The following guidance is based upon the best available evidence. All of the recommendations are grade D recommendations, which are based upon level IV evidence - that is, expert opinion derived from a consensus development process and the clinical experience of the Guideline Development Group.
For the tables set out by surgery grade and American Society of Anesthesiologists (ASA) grade, age categories are shown across the top of each table. For a patient with more than one comorbidity, follow the recommendations in all relevant tables.
Recommendations for individual tests are indicated as follows:
No: Test not recommended
Consider: Test to be considered (the value of carrying out a preoperative test is not known, and may depend on specific patient characteristics.)
Yes: Test recommended
Grades of Surgery
Surgery Grades |
Example |
Grade 1 (minor) |
Excision of lesion of skin; drainage of breast abscess |
Grade 2 (intermediate) |
Primary repair of inguinal hernia; excision of varicose vein(s) of leg; tonsillectomy/adenotonsillectomy; knee arthroscopy |
Grade 3 (major) |
Total abdominal hysterectomy; endoscopic resection of prostate; lumbar discectomy; thyroidectomy |
Grade 4 (major+) |
Total joint replacement; lung operations; colonic resection; radical neck dissection; neurosurgery; cardiac surgery |
ASA grades are a simple scale describing fitness to undergo an anaesthetic. The ASA clearly states that it does not endorse any elaboration of these definitions. However, anaesthetists in the UK often qualify (or interpret) these grades as relating to functional capacity -- that is comorbidity that does not (ASA Grade 2) or that does (ASA Grade 3) limit a patient's activity (see "Characterisation of 'Mild' and 'Severe' Comorbidity, Corresponding to ASA Grades 2 and 3, for Cardiovascular, Respiratory and Renal Comorbidities" below).
ASA Grades
ASA Grade 1: "Normal healthy patient" (that is without any clinically important comorbidity and without clinically significant past/present medical history)
ASA Grade 2: "A patient with mild systemic disease"
ASA Grade 3: "A patient with severe systemic disease"
ASA Grade 4: "A patient with severe systemic disease that is a constant threat to life"
Characterisation of 'Mild' and 'Severe' Comorbidity, Corresponding to ASA Grades 2 and 3, for Cardiovascular, Respiratory and Renal Comorbidities
|
ASA Grade 2 "A patient with mild systemic disease" |
ASA Grade 3 "A patient with severe systemic disease" |
Cardiovascular (CVD) |
Current angina |
Occasional use of GTN spray (two to three times per month). Does not include patients with unstable angina who would be ASA grade 3. |
Regular use of GTN spray (2 to 3 times per week) or unstable angina |
Exercise tolerance |
Not limiting activity |
Limiting activity |
Hypertension |
Well controlled using a single antihypertensive medication |
Not well controlled, requiring multiple antihypertensive medications |
Diabetes |
Well controlled, no obvious diabetic complications |
Not well controlled, diabetic complications (e.g. claudication, impaired renal function) |
Previous coronary revascularisation |
Not directly relevant - depends on current signs and symptoms |
Not directly relevant - depends on current signs and symptoms |
Respiratory disease |
COAD/COPD |
Productive cough, wheeze well controlled by inhalers, occasional episodes of acute chest infection |
Breathlessness on minimal exertion (e.g., stair climbing, carrying shopping); distressingly wheezy much of the time; several episodes per year of acute chest infection |
Asthma |
Well controlled by medications/inhalers; not limiting lifestyle |
Poorly controlled; limiting lifestyle; on high dose of inhaler/oral steroids; frequent hospital admission on account of asthma exacerbation |
Renal disease |
Elevated creatinine (creatinine >100 micromole/L and <200 micromol/L), some dietary restrictions |
Documented poor renal function (creatinine >200 micromol/L), regular dialysis programme (peritoneal or haemodialysis) |
COAD, chronic obstructive airways disease; COPD chronic obstructive pulmonary disease; GTN, glyceryl trinitrate
Further examples are available in Appendix 2 of the full version of the guideline (see Section 5).
