Your Partner in Evidence Based and Standardized Preoperative Optimization
Decrease Cancellations, Increase Patient and Surgeon Satisifaction, Decrease Length of Stay, Decrease Perioperative Complications
Perioperative Optimization is not a one-size-fits-all solution. Each client and healthcare system is unique. Our team draws on extensive experience and deep insights to identify key challenges and develop customized pathways to success. By addressing specific obstacles, we create targeted strategies and work closely with clients to ensure seamless, effective implementation.
We provide tailored solutions for all of your preoperative obstacles
Obstacle
Soteria Solution/what we provide
Day of surgery cancellations
30- and 90-Day Readmissions/Return to Surgery
Patient and surgeon satisfaction
Perioperative Complications
(SSI, DVT, postoperative respiratory failure, and more)
Standardized preoperative workup/notes
Record Gathering: time and labor intensive process
Evidence based perioperative guidance (prehabilitation, nutrition screening and education, ERAS, medication management)
Leapfrog Safety Scores
(Poor documentation leading to decreased reimbursement and low pepper report scores)
Timely specialty consults
Metrics: Identifying and Maintaining/Following
(LOS, Cancellations, Readmissions, postoperative complications, Satisfaction)
Reimbursement and and coding issues for preoperative optimization visits
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Evidence based Screening Tools
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Standardized optimization protocols
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Digital Health medication reminders
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Digital health instructions
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Evidence Based Screening Tools
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Optimization Protocols
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Enhanced Care Coordination
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Postoperative patient communication check ins/reminders
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Frailty digital modification reminder
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Prehabilitation and nutrition standardization
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Timely and Standardized Optimization
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Automated Digital health solutions/Improved communication
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Surgeon specific patient education throughout the perioperative period
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Evidence Based Screening
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Evidence based Modification of risk factors
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Standardized Template for Preoperative Optimization Visits
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Standardized Lab and diagnostic Study Protocols
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Aggregated EHR via digital health partnerships, all records in one location
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Standardized and Evidence Based Guidelines that directly address and effect postoperative complications
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Standardized and Evidence Basked Guidelines that directly address and effect postoperative complications
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Digital Heath Partnership Solutions
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Soteria Metrics Specialist: Setup and Implementation at your institution
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Perioperative Specific Reimbursement and Coding Consultation
Soteria Evidence-Based Risk Reduction Screening Tools and Protocols
Risk Reduction Screening Tools
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OSA Screening and modification
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Frailty Screening and modification
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Blood clot risk/VTE screening and treatment guidelines
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Post operative surgical site (SSI) infection screening and decolonization
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Anemia screening and modification
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Obesity screening and modification
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Depression screening
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PONV screening
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Pacemaker in implantable defibrillator management
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Nutrition screening and education specific to surgery
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Diabetes protocols for perioperative management
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Chronic pain and chronic narcotic use screening
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METS/DASI
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NSQUIP cardiac risk tool
Standardized Protocols
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Standardized medication management
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Standardized and evidence based perioperative lab and EKG protocols
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Standardized template for perioperative optimization visit
About Us
We are physician anesthesiologists who specialize in perioperative medicine. We offer in depth consulting, whether it be a de novo traditional optimization clinic set up or refining an existing clinic. If applicable to your institution, we offer digital health technology tools to further streamline and save costs.
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Courtney Simmons, MD
C0-Founder
courtney@soteriahealthma.org
Amy Mouat-Hunter, MD
Co-founder
amy@soteriahealthma.org
Our Team
Brad Evanovich
Calcium Solutions
Digital Health Partner
Anita Mudiaga
Administrative Assistant
Rey Villar
Calcium Solutions
Digital Health Partner
Perioperative Optimization In the Literature
The most current perioperative literature review
November 2024
October 2024
December 2024
Multidiscplinary Guidelines, GLP-1
Perioperative Frailty Screening, 30 day readmissions
AHA/ACC Updated Perioperative Guidelines
"The team should take into account patient-specific risk factors for delayed stomach emptying and consider the following guidance for patients at highest risk: Patients in the escalation phase of GLP-1 drugs (early in treatment) are more likely to have delayed stomach emptying. The escalation phase (when the patient is given increasing doses of the GLP-1 drug) typically lasts four to eight weeks, depending on the drug and the reason it has been prescribed. Elective surgery should be deferred and only proceed once the escalation phase has passed and GI side effects have dissipated. Patients who have GI symptoms, including nausea, vomiting, abdominal pain, shortness of breath or constipation should wait until their symptoms have dissipated before proceeding with elective surgery. Patients on a higher dose of the GLP-1 drug typically have more GI side effects and should follow a liquid diet for 24 hours before the procedure. Patients with other medical conditions that slow stomach emptying, such as Parkinson’s disease may further modify the perioperative management plan." https://www.asahq.org/about-asa/newsroom/news-releases/2024/10/new-multi-society-glp-1-guidance
"Implementation of a preoperative frailty screening and optimization pathway for vascular surgery patients is associated with decreased 30-day readmission" Conclusion: Successful implementation of a preoperative frailty screening and optimization pathway for patients undergoing elective vascular surgery led to a significant decrease in overall 30-day readmission and a trend toward reduced hospital length of stay, nonhome discharge, and 30-day readmission for frail patients. Further expansion to all surgical clinics has the potential to improve quality metrics for the health care system.
