Inspiratory muscle training using incentive spirometry breathing exercises preoperatively reduces postoperative pulmonary complications. An example of a preoperative inspiratory muscle training regimen is training patients to perform 20 min daily of incentive spirometry breathing exercises for at least 2 weeks prior to an operation. Following cardiac operations, this protocol can reduce both serious pulmonary complications and pneumonia by 50 %.

Stopping smoking can reduce postoperative complications. Numerous studies have found that smoking cessation can reduce postoperative complications, and particularly pulmonary complications, by more than 40 %. Evidence suggests that at least 4 weeks of no smoking is required to allow the postoperative benefits of smoking cessation; this fact may require delay in elective scheduling of an operation.

Managing anticoagulants in the perioperative setting is becoming increasingly commonplace. The decision regarding anticoagulation around an elective operation balances the risk of thromboembolism against the risk of bleeding. In patients with a high risk of thromboembolism (e.g., mechanical heart valve, venous thromboembolism within 3 months, high-risk atrial fibrillation), bridging of oral warfarin anticoagulation with shorter lasting low-molecular-weight heparin injections is recommended. An evidence-based regimen for bridging therapy is described in Table 3.2. In patients with low risk of thromboembolism (e.g., bileaflet valve without risk factors, venous thromboembolism more than 12 months previously, low-risk atrial fibrillation), no bridging with low-molecular-weight heparin is recommended. In these low-risk cases, warfarin should be stopped 5 days prior to the planned operation and started 12–24 h postoperatively.

Target specific oral anticoagulants are a new class of oral anticoagulants. These medications are cleared by the kidneys. With normal renal function, the medications rivaroxaban and dabigatran should be stopped 24 h prior to a standard bleeding risk operation and 48–72 h prior to a high-risk bleeding operation.

Antiplatelet drugs represent a common dilemma in perioperative care. In general for low-bleeding-risk operations, antiplatelet therapy with aspirin and clopidogrel can be continued throughout the perioperative setting. For high-risk bleeding operations, aspirin should be stopped 5 days prior to the procedure for low-cardiovascular-risk patient and are recommended to be continued throughout the perioperative period in patients with high risk of an adverse cardiovascular event. And finally, clopidogrel should be stopped 5 days prior to major operations. If patient are at high risk of an adverse cardiovascular event, bridging therapy with short-acting GPIIb/IIIa antagonists may be considered.

Despite advances in surgical techniques, anesthetic pharmacology, and perioperative care, which have made even major operations safe and accessible to a variety of patients potentially at risk, there remains a group of patients who have suboptimal recovery. Almost 30 % of patients undergoing major abdominal surgery have postoperative complications, and, even in the absence of morbid events, major surgery is associated with 40 % reduction in functional capacity. Patients experience physical fatigue, disturbed sleep, and a decreased capacity to mentally concentrate for up to 9 weeks once they return home from surgery. Long periods of physical inactivity induce loss of muscle mass, deconditioning, pulmonary complications, and decubitus. Preoperative health status, functional capacity and muscle strength, and anxiety and depression correlate with postoperative fatigue, medical complications, and postoperative cognitive disturbances, and this is particularly true in the elderly, persons with cancer, and persons with limited physiological and mental reserve who are the most susceptible to the negative effects of surgery.