1) A preanesthesia evaluation consists of reviewing a patient's medical records, conducting an interview, and performing a physical examination to assess risks and plan anesthetic care.
2) While no controlled trials have directly evaluated the benefits of a preanesthesia evaluation, observational studies link certain medical conditions to postoperative complications, and some studies found the evaluation changed patient care plans.
3) Expert opinion suggests reviewing records before surgery for highly invasive procedures, and on or before the day of surgery for less invasive procedures depending on patient severity and surgical invasiveness. A minimum physical exam includes checking the airway, lungs, and heart.
This document summarizes a study that evaluated the World Health Organization Disability Assessment Schedule 2.0 (WHODAS) as a tool for measuring postoperative disability. The study assessed WHODAS in 510 surgical patients across multiple timepoints. Results showed WHODAS demonstrated good criterion and convergent validity when compared to other measures of quality of recovery, physical functioning, quality of life and pain. WHODAS also showed excellent internal consistency and responsiveness over time. The study concludes WHODAS is a clinically valid, reliable and responsive tool for measuring postoperative disability in diverse surgical populations.
1) Medicare and other insurers will cover routine costs associated with clinical trials, such as standard of care procedures, but not investigational procedures or costs of administering investigational items.
2) A coverage analysis should determine which trial procedures will generate charges to ensure appropriate billing. Coding instructions inform the billing process of coverage.
3) Special circumstances like an absent or limited sponsor require identifying alternate payment sources for non-routine costs to avoid denying coverage of related routine costs.
This document summarizes evidence on improving intravenous access in patients with difficult veins. It finds that ultrasound-guided intravenous access is highly recommended (Level A), as it improves success rates and reduces pain and attempts compared to traditional methods. Warming the skin with heat packs is also recommended (Level B) as it may improve success. Alternative methods like intraosseous access, subcutaneous rehydration, or nitroglycerin ointment are conditionally recommended (Level C) if traditional methods fail. The document was created by reviewing current literature on different techniques for difficult intravenous access in emergency settings.
This document discusses clinical audits in anaesthesia. It defines clinical audits as quality improvement processes that systematically review care against criteria to improve outcomes. The document outlines the history of audits dating back to Florence Nightingale. It describes different types of audits including clinical, critical event, outcome, training, and survey audits. The audit cycle is also explained as preparing criteria, measuring performance, implementing improvements, and sustaining changes. Barriers to audits are a lack of resources, expertise, and leadership. Audits aim to improve standards but challenges include support, time constraints, and obtaining consent.
1) The study reviewed 122 malpractice claims from 4 insurers involving missed or delayed diagnoses in the emergency department.
2) 79 claims (65%) involved missed ED diagnoses that harmed patients, with 48% resulting in serious harm and 39% in death.
3) The leading causes of missed diagnoses were failures to order appropriate diagnostic tests or perform adequate exams, incorrect test interpretations, and failures to order appropriate consultations. The most common contributing factors were cognitive errors, patient factors, lack of supervision, and excessive workload.
Schemes for medical decision making a primer for traineesImad Hassan
An article on a practical road map for teaching trainees easy schemes for Clinical Decision Making. Due to appear soon on the journal "Perspectives on Medical Education"
Useful for Trainers and Trainees alike to complement and expand the PowerPoint presentation on the same subject.
Comparisonof Clinical Diagnoses versus Computerized Test Diagnoses Using the ...Nelson Hendler
The Diagnostic Paradigm from www.MarylandClinicalDiagnostics.com was able to help the former Dean of Los Angeles Chiropractic College detect medical diagnoses which he had overlooked, and he later confirmed.
The document discusses computer-based patient records for anesthesia. It notes that Cushing-Codman made the first ether chart for keeping anesthesia records. Computerization allows for easy retrieval of data which is an important advantage. Hospital information systems can have a monolithic or "best-in-breed" model. The monolithic system has smooth interoperability but some components may be inferior. Electronic health records provide tools for provider communication and access to population data for research. Specialty electronic health records have been developed including for anesthesia, emergency departments, and intensive care units.
This document summarizes a study that evaluated the World Health Organization Disability Assessment Schedule 2.0 (WHODAS) as a tool for measuring postoperative disability. The study assessed WHODAS in 510 surgical patients across multiple timepoints. Results showed WHODAS demonstrated good criterion and convergent validity when compared to other measures of quality of recovery, physical functioning, quality of life and pain. WHODAS also showed excellent internal consistency and responsiveness over time. The study concludes WHODAS is a clinically valid, reliable and responsive tool for measuring postoperative disability in diverse surgical populations.
1) Medicare and other insurers will cover routine costs associated with clinical trials, such as standard of care procedures, but not investigational procedures or costs of administering investigational items.
2) A coverage analysis should determine which trial procedures will generate charges to ensure appropriate billing. Coding instructions inform the billing process of coverage.
3) Special circumstances like an absent or limited sponsor require identifying alternate payment sources for non-routine costs to avoid denying coverage of related routine costs.
This document summarizes evidence on improving intravenous access in patients with difficult veins. It finds that ultrasound-guided intravenous access is highly recommended (Level A), as it improves success rates and reduces pain and attempts compared to traditional methods. Warming the skin with heat packs is also recommended (Level B) as it may improve success. Alternative methods like intraosseous access, subcutaneous rehydration, or nitroglycerin ointment are conditionally recommended (Level C) if traditional methods fail. The document was created by reviewing current literature on different techniques for difficult intravenous access in emergency settings.
This document discusses clinical audits in anaesthesia. It defines clinical audits as quality improvement processes that systematically review care against criteria to improve outcomes. The document outlines the history of audits dating back to Florence Nightingale. It describes different types of audits including clinical, critical event, outcome, training, and survey audits. The audit cycle is also explained as preparing criteria, measuring performance, implementing improvements, and sustaining changes. Barriers to audits are a lack of resources, expertise, and leadership. Audits aim to improve standards but challenges include support, time constraints, and obtaining consent.
1) The study reviewed 122 malpractice claims from 4 insurers involving missed or delayed diagnoses in the emergency department.
2) 79 claims (65%) involved missed ED diagnoses that harmed patients, with 48% resulting in serious harm and 39% in death.
3) The leading causes of missed diagnoses were failures to order appropriate diagnostic tests or perform adequate exams, incorrect test interpretations, and failures to order appropriate consultations. The most common contributing factors were cognitive errors, patient factors, lack of supervision, and excessive workload.
Schemes for medical decision making a primer for traineesImad Hassan
An article on a practical road map for teaching trainees easy schemes for Clinical Decision Making. Due to appear soon on the journal "Perspectives on Medical Education"
Useful for Trainers and Trainees alike to complement and expand the PowerPoint presentation on the same subject.
Comparisonof Clinical Diagnoses versus Computerized Test Diagnoses Using the ...Nelson Hendler
The Diagnostic Paradigm from www.MarylandClinicalDiagnostics.com was able to help the former Dean of Los Angeles Chiropractic College detect medical diagnoses which he had overlooked, and he later confirmed.
The document discusses computer-based patient records for anesthesia. It notes that Cushing-Codman made the first ether chart for keeping anesthesia records. Computerization allows for easy retrieval of data which is an important advantage. Hospital information systems can have a monolithic or "best-in-breed" model. The monolithic system has smooth interoperability but some components may be inferior. Electronic health records provide tools for provider communication and access to population data for research. Specialty electronic health records have been developed including for anesthesia, emergency departments, and intensive care units.
The document discusses randomization and blinding in clinical trials. It defines randomization as a process that assigns participants to experimental and control groups randomly to reduce bias. Randomization ensures groups are similar and comparable. Blinding refers to keeping participants and investigators unaware of group assignments to prevent bias in assessing outcomes. The document outlines various randomization techniques like simple randomization and stratification. It also discusses types of sampling and limitations of non-randomized trials in comparing interventions. In summary, the key points are that randomization and blinding are important design elements in clinical trials to reduce bias and ensure validity of results.
This systematic review evaluated regional analgesic techniques for post-thoracotomy pain management, including thoracic epidural, paravertebral block, intrathecal, intercostal, and interpleural methods. The review found that continuous paravertebral block provided analgesia comparable to thoracic epidural with fewer side effects. Paravertebral block also reduced pulmonary complications versus systemic opioids, though epidural did not. Epidural was superior to intrathecal or intercostal techniques, which were still better than systemic opioids. Interpleural analgesia was inadequate. The review concluded that either epidural with local anesthetic plus opioid or continuous paravertebral block with local anesthetic can be recommended, with intrathecal opioid
Course 2 the need for a careful and thorough historyNelson Hendler
The medical literature reports that 40%-80% of chronic pain patients are misdiagnosed. Clearly, misdiagnosis leads to ordering the wrong tests, and thereby obtaining an incorrect diagnosis, or overlooking a diagnosis totally, which results in mistreatment. Many reports in the medical literature indicate the best way to get an accurate diagnosis, is to obtain a complete and thorough history. However, this is a time consuming process, and most physicians don’t spend the needed time with a patient. Therefore, a team of doctors from Johns Hopkins Hospital developed a 72 question test, with 2008 possible answers, available over the Internet. When a patient completes the questionnaire, diagnoses are returned within 5 minutes. These diagnoses have a 96% correlation with diagnoses of Johns Hopkins Hospital doctors. This is the highest level of accuracy of any expert system available. The efficacy of this approach is proven by outcome studies, which prove that this approach results in a far higher return to work rate and reduced use of medication and doctors visits, when compared to other techniques. This is similar to the techniques used by Johns Hopkins Hospital to reduce their workers compensation payments by 54%.
This study aimed to determine the incidence and types of medical errors in ICU patients. The results found that 20% of patients experienced an adverse event, with 45% deemed preventable. A total of 223 serious medical errors occurred, with medications contributing to 78% of errors. The majority of errors were due to slips or lapses in care. The study suggests system-based changes like computerized order entry and barcoding could help reduce medical errors.