The following Top Take-Home Messages are taken directly from the AHA/ACC/Multisociety Perioperative Guideline. The ACC Perioperative Guideline Dissemination Workgroup selected 3 of the Top Take-Home Messages (in bold) as key themes for this Guideline-at-a-Glance as they represent the most impactful recommendation changes compared to previous guidelines and address known gaps in clinical practice. 1. A stepwise approach to perioperative cardiac assessment assists clinicians in determining when surgery should proceed or when a pause for further evaluation is warranted. 2. Cardiovascular screening and treatment of patients undergoing NCS should adhere to the same indications as nonsurgical patients, carefully timed to avoid delays in surgery and chosen in ways to avoid overscreening and overtreatment. 3. Stress testing should be performed judiciously in patients undergoing NCS, especially those at lower risk, and only in patients in whom testing would be appropriate independent of planned surgery. 4. Team-based care should be emphasized when managing patients with complex anatomy or unstable cardiovascular disease. 5. New therapies for management of diabetes, heart failure, and obesity have significant perioperative implications. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) should be discontinued 3 to 4 days before surgery to minimize the risk of perioperative ketoacidosis associated with their use. 6. Myocardial injury after noncardiac surgery (MINS) is a newly identified disease process that should not be ignored because it portends real consequences for affected patients. 7. Patients with newly diagnosed atrial fibrillation (AF) identified during or after NCS have an increased risk of stroke. These patients should be followed closely after surgery to treat reversible causes of arrhythmia and to assess the need for rhythm control and long-term anticoagulation. 8. Perioperative bridging of oral anticoagulant therapy should be used selectively only in those patients at highest risk for thrombotic complications and is not recommended in the majority of cases. 9. In patients with unexplained hemodynamic instability and when clinical expertise is available, emergency focused cardiac ultrasound can be used for perioperative evaluation; however, focused cardiac ultrasound should not replace comprehensive transthoracic echocardiography. https://www.jacc.org/doi/10.1016/j.jacc.2024.08.018
January 2025
February 2025
Digital Health in the Perioperative Space
Euglycemic Ketoacidosis and Perioperative Use of SGLT2 Inhibitors: Re-Examining Current Recommendations
Imagine a world where surgical teams can predict which patients are at high risk of cancellation, where artificial intelligence (AI) flags post-op complications before they escalate, and where patients receive step-by-step digital guidance tailored to their unique surgical journey. That world is no longer a distant vision; it’s happening now. Digital health is driving better surgical outcomes by… Reducing last-minute cancellations with automated reminders, pre-op education apps and AI-based risk prediction models. Lowering readmission rates through remote patient monitoring, smart wound detection and real-time alert systems. Enhancing patient engagement via mobile health (mHealth) apps, wearables and virtual coaching. Improving surgical efficiency with AI-driven scheduling, predictive analytics and smart operating rooms. Studies show that integrating machine learning into perioperative risk management can accurately predict complications such as acute kidney injury, pulmonary embolism and postoperative delirium (Darnall et al., 2025). These insights allow care teams to intervene earlier, reducing costly readmissions and improving recovery rates.