Grade 1 Surgery (Minor)
ASA Grade 1: Children <16 years
|
Age |
Test |
<6 months |
>6 to <12 months |
>1 to <5 years |
>5 to <12 years |
>12 to <16 years |
Chest x-ray |
No |
No |
No |
No |
No |
Electrocardiogram (ECG) |
No |
No |
No |
No |
No |
Full blood count |
No |
No |
No |
No |
No |
Haemostasis |
No |
No |
No |
No |
No |
Renal function |
No |
No |
No |
No |
No |
Random glucose |
No |
No |
No |
No |
No |
Urine analysisa |
No |
No |
No |
No |
No |
aDipstick urine testing in asymptomatic individuals is not recommended (UK National Screening Committee)
ASA Grade 1: Adults (>16 years)
|
Age (years) |
Test |
>16 to <40 |
>40 to <60 |
>60 to <80 |
>80 |
Chest x-ray |
No |
No |
No |
No |
ECG |
No |
Consider |
Consider |
Yes |
Full blood count |
No |
No |
Consider |
Consider |
Haemostasis |
No |
No |
No |
No |
Renal function |
No |
No |
Consider |
Consider |
Random glucose |
No |
No |
No |
No |
Urine analysisa |
Consider |
Consider |
Consider |
Consider |
*Dipstick urine testing in asymptomatic individuals is not recommended (UK National Screening Committee)
ASA Grade 2: Adults with Comorbidity from Cardiovascular Disease (CVD)
|
Age (years) |
Test |
>16 to <40 |
>40 to <60 |
>60 to <80 |
>80 |
Chest x-ray |
No |
Consider |
Consider |
Consider |
ECG |
Yes |
Yes |
Yes |
Yes |
Full blood count |
Consider |
Consider |
Consider |
Consider |
Haemostasis |
No |
No |
No |
No |
Renal function |
Consider |
Consider |
Consider |
Consider |
Random glucose |
No |
No |
No |
No |
Urine analysis |
Consider |
Consider |
Consider |
Consider |
Blood gases |
No |
No |
No |
No |
Lung function |
No |
No |
No |
No |
ASA Grade 3: Adults with Comorbidity from CVD
|
Age (years) |
Test |
>16 to <40 |
>40 to <60 |
>60 to <80 |
>80 |
Chest x-ray |
Consider |
Consider |
Consider |
Consider |
ECG |
Yes |
Yes |
Yes |
Yes |
Full blood count |
Consider |
Consider |
Consider |
Consider |
Haemostasis |
No |
No |
No |
No |
Renal function |
Yes |
Yes |
Yes |
Yes |
Random glucose |
No |
No |
No |
No |
Urine analysis |
Consider |
Consider |
Consider |
Consider |
Blood gases |
Consider |
Consider |
Consider |
Consider |
Lung function |
No |
No |
No |
No |
ASA Grade 2: Adults with Comorbidity from Respiratory Disease
|
Age (years) |
Test |
>16 to <40 |
>40 to <60 |
>60 to <80 |
>80 |
Chest x-rayb |
No |
Consider |
Consider |
Consider |
ECG |
No |
Consider |
Consider |
Consider |
Full blood count |
Consider |
Consider |
Consider |
Consider |
Haemostasis |
No |
No |
No |
No |
Renal function |
No |
No |
Consider |
Consider |
Random glucose |
No |
No |
No |
No |
Urine analysis |
Consider |
Consider |
Consider |
Consider |
Blood Gases |
Consider |
Consider |
Consider |
Consider |
Lung function |
No |
No |
No |
No |
bChest x-rays may be considered if there has been a change in patient's symptoms or if the patient needs ventilator support.
ASA Grade 3: Adults with Comorbidity from Respiratory Disease
|
Age (years) |
Test |
>16 to <40 |
>40 to <60 |
>60 to <80 |
>80 |
Chest x-ray |
Consider |
Consider |
Consider |
Consider |
ECG |
Consider |
Consider |
Consider |
Consider |
Full blood count |
Consider |
Consider |
Consider |
Consider |
Haemostasis |
No |
No |
No |
No |
Renal function |
Consider |
Consider |
Consider |
Consider |
Random glucose |
No |
No |
No |
No |
Urine analysis |
Consider |
Consider |
Consider |
Consider |
Blood gases |
Consider |
Consider |
Consider |
Consider |
Lung function |
No |
No |
No |
No |
ASA Grade 2: Adults with Comorbidity from Renal Disease
|
Age (years) |
Test |
>16 to <40 |
>40 to <60 |
>60 to <80 |
>80 |
Chest x-rayc |
No |
No |
No |
Consider |
ECGd |
No |
Consider |
Consider |
Consider |
Full blood count |
Consider |
Consider |
Consider |
Consider |
Haemostasis |
No |
No |
No |
No |
Renal function |
Yes |
Yes |
Yes |
Yes |
Random glucose |
No |
No |
No |
No |
Urine analysis |
Consider |
Consider |
Consider |
Consider |
Blood gases |
No |
No |
No |
No |
Lung function |
No |
No |
No |
No |
cChest x-rays may be considered if the patient has signs of other comorbidities often associated with renal disease, such as hypertension and coronary heart failure.
