What are common comorbidities (co-existing medical conditions) that require management in the preoperative setting?

Common Comorbidities in the Preoperative Setting

The most common comorbidities requiring management in the preoperative setting are hypertension, hyperlipidemia, diabetes mellitus, ischemic heart disease, anemia, arthritis, chronic kidney disease, chronic obstructive pulmonary disease (COPD), heart failure, and depression. 1

Cardiovascular Comorbidities

Hypertension

• Ranks as the #1 most common comorbidity across multiple patient populations 1
• Should be controlled prior to surgery with target <130/80 mmHg (<140/80 in elderly patients) 1
• Renin-angiotensin system blockers, calcium channel blockers, and diuretics are first-line treatments 1

Ischemic Heart Disease

• Among the top 3 most common comorbidities in patients over 65 years 1
• Requires preoperative optimization with medications including RAS blockers and beta-blockers 1
• May necessitate antiplatelet therapy management in the perioperative period 1

Heart Failure

• Present in approximately 36% of patients with ischemic heart disease 1
• Increases risk of postoperative complications and mortality 1
• Requires careful perioperative fluid management and hemodynamic monitoring 1

Atrial Fibrillation

• Common in older patients undergoing surgery 1
• Requires careful management of anticoagulation in the perioperative period 1
• Generally does not require modification of medical management if clinically stable 1

Pulmonary Comorbidities

Chronic Obstructive Pulmonary Disease (COPD)

• Significantly increases risk of postoperative respiratory complications 1
• Preoperative optimization should include:
  • Smoking cessation (at least 4 weeks before surgery) 1, 2
  • Pulmonary rehabilitation when possible 2
  • Optimization of bronchodilator therapy 1
  • Treatment of any active respiratory infections 1

Sleep Apnea

• Associated with pulmonary hypertension and increased perioperative risk 1
• Requires screening and consideration of perioperative CPAP therapy 1

Metabolic Comorbidities

Diabetes Mellitus

• Among the top 5 most common comorbidities across patient populations 1
• Identified as a significant risk factor for cardiac morbidity 1
• Requires careful perioperative glucose management with target glucose levels individualized based on surgical complexity 1
• Metformin should be temporarily discontinued before procedures with contrast or restricted food intake due to risk of lactic acidosis 3

Obesity

• Associated with numerous comorbidities including hypertension, diabetes, and sleep apnea 1
• Increases technical difficulty of surgery and risk of wound complications 1
• May require special considerations for medication dosing and positioning 1

Renal Comorbidities

Chronic Kidney Disease

• Among the top 8 most common comorbidities across patient populations 1
• Associated with increased risk of cardiovascular events 1
• Requires careful medication adjustment, especially for renally cleared drugs 1
• May necessitate perioperative renal protection strategies including hydration and avoidance of nephrotoxic agents 1

Hematologic Comorbidities

Anemia

• Among the top 5 most common comorbidities in patients over 65 years 1
• Associated with increased length of stay and postoperative complications 4
• May require preoperative evaluation and possible correction depending on severity and type of surgery 4

Other Important Comorbidities

Depression

• Common in patients under 65 years with cardiovascular disease 1
• Associated with poorer outcomes and compliance with treatment 1
• May require continuation of antidepressant therapy through perioperative period 5

Arthritis

• Among the top 6 most common comorbidities in patients over 65 years 1
• May affect positioning during surgery and postoperative mobility 5
• Management of anti-inflammatory medications requires careful consideration in perioperative period 5

Special Considerations for Multiple Comorbidities

• Patients with multiple chronic conditions (MCC) represent a complex and heterogeneous population requiring individualized care plans 1
• The presence of multiple comorbidities increases the complexity of perioperative management and risk of complications 1
• Shared decision-making is particularly important for patients with multiple comorbidities 1
• Clinicians should review all chronic conditions present in a patient and take those conditions into account when formulating treatment and follow-up plans 1

Preoperative Management Approach

1. Identify all comorbidities through comprehensive history, physical examination, and appropriate testing 1, 5
2. Optimize management of each comorbidity prior to elective surgery 1, 5
3. Consider the interaction between comorbidities and their treatments 1
4. Develop a perioperative plan that addresses each comorbidity 1
5. Communicate effectively between all members of the healthcare team 1

Common Pitfalls to Avoid

• Failing to recognize the impact of multiple interacting comorbidities on perioperative risk 1
• Overlooking less obvious comorbidities such as depression, cognitive impairment, and frailty 1
• Inadequate communication between specialists managing different comorbidities 1
• Inappropriate discontinuation of chronic medications in the perioperative period 1
• Underestimating the impact of comorbidities on postoperative recovery and length of stay 4