Transforming Surgical Care Delivery

DxSurgical empowers clinicians to tailor and optimize surgical and anesthetic planning based on a patient’s unique genetic profile.

Understanding a patient’s genetic risks with DxSurgical* testing services can help providers make more effective medication and management decisions throughout the perioperative experience.

Female clinician with a female patient

Patients often experience a wide range of responses to anesthesia and analgesia in the perioperative setting due to numerous factors including type of surgery, weight, age, pain sensitivity, tolerance to opioids, and genetics. As many as 40% of surgical patients experience respiratory depression and/or uncontrolled pain post-operatively, each instance adding nearly $5,000 to the cost of care as measured by hospital charges for affected patients.1,2

DxSurgical* is a non-invasive genetic test that can help health care providers optimize medication therapy for perioperative care and also identify patients at increased risk for thromboembolic complications following surgery.

Many perioperative complications are associated with genetic susceptibilities that may be unknown in advance of surgery. These complications may lead to:

  • Prolonged or complicated post-operative recovery
  • Increased likelihood of follow-up care or unplanned admission/readmission post-surgery
  • Risk of serious adverse effects or fatalities
20-40% of patients are expected to experience post-operative nausea and vomiting

Data suggests that, on average, 20-40% of patients are expected to experience post-operative nausea and vomiting.3

Studies have shown that post-surgery vomiting is ranked as the least desirable anesthesia outcome 4; while inadequate pain control and venous thromboembolism have been shown to be among the top 10 reasons for unplanned readmissions post-surgery.5

Optimize Therapy And Medication Selection At All Stages Of Perioperative Care

Personalized care tailored to a patient’s genetic profile with DxSurgical:

  • Provides objective information to help providers make rational, patient-tailored decisions throughout the surgical process
  • Identifies potential risk of surgical complications such as venous thromboembolism (VTE)
  • Helps guide medication selection and dosing of agents used in anesthetic and analgesic planning to maximize efficacy and minimize toxicity
Patient and doctor discussing DxSurgical

Effective medication selection helps to optimize sedation, anesthesia, and pain control, reduce postoperative nausea and vomiting, and reduce risk of perioperative complications.

Timely, Accurate, Clinically Actionable Information To Help Inform The Right Treatment Decisions For Each Patient

Clinical Impact of Perioperative Medication Management

Medication Class Medication Genes Potential Clinical Impact
Analgesics Codeine, Fentanyl, Hydrocodone, Morphine, Oxycodone, Tramadol CYP2D6, CYP3A4, CYP3A5, COMT, OPRM1 May be used to optimize analgesic selection or dosage to help reduce risk of opioid toxicity and achieve analgesia.6-9
Antiemetics Ondansetron CYP2D6 Ultrarapid metabolizers of CYP2D6 may experience therapeutic failure with ondansetron for the prevention and treatment of nausea and vomiting.10 A different anti-emetic therapy may be more effective.
Neuromuscular blockers Succinylcholine BCHE BCHE deficient patients receiving succinylcholine may be at risk of prolonged neuromuscular blockade, potentially leading to respiratory depression.11 A different neuromuscular blocker may be more appropriate.
Sedatives Midazolam CYP3A4/5 Genetic variations in CYP3A4/CYP3A5 may affect enzyme activity and plasma levels, potentially impacting efficacy and adverse events.6, 12-15
Consideration Genes or Markers Potential Clinical Impact
Warfarin sensitivity CYP2C9, VKORC1 Patients with increased sensitivity to warfarin may need a dose reduction to lower risk of bleeding. Limited evidence indicates that patients with reduced CYP2C9 function may not be able to achieve normalized INR with the standard 5 day interruption period prior to surgery.16-17
Venous Thromboembolism (VTE) Factor V Leiden, Factor II (G20210A) Patients with Factor V Leiden or Factor II (G20210A) have increased risk for VTE. These results should be considered as part of a comprehensive VTE risk assessment and mitigation strategy.18-21

A summary of the potential clinical impact a patient’s genetic profile may have on their response to medications or their risk for complications in perioperative management.

Knowledge of a patient’s genetic risk prior to scheduled surgery helps providers to optimize perioperative decision-making and tailor medication selection for each patient.