Evaluation of the Inpatient Hospital Experience while on PrecautionsKathryn Cannon
This study assessed patient satisfaction of those under contact/airborne isolation precautions versus those not under precautions at Yale-New Haven Hospital. 87 patients were interviewed using a survey measuring satisfaction with communication, treatment explanations, help from staff, pain control, and overall experience. Small variations were found between groups in nurse communication, timely help, pain control, and overall satisfaction. No significant difference was seen in doctor communication, but those under precautions expressed higher satisfaction with treatment explanations. The study aimed to understand differences to improve hospital processes and performance under new CMS reimbursement policies tied to patient satisfaction.
1) This randomized controlled trial compared care provided by nurse practitioners to care provided by general practitioners for 1,368 patients requesting same-day consultations across 10 general practices.
2) Results found that patients consulting with nurse practitioners reported higher satisfaction with their care, though for adults this difference was not observed in all practices. Consultations with nurse practitioners were also significantly longer.
3) In terms of clinical outcomes like resolution of symptoms, prescriptions issued, investigations ordered, and referrals, there was no significant difference between care provided by nurse practitioners versus general practitioners.
4) The study supports the role of nurse practitioners in providing care to patients requesting same-day consultations in primary care. Nurse
This document discusses observation units in emergency departments. It begins with introducing observation units and their objectives, then discusses the rationale and design features of such units. Key points covered include having clearly defined policies and staffing, focusing on conditions that can be better managed over a longer period of time than a traditional emergency department visit allows. The document also outlines potential pros and cons, as well as evidence from studies showing observation units can provide faster, better, cheaper care for certain patients.
The document discusses clinical decision making for nurses and healthcare professionals. It covers the principles of clinical decision making including pattern recognition, critical thinking, communication, evidence-based approaches, teamwork, reflection, and shared decision making. The decision making process involves gathering information, making judgements, deciding on a course of action, and evaluating outcomes. Shared decision making emphasizes involving patients in the decision making process from information gathering to agreeing on a treatment plan.
This document discusses clinical decision making for paramedics. It covers topics such as paramedics serving as prehospital medical practitioners, life-threatening patient conditions, protocols and standing orders, the critical thinking process, and the "Six R's" method for assessment and treatment. Paramedics must make critical decisions in emergency situations by gathering information, developing diagnoses, and using their medical knowledge and experience. They must also consider patient acuity, follow treatment guidelines, and continually re-evaluate patients.
Management of a Patient (All Types) - ROJosonReynaldo Joson
The document outlines the processes involved in managing a patient, whether surgical or nonsurgical. It discusses establishing rapport with the patient, performing a clinical diagnosis using pattern recognition and prevalence, determining when paraclinical diagnostic procedures are needed based on certainty of diagnosis and treatment plan, selecting and interpreting paraclinical tests, and choosing treatment modalities based on factors like effectiveness, risk and cost. For surgical patients specifically, it mentions preoperative preparation, intraoperative management phases, and postoperative care items. The overall goal is resolving the health problem while avoiding complications, disability, and legal issues.
The practice of anesthesia and sedation continues to expand beyond the operating room and now includes the gastroenterology suite, magnetic resonance imaging suites, and the cardiac catheterization laboratory. Non-anesthesiologists frequently administer sedation, in part because of a lack of available anesthesiologists and economic aspect, which emphasizes the safety of sedation. The Joint Commission International (JCI) set a standard responding to this issue indicating that qualified individuals who have drug and monitoring knowledge as well as airway management skills can only administer sedating agents.
Genomic variation partially explains interindividual variability in responses to perioperative stressors and drugs. The perioperative period represents an opportunity to implement precision medicine strategies through preemptive profiling, risk stratification incorporating genetics, and pharmacogenomics-guided drug selection. Specific genetic polymorphisms have shown associations with increased risk of perioperative adverse events like myocardial infarction and atrial fibrillation.
A randomized, double-blind, placebo-controlled pilot study was conducted to determine if preoperative modafinil improved recovery after general anesthesia in patients with obstructive sleep apnea (OSA). 102 patients with OSA were given either 200mg of modafinil or placebo before surgery. The primary outcome of length of stay in the post-anesthesia care unit (PACU) showed no difference between groups. Secondary measures of emergence and recovery also did not differ significantly. While respiratory rate was higher and blood pressure lower in the modafinil group in the PACU, the study results suggest single-dose preoperative modafinil does not improve functional recovery after general anesthesia in patients with OSA.
EMPACT: Emergency Medicine Professionalism and Communication TrainingPicker Institute, Inc.
"Emergency Medicine Resident Training in Interprofessional Skills: Evaluating a Needs-Based Curriculum"
Sondra Zabar, M.D., Principal Investigator Associate Professor of Medicine
Linda Regan M.D., Co-Investigator New York University School of Medicine
EMPACT aims to expand on previous work by assessing and improving EM resident competency in communication and professionalism through the development, implementation, and evaluation of new curriculum and assessment measures.
This document provides guidelines for the prevention of catheter-related infections from the CDC in 2011. It includes recommendations for education and training of healthcare staff, selection of catheter type and insertion site, hand hygiene and aseptic technique, skin preparation, dressing regimens, patient hygiene, safety devices, impregnated catheters, antibiotic prophylaxis, dressing changes, and catheter replacement. The guidelines are meant to help reduce the risk of catheter-related infections in hospitals.
This document provides an overview of clinical decision making (CDM) and discusses several related topics:
- It outlines the five domains of emergency care that involve CDM: assessment and stabilization; monitoring; assessing illness severity; making a differential diagnosis; and determining treatment.
- CDM can be influenced by many factors including knowledge, biases, context, and non-technical skills. Both intuitive and analytical thinking styles impact CDM.
- Improving CDM involves training to enhance critical thinking skills and address common cognitive errors and biases. Receiving timely feedback is also important to make better clinical judgments.
This document provides an outline for a presentation on electronic medical records (EMRs). It begins with defining the components of an EMR, including labs, admissions/discharge/transfer data, orders, radiology, notes, and billing. It then discusses the history and adoption of EMRs from the 1960s to present. The document reviews studies showing the effectiveness of EMRs in improving quality of care and achieving treatment standards. It also outlines how EMR data is structured in databases and data warehouses and describes common health data standards like ICD, CPT, LOINC, SNOMED, and HL7. The presentation covers meaningful use incentives and provides examples of using EMR data for research studies.
Practice guidelines for postanesthetic care 2013Ann Sodders
- These Practice Guidelines update the "Practice Guidelines for Postanesthetic Care" adopted by the American Society of Anesthesiologists in 2001 and published in 2002.*
- The purpose of developing these updated Guidelines was to evaluate available current evidence and provide recommendations to improve postanesthetic care outcomes for patients receiving anesthesia or sedation.
- The new Guidelines differ from existing Guidelines by providing an updated evaluation of scientific literature published after completion of the original Guidelines. However, the new evidence did not necessitate changes to the original recommendations.
Here are the designs I would recommend for each case:
Case 1: N-of-1 design. This design is well-suited for testing the efficacy of a treatment for an individual patient, as in this case assessing L-arginine for a carrier of OTCD.
Case 2: Randomized withdrawal design. This minimizes time on placebo by giving all patients open-label treatment initially to identify responders, who are then randomized to continue treatment or placebo. This is appropriate given the reversible but relatively slow outcome.
Case 3: Delayed start design. This can distinguish treatment effects on symptoms from effects on disease progression, which is important given the primary endpoint of changes on the UPDRS scale for Parkinson
The Big Climate Speech: Why Tackling climate change is one of America's greatest economic opportunities
How will technology impact global energy and climate challenges? What are the facts, the politics, the opportunities, and challenges for businesses? Join us for an extensive discussion of Obama’s climate speech impact on corporate and technology outcomes. Increase your knowledge, awareness, understand the facts, and assess the views.
Learning Outcomes: Increase knowledge and awareness of current events and business trends in climate change and future outcomes
At the end of this seminar, participants will be able to:
a) Explore Obama’s climate speech
b) Examine global challenges and business impact
c) Discuss the future of climate change, explore technology, and analyze business opportunities
The document discusses physical properties that can be used to identify and separate mixtures. It describes viscosity, conductivity, malleability, hardness, melting and boiling points, and density. These properties can help determine which of two unlabeled liquids is water and which is lemonade. They also aid in separating mixtures through filtration and distillation based on particle size and boiling points.
The document discusses randomization and blinding in clinical trials. It defines randomization as a process that assigns participants to experimental and control groups randomly to reduce bias. Randomization ensures groups are similar and comparable. Blinding refers to keeping participants and investigators unaware of group assignments to prevent bias in assessing outcomes. The document outlines various randomization techniques like simple randomization and stratification. It also discusses types of sampling and limitations of non-randomized trials in comparing interventions. In summary, the key points are that randomization and blinding are important design elements in clinical trials to reduce bias and ensure validity of results.