dDepending on the cause of renal disease (e.g., diabetes and hypertension)
ASA Grade 3: Adults with Comorbidity from Renal Disease
|
Age (years) |
Test |
>16 to <40 |
>40 to <60 |
>60 to <80 |
>80 |
Chest x-rayc |
No |
No |
Consider |
Consider |
ECG |
No |
Consider |
Consider |
Consider |
Full blood count |
Yes |
Yes |
Yes |
Yes |
Haemostasis |
Consider |
Consider |
Consider |
Consider |
Renal function |
Yes |
Yes |
Yes |
Yes |
Random glucose |
Consider |
Consider |
Consider |
Consider |
Urine analysis |
Consider |
Consider |
Consider |
Consider |
Blood gases |
Consider |
Consider |
Consider |
Consider |
Lung function |
No |
No |
No |
No |
cChest x-rays may be considered if the patient has signs of other comorbidities often associated with renal disease, such as hypertension and coronary heart failure.
Grade 2 Surgery (Intermediate)
ASA Grade 1: Children (<16 years)
|
Age
|
Test |
<6 months |
>6 to <12 months |
>1 to <5 years |
>5 to <12 years |
>12 to <16 years |
Chest x-ray |
No |
No |
No |
No |
No |
ECG |
No |
No |
No |
No |
No |
Full blood count |
No |
No |
No |
No |
No |
Haemostasis |
No |
No |
No |
No |
No |
Renal function |
No |
No |
No |
No |
No |
Random glucose |
No |
No |
No |
No |
No |
Urine analysisa |
No |
No |
No |
No |
No |
aDipstick urine testing in asymptomatic individuals is not recommended (UK National Screening Committee)
ASA Grade 1: Adults (>16 years)
|
Age (years) |
Test |
>16 to <40 |
>40 to <60 |
>60 to <80 |
>80 |
Chest x-ray |
No |
No |
No |
No |
ECG |
No |
Consider |
Consider |
Yes |
Full blood count |
No |
Consider |
Yes |
Yes |
Haemostasis |
No |
No |
No |
No |
Renal function |
No |
No |
Consider |
Consider |
Random glucose |
No |
Consider |
Consider |
Consider |
Urine analysisa |
Consider |
Consider |
Consider |
Consider |
aDipstick urine testing in asymptomatic individuals is not recommended (UK National Screening Committee)
ASA Grade 2: Adults with Comorbidity from CVD
|
Age (years) |
Test |
>16 to <40 |
>40 to <60 |
>60 to <80 |
>80 |
Chest x-ray |
Consider |
Consider |
Consider |
Consider |
ECG |
Yes |
Yes |
Yes |
Yes |
Full blood count |
Consider |
Consider |
Consider |
Consider |
Haemostasis |
No |
No |
No |
No |
Renal function |
Consider |
Consider |
Yes |
Yes |
Random glucose |
No |
No |
No |
No |
Urine analysis |
Consider |
Consider |
Consider |
Consider |
Blood gases |
No |
No |
No |
No |
Lung function |
No |
No |
No |
No |
ASA Grade 3: Adults with Comorbidity from CVD
|
Age (years) |
Test |
>16 to <40 |
>40 to <60 |
>60 to <80 |
>80 |
Chest x-ray |
Consider |
Consider |
Consider |
Consider |
ECG |
Yes |
Yes |
Yes |
Yes |
Full blood count |
Consider |
Consider |
Consider |
Consider |
Haemostasis |
No |
No |
No |
No |
Renal function |
Yes |
Yes |
Yes |
Yes |
Random glucose |
No |
No |
No |
No |
Urine analysis |
Consider |
Consider |
Consider |
Consider |
Blood gases |
Consider |
Consider |
Consider |
Consider |
Lung function |
No |
No |
No |
No |
ASA Grade 2: Adults with Comorbidity from Respiratory Disease
|
Age (years) |
Test |
>16 to <40 |
>40 to <60 |
>60 to <80 |
>80 |
Chest x-rayb |
Consider |
Consider |
Consider |
Consider |
ECG |
No |
Consider |
Consider |
Consider |
Full blood count |
Consider |
Consider |
Consider |
Consider |
Haemostasis |
No |
No |
No |
No |
Renal function |
No |
Consider |
Consider |
Consider |
Random glucose |
No |
No |
No |
No |
Urine analysis |
Consider |
Consider |
Consider |
Consider |
Blood gases |
Consider |
Consider |
Consider |
Consider |
Lung function |
No |
No |
No |
No |
bChest x-rays may be considered if there has been a change in patient's symptoms, or if the patient needs ventilator support