For an individual patient, a more complete description of the clinical significance is provided in the Perioperative Gene Analysis Report. This report provides medication specific genetic results in a user-friendly format with additional information about how a patient’s genetics may impact his or her response to common medications used in surgery and potential risks for certain surgery-related complications.


  1. The Treatment of Patients with Injectable Opioids for Uncontrolled Postoperative Pain in the Inpatient Setting: Incidence and Impact on Hospital Charges. Data on file; Millennium Health, 2016.
  2. The Impact of Respiratory Depression Following Planned Inpatient Surgeries on Hospital Resource Utilization and Charges across the United States. Data on file; Millennium Health, 2016.
  3. Candiotti KA, Birnbach DJ, Lubarsky DA, et al. The impact of pharmacogenomics on postoperative nausea and vomiting: do CYP2D6 allele copy number and polymorphisms affect the success or failure of ondansetron prophylaxis? Anesthesiology. 2005;102(3):543-549.
  4. Macario A, et al. Which Clinical Outcomes Are Important to Avoid? The Perspective of Patients. Anesth Analg 1999;89:652–8.
  5. Merkow, R.P., et al., Underlying reasons associated with hospital readmission following surgery in the United States. JAMA, 2015. 313(5): p. 483-95.
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  7. Walter C, Lotsch J. Meta-analysis of the relevance of the OPRM1 118A>G genetic variant for pain treatment. Pain. 2009;146(3):270-275
  8. Hwang IC, Park JY, Myung SK, Ahn HY, Fukuda K, Liao Q. OPRM1 A118G gene variant and postoperative opioid requirement: a systematic review and metaanalysis. Anesthesiology. 2014;121(4):825-834.
  9. Mura E, Govoni S, Racchi M, et al. Consequences of the 118A>G polymorphism in the OPRM1 gene: translation from bench to bedside? J Pain Res. 2013;6:331-353.
  10. Candiotti KA, Birnbach DJ, Lubarsky DA, et al. The impact of pharmacogenomics on postoperative nausea and vomiting: do CYP2D6 allele copy number and polymorphisms affect the success or failure of ondansetron prophylaxis? Anesthesiology. 2005;102(3):543-549.
  11. Thomsen JLN, C. V.; Eskildsen, K. Z.; Demant, M. N.; Gätke, M. R. Awake paralysis in patients with prolonged duration of action of succinylcholine and mivacurium: 9AP5–4. European Journal of Anaesthesiology. 2014;31(June 2014):155.
  12. Okubo M, Murayama N, Shimizu M, Shimada T, Guengerich FP, Yamazaki H. CYP3A4 intron 6 C>T polymorphism (CYP3A4*22) is associated with reduced CYP3A4 protein level and function in human liver microsomes. J Toxicol Sci. 2013; 38(3): 349-54.
  13. Elens L, Nieuweboer A, Clarke SJ, et al. CYP3A4 intron 6 C>T SNP (CYP3A4*22) encodes lower CYP3A4 activity in cancer patients, as measured with probes midazolam and erythromycin. Pharmacogenomics. 2013; 14(2): 137-149.
  14. Seng KY, Hee KH, Soon GH, et al. CYP3A4*3 and bilirubin predicts midazolam population pharmacokinetics in Asian cancer patients. J Clin Pharmacol. 2014; 54(2): 215-22.
  15. Wong M, Belleine RL, Collins M, Liddle C, Clarke CL, Gurney H. CYP3A5 genotype and midazolam clearance in Australian patients receiving chemotherapy. Clin Pharmacol Ther. 2004; 75(6): 529-538.
  16. Abohelaika S, Wynne H, Avery P, Kamali F. Influence of CYP2C9 polymorphism on the fall in International Normalized Ratio in patients interrupting warfarin therapy before elective surgery. J Thromb Haemost. 2015;13(8):1436-1440.
  17. Abohelaika S, Wynne H, Cope L, Kamali F. The impact of genetics on the management of patients on warfarin awaiting surgery. Age Ageing. 2015;44(4):721-722.
  18. The Surgeon General’s Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism. Rockville (MD)2008.
  19. Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e227S-277S.
  20. Coppola A, Tufano A, Cerbone AM, Di Minno G. Inherited thrombophilia: implications for prevention and treatment of venous thromboembolism. Semin Thromb Hemost. 2009;35(7):683-694
  21. Malone PC, Agutter PS. The aetiology of deep venous thrombosis. QJM. 2006;99(9):581-593.