What is the best preoperative assessment and optimization strategy for a 68-year-old woman with hypertension (HTN), chronic obstructive pulmonary disease (COPD), anemia, and a history of smoking, who is scheduled for a hysterectomy surgery in 6-8 weeks?

Preoperative Assessment and Optimization for a 68-Year-Old Woman Undergoing Hysterectomy

Smoking cessation should be encouraged immediately with nicotine replacement therapy offered upon discharge, as this is the most effective intervention to reduce postoperative complications for this patient with COPD who is scheduled for hysterectomy in 6-8 weeks.

Rationale for Smoking Cessation Recommendation

The patient is a 68-year-old woman with multiple risk factors that could impact surgical outcomes:

• COPD requiring maintenance inhalers
• Current smoker (half pack per day)
• Hypertension
• Anemia requiring hysterectomy
• Age over 65

Evidence Supporting Smoking Cessation:

• Smoking increases the risk of intra- and postoperative complications 1
• 4-8 weeks of preoperative smoking abstinence significantly reduces respiratory and wound-healing complications 1
• The patient's surgery is scheduled for 6-8 weeks from now, providing an optimal window for smoking cessation benefits 2
• Intense counseling and nicotine replacement therapy are most effective in the preoperative setting 1

Algorithm for Preoperative Optimization

1. Immediate intervention (during current hospitalization):

   • Initiate smoking cessation counseling
   • Offer nicotine replacement therapy upon discharge
   • Provide educational materials about the benefits of smoking cessation before surgery

2. Respiratory optimization:

   • Continue current COPD medications (fluticasone, umeclidinium/vilanterol combination inhaler)
   • The patient's baseline oxygen saturation (93% on room air) and ability to walk half a mile indicate adequate respiratory function

3. Anemia management:

   • Investigate and treat the underlying cause of anemia related to fibroids
   • Consider iron supplementation if iron deficiency is present

4. Cardiovascular assessment:

   • Continue beta-blocker therapy (no evidence supports discontinuation)
   • No indication for preoperative stress testing based on functional capacity (able to walk half a mile without difficulty)

Why Other Options Are Not Recommended

1. Preoperative stress test: Not indicated because:

   • Patient has good functional capacity (can walk half a mile without difficulty)
   • No symptoms of unstable cardiac disease
   • Surgery is moderate risk, and patient has stable cardiovascular status

2. Stopping beta-blocker prior to surgery:

   • Discontinuing beta-blockers preoperatively can increase cardiovascular risk
   • No evidence supports discontinuation in a patient with stable hypertension

3. Preoperative corticosteroids:

   • No evidence supports routine preoperative corticosteroid administration
   • Patient's COPD appears stable on current regimen
   • Unnecessary corticosteroid use may increase risk of wound complications and hyperglycemia

Common Pitfalls and Caveats

• Timing matters: Smoking cessation is most beneficial when initiated 4-8 weeks before surgery 2
• Short-term cessation: Even if the patient cannot achieve complete cessation before surgery, any reduction may be beneficial
• Medication management: Do not discontinue chronic medications like beta-blockers preoperatively unless specifically contraindicated
• Respiratory optimization: Focus on optimizing COPD management and smoking cessation rather than adding unnecessary medications like corticosteroids

The 6-8 week timeframe before surgery provides an ideal opportunity to implement smoking cessation, which represents the most impactful intervention to reduce this patient's perioperative risk, particularly given her COPD and planned abdominal surgery.