Over the past decade, sodium-glucose cotransporter-2 inhibitors (SGLT2i) have been well established as excellent therapeutic agents for the management of type 2 diabetes mellitus (T2DM).1 Several randomized controlled trials (EMPEROR and CANVAS) have further established that SGLT2i demonstrate additional benefits in heart failure and chronic kidney disease, leading to their increased prevalence in the perioperative setting.2-4 However, there has been growing concern regarding euglycemic ketoacidosis, an uncommon but life-threatening side effect associated with SGLT2i use.1 SGLT2i inhibit glucose reabsorption in the proximal convoluted tubule resulting in glycosuria and reductions in serum glucose levels without an increase in insulin levels. Additionally, glucagon production can be stimulated resulting in lipolysis, ketoacid production, and, rarely, anion gap metabolic acidosis.5 Since several perioperative factors (e.g., fasting state, increase in stress hormones) can exacerbate this risk, anesthesia professionals must carefully consider the risk of perioperative SGLT2i-associated ketoacidosis. REVIEW OF CURRENT RECOMMENDATIONS AND CHALLENGES Currently, there is no consensus on perioperative management of SGLT2i and many published recommendations are outdated or based on limited data (Table 1). In 2020, an article in Anesthesiology recommended continuing SGLT2i for ambulatory surgery but stopping on the morning of surgery.6 However, these recommendations were extrapolated from expert opinions. In addition, they were published before United States Food and Drug Administrative (FDA) updated its recommendation to stop SGLT2i at least 3–4 days before all scheduled surgery. The FDA’s current recommendations also appear to be based on limited case reports and the elimination half-life of SGLT2i.1 In 2023, the validity of the FDA recommendations were evaluated by reviewing 99 reported cases of SGLT2i associated diabetic ketoacidosis; no cases were found in patients who held SGLT2i for longer than 3 days.7 Despite this being the largest systematic review to date on the subject, only 58.6% of the reviewed cases discontinued SGLT2i preoperatively, making the study further underpowered, and none of the reviewed cases discontinued SGLT2i for more than 2 days preoperatively. Despite a lack of validity, the FDA’s recommendation has been adopted by several organizations. Other individual institutions have published their own recommendations, but these are still based on limited case reports and do not demonstrate consensus on hold times for SGLT2i.8-10 Table 1: Summary of Current Notable Recommendations on Perioperative SGLT2i Use. Table 1: Summary of Current Notable Recommendations on Perioperative SGLT2i Use. Several factors contribute to the current lack of evidence for perioperative management of SGLT2i. The most concerning factor is that, due to its atypical presentation, SGLT2i-associated euglycemic ketoacidosis is underreported, which makes it challenging to understand its prevalence and impact on a patient’s perioperative outcome.11 In fact, outside the perioperative setting, two large meta-analyses assessing 82 randomized controlled trials demonstrated that SGLT2i are not significantly associated with a higher risk of diabetic ketoacidosis compared to other hypoglycemic agents.12,13 Position statements from the American Association of Clinical Endocrinologists and American College of Endocrinology also suggest that the risk of diabetic ketoacidosis associated with SGLT2i is no greater than the low levels occurring in the general diabetes population.8 However, neither the meta-analyses nor position statements specifically comment on the risk of euglycemic ketoacidosis, which is marked by a different clinical presentation, diagnostic criteria, and occurrence rate. The question remains: what makes SGLT2i administration an exceptional risk factor for euglycemic ketoacidosis compared to other hypoglycemic agents during the perioperative period? Are there other perioperative factors that affect the risk of SGLT2i- associated euglycemic ketoacidosis? Several sources repeatedly comment that these critical questions are yet to be answered, which impedes the development of evidence-based perioperative guidelines for SGLT2i. RECENT UPDATES ON PERIOPERATIVE SGLT2I USE Based on an updated review of current literature, there are new findings that elucidate the prevalence and impact of perioperative SGLT2i-associated diabetic ketoacidosis. In 2022, the first and largest population-based study examining the incidence rate of SGLT2i-associated postoperative diabetic ketoacidosis was published.14 The incidence of postoperative diabetic ketoacidosis within 30 days postoperatively was six times higher in SGLT2i users compared to nonusers, which is much higher than previously suspected. SGLT2i users who developed diabetic ketoacidosis postoperatively had higher rates of complications (e.g., need for mechanical ventilation, infection, longer hospital stay) and