Rationale and impact
These sections briefly explain why the committee made the recommendations and how they might affect practice.
Evidence from studies using patient focus groups and face-to-face interviews showed that people place a high value on having information that is consistent and available when they need it. Patients in these studies stressed the importance of knowing who to contact if they have concerns or queries, particularly after discharge. The studies also illustrated how people's information needs change before, during and after surgery, with some postoperative patients reporting difficulty recalling information given to them before surgery. The committee agreed that their experience reflects the evidence. They also noted that people who feel well informed about their surgery and recovery are less anxious than those who do not.
The committee concurred that their recommendation, together with the recommendations in the NICE guidelines on patient experience in adult NHS services and care and support of people growing older with learning disabilities cover the information and support needed by adults during perioperative care.
In larger hospitals the point of contact could be a specific team member such as a clinical nurse specialist. In smaller units the point of contact may need to be a team of people. The point of contact may change as people's needs change throughout the stages of perioperative care. In current practice the amount, availability and sources of information for people having surgery all vary. This recommendation is not expected to lead to major changes in practice.
There was a large body of evidence showing that hospital stays are shorter, postoperative complications less frequent and overall costs lower when people having elective major or complex surgery follow an enhanced recovery programme (ERP).
The committee agreed that, for optimum effectiveness, an ERP should span the preoperative, intraoperative and postoperative stages, so recommended that components covering all 3 stages be included. They acknowledged that the specific components of an ERP depend on the type of surgery so did not make recommendations detailing the particulars of these components.
There is no evidence on the effectiveness of ERPs in emergency surgery, but the committee thought they might be beneficial and made a recommendation for research on enhanced recovery programmes.
According to the Perioperative Quality Improvement Programme (PQIP) 2017/2018 annual report, 61% of patients enrolled in the PQIP were following an ERP. The report noted that the use of ERPs varies across specialties and hospitals. To implement this recommendation, specialties and hospitals that do not currently provide an ERP covering all 3 stages of perioperative care for patients having major or complex elective surgery will need to restructure their surgical care. This might have an initial resource impact, although some features of an ERP, such as early mobilisation and early intake of food and fluids, are current practice in many hospitals. Introducing an ERP can be expected to reduce the length of hospital stays and the incidence of complications, thereby reducing overall costs.
Validated preoperative risk stratification tools are freely available and can be completed rapidly. Although no risk stratification tool is 100% accurate, the evidence showed that validated tools are sufficiently accurate to be a useful supplement to clinical assessment.
The committee noted that a validated risk stratification tool can also help to frame discussions about risk with the person having surgery. This includes changes the person can make to reduce their risk, such as stopping smoking. The committee agreed that the risk of postoperative morbidity is an important concern for people when they are making decisions about surgery.
Preoperative optimisation clinics for older people are designed to reduce complications and deaths associated with surgery by proactively addressing risk factors identified during the preoperative assessment. These clinics are not available in all areas and are expensive to establish. Although a small number of studies suggested a possible improvement in surgical outcomes, the evidence was inconclusive. The committee decided that, because of the high cost and lack of clear evidence, they could not make a recommendation on these clinics. However, they agreed that this is an important area and made a recommendation for research on preoperative optimisation clinics for older people.
Oral iron supplements are usually taken daily but some people have unpleasant side effects from daily iron. The committee thought that, for these people, switching to an alternate-day regimen should be considered as a means of reducing side effects and encouraging adherence. They noted that an alternate-day regimen does not address problems with tolerability or absorption, and the potential benefits need to be balanced against the risk that an alternate-day regimen might be more complicated for people taking multiple daily medicines. There was no evidence on the comparative effectiveness of daily and alternate-day oral iron regimens.
In all of the studies, iron supplementation had been started about 3 weeks before surgery. In current practice, this varies. There were no studies that compared different starting times so the committee were unable to determine the best time to start iron therapy before surgery.
The committee made a recommendation for research on oral iron supplementation.
People who take a vitamin K antagonist are at high risk of venous thromboembolism or stroke and therefore, it is usual practice to provide bridging anticoagulation during surgery with either subcutaneous low molecular weight heparin (LMWH) or intravenous unfractionated heparin (UFH). No clinical evidence was identified comparing LMWH with UFH in this high-risk group of patients. The committee noted that people who take a vitamin K antagonist with a target international normalised ratio (INR) of more than 3 and who need bridging therapy are a small proportion of the population taking vitamin K antagonists, and that many of these people have mechanical heart valves. Because of the lack of evidence, the committee made a recommendation for research on managing anticoagulation treatment for people taking a vitamin K antagonist who need bridging therapy.
