Practical Advice for Perioperative Management of Patients With Harmful Alcohol Intake

In 2023, the National Survey on Drug Use and Health revealed that 16.4 million individuals aged 12 and older reported heavy alcohol use in the past month. The National Institute on Alcohol Abuse and Alcoholism defines heavy alcohol use as 5 or more drinks on any given day or 15 or more drinks per week for men; and 4 or more drinks per day or 8 or more drinks per week for women.¹

Perioperative patients with a history of persistent harmful alcohol intake pose a complex challenge for surgical teams. Any variation of organ dysfunction (ie, alcohol-related liver disease) caused by chronic alcohol intake combined with acute alcohol intoxication can significantly complicate and, in some cases, delay elective or emergency surgeries.²

A team of clinical and academic experts from the Association of Anaesthetists produced a consensus statement outlining the key components to minimizing the impact of harmful alcohol intake in the surgical population.² They generated a primary list of recommendations following targeted literature reviews for all pertinent phases of the perioperative patient care experience. The team then rated each recommendation as include, exclude, or revise. They incorporated recommendations that received 75% or greater for include into the final list.

The 10 key perioperative management recommendations are as follows²:

• Screening tools such as the Alcohol Use Identification Test consumption (AUDIT-C) questionnaire should be used during preassessment for surgery. The 3 self-reported questions of the AUDIT-C focus on the frequency and quantity of alcohol consumption and highlight potential at-risk patients who would benefit from the more comprehensive Alcohol Use Identification Test (AUDIT).
• Patients with confirmed harmful chronic alcohol intake or those deemed to be at high risk for alcohol-related liver disease should have an extensive physical examination and any relevant additional clinical work-up (ie, liver function tests, platelet count). This includes patients with an AUDIT score greater than 19 and/or consumption of 35 or more units of alcohol per week (women) or 50 or more units per week (men).
• Elevated AUDIT scores in preoperative patients should trigger an appropriate response. Depending on the severity of the situation, options range from initiating a brief intervention to involving an inpatient specialist to adequately monitor the patient.
• Consider the patient’s entire history of harmful alcohol consumption. A patient may still be at high risk of alcohol-related liver disease regardless of current AUDIT scores if alcohol misuse or abuse has been previously documented.
• Use the Surgical Outcome Risk Tool (SORT) or other validated scoring systems when assessing risk and decision making in patients with established alcohol-related liver disease. SORT helps quantify perioperative risk and can be combined with a disease-specific risk calculator, such as the Child-Turcotte-Pugh score, to further solidify a surgical recommendation.
• Consider the surgical urgency according to recognized classification systems. Even in emergency surgery situations, patients may benefit from a delay in surgical procedures to correct metabolic and neurologic abnormalities that commonly present with acute alcohol withdrawal syndrome.
• Some patients with chronic harmful alcohol consumption may still be appropriate candidates for a same-day surgery. In addition to thorough clinical assessment, investigating the social circumstance the patient would be returning to upon discharge can help guide important discussion about postoperative expectations.
• Analgesic techniques must be nuanced. Seek the assistance of pain management specialists to develop a plan for the acute operative and postoperative phases of care. Opioid use in particular should be limited in patients with significant hepatic impairment due to the decreased ability of first pass metabolism and increased risk of accumulation. Strive for regional pain interventions when appropriate.
• Common postoperative complications of patients with harmful alcohol intake include infection, arrhythmias, bleeding, and delirium. Active monitoring of these complications is necessary and should take precedence in the event of a postsurgical critical care admission.
• Require a perioperative alcohol withdrawal screen for all at-risk patients. An objective scoring test such as the Clinical Institute Withdrawal Assessment Alcohol-Revised (CIWA-Ar) scale can be used to assess the severity of alcohol withdrawal and direct the appropriate pharmacologic intervention. It is important to note that longer acting benzodiazepines (ie, diazepam) may not be appropriate in patients with liver dysfunction or in advanced age. Case-by-case decision making may vary based on individual patient characteristics.

Patients with harmful alcohol intake can create significant challenges in the perioperative care setting. A multidisciplinary team-based approach with a common understanding of the unique direct and indirect effects of alcohol intake is necessary for a positive patient outcome. Currently, there are no national or international guidelines for screening, identification, or standardized management of patients with excessive alcohol consumption who are having elective or emergency surgeries. Perhaps this list of key recommendations will serve as a blueprint for a set of guidelines in the future.

REFERENCES

1. Alcohol Use in the United States: Age Groups and Demographic Characteristics. National Institute on Alcohol Abuse and Alcoholism. Updated February 2025. Accessed March 3, 2025. https://www.niaaa.nih.gov/alcohols-effects-health/alcohol-topics-z/alcohol-facts-and-statistics/alcohol-use-united-states-age-groups-and-demographic-characteristics#prevalence-of-past-month-heavy-alcohol-use

2. Jenkins MJA, Kinsella SM, Wiles MD, et al. Peri-operative identification and management of patients with unhealthy alcohol intake. Anaesthesia. 2025;80(3):311-326. doi:10.1111/anae.16530