ASA Grade 3: Adults with Comorbidity from Respiratory Disease
|
Age (years) |
Test |
>16 to <40 |
>40 to <60 |
>60 to <80 |
>80 |
Chest x-ray |
Consider |
Consider |
Consider |
Consider |
ECG |
Consider |
Consider |
Yes |
Yes |
Full blood count |
Consider |
Consider |
Consider |
Yes |
Haemostasis |
No |
No |
No |
No |
Renal function |
Consider |
Consider |
Consider |
Consider |
Random glucose |
No |
No |
No |
No |
Urine analysis |
Consider |
Consider |
Consider |
Consider |
Blood gases |
Consider |
Consider |
Consider |
Consider |
Lung function |
Consider |
Consider |
Consider |
Consider |
ASA Grade 2: Adults with Comorbidity from Renal Disease
|
Age (years) |
Test |
>16 to <40 |
>40 to <60 |
>60 to <80 |
>80 |
Chest x-rayc |
No |
No |
Consider |
Consider |
ECGd |
Consider |
Consider |
Yes |
Yes |
Full blood count |
Consider |
Consider |
Consider |
Consider |
Haemostasis |
No |
No |
No |
No |
Renal function |
Yes |
Yes |
Yes |
Yes |
Random glucose |
No |
No |
No |
No |
Urine analysis |
Consider |
Consider |
Consider |
Consider |
Blood gases |
No |
No |
No |
No |
Lung function |
No |
No |
No |
No |
cChest x-rays may be considered if the patient has signs of other comorbidities often associated with renal disease, such as hypertension and coronary heart failure.
dDepending on the cause of renal disease (e.g., diabetes and hypertension)
ASA Grade 3: Adults with Comorbidity from Renal Disease
|
Age (years) |
Test |
>16 to <40 |
>40 to <60 |
>60 to <80 |
>80 |
Chest x-ray |
Consider |
Consider |
Consider |
Consider |
ECG |
Consider |
Consider |
Yes |
Yes |
Full blood count |
Yes |
Yes |
Yes |
Yes |
Haemostasis |
Consider |
Consider |
Consider |
Consider |
Renal function |
Yes |
Yes |
Yes |
Yes |
Random glucose |
Consider |
Consider |
Consider |
Consider |
Urine analysis |
Consider |
Consider |
Consider |
Consider |
Blood gases |
Consider |
Consider |
Consider |
Consider |
Lung function |
No |
No |
No |
No |
Grade 3 Surgery (Major)
ASA Grade 1: Children (<16 years)
| Age |
Test |
<6 months |
>6 to <12 months |
>1 to <5 years |
>5 to <12 years |
>12 to <16 years |
Chest x-ray |
No |
No |
No |
No |
No |
ECG |
No |
No |
No |
No |
No |
Full blood count |
Consider |
Consider |
Consider |
Consider |
Consider |
Haemostasis |
No |
No |
No |
No |
No |
Renal function |
Consider |
Consider |
Consider |
Consider |
Consider |
Random glucose |
No |
No |
No |
No |
No |
Urine analysisa |
Consider |
Consider |
Consider |
Consider |
Consider |
aDipstick urine testing in asymptomatic individuals is not recommended (UK National Screening Committee)
ASA Grade 1: Adults (>16 years)
|
Age (years) |
Test |
>16 to <40 |
>40 to <60 |
>60 to <80 |
>80 |
Chest x-ray |
No |
No |
Consider |
Consider |
ECG |
No |
Consider |
Yes |
Yes |
Full blood count |
Yes |
Yes |
Yes |
Yes |
Haemostasis |
No |
No |
No |
No |
Renal function |
Consider |
Consider |
Yes |
Yes |
Random glucose |
Consider |
Consider |
Consider |
Consider |
Urine analysisa |
Consider |
Consider |
Consider |
Consider |
aDipstick urine testing in asymptomatic individuals is not recommended (UK National Screening Committee)
ASA Grade 2: Adults with Comorbidity from CVD
|
Age (years) |
Test |
>16 to <40 |
>40 to <60 |
>60 to <80 |
>80 |
Chest x-ray |
Consider |
Consider |
Consider |
Consider |
ECG |
Yes |
Yes |
Yes |
Yes |
Full blood count |
Yes |
Yes |
Yes |
Yes |
Haemostasis |
No |
No |
No |
No |
Renal function |
Yes |
Yes |
Yes |
Yes |
Random glucose |
No |
No |
No |
No |
Urine analysis |
Consider |
Consider |
Consider |
Consider |
Blood gases |
Consider |
Consider |
Consider |
Consider |
