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Available data suggests that short and long-term interventions can decrease alco­hol use in the perioperative period, but data are lacking on whether there is a cor­responding reduction in complication rates [39]. Preoperative alcohol screening is encouraged to prevent POCs from alcohol withdrawal syndrome, nominally delir- ium tremens which can impact LOSH as well as mortality [40].

Perioperative glycemic control is recommended by most major societies as a strategy to reduce infections complications, lower mortality, and shorten LOSH [58]. This applies to both diabetic and non-diabetic patients. Attention should be paid to which agents are most likely to cause hypoglycemia in patients who are nil per os (NPO), as this is a potentially serious side-effect of anti-diabetic drugs. These higher risk agents, such as short-acting insulin, SGLT-2 inhibitors, meglitinides, and sulfonyl­ureas, should be held until patients are eating well [58]. Other agents can be contin­ued throughout the perioperative period with attention paid to a dose reduction for long-acting insulins [58]. In North America, it is common practice to withhold met­formin perioperatively; however, this agent does not cause hypoglycemia and the risk of lactic acidosis is extremely low. Given this, it should only be held if the patient’s eGFR is less than 30mL/min/1.73m levels above 180mg/dL (10mmol/L), intervention with basal bolus insulin therapy reduces POCs in comparison with traditional sliding-scale insulin regimens [58, 59].

In the event of hypokalemia, this is replaced orally if the patient is asymptomatic and tolerating enteral nutrition, with the parenteral route used for symptomatic patients, those who cannot tolerate oral supplementation, or those with critically low values. Muild hypophosphatemia and hypomagnesemia are replaced with oral supplementation. Parenteral supplementation is indicated if the refeeding syndrome is suspected, or in those not tolerating enteral nutrition. Magnesium should be infused over a prolonged period, ideally 24h at up to 1g/h, to maximize absorption and minimize renal excretion [60].

Postoperative hypertension (systolic pressure greater than 180mmHg) is associ­ated with increased risk of heart attack, arrhythmia, pulmonary complications, stroke, and bleeding [71]. Curiously there is no demonstrated benet from lowering blood pressure substantially below 180mmHg postoperatively [71].

Atrial brillation (AFib) occurs in up to 10% of patients undergoing non-cardiac surgery and the vast majority will revert to sinus rhythm prior to discharge [72]. Despite this, perioperative AFib is associated with an increased risk of early and late stroke (62% higher odds of early, 37% higher odds of late) and mortality (37–44% higher odds), particularly in those undergoing non-cardiac surgery [72]. In the POISE trial evaluating prophylactic metoprolol in the perioperative period, there were fewer new AFib events however signicantly higher rates of mortality and stroke [71, 72]. Therefore this practice is not encouraged. In contrast meta-analyses with cardiac surgery cohorts identied risk reduction with such drugs as amioda­rone, landiolol, and colchicine.

Perioperative GDFT to optimize uid status and hemodynamics, with the appro­priate use of uids as well as the use of earlier/preemptive inotropes and vasopressors has been adopted in some centers, however not in others [75]. Vasopressor selection (dopamine, norepinephrine, epinephrine, phenylephrine, vasopressin) should be based on rectifying underlying physiologic decits. Practically speaking, which agent is chosen initially does not seem as important as reaching and maintaining hemody­namic goals. A supraphysiologic goal for cardiac output has not been benecial and may cause morbidity [75]. A second medication with a different mechanism of action should be added when maximum doses of the initial agent are inadequate [75].

Evidence of at least moderate certainty indicates reduced SSI risk when IV anti­biotics are administered prior to cesarean incision, breast cancer surgery, and hernia repair. Iodine-impregnated adhesive drapes are not recommended, and there is prob­ably no difference in SSI risk when antibiotics are stopped the day of surgery com­pared to longer duration during colorectal surgery [79]. Optimization of stroke volume and cardiac output is defended by some, so that circulation to the surgical wound area is not compromised [80].