1. Proceed to Surgery? Are You Kidding Me? COPYRIGHT © 2015, ALL RIGHTS RESERVED From the Publishers of

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3. Guys: I am in our pre-op holding area and need your advice on an urgent basis. I am here with a patient who I saw in preoperative evaluation three weeks ago. He is scheduled for a left total knee replacement that is to be done today. He is 75 years old. He has diabetes treated with oral agents and is in excellent health. He leads an active life. The hip replacement was scheduled 6 months ago and it was planned to accommodate his busy schedule. He scheduled it for today because he has a brief window of time to get this done before he starts a new business venture. Here are the problems: Three days ago he had the onset of cough, nasal congestion, rhinorrhea. He has no fever. He had spent the previous week with his grandchildren and they had similar URI symptoms. His symptoms are unchanged compared to two days ago. He takes fish oil daily and was instructed to stop the fish oil one week prior to the surgical procedure. He forgot to do so and last had fish oil this morning. I just checked the screening urinalysis and it was positive for bacteria. There were no white blood cells. His pre-op labs also reveal HbA1C 7.1 So the question is, for this patient who scheduled this surgery six months ago and planned a brief window of opportunity for recuperation, do we have to cancel the surgery to allow him to recover from the URI, for the fish oil to be withdrawn, and for the bacteriuria to be treated, and for the diabetes to be better treated? Guys: I am in our pre-op holding area and need your advice on an urgent basis. I am here with a patient who I saw in preoperative evaluation three weeks ago. He is scheduled for a left total knee replacement that is to be done today. He is 75 years old. He has diabetes treated with oral agents and is in excellent health. He leads an active life. The hip replacement was scheduled 6 months ago and it was planned to accommodate his busy schedule. He scheduled it for today because he has a brief window of time to get this done before he starts a new business venture. Here are the problems: Three days ago he had the onset of cough, nasal congestion, rhinorrhea. He has no fever. He had spent the previous week with his grandchildren and they had similar URI symptoms. His symptoms are unchanged compared to two days ago. He takes fish oil daily and was instructed to stop the fish oil one week prior to the surgical procedure. He forgot to do so and last had fish oil this morning. I just checked the screening urinalysis and it was positive for bacteria. There were no white blood cells. His pre-op labs also reveal HbA1C 7.1 So the question is, for this patient who scheduled this surgery six months ago and planned a brief window of opportunity for recuperation, do we have to cancel the surgery to allow him to recover from the URI, for the fish oil to be withdrawn, and for the bacteriuria to be treated, and for the diabetes to be better treated? Copyright © 2015

4. Joint replacement, should it be cancelled? URI Fish oil Bacteriuria Diabetes Copyright © 2015 Surgery in the presence of a URI: Does anesthesia in the setting of a URI increase the risk of infection?

5. *Tait AR, Malviya S. Anesthesia for the child with an upper respiratory tract infection: still a dilemma? Anesth Analg. 2005 Jan;100(1):59-65.

6. Fish Oil: What is the benefit? Benefit Hypertriglyceridemia: high dose may decrease TG 50% Progression of atherosclerosis: may slow progression May decrease risk of sudden coronary death in high risk patients Copyright © 2015

7. Surgery, should it be cancelled? The fish oil – is it a reason to cancel the surgery? The concern- will the fish oil increase the risk of bleeding Copyright © 2015

8. Fish Oil and Heart Disease: A Myth “Busted” Fodor GJ, et al. “Fishing” for the origins of the “Eskimos and heart disease” story: Facts or wishful thinking? Canadian Journal of Cardiology. 2014; 30: 864-868. Flaw in the recording of Greenland Eskimos cause of death  CV disease greatly underestimated Copyright © 2015

9. *Mozaffarian D. et al. Fish Oil and Postoperative Atrial Fibrillation The Omega-3 Fatty Acids for Prevention of Post-operative Atrial Fibrillation (OPERA) Randomized Trial. JAMA. 2012;308(19):2001-2011.

10. OPERA Trial Omega-3 Fish oil to reduce perioperative afib  Cardiac surgery (50% valve replacement / repair)  758 patients placebo, 758 patients fish oil  No reduction of afib  No difference in perioperative bleeding  In fish oil group  50% aspirin  8% clopidogrel  2% warfarin  13% heparin Copyright © 2015

11. Bacteriuria and joint replacement Concern: urine bacteria will infect the joint prosthesis?  Reality:  No evidence that asymptomatic bacteriuria linked to prosthetic joint infection  No evidence that pre-operative antibiotic treatment of asymptomatic bacteriuria affects risk of prosthetic joint infection Copyright © 2015

12. *Sousa R, et al. Is Asymptomatic Bacteriuria a Risk Factor for Prosthetic Joint Infection? Clin Infect Dis. 2014; 59: 41-47.

13. *Adams A, et al. Surgical Outcomes of Total Knee Replacement According to Diabetes Status and Glycemic Control, 2001 to 2009. J Bone Joint Surg Am. 2013; 95: 481 -487.

14. Pearls from the Guys There is no evidence to support cancellation of surgery in patients with presumed viral URI There is no evidence to support the widely held belief that fish oil increases the risk of perioperative bleeding and there is no evidence to support the cancellation of this surgery There is no evidence that asymptomatic bacteriuria results in prosthetic joint infection. There is no evidence that antibiotic treatment of asymptomatic bacteriuria decreases incidence of prosthetic joint infection There is no evidence that better control of his diabetes will lower incidence of joint infection Copyright © 2015

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