No evidence on nutritional assessment was available. The committee noted that nutritional deficiency contributes to reduced physiological resilience, which is associated with increased complications and perioperative mortality. Because of this, they agreed that preoperative nutritional screening is useful for people having intermediate, major or complex surgery.
Preoperative risk stratification tools are commonly used in current practice and the recommendation is not expected to change practice.
The option to consider switching from a daily to an alternate-day regimen might increase adherence to oral iron therapy in people who have unpleasant side effects from daily iron. This has the potential to reduce the need for blood transfusions and improve surgical outcomes for this group of people.
Preoperative nutritional assessment for intermediate, major or complex surgery is current practice and the recommendation is not expected to lead to changes in practice.
Some evidence showed that drinking water until 2 hours before surgery reduces postoperative headaches, nausea and vomiting. The committee noted that many patients are not aware of this and that there is a widespread belief that fluids should be avoided before surgery. They agreed that there was sufficient evidence to recommend drinking clear fluids before surgery, and that the benefits should be explained to patients.
There was not enough evidence to justify the routine use of preoperative carbohydrate drinks for most types of surgery. A small amount of evidence suggested reductions in postoperative thirst and headache in people given a carbohydrate drink before surgery. However, the evidence did not show any substantial benefits in terms of patient satisfaction or the occurrence of other side effects.
The committee noted that people having major abdominal surgery may need longer postoperative fasting periods and therefore might benefit more than others from preoperative carbohydrate drinks. Some evidence also suggested that length of hospital stay after major abdominal surgery is reduced in people given a preoperative carbohydrate drink. For these reasons, the committee agreed that carbohydrate drinks could be considered for people having this type of surgery.
There was no evidence on the best time to give preoperative carbohydrate drinks or clear fluids so the committee made a recommendation for research on preoperative carbohydrate drinks.
A small amount of evidence suggested a possible reduction in mortality when intravenous crystalloid, rather than colloid, is used for intraoperative fluid management. However, there was also evidence showing that crystalloids resulted in a clinically important increase in nausea and vomiting. The committee were aware that crystalloid use has become more common after reports of increased risks of acute kidney injury, coagulopathy and mortality with colloid. They also noted that crystalloid is less expensive than colloid. They concluded that crystalloid should be considered for intraoperative fluid maintenance.
Older evidence suggested that cardiac output monitoring reduces some complications. However, the relevance of this evidence to current practice was unclear because of subsequent improvements in perioperative care such as better preoperative risk assessment and advancements in surgical techniques. More recent evidence also supported the use of cardiac output monitoring to reduce complications, but this evidence was from 1 small study. The committee agreed that cardiac output monitoring should be considered on a case-by-case basis.
There was no evidence that tight blood glucose control in hospital improves outcomes for people with type 2 diabetes or those without diabetes. In addition, there was evidence suggesting that tight blood glucose control increases episodes of hypoglycaemia. The committee therefore concluded that tight blood glucose control is not necessary for people in these 2 groups.
Evidence showed that using the World Health Organization (WHO) surgical safety checklist (SSC) reduces complications and mortality. Although the SSC is mandatory in NHS practice, the committee were aware from their experience that completion of the checklist varies. They reasoned that the occurrence of preventable 'never events' could be associated with this variation in completion of the SSC. They therefore decided to make a recommendation to highlight the importance of completing the SSC.
In the committee's view, reducing 'never events' should be a primary focus of surgical safety checklists. They agreed that adding steps to the SSC could help to achieve this and should be considered whenever relevant events are reported.
Current clinical practice on allowing oral fluids before surgery varies, with some services offering carbohydrate drinks before surgery, some allowing clear fluids until 2 to 4 hours before surgery, and others advising people to fast from midnight before surgery. The committee noted that more centres are moving away from traditional preoperative fasting regimens and using the more liberal regimen of clear fluids up to 2 hours before surgery. This recommendation is expected to increase the number of services adopting more liberal regimens.
The use of intravenous crystalloid for intraoperative fluid maintenance reflects current practice and is not expected to result in a change in practice.
The recommendation on cardiac output monitoring reflects current practice and is not expected to lead to major changes in practice.
Blood glucose control varies in current practice, although there has been a shift away from tight control because of concerns about hypoglycaemic events. The recommendation is expected to change practice in services that still use tight blood glucose control for people with type 2 diabetes or without diabetes. It may also prevent operations being cancelled unnecessarily on the basis of blood glucose levels.
The recommendations are expected to reinforce use of the SSC in current practice. Modifying the SSC to address risks highlighted in national patient safety alerts and 'never events' reports is expected to reduce the number of preventable 'never events' that occur.
