Iron supplementation

1.3.4.

For people with iron-deficiency anaemia having surgery, follow the recommendations on intravenous and oral iron in the NICE guideline on blood transfusion.

Oral iron regimens

1.3.5.

Consider an alternate-day oral iron regimen for people who have side effects from taking oral iron every day.

When to start oral iron supplementation

1.3.6.

Be aware that there was no evidence comparing different starting times for iron supplementation, so the committee made a recommendation for research.

Medicines adherence

1.3.7.

Follow the recommendations in the NICE guideline on medicines adherence to encourage adherence to oral iron regimens.

Oral fluids

1.4.1.

Tell people having surgery, including dental surgery, that:

• they may drink clear fluids until 2 hours before their operation
• drinking clear fluids before the operation can help reduce headaches, nausea and vomiting afterwards
• clear fluids are water, fruit juice without pulp, coffee or tea without milk and ice lollies.

1.4.2.

Consider carbohydrate drinks before surgery for people having abdominal major or complex surgery.

Intravenous fluids

1.4.3.

Consider using intravenous crystalloid for intraoperative fluid maintenance.

1.4.4.

Follow the recommendations in the NICE guideline on intravenous fluid therapy in adults in hospital on resuscitation and routine maintenance.

Paracetamol

1.6.5.

Offer oral paracetamol before and after surgery, including dental surgery, irrespective of pain severity.

1.6.6.

Do not offer intravenous paracetamol unless the person cannot take oral medicine.

Non-steroidal anti-inflammatory drugs (NSAIDs)

1.6.7.

Offer oral ibuprofen to manage immediate postoperative pain of all severities (including pain after dental surgery) unless the person has had surgery for hip fracture (see the recommendations on analgesia in the NICE guideline on hip fracture).

1.6.8.

Do not offer an intravenous NSAID to manage immediate postoperative pain (including pain after dental surgery) unless the person cannot take oral medicine.

1.6.9.

If offering an intravenous NSAID to manage immediate postoperative pain, choose a traditional NSAID rather than a COX-2 (cyclo-oxygenase-2) inhibitor.

Opioids

1.6.10.

Offer an oral opioid only if immediate postoperative pain is expected to be moderate to severe. When giving an oral opioid:

• give the opioid as soon as the person can eat and drink after surgery
• adjust the dose to help the person achieve functional recovery (such as coughing and mobilising) as soon as possible.

1.6.11.

For people who cannot take oral opioids, offer a choice of PCA (patient-controlled analgesia) or a continuous epidural to relieve pain after surgery. Take into account the benefits of a continuous epidural for people who:

• are having major or complex open-torso surgery or
• are expected to have severe pain or
• have cognitive impairment.

Intravenous ketamine

1.6.12.

Consider a single dose (0.25 mg/kg to 1 mg/kg) of intravenous ketamine given either during or immediately after surgery to supplement other types of pain relief if:

• the person’s pain is expected to be moderate to severe and an intravenous opioid alone does not provide adequate pain relief or
• the person has opioid sensitivity.

In August 2020, this was an off-label use of intravenous ketamine. See NICE’s information on prescribing medicines.

Gabapentin

1.6.13.

Be aware that, although there was evidence showing that the use of gabapentin to supplement other types of pain relief can be beneficial, the evidence about when to give gabapentin, and how much to give, was inconclusive. The committee therefore made a recommendation for research.

Assessing the risks of surgery

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

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 regimens

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.

When to start oral iron supplementation

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.

Anticoagulation for people taking a vitamin K antagonist who need bridging therapy

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.

Nutritional assessment

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.

Assessing the risks of surgery

Preoperative risk stratification tools are commonly used in current practice and the recommendation is not expected to change practice.

Oral iron regimens

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.

Nutritional assessment

Preoperative nutritional assessment for intermediate, major or complex surgery is current practice and the recommendation is not expected to lead to changes in practice.

Return to recommendations

Oral fluids

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.

Intravenous fluids

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.

Cardiac output monitoring

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.

Blood glucose control in hospital

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.

Surgical safety checklists

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.

Oral fluids

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.

Intravenous fluids

The use of intravenous crystalloid for intraoperative fluid maintenance reflects current practice and is not expected to result in a change in practice.

Cardiac output monitoring

The recommendation on cardiac output monitoring reflects current practice and is not expected to lead to major changes in practice.

Blood glucose control in hospital

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.

Surgical safety checklists

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.

Return to recommendations

Planning pain management

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.

Selecting analgesia

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.

Paracetamol

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.

Non-steroidal anti-inflammatory drugs (NSAIDs)

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.

Opioids

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.

Intravenous ketamine

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.

Gabapentin

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.

Planning pain management

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.

Selecting analgesia

A multimodal approach is current practice and the recommendation is not expected to change this.

Paracetamol

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.

NSAIDs

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.

Opioids

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.

Intravenous ketamine

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.

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