burden using validated indices and guideline-driven algorithms to trigger further testing and optimization ^[3], ^[1].

Optimize modifiable risks early

Proactively treat anemia, malnutrition, hyperglycemia, smoking, and deconditioning to lower complications and enhance resilience before surgery ^[4], ^[5], ^[6], ^[7].

Prehabilitation pays dividends

Structured exercise, nutrition, and psychosocial conditioning improve functional capacity and recovery trajectory, especially in higher-risk patients ^[6], ^[8].

Use standardized pathways

Enhanced Recovery pathways reduce LOS and opioid needs and accelerate GI recovery; embed risk assessment and optimization within ERAS timelines ^[2].

Close gaps in knowledge

Internists report gaps in procedure-specific risk, bleeding, and thrombosis assessment—highlighting the need for standardized tools and education ^[9].

Evidence highlights

≈27 million ^[1]

Annual noncardiac surgeries (US)

≈50,000 events/year; CV complications ≈1–5% in vascular surgery ^[1]

Postoperative MI burden

Shorter LOS, less pain/analgesia, faster bowel recovery ^[2]

ERAS impact

Structured Approach

Five-Step Perioperative Risk and Optimization Workflow

Integrates guideline-concordant assessment with pragmatic, time-bound interventions.

1) Define surgical risk and urgency

Classify procedural risk (low, intermediate, high) and urgency (elective to emergent). High-risk categories (e.g., major vascular) confer higher MACE and warrant intensive evaluation and optimization before proceeding when feasible ^[3], ^[1].

2) Assess patient baseline risk

Take focused history (prior CAD, HF, stroke, diabetes, CKD, COPD), medications (antiplatelet/anticoagulant), frailty, and functional capacity. Use validated indices and prospective methods to identify safety risks and hotspots for failure ^[10], ^[11], ^[12], ^[1].

3) Targeted testing only if results change management

Follow ACC/AHA-style principles: reserve noninvasive testing for poor functional capacity with elevated surgical risk if it will alter therapy. Routine testing without indication increases cost and delays without benefit ^[3], ^[1].

4) Optimize modifiable risks with prehabilitation

Institute time-bound optimization bundles: anemia detection/treatment, glycemic control, smoking cessation, pulmonary conditioning, nutrition, exercise, and psychosocial support. Early initiation (≥2–4 weeks) yields better outcomes ^[4], ^[5], ^[6], ^[8], ^[7].

5) Implement ERAS-aligned perioperative plan

Standardize analgesia, fluids, PONV prophylaxis, thromboembolism prophylaxis, early feeding/mobilization, and catheter minimization. ERAS reduces LOS and analgesic needs and accelerates bowel recovery ^[2].

What to Measure and Modify

Risk Domains, Metrics, and Optimization Tactics

Align assessments with evidence-based interventions that demonstrably improve outcomes.

Cardiovascular

Estimate MACE risk with clinical indices; consider stress testing only if results change management ^[3], ^[12], ^[1].

Continue beta-blockers if already prescribed; avoid new initiation on day of surgery; consider initiation weeks prior in select high-risk patients ^[3], ^[1].

Optimize HF: volume status, guideline-directed medical therapy; decompensation is a reason to defer if elective ^[3], ^[1].

Perioperative antiplatelet/anticoagulant plan individualized to stent type/timing and bleeding risk; coordinate with proceduralist ^[3], ^[1].

Anemia and Hematinics

Screen CBC, ferritin/TSAT in moderate–high-risk surgery or expected blood loss; anemia is common and prognostic ^[4], ^[7].

Treat iron deficiency with IV iron when time-limited; consider ESA selectively; transfuse based on symptoms and thresholds per procedure ^[4], ^[7].

Set cell-sparing strategies: antifibrinolytics, restrictive transfusion triggers where appropriate ^[4], ^[7].

Metabolic and Glycemic

Optimize diabetes: target preop A1c where feasible; maintain intraop/postop glucose generally 140–180 mg/dL to reduce infection and complications ^[5], ^[7].

Adjust SGLT2 inhibitors (hold preop to reduce euglycemic DKA risk) and metformin (hold on day of surgery for renal/hemodynamic considerations) ^[5], ^[7].

Prehabilitation and Function

Assess functional capacity; if poor (<4 METs) and elevated surgical risk, consider cardiopulmonary exercise testing when it changes care ^[3], ^[6].

Implement multimodal prehabilitation: aerobic/resistance training, inspiratory muscle training, and behavioral coaching—improves resilience and recovery ^[6], ^[8].

Pulmonary

Identify COPD/asthma, OSA; optimize bronchodilators/inhaled steroids; smoking cessation ≥4 weeks (earlier is better) ^[5], ^[7].

Use incentive spirometry education, inspiratory muscle training; plan postoperative pulmonary hygiene and early mobilization ^[6], ^[7].

Nutrition and Frailty

Screen for malnutrition and frailty; initiate protein-rich supplementation and vitamin D if deficient ^[6], ^[7].

Address sarcopenia with resistance training; plan early postoperative feeding via ERAS ^[2], ^[7].

Thrombosis and Bleeding

Estimate procedural bleeding risk and patient thrombosis risk; map to perioperative anticoagulant/antiplatelet strategy with bridging only when clear net benefit ^[3], ^[9].

Standardize VTE prophylaxis per risk; implement TXA for high-blood-loss procedures as appropriate ^[4], ^[2].

Systems and Safety

Use prospective hazard identification (checklists, failure mode and effects analysis) to preempt errors across the pathway ^[10], ^[11].

Embed ERAS order sets: multimodal analgesia, PONV prophylaxis, euvolemic fluid therapy, early mobilization, catheter/line minimization ^[2].

Evidence Signals

Strength of Evidence and Outcomes

Where data are robust versus evolving.

ERAS benefits are consistent

Across specialties, ERAS is associated with shorter length of stay and decreased postoperative pain/analgesia with faster GI recovery—signal consistent and clinically meaningful ^[2].

Risk modification is necessary but heterogeneous

Preoperative optimization of comorbidities is essential; effect sizes vary by domain and timing. Programs targeting anemia, glycemia, and smoking show favorable associations with fewer complications and transfusions ^[4], ^[5], ^[7].

Prehabilitation is promising

Multimodal prehabilitation improves functional capacity and recovery metrics; growing evidence supports implementation, particularly in high-risk cohorts ^[6], ^[8].

Cardiac risk tools guide, not dictate

Validated indices and guideline algorithms help select testing and perioperative therapy, reducing unnecessary investigations and delays ^[3], ^[12], ^[1].

Knowledge gaps persist

Clinicians variably assess procedure-specific cardiac, bleeding, and thrombotic risk; targeted education and standardized tools can close gaps ^[9].

References

Source material

Primary literature that informs this article.