overall increased mortality. This is the first study to establish SGLT2i as an independent risk factor for developing postoperative diabetic ketoacidosis. However, this population study did not have uniform diagnostic criteria for diabetic ketoacidosis and did not clarify which of them, if any, were euglycemic at presentation. This is concerning since SGLT2i can cause prolonged glycosuria and ketonemia up to 9–10 days after cessation, which can confound the diagnosis.15 In fact, a 2023 single-institution retrospective analysis showed that all patients on SGLT2i, after average preoperative hold time of 1.5 days, developed some degree of ketoacidosis with mean increase in anion gap from 12.6 mmol/L preoperatively to 13.4 mmol/L postoperatively.16 These findings suggest that diagnosis of clinically significant ketoacidosis is a complex clinical consideration of not just pertinent laboratory values, but also clinical symptoms and presenting circumstances. Without clear diagnostic criteria differentiating the types of ketoacidosis, we may not understand the true incidence and impact of SGLT2i-associated euglycemic ketoacidosis, which continues to hinder the development of evidence-based perioperative SGLT2i guidelines. PRACTICE CONSIDERATIONS AND RECOMMENDATIONS There are several perioperative factors that should be considered when assessing the risk of SGLT2i-associated diabetic ketoacidosis (Table 2). Advanced T2DM (HgbA1c >8%) was recently reported to increase the risk by 3.1-fold.14 Emergent surgery, which was previously suggested as a risk factor given its inherent stress and urgency, was also recently reported to increase the risk by 24.5-fold.14 Bariatric surgery has long been considered a risk factor as perioperative SGLT2i-associated euglycemic ketoacidosis was first reported in bariatric patients, thought due to postoperative dietary changes as well as complications.7,11 This concern can be expanded to consider adequate postoperative nutritional intake (to overcome postoperative catabolic state) as an indicator for when to resume SGLT2i. Such a complex variety of factors should be incorporated when developing a guideline to manage patients on SGLT2i. For example, the University of Pennsylvania recently published a comprehensive single-center guideline incorporating factors such as anticipated procedure duration, anesthesia type, preoperative HgbA1c and glucose and basic metabolic panel, and underlying patient comorbidities to better identify which patients may be at high risk of perioperative SGLT2i-associated euglycemic ketoacidosis.17 While this guideline still endorses the FDA recommendation for preoperative SGLT2i cessation and needs further evidence for optimization, this is the first published approach to developing an algorithm to guide the management of high-risk euglycemic ketoacidosis cases for anesthesia providers taking care of patients on SGLT2i. Table 2: Factors That Can Increase the Risk of Perioperative SGLT2i-Associated Euglycemic Ketoacidosis. Underlying comorbidities Female sexSuggested based on case review.7 Advanced or poorly controlled T2DMPreviously suggested as an independent factor.7,19 Recently, HgbA1c >8% reported to cause 3.1-fold increased risk.14 Liver diseaseSuggested as liver function is critical in glucose metabolism.19 Concomitant insulin useRecently reported to cause 2.8-fold increased risk.14 ObesitySuggested due to ketosis.7 Surgical type EmergencyPreviously suggested as an independent factor associated with as much as 25% of SGLT2-associated DKA.7,16 Recently reported to cause 24.5-fold increased risk.14 BariatricSupported by several systematic reviews as a prominent factor due to its postoperative nutrition management.7,11 CardiacSuggested through several case reports.16 Other perioperative considerations Pre- and Postoperative hypovolemiaSuggested as it can mask the usual hyperglycemia induced polyuria.11 Postoperative nutritionSupported by current guidelines, reviews and meta-analyses; inadequate nutrition can worsen postoperative catabolic state and worsen metabolic complications.19 Infection/sepsisSuggested as it can impair adequate glycemic control and cause physiological stress.7,11 Glucocorticoid useSuggested as it can promote hyperglycemia and insulin resistance.11 T2DM: Type 2 Diabetes Mellitus; DKA: Diabetic Ketoacidosis Finally, it is important to highlight that for certain patients, SGLT2i cessation in the perioperative setting may be more harmful. At the end of EMPEROR trials that demonstrated cardioprotective benefit of empagliflozin, the patients who were prospectively withdrawn from treatment had increased risk of cardiovascular death and hospitalization for heart failure within 30 days of discontinuation back to pretreatment baseline.18 Given the rapid reversal of the cardioprotective benefits of SGLT2i, some advocate for early detection and treatment of ketoacidosis (e.g., intraoperative lab monitoring for acidosis and insulin infusion use) rather than perioperative discontinuation