Lung function |
No |
No |
No |
No |
ASA Grade 3: Adults with Comorbidity from CVD
|
Age (years) |
Test |
>16 to <40 |
>40 to <60 |
>60 to <80 |
>80 |
Chest x-ray |
Consider |
Consider |
Consider |
Consider |
ECG |
Yes |
Yes |
Yes |
Yes |
Full blood count |
Yes |
Yes |
Yes |
Yes |
Haemostasis |
Consider |
Consider |
Consider |
Consider |
Renal function |
Yes |
Yes |
Yes |
Yes |
Random glucose |
No |
No |
No |
No |
Urine analysis |
Consider |
Consider |
Consider |
Consider |
Blood gases |
Consider |
Consider |
Consider |
Consider |
Lung function |
No |
No |
No |
No |
ASA Grade 2: Adults with Comorbidity from Respiratory Disease
|
Age (years) |
Test |
>16 to <40 |
>40 to <60 |
>60 to <80 |
>80 |
Chest x-rayb |
Consider |
Consider |
Consider |
Consider |
ECG |
Consider |
Consider |
Consider |
Yes |
Full blood count |
Yes |
Yes |
Yes |
Yes |
Haemostasis |
No |
No |
No |
No |
Renal function |
Consider |
Consider |
Yes |
Yes |
Random glucose |
No |
No |
No |
No |
Urine analysis |
Consider |
Consider |
Consider |
Consider |
Blood gases |
Consider |
Consider |
Consider |
Consider |
Lung function |
No |
Consider |
Consider |
Consider |
bChest x-rays may be considered if there has been a change in patient's symptoms, or if the patient needs ventilator support
ASA Grade 3: Adults with Comorbidity from Respiratory Disease
|
Age (years) |
Test |
>16 to <40 |
>40 to <60 |
>60 to <80 |
>80 |
Chest x-ray |
Consider |
Consider |
Consider |
Consider |
ECG |
Consider |
Consider |
Yes |
Yes |
Full blood count |
Yes |
Yes |
Yes |
Yes |
Haemostasis |
No |
No |
No |
No |
Renal function |
Yes |
Yes |
Yes |
Yes |
Random glucose |
Consider |
Consider |
Consider |
Consider |
Urine analysis |
Consider |
Consider |
Consider |
Consider |
Blood gases |
Consider |
Consider |
Consider |
Consider |
Lung function |
Consider |
Consider |
Consider |
Consider |
ASA Grade 2: Adults with Comorbidity from Renal Disease
|
Age (years) |
Test |
>16 to <40 |
>40 to <60 |
>60 to <80 |
>80 |
Chest x-ray |
Consider |
Consider |
Consider |
Consider |
ECGd |
Consider |
Consider |
Yes |
Yes |
Full blood count |
Yes |
Yes |
Yes |
Yes |
Haemostasis |
Consider |
Consider |
Consider |
Consider |
Renal function |
Yes |
Yes |
Yes |
Yes |
Random glucose |
Consider |
Consider |
Consider |
Consider |
Urine analysis |
Consider |
Consider |
Consider |
Consider |
Blood gases |
Consider |
Consider |
Consider |
Consider |
Lung function |
No |
No |
No |
No |
dDepending on the cause of renal disease (e.g., diabetes and hypertension)
ASA Grade 3: Adults with Comorbidity from Renal Disease
|
Age (years) |
Test |
>16 to <40 |
>40 to <60 |
>60 to <80 |
>80 |
Chest x-ray |
Consider |
Consider |
Consider |
Consider |
ECG |
Consider |
Consider |
Yes |
Yes |
Full blood count |
Yes |
Yes |
Yes |
Yes |
Haemostasis |
Consider |
Consider |
Consider |
Consider |
Renal function |
Yes |
Yes |
Yes |
Yes |
Random glucose |
Consider |
Consider |
Consider |
Consider |
Urine analysis |
Consider |
Consider |
Consider |
Consider |
Blood gases |
Consider |
Consider |
Consider |
Consider |
Lung function |
No |
No |
No |
No |
Grade 4 Surgery (Major +)
ASA Grade 1: Children (<16 years)
|
Age |
Test |
<6 months |
>6 to <12 months |
>1 to <5 years |
>5 to <12 years |
>12 to <16 years |
Chest x-ray |
No |
No |
No |
No |
No |
ECG |
No |
No |
No |
No |
No |
Full blood count |
Consider |
Consider |
Consider |
Consider |
Consider |
Haemostasis |
No |
No |
No |
No |
No |
Renal function |
Consider |
Consider |
Consider |
Consider |
Consider |
Random glucose |
No |
No |
No |
No |
No |
Urine analysisa |
Consider |
Consider |
Consider |
Consider |
Consider |