This systematic review evaluated regional analgesic techniques for post-thoracotomy pain management, including thoracic epidural, paravertebral block, intrathecal, intercostal, and interpleural methods. The review found that continuous paravertebral block provided analgesia comparable to thoracic epidural with fewer side effects. Paravertebral block also reduced pulmonary complications versus systemic opioids, though epidural did not. Epidural was superior to intrathecal or intercostal techniques, which were still better than systemic opioids. Interpleural analgesia was inadequate. The review concluded that either epidural with local anesthetic plus opioid or continuous paravertebral block with local anesthetic can be recommended, with intrathecal opioid
Course 2 the need for a careful and thorough historyNelson Hendler
The medical literature reports that 40%-80% of chronic pain patients are misdiagnosed. Clearly, misdiagnosis leads to ordering the wrong tests, and thereby obtaining an incorrect diagnosis, or overlooking a diagnosis totally, which results in mistreatment. Many reports in the medical literature indicate the best way to get an accurate diagnosis, is to obtain a complete and thorough history. However, this is a time consuming process, and most physicians don’t spend the needed time with a patient. Therefore, a team of doctors from Johns Hopkins Hospital developed a 72 question test, with 2008 possible answers, available over the Internet. When a patient completes the questionnaire, diagnoses are returned within 5 minutes. These diagnoses have a 96% correlation with diagnoses of Johns Hopkins Hospital doctors. This is the highest level of accuracy of any expert system available. The efficacy of this approach is proven by outcome studies, which prove that this approach results in a far higher return to work rate and reduced use of medication and doctors visits, when compared to other techniques. This is similar to the techniques used by Johns Hopkins Hospital to reduce their workers compensation payments by 54%.
This study aimed to determine the incidence and types of medical errors in ICU patients. The results found that 20% of patients experienced an adverse event, with 45% deemed preventable. A total of 223 serious medical errors occurred, with medications contributing to 78% of errors. The majority of errors were due to slips or lapses in care. The study suggests system-based changes like computerized order entry and barcoding could help reduce medical errors.
Evaluation of the Inpatient Hospital Experience while on PrecautionsKathryn Cannon
This study assessed patient satisfaction of those under contact/airborne isolation precautions versus those not under precautions at Yale-New Haven Hospital. 87 patients were interviewed using a survey measuring satisfaction with communication, treatment explanations, help from staff, pain control, and overall experience. Small variations were found between groups in nurse communication, timely help, pain control, and overall satisfaction. No significant difference was seen in doctor communication, but those under precautions expressed higher satisfaction with treatment explanations. The study aimed to understand differences to improve hospital processes and performance under new CMS reimbursement policies tied to patient satisfaction.
1) This randomized controlled trial compared care provided by nurse practitioners to care provided by general practitioners for 1,368 patients requesting same-day consultations across 10 general practices.
2) Results found that patients consulting with nurse practitioners reported higher satisfaction with their care, though for adults this difference was not observed in all practices. Consultations with nurse practitioners were also significantly longer.
3) In terms of clinical outcomes like resolution of symptoms, prescriptions issued, investigations ordered, and referrals, there was no significant difference between care provided by nurse practitioners versus general practitioners.
4) The study supports the role of nurse practitioners in providing care to patients requesting same-day consultations in primary care. Nurse
This document discusses observation units in emergency departments. It begins with introducing observation units and their objectives, then discusses the rationale and design features of such units. Key points covered include having clearly defined policies and staffing, focusing on conditions that can be better managed over a longer period of time than a traditional emergency department visit allows. The document also outlines potential pros and cons, as well as evidence from studies showing observation units can provide faster, better, cheaper care for certain patients.
The document discusses clinical decision making for nurses and healthcare professionals. It covers the principles of clinical decision making including pattern recognition, critical thinking, communication, evidence-based approaches, teamwork, reflection, and shared decision making. The decision making process involves gathering information, making judgements, deciding on a course of action, and evaluating outcomes. Shared decision making emphasizes involving patients in the decision making process from information gathering to agreeing on a treatment plan.
This document discusses clinical decision making for paramedics. It covers topics such as paramedics serving as prehospital medical practitioners, life-threatening patient conditions, protocols and standing orders, the critical thinking process, and the "Six R's" method for assessment and treatment. Paramedics must make critical decisions in emergency situations by gathering information, developing diagnoses, and using their medical knowledge and experience. They must also consider patient acuity, follow treatment guidelines, and continually re-evaluate patients.
Management of a Patient (All Types) - ROJosonReynaldo Joson
The document outlines the processes involved in managing a patient, whether surgical or nonsurgical. It discusses establishing rapport with the patient, performing a clinical diagnosis using pattern recognition and prevalence, determining when paraclinical diagnostic procedures are needed based on certainty of diagnosis and treatment plan, selecting and interpreting paraclinical tests, and choosing treatment modalities based on factors like effectiveness, risk and cost. For surgical patients specifically, it mentions preoperative preparation, intraoperative management phases, and postoperative care items. The overall goal is resolving the health problem while avoiding complications, disability, and legal issues.
The practice of anesthesia and sedation continues to expand beyond the operating room and now includes the gastroenterology suite, magnetic resonance imaging suites, and the cardiac catheterization laboratory. Non-anesthesiologists frequently administer sedation, in part because of a lack of available anesthesiologists and economic aspect, which emphasizes the safety of sedation. The Joint Commission International (JCI) set a standard responding to this issue indicating that qualified individuals who have drug and monitoring knowledge as well as airway management skills can only administer sedating agents.
Genomic variation partially explains interindividual variability in responses to perioperative stressors and drugs. The perioperative period represents an opportunity to implement precision medicine strategies through preemptive profiling, risk stratification incorporating genetics, and pharmacogenomics-guided drug selection. Specific genetic polymorphisms have shown associations with increased risk of perioperative adverse events like myocardial infarction and atrial fibrillation.
A randomized, double-blind, placebo-controlled pilot study was conducted to determine if preoperative modafinil improved recovery after general anesthesia in patients with obstructive sleep apnea (OSA). 102 patients with OSA were given either 200mg of modafinil or placebo before surgery. The primary outcome of length of stay in the post-anesthesia care unit (PACU) showed no difference between groups. Secondary measures of emergence and recovery also did not differ significantly. While respiratory rate was higher and blood pressure lower in the modafinil group in the PACU, the study results suggest single-dose preoperative modafinil does not improve functional recovery after general anesthesia in patients with OSA.
EMPACT: Emergency Medicine Professionalism and Communication TrainingPicker Institute, Inc.
"Emergency Medicine Resident Training in Interprofessional Skills: Evaluating a Needs-Based Curriculum"
Sondra Zabar, M.D., Principal Investigator Associate Professor of Medicine
Linda Regan M.D., Co-Investigator New York University School of Medicine
EMPACT aims to expand on previous work by assessing and improving EM resident competency in communication and professionalism through the development, implementation, and evaluation of new curriculum and assessment measures.
This document provides guidelines for the prevention of catheter-related infections from the CDC in 2011. It includes recommendations for education and training of healthcare staff, selection of catheter type and insertion site, hand hygiene and aseptic technique, skin preparation, dressing regimens, patient hygiene, safety devices, impregnated catheters, antibiotic prophylaxis, dressing changes, and catheter replacement. The guidelines are meant to help reduce the risk of catheter-related infections in hospitals.
This document provides an overview of clinical decision making (CDM) and discusses several related topics:
- It outlines the five domains of emergency care that involve CDM: assessment and stabilization; monitoring; assessing illness severity; making a differential diagnosis; and determining treatment.
- CDM can be influenced by many factors including knowledge, biases, context, and non-technical skills. Both intuitive and analytical thinking styles impact CDM.
- Improving CDM involves training to enhance critical thinking skills and address common cognitive errors and biases. Receiving timely feedback is also important to make better clinical judgments.
This document provides an outline for a presentation on electronic medical records (EMRs). It begins with defining the components of an EMR, including labs, admissions/discharge/transfer data, orders, radiology, notes, and billing. It then discusses the history and adoption of EMRs from the 1960s to present. The document reviews studies showing the effectiveness of EMRs in improving quality of care and achieving treatment standards. It also outlines how EMR data is structured in databases and data warehouses and describes common health data standards like ICD, CPT, LOINC, SNOMED, and HL7. The presentation covers meaningful use incentives and provides examples of using EMR data for research studies.
Practice guidelines for postanesthetic care 2013Ann Sodders
- These Practice Guidelines update the "Practice Guidelines for Postanesthetic Care" adopted by the American Society of Anesthesiologists in 2001 and published in 2002.*
- The purpose of developing these updated Guidelines was to evaluate available current evidence and provide recommendations to improve postanesthetic care outcomes for patients receiving anesthesia or sedation.
- The new Guidelines differ from existing Guidelines by providing an updated evaluation of scientific literature published after completion of the original Guidelines. However, the new evidence did not necessitate changes to the original recommendations.
Here are the designs I would recommend for each case:
Case 1: N-of-1 design. This design is well-suited for testing the efficacy of a treatment for an individual patient, as in this case assessing L-arginine for a carrier of OTCD.
Case 2: Randomized withdrawal design. This minimizes time on placebo by giving all patients open-label treatment initially to identify responders, who are then randomized to continue treatment or placebo. This is appropriate given the reversible but relatively slow outcome.
Case 3: Delayed start design. This can distinguish treatment effects on symptoms from effects on disease progression, which is important given the primary endpoint of changes on the UPDRS scale for Parkinson
The Big Climate Speech: Why Tackling climate change is one of America's greatest economic opportunities
How will technology impact global energy and climate challenges? What are the facts, the politics, the opportunities, and challenges for businesses? Join us for an extensive discussion of Obama’s climate speech impact on corporate and technology outcomes. Increase your knowledge, awareness, understand the facts, and assess the views.
Learning Outcomes: Increase knowledge and awareness of current events and business trends in climate change and future outcomes
At the end of this seminar, participants will be able to:
a) Explore Obama’s climate speech
b) Examine global challenges and business impact
c) Discuss the future of climate change, explore technology, and analyze business opportunities
The document discusses physical properties that can be used to identify and separate mixtures. It describes viscosity, conductivity, malleability, hardness, melting and boiling points, and density. These properties can help determine which of two unlabeled liquids is water and which is lemonade. They also aid in separating mixtures through filtration and distillation based on particle size and boiling points.
