2. PREOPERATIVE TESTING CONSENSUS GUIDELINES
Use of these guidelines may help avoid “routine”
preoperative testing and direct the preoperative evaluation
using an evidence-based methodology. They are intended to
facilitate and provide a “best evidence basis” for preoperative
testing. This should help avoid both delays on the day of
surgery and unnecessary cost, while still providing an
appropriate workup for the patient before minor, intermediate
and major or complex surgery , taking into account specific
comorbidities (cardiovascular, renal, and respiratory conditions
and diabetes and obesity)
3. Routine preoperative testing
Numerous studies show that there is a lack of an association
between patient benefit and routine testing
On average, 1/2000 preoperative tests lead to patient harm
secondary to the further investigation warranted by an abnormal
result.
On the other hand, only 1/10,000 preoperative tests is actually of
benefit to the patient.
4. Routine preoperative testing
In a multivariate regression analysis done to determine what
risk factorsare associated with an adverse outcome, the only two
factors consistently found to have suchan association were:
1. ASA PS 3 or greater
2. The risk of surgery as classified by the ACC/AHA guidelines
5. The tests covered by this guideline are:
• chest X-ray
• electrocardiography (ECG; resting)
• full blood count (haemoglobin, white blood cell
count and platelet count)
• serum electrolytes
• urinalysis
6. Test selection is based on Past Medical History,
current problem, nature of surgery and current
medications.
Young, healthy asymptomatic patients often require
NO TESTING
7. GUIDELINE SUMMARY FOR PREOPERATIVE ECG
1. ECG is not indicated for asymptomatic patients undergoing low-risk
surgery
2. ECG may be indicated for patients with cardiovascular risk factors
3. ECG is recommended for:
- Patients with known heart disease, peripheral vascular disease , or
cerebrovascular disease who are undergoing intermediate – or high risk
surgery
- Patients with one or more clinical risk factors (e.g., coronary artery
disease, history of congestive heart failure , cerebrovascular disease,
diabetes mellitus, renal insufficiency) who are undergoing vascular
surgery.
8. GUIDELINE SUMMARY FOR PREOPERATIVE
CHEST RADIOGRAPHY
Consider Chest radiography for:
◦Patients who smoke
◦Patients with a history of recent upper respiratory infection
◦Patients with chronic obstructive pulmonary disease (COPD)
◦Patients with cardiac disease
◦However, if these conditions are chronic and stable,
preoperative chest radiography is not necessarily indicated.
9. GUIDELINE SUMMARY FOR PREOPERATIVE
CBC
Consider CBC for:
◦Patients with liver disease
◦Patients at extremes of age
◦Patients with a history of anemia or bleeding
◦Patients with other hematologic disorders
◦Type and invasiveness of the surgical procedure
(not specified by guideline)
10. GUIDELINE SUMMARY FOR PREOPERATIVE
ELECTROLYTE MEASUREMENT
Preoperative Electrolyte Measurement could be
considered if:
◦Abnormal results would change perioperative
management
◦Patient is at risk of abnormal results based on history and
physical examination (e.g., liver or renal disease, use of
certain medications)
11. GUIDELINE SUMMARY FOR PREOPERATIVE
URINALYSIS
Urinalysis is recommended for:
◦Patients with new urinary symptoms
◦Patients with undergoing urologic surgery
◦Patients undergoing surgery with implantation of foreign
material
12. SUGGESTED METRIC FOR PREOPERATIVE TESTING (TO INCLUDE BUN/Cr/Gluc)
ASA LOW RISK MODERATE RISK HIGH RISK
I ECG (M>45; F>55)
BUN/Cr/Gluc >65
ECG (M>45; F>55)
BUN/Cr/Gluc >65
CBC>65
ECG (M>45; F>55)
BUN/Cr/Gluc >65
CBC>65
II ECG (M>45; F>55)
BUN/Cr/Gluc >65
CXR
ECG (M>45; F>55)
BUN/Cr/Gluc >65
CXR/CBC>65
ECG/CXR/CBC
BUN/Cr/Gluc>65
III ECG/CXR/CBC
Electrolytes/BUN/Cr/Gluc
ECG/CXR/CBC
Electrolytes/BUN/Cr/Gl
uc
ECG/CXR/CBC
Electrolytes/BUN/Cr/Gluc
IV Labs according to underlying condition
13. CARDIAC RISK FOR NON CARDIAC SURGERY
LOW RISK (<1%) INTERMEDIATE RISK (<5%) HIGH RISK (>5%)
Endoscopic Surgeries Carotid Endarterectomy Emergency Surgery
Superficial Procedures Head and Neck Surgery Aortic and Major Vascular
Surgery
Cataract Surgery Intraperitoneal and
Intrathoracic Surgery
Peripheral Vascular
Surgery
Breast Procedures Orthopedic Surgery Lengthy Procedures with
Major Blood Loss or Fluid
Shifts
Ambulatory Surgery Prostate Surgery
14. ASA PS Classification Definition Adult Examples, Including, but not Limited to:
ASA I A normal healthy patient Healthy, non-smoking, no or minimal alcohol use
ASA II A patient with mild systemic disease Mild diseases only without substantive functional limitations.
Current smoker, social alcohol drinker, pregnancy, obesity
(30<BMI<40), well-controlled DM/HTN, mild lung disease
ASA III A patient with severe systemic disease Substantive functional limitations; One or more moderate to
severe diseases. Poorly controlled DM or HTN, COPD, morbid
obesity (BMI ≥40), active hepatitis, alcohol dependence or abuse,
implanted pacemaker, moderate reduction of ejection fraction,
ESRD undergoing regularly scheduled dialysis, history (>3
months) of MI, CVA, TIA, or CAD/stents.
ASA IV A patient with severe systemic disease
that is a constant threat to life
Recent (<3 months) MI, CVA, TIA or CAD/stents, ongoing cardiac
ischemia or severe valve dysfunction, severe reduction of ejection
fraction, shock, sepsis, DIC, ARD or ESRD not undergoing
regularly scheduled dialysis
ASA V A moribund patient who is not expected
to survive without the operation
Ruptured abdominal/thoracic aneurysm, massive trauma,
intracranial bleed with mass effect, ischemic bowel in the face of
significant cardiac pathology or multiple organ/system dysfunction
ASA VI A declared brain-dead patient whose
organs are being removed for donor
purposes
15. References:
1. Routine preoperative tests for elective surgery. NICE guideline Published: 5 April 2016.
nice.rog.uk/guidance/ng45
2. GUIDELINES: “PREOPERATIVE ADULT PATIENT EVALUATION FOR ELECTIVE SURGERY:..
www.euroanesthesia.org/publicationsAndServices/sgstoc.htm
3. American Society of Anesthesiologists. Preoperative Testing Guidelines. March 15, 2013. Volume
87, Number 6. www.aafp.org/afp
4. European Society of Cardiology and European Society of Anesthesiology. Preoperative Testing
Guidelines. March 15,2013. Volume 87, Number 6. www.aafp.org/afp.
5. American College of Cardiology/ American Heart Association. Preoperative Testing Guidelines.
March 15,2013. Volume 87, Number 6. www.aafp.org/afp.
6. Anesthesiology Handbook. Richard D. Urman, Jesse M. Ehrenfeld. Lippincott Williams and
Wilkins. 2009. USA