aDipstick urine testing in asymptomatic individuals is not recommended (UK National Screening Committee)
ASA Grade 1: Adults (>16 years)
|
Age (years) |
Test |
>16 to <40 |
>40 to <60 |
>60 to <80 |
>80 |
Chest x-ray |
No |
No |
Consider |
Consider |
ECG |
No |
Consider |
Yes |
Yes |
Full blood count |
Yes |
Yes |
Yes |
Yes |
Haemostasis |
Consider |
Consider |
Consider |
Consider |
Renal function |
Yes |
Yes |
Yes |
Yes |
Random glucose |
Consider |
Consider |
Consider |
Consider |
Urine analysisa |
Consider |
Consider |
Consider |
Consider |
aDipstick urine testing in asymptomatic individuals is not recommended (UK National Screening Committee)
ASA Grade 2: Adults with Comorbidity from CVD
|
Age (years) |
Test |
>16 to <40 |
>40 to <60 |
>60 to <80 |
>80 |
Chest x-ray |
Consider |
Consider |
Consider |
Consider |
ECG |
Yes |
Yes |
Yes |
Yes |
Full blood count |
Yes |
Yes |
Yes |
Yes |
Haemostasis |
Consider |
Consider |
Consider |
Consider |
Renal function |
Yes |
Yes |
Yes |
Yes |
Random glucose |
No |
No |
No |
No |
Urine analysis |
Consider |
Consider |
Consider |
Consider |
Blood gases |
Consider |
Consider |
Consider |
Consider |
Lung function |
No |
No |
No |
No |
ASA Grade 3: Adults with Comorbidity from CVD
|
Age (years) |
Test |
>16 to <40 |
>40 to <60 |
>60 to <80 |
>80 |
Chest x-ray |
Consider |
Consider |
Yes |
Yes |
ECG |
Yes |
Yes |
Yes |
Yes |
Full blood count |
Yes |
Yes |
Yes |
Yes |
Haemostasis |
Consider |
Consider |
Consider |
Consider |
Renal function |
Yes |
Yes |
Yes |
Yes |
Random glucose |
No |
No |
No |
No |
Urine analysis |
Consider |
Consider |
Consider |
Consider |
Blood gases |
Consider |
Consider |
Consider |
Consider |
Lung function |
No |
No |
No |
No |
ASA Grade 2: Adults with Comorbidity from Respiratory Disease
|
Age (years) |
Test |
>16 to <40 |
>40 to <60 |
>60 to <80 |
>80 |
Chest x-rayb |
Consider |
Consider |
Consider |
Consider |
ECG |
Consider |
Consider |
Yes |
Yes |
Full blood count |
Yes |
Yes |
Yes |
Yes |
Haemostasis |
Consider |
Consider |
Consider |
Consider |
Renal function |
Yes |
Yes |
Yes |
Yes |
Random glucose |
No |
No |
No |
No |
Urine analysis |
Consider |
Consider |
Consider |
Consider |
Blood gases |
Consider |
Consider |
Consider |
Consider |
Lung function |
Consider |
Consider |
Consider |
Consider |
bChest x-rays may be considered if there has been a change in patient's symptoms, or if the patient needs ventilator support
ASA Grade 3: Adults with Comorbidity from Respiratory Disease
|
Age (years) |
Test |
>16 to <40 |
>40 to <60 |
>60 to <80 |
>80 |
Chest x-ray |
Consider |
Consider |
Consider |
Consider |
ECG |
Consider |
Yes |
Yes |
Yes |
Full blood count |
Yes |
Yes |
Yes |
Yes |
Haemostasis |
Consider |
Consider |
Consider |
Consider |
Renal function |
Yes |
Yes |
Yes |
Yes |
Random glucose |
Consider |
Consider |
Consider |
Consider |
Urine analysis |
Consider |
Consider |
Consider |
Consider |
Blood gases |
Consider |
Consider |
Consider |
Consider |
Lung function |
Consider |
Consider |
Consider |
Consider |
ASA Grade 2: Adults with Comorbidity from Renal Disease
|
Age (years) |
Test |
>16 to <40 |
>40 to <60 |
>60 to <80 |
>80 |
Chest x-ray |
Consider |
Consider |
Consider |
Consider |
ECGd |
Consider |
Yes |
Yes |
Yes |
Full blood count |
Yes |
Yes |
Yes |
Yes |
Haemostasis |
Consider |
Consider |
Consider |
Consider |
Renal function |
Yes |
Yes |
Yes |
Yes |
Random glucose |
Consider |
Consider |
Consider |
Consider |
Urine analysis |
Consider |
Consider |
Consider |
Consider |
Blood gases |
Consider |
Consider |
Consider |
Consider |
Lung function |
No |
No |
No |
No |