7 la geointeligencia comercial eduardo cobera kiteEvelyn Femat
Este documento resume la historia y evolución de la cartografía y la geointeligencia comercial. Explica que los primeros mapas fueron creados por los babilonios en el 2300 a.C. y que la cartografía moderna surgió en Europa en los siglos XVII y XVIII cuando se empezaron a incluir datos precisos de latitud, longitud y corrientes oceánicas. También describe cómo la fotografía aérea y la tecnología digital han enriquecido la cartografía moderna y cómo la geointeligencia comercial se usa hoy
Integrating technology into the classroom curriculum provides students with skills needed for the future. It allows them to research topics, create websites, and take online assessments. When technology is used effectively, it engages students, enhances learning, and changes the teacher's role to advising and coaching.
The document summarizes key events around the expansion of slavery and passage of the Compromise of 1850. It discusses the debates over whether new territories gained from Mexico would allow slavery. The Compromise of 1850 admitted California as a free state while establishing popular sovereignty in Utah and New Mexico. It also included a stronger Fugitive Slave Act, which faced opposition from abolitionists and led to incidents like the failed rescue of Anthony Burns.
Drop forging is a manufacturing process that shapes metals by hammering or pressing them between two dies. There are two main types - open die forging, where the operator positions the workpiece for each press, and closed die forging, where both upper and lower dies form the part in a single press. Closed die forging produces near-net shapes and is best for high production runs, while open die is used for simpler parts or prototype work. Common applications include tools, gears, and vehicle components.
Este documento describe conceptos básicos sobre comunicación de datos y redes informáticas, incluyendo dispositivos, medios de comunicación, protocolos y clasificación de redes. Explica que una red conecta nodos mediante canales de comunicación, y que los elementos necesarios para la comunicación de datos son dispositivos emisores, receptores, medios, protocolos y mensajes. Además, clasifica las redes según su extensión geográfica, topología y relaciones lógicas entre nodos.
Spring flood reconstruction from tree rings (continuous and discontinuous ser...etbou24
In this presentation, we use tree rings (continuous and discontinuous series) to reconstruct past spring floods in cold environments. Spring floods are short duration events that may not be visible in classical tree ring indicators such as ring widths. Ice scars are conspicuous evidences of past spring floods and can greatly augment the reconstruction’s reliability, but pose a certain number of statistical problems when they are used as proxies. Some of these problems are described and solved here, using a novel reconstruction procedure.
I gem 2012 design competition design team 4 proposalpittus23
The document proposes expressing the li16 gene from wood frogs in E. coli to study its antifreeze protein Li16. Li16 increases in wood frogs after freezing and may help freezing survival. The team will obtain li16, express it in E. coli, and test the effects on freezing using ice recrystallization assays and freeze tolerance tests. Isolated Li16 protein will then be applied to crops to study effects on freezing preservation. Challenges include obtaining li16 and ensuring proper folding in E. coli.
The document summarizes a Disaster Risk Reduction Practitioners Workshop held in Bangkok, Thailand from November 13-14, 2013. Over 60 DRR practitioners from Southeast Asia attended to share experiences and lessons learned. The workshop focused on six themes: advocacy and awareness; community mobilization; school safety; early warning systems; livelihoods; and urban DRR. For each theme, presentations were given and challenges, best practices, and gaps were discussed. Key recommendations included the need for champions to promote DRR, aligning projects with national strategies, targeting awareness campaigns appropriately, and addressing challenges like institutionalizing DRR long-term. The workshop provided a valuable learning and networking opportunity for participants.
Karmen Guevara, University of Cambridge: Dimensions of Identity, Trust and Pr...i_scienceEU
Network of Excellence Internet Science Summer School. The theme of the summer school is "Internet Privacy and Identity, Trust and Reputation Mechanisms".
More information: http://www.internet-science.eu/
This document provides an overview of strategies for effective group work in college classrooms. It discusses common challenges with group work, such as some students doing more work than others or groups being ineffective due to poorly designed tasks. It then highlights 10 articles from The Teaching Professor that offer tips for creating more effective group activities and assessments. These include using group quizzes, pairing students versus small groups, providing incentives for group leaders, strategies for dealing with students who dislike group work, and incorporating both cooperation and competition among groups. The document aims to help faculty improve the way their students experience and engage with group work.
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This summary provides an overview of the key points about Groovy 2.0 discussed in the document:
1. Groovy 2.0 features a more modular architecture with smaller JAR files for individual features, as well as the ability to create custom extension modules.
2. It includes support for Java 7 features like binary literals, underscores in literals, and multicatch exceptions.
3. The new static type checking functionality in Groovy 2.0 aims to catch errors like typos, missing methods, and wrong assignments at compile time rather than runtime.
El documento describe el test de la familia, un método proyectivo para evaluar la personalidad de un niño. Se le pide al niño que dibuje una familia real o imaginaria y luego se le hace preguntas sobre el dibujo para analizar sus sentimientos hacia los miembros de la familia y su posición dentro de ella. El análisis del dibujo y las respuestas puede revelar factores como la inteligencia, las emociones y las relaciones del niño.
Aplicacion de las ecuaciones diferenciales de orden superiorIsai Esparza Agustin
Este documento resume las aplicaciones de ecuaciones diferenciales de orden superior en mecánica y electricidad. En particular, analiza oscilaciones libres y forzadas de sistemas oscilatorios, tanto no amortiguados como amortiguados. Describe cómo la frecuencia y el período de oscilación dependen de parámetros como la masa, la constante elástica y la constante de amortiguamiento. También examina cómo cambios en las condiciones iniciales afectan la solución pero no la frecuencia natural del sistema.
Este documento explica qué es la biodiversidad, incluyendo la diversidad de ecosistemas, especies y genes. También describe cómo se puede medir la biodiversidad, siendo el número de especies uno de los mejores indicadores. Finalmente, señala que a pesar de los esfuerzos, todavía no se conoce con certeza el número total de especies en el planeta.
strategic management project on Maruti Suzuki udhog limitedSunny Gandhi
This document provides an analysis of various strategic factors related to Maruti Suzuki, an automobile company in India. It discusses Maruti Suzuki's vision, mission, objectives, and evaluates them against various criteria. It then analyzes the general and specific environmental factors affecting Maruti Suzuki's performance. Porter's five forces analysis identifies bargaining power of suppliers and buyers, threat of substitutes and new entrants, and rivalry among competitors as unfavorable for Maruti Suzuki. The document categorizes the automobile industry as global in nature and having a differentiated oligopoly structure. It comments on the industry's attractiveness and performance, and identifies strategic groups within the automobile industry.
A very vital article that briefly and nicely describes how shpuld evidence be handled in order to evaluate it and make use of the information provided.
This document discusses sedation and guidelines for qualified sedation providers. It defines levels of sedation from minimal to general anesthesia. Certified registered nurse anesthetists, anesthesiologists, and specifically trained physicians, dentists, oral surgeons, and registered nurses can provide conscious sedation. The American Society of Anesthesiologists' practice guidelines for non-anesthesiologist sedation were developed through an extensive review process. The guidelines also address training requirements for sedation personnel. Kaiser Moanalua's registered nurse training involves an online test and hands-on training in an operating room. A sedation simulation aims to supplement online training through realistic scenarios that simulate dynamic decision making. Evaluation of the simulation involves surveys of
Guidelines for the preformance of fusion procedures for degenerative disease ...INUB
The document discusses guidelines for assessing functional outcomes following lumbar fusion procedures for degenerative lumbar disease. It recommends using reliable, valid, and responsive scales to measure functional outcomes, listing several examples. There is insufficient evidence to recommend a specific guideline. Patient satisfaction scales are only recommended for use in retrospective case series when better alternatives are unavailable, as they are not reliable for assessing outcomes. The rationale provided is the importance of objective assessment of outcomes given increasing costs and procedures, and the need to correlate outcomes with economic impacts.
The document discusses evidence-based nursing practice. It defines evidence-based practice as integrating the best research evidence, clinical expertise, and patient values and needs. The key steps in evidence-based practice are asking questions, acquiring evidence, appraising the evidence, applying it to a patient, and evaluating outcomes. Barriers to evidence-based nursing include lack of time and resources, as well as difficulties interpreting and applying research. Facilitators include administrative support and accessible, clearly written research. Maximizing evidence-based nursing requires overcoming barriers, incorporating different types of evidence, and accounting for issues beyond measurement like patient preferences.
This study evaluated the association between leadership walkrounds (WRs) and caregiver assessments of patient safety climate and risk reduction across 49 hospitals. WRs involve hospital leaders visiting clinical units to openly discuss safety issues with staff. The study found that units where ≥60% of caregivers reported exposure to at least one WR had significantly higher safety climate scores, greater reported risk reduction, and more feedback on actions taken compared to units with <60% exposure. Higher rates of WR participation at the unit level were positively associated with more favorable caregiver assessments of patient safety culture and outcomes.
The medication safety project had two aims: 1) to identify areas of exposure to risk and make recommendations to enhance medication safety, and 2) to inform the development of a medication safety checklist specific to operating rooms. An interdisciplinary team conducted a review of medication use in operating rooms and related areas. They observed environments where medications were prescribed, stored, prepared, dispensed and administered. The team made recommendations in areas like improving documentation of patient medication histories, reducing abbreviations, enhancing pharmacist support, and standardizing medication storage, labeling and carts. Many of the recommendations have been implemented.
This document discusses evidence-based laboratory medicine and the need to support clinical decision-making with robust evidence. It notes that while laboratory medicine is perceived as scientific, evidence for many diagnostic tests is limited or flawed. An evidence-based approach can help improve education, guidelines, decision-making and resource allocation. The challenges include a lack of evidence demonstrating the impact of diagnostic tests on patient outcomes. Health technology assessment and outcomes research are important tools to develop high-quality evidence and address the current pressures on healthcare systems.