of SGLT2i in heart failure patients.19,20 There also has never been a case of euglycemic ketoacidosis in patients taking SGLT2i for cardiorenal indications in the absence of T2DM, so SGLT2i should be continued in this population.17 We suggest a perioperative algorithm for patients on SGLT2i (Figure 1). Given the lack of evidence in current literature, this algorithm may not apply to every case. However, we highlight the most significant perioperative considerations supported by current data, such as emergent procedures and other confounding risk factors for diabetic ketoacidosis.7,11,14,16,19 For emergent or urgent procedures, we recommend proceeding with surgery with close perioperative monitoring for acidosis and early initiation of insulin infusion, as the risk of delaying surgery may outweigh the risk of diabetic ketoacidosis. While data are lacking, the current FDA and other institutional guidelines suggest holding SGLT2i for all scheduled surgeries, including outpatient procedures with expected rapid return to preoperative state. 1,8,9 Therefore, for elective procedures, if the patient is considered high risk, we recommend rescheduling surgery, but if the patient is considered low risk, we recommend assessing other patient and surgical factors.17 For non-diabetic patients taking SGLT2i for heart failure or cardiorenal protection, we do not believe this algorithm applies; based on current data, they should continue SGLT2i and are considered at low risk for diabetic ketoacidosis. However, depending on other confounding risk factors, they too may require close perioperative monitoring for acidosis. Figure 1: Recommendations for perioperative management of SGLT2i. Management pathways are influenced by the urgency of surgery and other significant patient or surgical factors that may increase risk of perioperative diabetic ketoacidosis. This algorithm does not apply to nondiabetic patients taking SGLT2i for heart failure or cardiorenal protection, as data suggest they should continue SGLT2i. Note that there are no Class 1 evidence for the perioperative management of SGLT2i. SGLT2i: Sodium-Glucose Cotransporter-2 Inhibitor; BMP: Basic Metabolic Panel; T2DM: Type 2 Diabetes Mellitus; DKA: Diabetic Ketoacidosis; MAC: Monitored Anesthesia Care. Figure 1: Recommendations for perioperative management of SGLT2i. Management pathways are influenced by the urgency of surgery and other significant patient or surgical factors that may increase risk of perioperative diabetic ketoacidosis. This algorithm does not apply to nondiabetic patients taking SGLT2i for heart failure or cardiorenal protection, as data suggest they should continue SGLT2i. Note that there are no Class 1 evidence for the perioperative management of SGLT2i. SGLT2i: Sodium-Glucose Cotransporter-2 Inhibitor; BMP: Basic Metabolic Panel; T2DM: Type 2 Diabetes Mellitus; DKA: Diabetic Ketoacidosis; MAC: Monitored Anesthesia Care. In summary, we believe that SGLT2i pose an increased risk for diabetic ketoacidosis and other morbidities in the perioperative setting. However, the optimal preoperative hold time for SGLT2i and how cases should be handled if the hold time is not met remains controversial. The latter is particularly important for anesthesia professionals as many patients currently do not adhere to a universal hold time. While further research is needed, we encourage clinicians to consider the currently reported risk factors, along with other patient and surgical factors, to risk-stratify and individualize the management of patients taking SGLT2i, from case cancellation consideration to enhanced postoperative monitoring. Soyun M. Hwang is an assistant professor of anesthesiology and critical care, Mayo Clinic, Rochester, MN. Arney S. Abcejo is an associate professor of anesthesiology, Mayo Clinic, Rochester, MN. Adam K. Jacob is a professor of anesthesiology, Mayo Clinic, Rochester, MN. Jesse M. Raiten is a professor of anesthesiology and critical care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA. Manpreet S. Mundi is a professor of medicine in the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN. That world is no longer a distant vision; it’s happening now. Digital health is driving better surgical outcomes by… Reducing last-minute cancellations with automated reminders, pre-op education apps and AI-based risk prediction models. Lowering readmission rates through remote patient monitoring, smart wound detection and real-time alert systems. Enhancing patient engagement via mobile health (mHealth) apps, wearables and virtual coaching. Improving surgical efficiency with AI-driven scheduling, predictive analytics and smart operating rooms. Studies show that integrating machine learning into perioperative risk management can accurately predict complications such as acute kidney injury, pulmonary embolism and postoperative delirium (Darnall et al., 2025). These insights allow care teams to intervene earlier, reducing costly readmissions and improving recovery rates.