dDepending on the cause of renal disease (e.g., diabetes and hypertension)
ASA Grade 3: Adults with Comorbidity from Renal Disease
|
Age (years) |
Test |
>16 to <40 |
>40 to <60 |
>60 to <80 |
>80 |
Chest x-ray |
Consider |
Consider |
Consider |
Consider |
ECG |
Consider |
Yes |
Yes |
Yes |
Full blood count |
Yes |
Yes |
Yes |
Yes |
Haemostasis |
Consider |
Consider |
Consider |
Consider |
Renal function |
Yes |
Yes |
Yes |
Yes |
Random glucose |
Consider |
Consider |
Consider |
Consider |
Urine analysis |
Consider |
Consider |
Consider |
Consider |
Blood gases |
Consider |
Consider |
Consider |
Consider |
Lung function |
No |
No |
No |
No |
Neurosurgery
ASA Grade 1: Children <16 years
|
Age |
Test |
<6 months |
>6 to <12 months |
>1 to <5 years |
>5 to <12 years |
>12 to <16 years |
Chest x-ray |
No |
No |
No |
No |
No |
ECG |
No |
No |
No |
No |
No |
Full blood count |
Consider |
Consider |
Consider |
Consider |
Consider |
Haemostasis |
Consider |
Consider |
Consider |
Consider |
Consider |
Renal Function |
Yes |
Yes |
Yes |
Yes |
Yes |
Random glucose |
No |
No |
No |
No |
No |
Urine analysisa |
Consider |
Consider |
Consider |
Consider |
Consider |
aDipstick urine testing in asymptomatic individuals is not recommended (UK National Screening Committee)
ASA Grade 1: Adults >16 years
|
Age (years) |
Test |
>16 to <40 |
>40 to <60 |
>60 to <80 |
>80 |
Chest x-ray |
No |
No |
Consider |
Consider |
ECG |
Consider |
Consider |
Yes |
Yes |
Full blood count |
Consider |
Consider |
Yes |
Yes |
Haemostasis |
Consider |
Consider |
Consider |
Consider |
Renal Function |
Yes |
Yes |
Yes |
Yes |
Random glucose |
Consider |
Consider |
Consider |
Consider |
Urine analysisa |
Consider |
Consider |
Consider |
Consider |
aDipstick urine testing in asymptomatic individuals is not recommended (UK National Screening Committee)
Cardiovascular Surgery
ASA Grade 1: Children (<16 years)
|
Age |
Test |
<6 months |
>6 to <12 months |
>1 to <5 years |
>5 to <12 years |
>12 to <16 years |
Chest x-ray |
Yes |
Yes |
Yes |
Yes |
Yes |
ECG |
Yes |
Yes |
Yes |
Yes |
Yes |
Full blood count |
Yes |
Yes |
Yes |
Yes |
Yes |
Haemostasis |
Consider |
Consider |
Consider |
Consider |
Consider |
Renal Function |
Yes |
Yes |
Yes |
Yes |
Yes |
Random glucose |
No |
No |
No |
No |
No |
Urine analysisa |
Consider |
Consider |
Consider |
Consider |
Consider |
aDipstick urine testing in asymptomatic individuals is not recommended (UK National Screening Committee)
ASA Grade 1: Adults (>16 years)
|
Age (years) |
Test |
>16 to <40 |
>40 to <60 |
>60 to <80 |
>80 |
Chest x-ray |
Yes |
Yes |
Yes |
Yes |
ECG |
Yes |
Yes |
Yes |
Yes |
Full blood count |
Yes |
Yes |
Yes |
Yes |
Haemostasis |
Consider |
Consider |
Consider |
Consider |
Renal Function |
Yes |
Yes |
Yes |
Yes |
Random glucose |
Consider |
Consider |
Consider |
Consider |
Urine analysisa |
Consider |
Consider |
Consider |
Consider |
aDipstick urine testing in asymptomatic individuals is not recommended (UK National Screening Committee)
Tests for the Sickle Cell Gene in Adults and Children
Appropriateness of testing in patients from the following ethnic groups |
North African |
Yes |
West African |
Yes |
South/sub-Saharan African |
Yes |
Afro Caribbean |
Yes |
Should informed consent be obtained? |
Yes |
The following recommendations and observations are in addition to those shown in the table above:
- The sickle cell gene is found in many nationalities including families that come from Africa, the Caribbean, the Eastern Mediterranean, Middle East and Asia. It has also been detected in Cypriot people and a few other white ethnic groups.