Medical Devices and Embase webinar - 18 Sept Ann-Marie Roche
Daniel E. McLain, President of Walker Downey & Associates, Inc., an evidence-based product safety and development consultancy located near Madison, WI. presented a webinar, which showcased a soon to be released Medical Device White Paper and walked us through a clinical evaluation using Embase.
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This document discusses evidence-based surgery and how surgeons evaluate the strength of evidence for surgical practices. It covers:
1) Guidelines and secondary sources that surgeons can use to inform evidence-based practice, but notes individual surgeons must also evaluate primary studies.
2) Factors used to evaluate the validity of scientific studies, including internal validity (study quality), external validity (generalizability), and the influence of chance, bias, and confounding.
3) Hierarchies of evidence that rank study designs, with randomized controlled trials considered the strongest, but these systems have limitations and surgeons must make judgments.
Nurse-led pre-operative assessment ensures patients are prepared for surgery through a systematic 4-stage process: 1) collecting medical history, 2) nursing assessment, 3) ordering relevant investigations/tests, and 4) providing information. This identifies risks and needs to improve outcomes by reducing cancellations. Pre-operative assessment by nurses trained to advanced levels can provide equivalent care to doctors. Effective communication among the healthcare team during assessment benefits patients.
Nurse-led pre-operative assessment ensures patients are prepared for surgery through a systematic 4-stage process: 1) collecting medical history, 2) nursing assessment, 3) ordering relevant investigations/tests, and 4) providing information. This identifies risks and needs to improve outcomes by reducing cancellations. Pre-operative nurses are trained to perform assessments previously done by junior doctors. Effective pre-operative assessment through nurse-led coordination of care and communication between healthcare professionals results in positive surgical experiences for patients.
Practice guidelines for_central_venous_access__a.13Felipe Posada
This document provides guidelines for central venous access developed by the American Society of Anesthesiologists Task Force. It defines central venous access, outlines the purposes for developing the guidelines which are to provide guidance on placement and management of central lines and reduce adverse outcomes. It focuses on elective procedures performed by anesthesiologists and provides definitions but does not address clinical indications, emergency placement, peripherally inserted central catheters, pulmonary artery catheters, tunneled lines, or infectious complications treatment. The guidelines are intended for use by anesthesiologists and those under their supervision.
The document discusses evidence based nursing practice. It defines nursing research, evidence, evidence based decision making and evidence based practice. Evidence based nursing practice refers to using the best research evidence, clinical expertise and patient preferences in clinical decision making. The evidence based practice movement started in the 1990s to improve care quality. Models like the Stetler model and Iowa model provide frameworks for evidence based practice. Barriers to evidence based practice include lack of time, skills and research access. Guidelines and systematic reviews are sources of best evidence.
Guias de manejo del dolor pos op 2016 jounal of painMiretti Francisco
This document provides guidelines for the management of postoperative pain developed by a multidisciplinary panel of experts. It summarizes that most patients experience acute pain after surgery but less than half report adequate relief. It recommends multimodal regimens tailored to individual patients and procedures when possible. The guidelines are based on a systematic review of the evidence but many research gaps were identified. Of the 32 recommendations, 4 were supported by high quality evidence and 11 by low quality evidence related to areas like patient education and assessment.
Practice guidelines-for-obstetric-anesthesiakiennguyen255
These guidelines update the 2006 American Society of Anesthesiologists guidelines on obstetric anesthesia. They were developed through a literature review and surveys of experts and anesthesiologists. The guidelines focus on anesthesia management during labor, delivery, and immediate postpartum care. They do not address all aspects of obstetric anesthesia or patients with medical complications. The guidelines are intended to improve quality of care, safety, and patient satisfaction for obstetric patients receiving anesthesia.
Prevencion de ulceras por presion y protocolo de tratamientoGNEAUPP.
This document provides a summary of the NGC-8962 guideline for pressure ulcer prevention and treatment. It was developed by the Institute for Clinical Systems Improvement (ICSI) and provides recommendations in the form of an inpatient and outpatient algorithm with 11 components and detailed annotations. The major recommendations include performing risk assessments using tools like the Braden or Braden Q scale, conducting skin inspections regularly, implementing prevention plans to reduce pressure and manage moisture/nutrition, and treating existing pressure ulcers with a comprehensive assessment and evidence-based interventions. Special considerations are provided for different patient populations and settings.
Evidence-Based Practice and the Future of NursingOther Mother
This document discusses evidence-based practice and its importance for nursing. It provides an overview of the evolution of evidence-based practice from its origins in medicine in the early 1990s to its growing emphasis and application in nursing. Key points discussed include defining evidence-based practice, the various levels of evidence, common questions nurses ask to identify opportunities to improve care, and the steps of the evidence-based practice process. Barriers to implementing evidence-based practice like lack of time, access, and research expertise are also addressed.
Evidence Base Practice (EBP)-Define, Benefits,Resource, steps PPTsonal patel
Evidence based practice (EBP) involves integrating the best available research evidence with clinical expertise and patient values to provide optimal care. EBP aims to move away from relying on "tried and true" practices and instead make decisions based on high-quality clinical research. The key steps of EBP include asking answerable clinical questions, searching for relevant evidence, appraising the evidence quality and applicability, integrating the evidence with expertise and context, and evaluating outcomes. EBP has benefits like improved patient outcomes, more efficient care, and keeping nursing practice current with the latest research findings.
Similar to Evaluacion preanestesica taskforce 2002 (20)
La diabetes es una enfermedad crónica caracterizada por niveles altos de azúcar en la sangre, que puede ser causada por una falta de insulina o resistencia a la insulina. Existen tres principales tipos de diabetes: tipo 1, tipo 2 y gestacional. La diabetes es una amenaza grave para la salud que puede causar ceguera, amputaciones, enfermedad renal y ataques cardíacos si no se controla y trata adecuadamente.
Este documento presenta el plan de estudios de Alta Especialidad en Medicina Perioperatoria de la Universidad Autónoma de Sinaloa a través del Hospital Civil de Culiacán y el Centro de Investigación y Docencia en Ciencias de la Salud. El plan tiene una duración de un año y se estructura en módulos y unidades de aprendizaje para desarrollar competencias genéricas, básicas y específicas del área. El objetivo es formar profesionales competentes en el manejo del paciente durante el periodo perioperatorio.
The panel recommends the following for treatment of hypertension in adults:
- For those aged 60 years and older, treat to a blood pressure goal of less than 150/90 mm Hg.
- For those aged 30-59 years, treat to a blood pressure goal of less than 140/90 mm Hg.
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- Initiate treatment with one of four classes of antihypertensive drugs (angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, calcium channel blocker, or thiazide-type diuretic).
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Séptimo Reporte del comité nacional para la prevención, detección, evaluación...sandoriver
Este documento presenta el séptimo informe del Comité Nacional Conjunto sobre la prevención, detección, evaluación y tratamiento de la hipertensión arterial. El informe actualiza las guías anteriores sobre la hipertensión basándose en nuevos estudios publicados desde el último informe de 1997. El informe simplifica la clasificación de la presión arterial y proporciona recomendaciones actualizadas sobre el tratamiento de la hipertensión, incluyendo el uso preferente de diuréticos tiazídicos y el tratamiento combinado con dos o más f
Guías de manejo evaluación cardiovascular preoperatoria en cirugía no cardiac...sandoriver
This document provides updated guidelines for the perioperative cardiovascular evaluation and care of patients undergoing noncardiac surgery. It summarizes the key recommendations, which include:
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The document discusses a practice advisory for preanesthesia evaluation published by the American Society of Anesthesiologists. It defines preanesthesia evaluation as the clinical assessment process performed before anesthesia care for surgery or other procedures. The evaluation involves considering information from medical records, interviews, exams, and tests to inform perioperative care planning. The purposes of the advisory are to assess evidence on the healthcare benefits of preanesthesia evaluation and provide a framework to guide anesthesiologists in conducting evaluations.
This document presents the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). It aims to provide an evidence-based approach to hypertension prevention and management. Some key points:
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- While awareness, treatment and control of hypertension have improved since previous reports, current control rates remain unacceptably low. About 30% of adults are still unaware of their hypertension, over 40% of those with hypertension are untreated, and two-thirds of treated hypertensives are not controlled.
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Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
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2. 486 PRACTICE ADVISORY
Application of this Advisory. Sixth, all available information was used
to build consensus within the Task Force on the
This Advisory is intended for use by anesthesiologists Advisory.
and those who provide care under the direction of an
anesthesiologist. The Advisory applies to patients of all
ages who are scheduled to receive general anesthesia, Availability and Strength of Evidence
regional anesthesia, moderate or deep sedation for elec-
tive surgical and nonsurgical procedures. The Advisory Practice advisories are developed by a systematic, con-
does not address the selection of anesthetic technique sensus-based process. In contrast to evidence-based
nor the preanesthesia evaluation of patients requiring guidelines, practice advisories lack the support of a suf-
urgent or emergency surgery or anesthetic management ficient number of adequately controlled scientific studies
provided on an urgent basis in other locations (e.g., to permit aggregate analyses of data with rigorous statis-
emergency rooms). tical techniques such as meta-analysis. Nonetheless, lit-
erature-based evidence for practice advisories is avail-
able from limited controlled trials, case reports,
Criteria for Anesthesia Intervention, Testing, descriptive studies, and by the assessment of the
and Consultation strengths and weaknesses of published studies. This lit-
erature often permits the identification of recurring
Any evaluations, tests, and consultations required for a patterns of clinical practice. Opinion surveys often
patient are done with the reasonable expectation that reveal similar patterns. The advisory statements con-
such activities will result in benefits that exceed the tained in a practice advisory represent a consensus-based
potential adverse effects. Potential benefits may include distillation of the clearest patterns of agreement or
a change in the content or timing of anesthetic manage- disagreement.