The committee agreed that people with a high risk of complications or mortality should have postoperative care in a non-ward-based specialist recovery area to improve outcomes such as quality of life and to reduce the incidence of adverse events. However, they noted that there is a large group of people in whom the need for postoperative care in a specialist recovery area is less clear, and made a recommendation for research on specialist recovery areas.
The recommendation is expected to lead to a need for increased capacity and staff in hospitals performing major or complex surgery, or surgery in patients with a high risk of complications or mortality. The resource impact for the NHS is likely to be significant because of the high cost of care in specialist recovery areas and the large number of patients likely to need this care. However, there may also be savings achieved by reducing the occurrence of postoperative adverse events and the need to manage these.
Based on their experience, the committee agreed that people having surgery should be informed of the options for pain management and be actively involved in choosing their own pain management whenever possible.
The committee agreed, based on their experience, that multimodal analgesia provides more effective pain relief and reduces the need for opioids and the occurrence of opioid-related complications. They also agreed that prescribing pre‑emptive analgesia should be considered to ensure that pain is managed when local anaesthesia wears off.
Some evidence suggested that paracetamol used alongside opioid analgesia reduces the amount of opioid needed to manage pain. The committee therefore agreed that paracetamol is beneficial in reducing opioid consumption. There was no evidence showing a significant difference in effectiveness between oral and intravenous paracetamol. Intravenous paracetamol is much more expensive so the committee did not recommend it for people who can take oral medicines.
The evidence showed that NSAIDs provide effective additional pain relief, reducing the amount of other types of analgesia needed. Traditional NSAIDs are more cost effective than COX‑2 (cyclo‑oxygenase‑2) inhibitors, and oral ibuprofen is the most cost-effective traditional NSAID. There was no evidence showing a significant difference in effectiveness between NSAIDs or routes of administration. Intravenous NSAIDs are more expensive so the committee did not recommend them for people who can take oral medicines.
There was no evidence showing a significant difference in effectiveness between oral and intravenous opioids. Intravenous opioids are more expensive so the committee did not recommend them for people who can take oral medicines.
For people who cannot take an oral opioid, the committee agreed that a choice of PCA (patient-controlled analgesia) or epidural should be offered because there was no evidence favouring either mode of administration for most people having surgery. An exception is the group having major or complex open-torso surgery, who may benefit from the early pain relief provided by a continuous epidural. The committee pointed out that factors such as patient preference and ability to use a PCA pump effectively should be taken into account when choosing between PCA and continuous epidural. The committee looked at the possible benefits of spinal administration and agreed that there was insufficient evidence to support a recommendation.
There was evidence showing that adding intravenous ketamine to an intravenous opioid can reduce both pain and opioid consumption. The committee noted that ketamine has an additive analgesic effect. They agreed, based on their experience, that intravenous ketamine is helpful if an intravenous opioid alone does not provide adequate pain relief, or if the person is opioid sensitive (abnormal pain sensitivity). Based on the evidence and their experience, the committee agreed that a single dose of 0.25 mg/kg to 1 mg/kg should be considered in these situations.
Evidence showed that a single dose of gabapentin can lessen postoperative pain and reduce the amount of opioid needed. However, the studies used a range of doses and administered the gabapentin at different times, so the optimal dose and timing of administration remain uncertain. The committee therefore made a recommendation for research on single-dose gabapentin.
The committee noted that pain management is usually planned during a preoperative assessment. Although preoperative assessments are standard in current practice, actively involving the person in decisions about their pain management may lead to a small increase in staff time required.
A multimodal approach is current practice and the recommendation is not expected to change this.
The recommendations can be expected to result in cost savings by reducing the use of intravenous paracetamol. They are also expected to lead to dose reductions in opioid analgesia, resulting in fewer side effects from opioid consumption.
Concerns about cardiac and renal complications have limited the use of NSAIDs in people having surgery. These recommendations can be expected to change practice by increasing the use of short courses of traditional oral NSAIDs for people having surgery.
Intravenous opioid administration is often used in current practice because it is perceived to be more convenient and offer better pain relief. The recommendations are expected to lead to a change in this practice, with a reduction in intravenous opioid administration and a concomitant increase in the use of oral opioids.
PCA and continuous epidurals are used routinely in current practice, although there are variations in their use across services.
Because these recommendations are for the perioperative period only, an opiate withdrawal plan is not necessary, but one would need to be considered if opioids were used in the longer term.
This recommendation is not expected to lead to major changes in practice.
The use of intravenous ketamine in postoperative pain management has increased in recent years. Although ketamine is more expensive than other analgesics, the recommendation is not expected to have a significant impact because it is restricted to a single dose and only one-third of people having surgery are expected to experience moderate to severe pain.