- It is important to offer to test all people considered to be at risk before an anaesthetic, both at hospital and dental clinics. This is especially important for patients who have a family history of ethnic groups considered to be at risk, who have a family history of homozygous sickle cell anaemia or sickle cell trait and who do not have a surgical history where it may have been detected previously.
- People of ethnic origin considered to be at risk should be offered screening, with genetic counselling before and after screening.
- Appropriate counselling for this test is important so that patients are able to give their informed consent, as there may be implications for patients who discover they are carriers of the sickle cell gene. The results of testing, even when negative, should be reported to families, with the patient's consent, and documented in the patient's medical record to avoid unnecessary repeat testing.
Pregnancy Test
Pregnancy testing should be carried out in female patients of reproductive age: |
With history of last menstrual period |
Consider |
Who says that it is not possible for her to be pregnant |
Consider |
Who says it is possible that she may be pregnant |
Yes |
Should informed consent be obtained? |
Yes |
The following recommendations and observations are in addition to those shown in the table above:
- The need to test for pregnancy depends on the risk presented to the fetus by the anaesthetic and surgery. All women of childbearing age should be asked sensitively whether or not there is any chance that they may be pregnant.
- Women must be made aware of the risks of surgery to the fetus.
- A pregnancy test should be carried out with the woman's consent if there is any doubt about whether the woman may be pregnant.
- Before having a chest x-ray, all women of childbearing age should be asked sensitively whether they may be pregnant
Good Practice Recommendations
During the development of this guideline, the Guideline development Group (GDG) agreed certain principles of good practice. Although the aspects of preoperative testing to which they relate were not strictly within the scope of the guideline, it is important to describe them because the guideline was developed with the assumption that these principles were in place.
Ensuring Clinical Competence
It is important to ensure that staff undertaking clinical preoperative assessments receive appropriate education and training to allow them to apply the guideline correctly.
Preoperative Assessment
It is crucial to ensure that a thorough medical history is taken from the patient to inform the recommendations about which preoperative tests to carry out. Taking a thorough medical history requires someone with the appropriate training.
Timing and Setting of Tests
The consensus process did not cover the issue of who should carry out the preoperative tests. However, it is clear that preoperative tests are often ordered or carried out by nurses in preoperative assessment clinics. The timing of tests should be appropriate for the tests concerned. It may be appropriate both from the doctor's and patient's perspective to test for certain conditions at the earliest stage possible, after a patient has been placed on the waiting list for an operation, so that there is time for the patient to be treated and for their condition to stabilise, ensuring patients are in the best possible state when they have surgery.
Some tests could be carried out in the primary care setting by the patient's General Practitioner (GP) or practice nurse. For example, when a patient is listed for a particular operation it may be appropriate for the consultant in charge of the patient's care to consider the possible tests that may be required for the patient and, after discussion with the patient, to inform their GP. Excellent communication between primary and secondary care, to ensure that test results are shared, would be essential if such changes in the responsibility and timing of testing were to be implemented.
Whoever carries out the tests, protocols for testing should be followed. This is particularly important for tests like urine analysis (dipstick), where not following the recommended protocol may render the result of the test meaningless.
Patient Information and Consent
Staff undertaking clinical preoperative assessments should discuss with patients which tests are recommended (or required), what they involve, and why they are being carried out.
Decisions about whether or not to test should follow discussion between the patient and the doctor or nurse, especially where there is uncertainty about whether a test should be recommended or not. For some tests, a positive result carries a far greater significance for the patient than others, such as testing for previously undetected diabetes, the sickle cell gene, and pregnancy.
Patients should have access to information about the tests and the possible implications of a positive result so that they can give their informed consent. Doctors or nurses carrying out or ordering tests should write in the patient's notes that they have discussed the recommended tests and their implications with the patient.
Patients should be informed of the results of tests and about the implications for treatment, and any longer term implications for their health, if the results are abnormal.
For further guidance, clinicians should refer to the Good Practice in Consent guidance on issues of consent in the NHS (available from: www.doh.gov.uk/consent). This guideline supports the advice given in that publication - that it is "a general legal and ethical principle that valid consent must be obtained before starting treatment or physical examination, or providing personal care, for a patient" and that patients should have access to sufficient information about risks, benefits and alternatives to be able to make an informed decision about whether to consent.