ment or perioperative resource utilization that may im-
prove the safety and effectiveness of anesthetic pro-
cesses involved with perioperative care. Potential Advisory Statements
adverse effects may include interventions that result in
injury, discomfort, inconvenience, delays, or costs that
are not commensurate with the anticipated benefits. Preanesthesia History and Physical
Examination
Impact. A preanesthesia history and physical exami-
Task Force Members and Consultants
nation precedes the ordering, requiring, or performance
The American Society of Anesthesiologists (ASA) ap- of specific preanesthesia tests, and consists of (1) evalu-
pointed a task force of 12 members to (1) review pub- ation of pertinent medical records, (2) patient inter-
lished evidence; (2) obtain expert and public consensus view(s), and (3) physical examination. No controlled
opinion; and (3) create a consensus-based assessment of trials of the clinical impact of performing a preanesthesia
currently available scientific literature and opinion. The medical records review or physical examination were
ASA Task Force members consisted of anesthesiologists found. Several studies reported specific perioperative
in both private and academic practices from various outcomes (e.g., cardiac, respiratory, renal, hemorrhagic)
geographic areas of the United States, and methodolo- occurring in patients with specific preexisting condi-
gists from the ASA Committee on Practice Parameters. tions (e.g., hypertension, previous myocardial infarction,
The Task Force used a six-step process. First, they smoking, pulmonary disease, and age).1– 63 Such condi-
reached consensus on the criteria for evidence of effec- tions often are noted in a patient’s medical record. Ad-
tiveness of preanesthesia evaluation. Second, original ditional studies were examined that reported preexisting
published research studies relevant to these issues were conditions (e.g., airway abnormalities, cardiopulmonary
reviewed. Third, consultants who had expertise or inter- disorders) detected during a preanesthesia examination
est in preanesthesia evaluation, and who practiced or or interview.6,28,44,47,49,59,64 –91 Five of these studies re-
worked in various settings (e.g., academic and private sulted in changes in resource management.49,64,74,82,84
practice) were asked to (1) participate in opinion sur- These studies were not controlled trials and were not
veys on the effectiveness of various preanesthesia eval- considered sufficiently rigorous to provide unequivocal
uation strategies, and (2) review and comment on draft evidence of the value of performing a preanesthetic
reports of the Task Force. Fourth, opinions about various medical records review or physical examination.
elements of this Practice Advisory were solicited from a
random sample of active members of the ASA. Fifth, the Advisory
Task Force held several open forums at major national The Task Force believes that the assessment of anes-
anesthesia meetings to solicit input on the key concepts thetic risks associated with the patient’s medical condi-
Anesthesiology, V 96, No 2, Feb 2002
3. PRACTICE ADVISORY 487
Table 1. Timing of the Initial Assessment of Pertinent Medical Records–Survey Opinions
Surgical Invasiveness High Medium Low
Consultants ASA Members Consultants ASA Members Consultants ASA Members
(N 72) (N 234) (N 72) (N 231) (N 72) (N 233)
Prior to the day of surgery 89% 75% 58% 33% 17% 11%
On or before the day of surgery 11% 24% 39% 61% 69% 59%
Only on the day of surgery 0% 1% 3% 6% 14% 30%
ASA American Society of Anesthesiologists.
tions, therapies, alternative treatments, surgical and medical records should be done prior to the day of
other procedures, and of options for anesthetic tech- surgery by anesthesia staff. For medium surgical invasive-
niques is an essential component of basic anesthetic ness, the majority of consultants indicate that the initial
practice. Benefits may include, but are not limited to, the assessment of pertinent medical records should be done
safety of perioperative care, optimal resource utilization, prior to the day of surgery by anesthesia staff, although
improved outcomes, and patient satisfaction. the majority of ASA members indicate that the initial
Timing. The activities encompassed by a preanesthe- assessment may be done on or before the day of surgery.
sia history and physical examination occur over a vari- For low surgical invasiveness, the majority of consultants
able period of time. The timing of an initial preanesthesia and ASA members agree that the initial assessment may
evaluation is guided by such factors as patient demo- be done on or before the day of surgery.
graphics, clinical conditions, type and invasiveness of Consultant and ASA membership opinions regarding
procedure, and the nature of the healthcare system. the timing of an initial preanesthesia interview and phys-
Three options that practices utilize for the timing of an ical examination for high and low severities of disease
initial preanesthesia evaluation are (1) always prior to are reported in table 2. The majority of consultants and
the day of surgery, (2) either on or before the day of ASA members agree that, for patients with high severity
surgery, and (3) only on the day of surgery. of disease, it is preferable that the interview and physical
Although no controlled trials addressing the timing of examination be done before the day of surgery by anes-
a preanesthesia evaluation were found, survey opinions thesia staff. For low severity of disease and high surgical
from expert consultants and a random sample of ASA invasiveness, consultants and ASA members agree that it
members were obtained to examine potential clinical is preferable that the interview and physical examination
influences (i.e., patient severity of disease and surgical be done prior to the day of surgery. For patients with
invasiveness) on timing decisions. Consultant and ASA low severity of disease and medium or low surgical
member opinions regarding the timing of an initial as- invasiveness, consultants and ASA members agree that
sessment of pertinent medical records for high, medium, the interview and physical examination may be done on
and low levels of surgical invasiveness, independent of or before the day of surgery.
medical condition, are reported in table 1. The majority A majority of consultants and the ASA membership,
of consultants and ASA members agree that, for high respectively, agree that, at a minimum, a preanesthesia
surgical invasiveness, the initial assessment of pertinent physical examination should include (1) an airway exam
Table 2. Timing of the Preanesthetic Interview and Physical Examination–Survey Opinions
High Severity of Disease Surgical Invasiveness
High Medium Low
Consultants ASA Members Consultants ASA Members Consultants ASA Members
(N 72) (N 232) (N 72) (N 232) (N 72) (N 232)
Prior to the day of surgery 96% 89% 94% 69% 71% 53%
On or before the day of surgery 4% 9% 4% 28% 24% 32%
Only on the day of surgery 0% 2% 1% 3% 5% 15%
Low Severity of Disease Surgical Invasiveness
High Medium Low
Consultants ASA Members Consultants ASA Members Consultants ASA Members
(N 72) (N 229) (N 72) (N 229) (N 72) (N 229)
Prior to the day of surgery 72% 53% 29% 21% 13% 25%
On or before the day of surgery 11% 20% 49% 46% 39% 34%
Only on the day of surgery 15% 11% 21% 34% 47% 56%
ASA American Society of Anesthesiologists.
Anesthesiology, V 96, No 2, Feb 2002
4. 488 PRACTICE ADVISORY
(100%, 100%), (2) a pulmonary examination to include gical screening” are not considered as specific clinical
auscultation of the lungs (88%, 85%), and (3) a cardio- indications or purposes. An indicated test is defined as a
vascular examination (81%, 82%). test that is ordered for a specific clinical indication or
purpose. For example, assessment of warfarin therapy
Advisory effects would be considered an indication for specific
The Task Force consensus is that an assessment of coagulation studies.
readily accessible, pertinent medical records with con-
sultations, when appropriate, should be performed as Electrocardiogram. Routine electrocardiographic
part of the preanesthesia evaluation prior to the day of findings were reported as abnormal in 7.0 – 42.7% of
surgery for procedures with high surgical invasiveness. cases (N 12 studies)92–103 and led to changes in clin-
For procedures with low surgical invasiveness, the re- ical management in 9.1% of the cases found to be abnor-
view and assessment of medical records may be done on mal (N 1 study).100 Preoperative electrocardiograms
or before the day of surgery by anesthesia staff. The that were ordered as indicated tests resulted in reports of
information obtained may include, but should not be abnormal findings in 4.8 –78.8% of cases (N 17 stud-
limited to (1) a description of current diagnoses, (2) ies)49,51,82,100,104 –116 and led to changes in clinical man-
treatments, including medications and alternative thera- agement in 2.0 –20.0% of the cases found to be abnormal
pies used, and (3) determination of the patient’s medical (N 6 studies).49,82,100,104,111,112 One observational
condition(s). Public commentary at open forums and study with investigator and practitioner blinding found
from the Internet corroborates the Task Force that preoperative electrocardiographic ischemic epi-
consensus. sodes were associated with intra- and-postoperative myo-
The Task Force consensus is that an initial record cardial infarction for older patients with severe coronary
review, patient interview, and physical examination artery disease scheduled for elective coronary artery
should be performed prior to the day of surgery for bypass grafting (CABG).110 One observational study re-
patients with high severity of disease. For patients with ported a 10% or greater incidence of coronary events
low severity of disease and undergoing procedures with during the subsequent 10 yr for men over 60 without
high surgical invasiveness, the interview and physical specific clinical indicators and for women over 65 with-
exam should also be performed prior to the day of out specific clinical indicators. The incidence increased
surgery. For patients with low severity of disease under- to 25% in the decade after such patients’ seventy-fifth
going procedures with medium or low surgical invasive- birthday.107
ness, the initial interview and physical exam may be Other Cardiac Evaluation. No studies were found
performed on or before the day of surgery. that examined outcomes from routine preoperative car-
At a minimum, a focused preanesthesia physical ex- diac evaluations of angiography, echocardiography, or
amination should include an assessment of the airway, stress tests. For patients with indicated cardiac evalua-
lungs, and heart, with documentation of vital signs. Pub- tions, abnormal findings were found with angiography:
lic commentary at open forums and from the Internet 22.5– 47.0% of cases (N 4 studies)117–120; echocardi-
corroborate the Task Force opinions. ography: 7.5%-50.0% of cases (N 5 studies)121–125;
The Task Force cautions that timing of preanesthesia stress or exercise tests; 15.0 –71.0% of cases (N 3
assessments may not be practical with the current limi- studies).105,126,127 Changes in clinical management were
tation of resources provided by a specific healthcare not uniformly reported.
system or practice environment. The Task Force believes Chest X-ray. Routine chest x-ray findings were re-
it is the obligation of the healthcare system to, at a ported as abnormal in 2.5– 60.1% of cases (N 20
minimum, provide pertinent information to the anesthe- studies)96,98,100,102,128 –142 and led to changes in clinical
siologist for the appropriate assessment of the severity of management in 0 –51% of the cases found to be abnor-
the medical condition of the patient and invasiveness of mal (N 9 studies).100,102,128,129,136,139 –142 For patients
the proposed surgical procedure well in advance of the with indicated preoperative chest x-rays, abnormal find-
anticipated day of the procedure for all elective patients. ings were reported in 7.7– 65.4% of cases (N 18
studies)30,82,92,100,106,112,128,137,143–152 and led to
changes in clinical management in 0.5–74.3% of the
Selection and Timing of Preoperative Tests cases found to be abnormal (N 9 stud-
ies).82,100,112,128,143,145–147,152 Two nonrandomized stud-
Literature regarding controlled trials and test findings ies compared asymptomatic patients receiving chest x-
regarding the incidence or frequency of commonly used rays versus asymptomatic patients not receiving chest
preoperative tests are described below. For purposes of x-rays and found no differences in delays or cancellations
this Advisory, a routine test is defined as a test ordered of surgery.141,142 However, the studies found that an
in the absence of a specific clinical indication or pur- abnormal preoperative chest x-ray finding altered care in
pose. Global designations such as “preop status” or “sur- 8.6% and 9.9% of the cases found to be abnormal.
Anesthesiology, V 96, No 2, Feb 2002
5. PRACTICE ADVISORY 489
Pulmonary Evaluation (i.e., Pulmonary Function Serum Chemistries. In routine preoperative potas-
Tests, Spirometry). Studies examining routine pulmo- sium tests, abnormal levels of potassium were found in
nary function tests (PFT’s) did not contain data on ab- 1.5–12.8% of cases (N 3 studies).133,162,188 For indi-
normal findings (N 2).46,153 Studies examining routine cated potassium tests, abnormal levels were found in
preoperative spirometry reported abnormal findings in 1.0 –29.5% of cases (N 4 studies).51,148,189,190 One
15.0 –51.7% of cases (N 3 studies).154 –156 Findings for randomized clinical trial compared preoperative serum
indicated preoperative PFT’s were reported as abnormal potassium levels at induction with serum potassium lev-
in 17.0 –27.1% of cases (N 3 studies),157–159 and indi- els 3 days before surgery, and found lower potassium
cated preoperative spirometry (a limited form of PFT’s) levels (hypokalemia) at induction.188 No blinded studies
were reported as abnormal in 33.1– 45.0% of cases (N were found that assessed the benefits or harms of prac-
3 studies).30,157,160 Changes in clinical management titioner awareness of potassium abnormalities.
were not reported. No studies were found that reported In routine preoperative glucose tests in nondiabetic
results of routine preanesthesia office spirometry (i.e., patients or patients without altered glucose metabolism,
portable or hand held spirometers). abnormal levels of glucose were found in 5.4 –13.8% of
Hemoglobin and Hematocrit Measurement. Rou- cases (N 3 studies).133,162,171 Changes in clinical man-
tine hemoglobin measurements were reported as abnor- agement were not reported.
mal in 0.5– 43.8% of cases (N 7 studies)102,133,161–165 Urine Testing. In routine preoperative urinalysis (not
and led to changes in clinical management in 0%-28.6% including pregnancy testing), abnormal results were re-
of the cases found to be abnormal (N 3 stud- ported in 0.7–38.0% of cases (N 9 stud-
ies).102,161,164 Indicated hemoglobin measurements ies)92,96,102,136,162,170,172,191,192 and led to changes in
were reported as abnormal in 38.6 – 62.0% of cases (N clinical management in 2.3–100% of the cases found to
2 studies).166,167 Changes in clinical management were be abnormal (N 6 studies).102,136,170,172,191,192 For
not reported. indicated urinalysis, abnormal results were found in
Routine hematocrit measurements were reported as 4.6 – 42.0% of cases (N 4 studies)92,108,112,148 and led
abnormal in 0.2–38.9% of cases (N 5 stud- to changes in clinical management in 0.0 –23.1% of the
ies)136,162,168 –170 and led to changes in clinical manage- cases found to be abnormal (N 2 studies).108,112
ment in 0 –100% of the cases found to be abnormal (N Pregnancy Testing. Routine pregnancy tests (routine
3 studies).136,168,170 Indicated hematocrit measurements refers to premenopausal menstruating females, not ex-
were reported as abnormal in 0.4 –5.0% of cases (N 2 cluding anyone on the basis of history) resulted in pos-
studies).51,148 Changes in clinical management were not itive findings in 0.3–2.2% of cases (N 5 studies)193–197
reported. and led to changes in clinical management, delays or
In studies reporting routine complete blood counts cancellation of surgery in 100% of the cases found to be
(i.e., individual test results not reported), abnormal find- pregnant.
ings were reported in 2.9 –17.6% of cases (N 4 stud- Consultants and ASA members were asked to consider
ies)92,98,171–172 and led to changes in clinical manage- whether specific preoperative tests should be conducted
ment in 2.4% of the cases found to be abnormal (N 1 (1) on a routine basis (i.e., given to patients regardless of
study).172 For indicated complete blood counts, abnor- known or suspected diseases or disorders), (2) for se-
mal findings were reported in 6.3– 60.8% of cases (N lected patients or for selected types of surgery, or (3) the
4 studies)92,107,108,112 and led to changes in clinical man- test is not necessary. For the tests considered, consultant
agement in 0.0%-14.9% of the cases found to be abnor- and ASA membership responses are reported in table 3.
mal (N 2 studies).108,112 Consultants and ASA members were also asked to iden-
Coagulation Studies. Routine coagulation studies re- tify specific patient characteristics that would favor a
ported abnormalities in bleeding time, prothrombin decision to order, require, or perform a preoperative
time, partial prothrombin time, or platelet count in test. For these specific patient characteristics, consultant
0.8 –22.0% of cases (N 15 studies)13,136,162,173–184 and and ASA membership responses are reported in table 4.
led to changes in clinical management in 1.1– 4.0% of
Consultants and ASA members were asked whether
the cases found to be abnormal (N 2 studies).13,136
selected preoperative tests are acceptable if obtained
Findings for indicated coagulation studies were reported
from the patient’s medical chart, assuming the patient’s
as abnormal in 3.4 –29.1% of cases (N 4 stud-
medical history has not changed substantially since the
ies).183,185–187 Changes in clinical management were not
test was obtained. Majority opinions of consultants and
reported. The incidence of routine coagulation study
ASA members are reported as percentage agreement,
abnormalities in patients scheduled for regional anesthe-
respectively, as follows:
sia or postoperative analgesia in surgical patients has not
been reported. The incidence of routine coagulation 1. Electrocardiogram (99%, 98%)
study abnormalities in obstetric patients has not been 2. Other cardiac evaluation (94%, 98%)
reported. 3. Chest x-ray (97%, 92%)
Anesthesiology, V 96, No 2, Feb 2002
6. 490 PRACTICE ADVISORY
Table 3. Routine or Selective Preoperative Testing–Survey Opinions
All Patients (Routine) Selected Patients Test Not Necessary
Preoperative Test % Agreement* % Agreement % Agreement
Electrocardiogram
Consultants (N 72) 0 100% 0
ASA members (N 233) 1% 98% 1%
Cardiac tests other than electrocardiogram
Consultants (N 72) 0 97% 0
ASA members (N 233) 1% 99% 0
Chest x-rays
Consultants (N 72) 3% 90% 7%
ASA members (N 233) 1% 92% 6%
Pulmonary function tests
Consultants (N 42) 0 98% 2%
ASA members (N 234) 0 96% 3%
Office spirometry
Consultants (N 42) 0 88% 10%
ASA members (N 234) 1% 63% 20%
Hemoglobin/hematocrit
Consultants (N 72) 3% 96% 1%
ASA members (N 234) 4% 95% 1%
Coagulation studies
Consultants (N 72) 3% 94% 1%
ASA members (N 234) 1% 98% 1%
Serum chemistries
Consultants (N 72) 1% 99% 0
ASA members (N 234) 1% 99% 0
Urinalysis
Consultants (N 72) 1% 53% 46%
ASA members (N 233) 2% 47% 49%
Pregnancy test
Consultants (N 72) 7% 88% 5%
ASA members (N 232) 17% 78% 3%
* Row percentages do not include “don’t know” responses, therefore row totals may not equal 100%.
ASA American Society of Anesthesiologists.
4. Hemoglobin/hematocrit (99%, 96%) should be documented and based on information ob-
5. Coagulation studies (86%, 98%) tained from medical records, patient interview, physical
6. Serum chemistries (96%, 98%) examination, and type and invasiveness of the planned
procedure. Public commentary from open forums cor-
Respondents who agreed that test findings might be
roborates the Task Force consensus.
obtained from a patient’s medical chart were asked how
recent the findings should be in order to be acceptable.
Opinions on how recent test findings should be are Preoperative Testing in the Presence of Specific
reported in table 5. Clinical Characteristics
The current literature is not sufficiently rigorous to
Advisory
permit an unambiguous assessment of the clinical bene-
Routine Preoperative Testing fits or harms associated with selected preoperative test
The current literature is not sufficiently rigorous to findings. The studies examined by the Task Force re-
permit an unambiguous assessment of the clinical bene- ported a wide range of abnormal preoperative test re-
fits or harms of routine preoperative tests. The studies sults. In addition, when abnormal or positive results
examined by the Task Force reported a wide range of were found, the percentage of patients with subsequent
abnormal results associated with preoperative testing. changes in their clinical management varied widely. Few
When abnormal or positive results were found, the per- randomized controlled trials were found that examined
centage of patients with subsequent changes in their the outcomes for patients who had routine preoperative
clinical management varied widely. tests compared with outcomes for patients with indi-
The Task Force agrees with the consultants and ASA cated preoperative tests.198
members that preoperative tests should not be ordered The Task Force believes that there is insufficient evi-
routinely. The Task Force agrees that preoperative tests dence to identify explicit decision parameters or rules
may be ordered, required, or performed on a selective for ordering preoperative tests on the basis of specific
basis for purposes of guiding or optimizing periopera- clinical characteristics. However, the Task Force be-
tive management. The indications for such testing lieves that consideration of selected clinical characteris-
Anesthesiology, V 96, No 2, Feb 2002
7. PRACTICE ADVISORY 491
Table 4. Patient Characteristics for Selected Preoperative Testing
Consultants ASA Members
Preoperative Test Patient Characteristics (N 72) (N 234)
Electrocardiogram Advanced age 93% 94%
Cardiocirculatory disease 97% 98%
Respiratory disease 74% 74%
Other cardiac evaluation (e.g. stress test) Cardiovascular compromise 88% 95%
Chest radiograph Recent upper respiratory infection 45% 59%
Smoking 42% 60%
COPD 71% 76%
Cardiac disease 62% 75%
Pulmonary function tests Reactive airway disease 68% 71%
COPD 80% 89%
Scoliosis 53% 60%
Office spirometry (i.e. portable spirometer) Reactive airway disease 83% 86%
COPD 77% 90%
Scoliosis 51% 52%
Hemoglobin/hematocrit Advanced age 57% 68%
Very young age 52% 56%
Anemia 96% 99%
Bleeding disorders 93% 94%
Other hematological disorders 74% 84%
Coagulation studies Bleeding disorders 99% 98%
Renal dysfunction 40% 52%
Liver dysfunction 97% 91%
Anticoagulants 97% 96%
Serum chemistries (sodium, potassium, carbon Endocrine disorders 93% 95%
dioxide, chloride, glucose) Renal dysfunction 96% 98%
Medications 87% 89%
Pregnancy test Uncertain pregnancy history 84% 91%
History suggestive of current pregnancy 94% 96%
ASA American Society of Anesthesiologists; COPD chronic obstructive pulmonary disease.
tics may assist the anesthesiologist when deciding to ness of surgery. The Task Force recognizes that
order, require, or perform preoperative tests. The fol- electrocardiogram abnormalities may be higher in older
lowing clinical characteristics may be of merit, although patients and in patients with multiple cardiac risk
anesthesiologists should not limit their consideration factors.
only to those suggested below. No consensus was obtained from the consultants and
Electrocardiogram. The Task Force agrees that im- ASA membership regarding a minimum age for obtaining
portant clinical characteristics may include cardiocircu- a preanesthesia electrocardiogram. The Task Force did
latory disease, respiratory disease, and type or invasive- not reach consensus on a specific minimum age in those
Table 5. Timing of Test Findings–Survey Opinions
Preoperative Test 24 h 48 h 1 wk 2 wk 1 mo 3 mo 6 mo 1 yr 1 yr
Electrocardiogram
Consultants (N 72) 0 0 4% — 31% — 46% 19% 0
ASA members (N 218) 1% 0 6% — 34% — 45% 12% 2%
Other cardiac tests
Consultants (N 72) 0 0 5% — 33% — 27% 26% 10%
ASA members (N 217) 0 0 7% — 33% — 40% 18% 4%
Chest x-ray
Consultants (N 72) 0 5% 5% — 25% 23% 19% 23% —
ASA members (N 206) 0 2% 8% — 27% 9% 31% 23% —
Hemoglobin/hematocrit
Consultants (N 72) — — 14% 8% 42% 23% 8% 5% —
ASA members (N 213) — — 13% 11% 46% 17% 11% 1% —
Coagulation studies
Consultants (N 42) 28% 11% 30% 6% 19% 6% — — —
ASA members (N 194) 33% 16% 26% 6% 16% 4% — — —
Serum chemistries
Consultants (N 72) 15% 7% 27% 17% 27% 7% — — —
ASA members (N 203) 11% 12% 26% 9% 34% 7% — — —
ASA American Society of Anesthesiologists.
Anesthesiology, V 96, No 2, Feb 2002
8. 492 PRACTICE ADVISORY
patients without specific risk factors. The Task Force apies may present an additional perioperative risk. The
recognizes that age alone may not be an indication for an Task Force believes that there were not enough data to
electrocardiogram. The Task Force agrees that an elec- comment on the advisability of coagulation tests before
trocardiogram may be indicated for patients with known regional anesthesia. The Task Force strongly recom-
cardiovascular risk factors or for patients with risk fac- mends appropriately controlled studies of such specific
tors identified in the course of a preanesthesia indications.
evaluation. Preanesthesia Serum Chemistries (i.e., Potas-
Preanesthesia Cardiac Evaluation (other than sium, Glucose, Sodium, Renal and Liver Function
Electrocardiogram). Preanesthesia cardiac evaluation Studies). The Task Force recognizes that laboratory val-
may include consultation with specialists and ordering, ues may differ from normal values at extremes of age.
requiring, or performing tests that range from noninva- Clinical characteristics to consider before ordering such
sive passive or provocative screening tests (e.g., stress tests include likely perioperative therapies, endocrine
testing) to noninvasive and invasive assessment of car- disorders, risk of renal and liver dysfunction, and use of
diac structure, function, and vascularity (e.g., echocar- certain medications or alternative therapies.
diogram, radionucleotide imaging, cardiac catheteriza- Preanesthesia Urinalysis. The consensus of the Task
tion). Anesthesiologists should balance the risks and Force is that urinalysis is not indicated except for spe-
costs of these evaluations against their benefits. Clinical cific procedures (e.g., prosthesis implantation, urologic
characteristics to consider include cardiovascular risk procedures) or when urinary tract symptoms are
factors and type of surgery. present.
Preanesthesia Chest Radiographs (X-ray). Clinical Preanesthesia Pregnancy Testing. The Task Force
characteristics to consider include smoking, recent up- recognizes that a history and physical examination may
per respiratory infection, chronic obstructive pulmonary be insufficient for identification of early pregnancy. Preg-
disease (COPD), and cardiac disease. The Task Force nancy testing may be considered for all female patients
recognizes that chest radiographic abnormalities may be of childbearing age. Clinical characteristics to consider
higher in such patients, but does not believe that ex- include an uncertain pregnancy history or a history sug-
tremes of age, smoking, stable COPD, stable cardiac gestive of current pregnancy.
disease, or resolved recent upper respiratory infection
should be considered unequivocal indications for chest Timing of Preoperative Testing
radiography. The current literature is not sufficiently rigorous to
Preanesthesia Pulmonary Evaluation (other than permit an unambiguous assessment of the clinical bene-
Chest X-ray). Preanesthesia pulmonary evaluation fits or harms of the timing for preoperative tests. The
other than chest x-ray may include consultation with Task Force believes that there is insufficient evidence to
specialists and tests that range from noninvasive passive identify explicit decision parameters or rules for order-
or provocative screening tests (e.g., pulmonary function ing preoperative tests on the basis of specific patient
tests, spirometry, pulse oximetry) to invasive assessment factors.
of pulmonary function (e.g., arterial blood gas). Anesthe- The Task Force believes that test results obtained from
siologists should balance the risks and costs of these the medical record within 6 months of surgery are gen-
evaluations against their benefits. Clinical characteristics erally acceptable if the patient’s medical history has not
that the Task Force believes should be considered in- changed substantially. More recent test results may be
clude type and invasiveness of the surgical procedure, desirable when the medical history has changed, or
interval from prior evaluation, treated or symptomatic when test results may play a role in the selection of a
asthma, symptomatic COPD, and scoliosis with restric- specific anesthetic technique (e.g., regional anesthesia in
tive function. the setting of anticoagulation therapy.) Public commen-
Preanesthesia Hemoglobin or Hematocrit. The tary from open forums and from the Internet corrobo-
Task Force believes that routine hemoglobin or hemat- rates the Task Force consensus.
ocrit is not indicated. Clinical characteristics to consider
as indications for such tests include type and invasive-
ness of procedure, patients with liver disease, extremes Summary and Conclusions
of age, history of anemia, bleeding, and other hemato-
logic disorders. A preanesthesia evaluation involves the assessment of
Preanesthesia Coagulation Studies (e.g., INR, PT, information from multiple sources, including medical
PTT, platelets). Clinical characteristics to consider for records, patient interviews, physical examinations, and
ordering selected coagulation studies include bleeding findings from preoperative tests.
disorders, renal dysfunction, liver dysfunction, and type The current scientific literature does not contain suffi-
and invasiveness of procedure. The Task Force recog- ciently rigorous information about the components of a
nizes that anticoagulant medications and alternative ther- preanesthesia evaluation to permit recommendations
Anesthesiology, V 96, No 2, Feb 2002
9. PRACTICE ADVISORY 493
that are unambiguously based. Therefore, the Task Force The references listed here do not represent a complete bibliography of
has relied primarily upon noncontrolled literature, opin- the literature reviewed. A complete bibliography is available by writing
to the American Society of Anesthesiologists or by accessing the ANES-
ion surveys of consultants, and opinion surveys of a THESIOLOGY Web site: http://www.anesthesiology.org.
random sample of members of the ASA. The focus of
opinion surveys has been threefold (1) the content of the
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