Note from the National Guideline Clearinghouse (NGC) and the Institute for Clinical Systems Improvement (ICSI): For a description of what has changed since the previous version of this guidance, refer to Summary of Changes Report – July - 2008.

The recommendations for preoperative evaluation are presented in the form of an algorithm with 11 components, accompanied by detailed annotations. An algorithm is provided for Preoperative Evaluation. Clinical highlights and selected annotations (numbered to correspond with the algorithm) follow.

Class of evidence (A-D, M, R, X) and conclusion grade (I-III, Not Assignable) definitions are repeated at the end of the "Major Recommendations" field).

Priority Aims

1. Obtain appropriate preoperative history and physical examination, and reduce diagnostic tests performed without clinical indications (Annotation #4)
2. Increase the percentage of patients who receive appropriate management of stable comorbidities prior to surgery. (Annotation #8)
3. Eliminate canceled or delayed surgical procedures due to incomplete preoperative history and physical examination and communication. (Annotation #4)

Clinical Highlights

• Provide a comprehensive preoperative basic health assessment for all patients undergoing a diagnostic or therapeutic procedure as defined in the guideline. (Annotation #4, Aim #1)
• Most laboratory and diagnostic tests including electrocardiograms are not necessary with routine procedures unless a specific indication is present. (Annotation #6, Aim #1)
• Electrocardiograms are not indicated, regardless of age, for those patients having cataract surgery. (Annotation #6, Aim #1)
• Patients on chronic beta-blocker therapy should continue taking their beta-blocker medication up to and including the day of surgery. If beta-blocker therapy is stopped prior to surgery, patients are at increased risk for complications postoperatively. (Annotation #8, Aim #2)

Preoperative Evaluation Algorithm Annotations

1. Decision to Perform Elective Procedure

   The decision to perform an elective procedure is usually made at the time of the surgical or other consultation. There may be exceptions; for example, a nonsurgical procedure such as a computed tomography (CT)-guided lung biopsy might be arranged by the primary physician after discussion with a radiologist.

   A member of the surgical team explains to the patient the procedure and the need for anesthesia and may obtain and document consent. (These issues must be addressed but are not part of this guideline.)

   Patient education is essential to assist the patient in preparing for the surgical procedure and to reinforce compliance to preoperative instructions. The "Patient Preoperative Guide," an optional tool, may assist in these efforts. Please refer to Appendix A in the original guideline document (see "Availability of Companion Documents" field).

   Patients undergoing high-risk or emergent procedures are beyond the scope of this guideline as a more extensive evaluation and risk assessment may be needed.

2. High-Risk Procedure?

   Key Points:

   • High-risk procedures include those where cardiovascular complications (for adults) and pulmonary complications (for children) inherently exist.
   • Procedural risk stratification changes rapidly due to the introduction of different anesthesia types and the development of less-invasive surgical procedures.

   High-risk referred to here is primarily surgical procedure-derived risk of cardiac/pulmonary complications. Cardiovascular complications are more common in adults, and pulmonary complications are more common in children. If a procedure presents other specific noncardiovascular associated high-risk, that risk and its stratification are beyond the scope of this guideline and need to be individually addressed by the surgeon. For example, a neurosurgical procedure may have an inherent elevated hemostasis risk.

   The above scheme only distinguishes between high-risk procedures and non-high-risk procedures. Certainly further refinement is possible as illustrated in one reported study (high-, intermediate- and low-cardiac-risk categories) [R]. This guideline work group took the approach of universal precautions, meaning that, if all high-risk procedures are excluded and all patients are adequately evaluated preoperatively, there is questionable gain in further procedural risk stratification.

   Although it is ultimately up to the involved providers to determine whether a particular procedure is considered to be high risk, it is generally accepted that most high-risk (greater than 5 percent combined incidence of cardiac death and nonfatal myocardial infarction) procedures fall into the following categories:

   • Major cardiac and non-cardiac thoracic procedures
   • Aortic and other major vascular procedures
   • Anticipated prolonged surgical procedures (usually greater than two hours) associated with large fluid shifts and/or blood loss (e.g., pancreas resection [Whipple procedure], major spinal surgery).

4. Preoperative Basic Health Assessment

   This guideline follows the basic premise that diagnostic tests (lab and x-ray) are not part of the preoperative basic health assessment.

   A complete preoperative basic health assessment includes:

   • Medical History

     Indication for surgical procedure

     Allergies and intolerances to medications, anesthesia, or other agents (specify reaction type)

     Known medical problems

     Surgical history

     Trauma (major)

     Current medications (prescription, over-the-counter medications, herbal and dietary supplements, and illicit drugs)

     Risk factors for development of surgical site infection

     Focused review of issues pertinent to the planned anesthesia and procedure:

     • Current status of pertinent known medical problems
     • Cardiac status
     • Pulmonary status
     • Functional status
     • Hemostasis status (personal or family history of abnormal bleeding)
     • Possibility of severe (symptomatic) anemia
     • Possibility of pregnancy
     • Past personal or family history of anesthesia problems
     • Smoking and alcohol history
   • Physical Exam

     Weight and height

     Vital signs - blood pressure, pulse (rate and regularity), respiratory rate

     Cardiac

     Pulmonary

     Other pertinent exam [R]

   A sample preoperative form is attached in Appendix B, "Preoperative Forms – Adult and Pediatric," in the original guideline document (see "Availability of Companion Documents" field).

   Basic Health Assessment Applications

   A preoperative basic health assessment as outlined in this guideline is required for all patients undergoing a diagnostic or therapeutic procedure, regardless of setting, except for:

   • Otherwise healthy patients receiving peripheral nerve blocks, local or topical anesthesia, and/or no more than 50% nitrous oxide/oxygen and no other sedative or analgesic agents administered by any route (for example, most dental procedures or excision of simple skin lesions).
   • Patients receiving "sedation/analgesia" (often referred to as "conscious sedation") defined as "a state that allows patients to tolerate unpleasant procedures while maintaining adequate cardiopulmonary function and the ability to respond purposefully to verbal command and/or tactile stimulation." This technique is commonly used for procedures such as endoscopy and bronchoscopy, and may be used for certain surgical procedures. Patient history must be available at the time they receive sedation/analgesia.

   Although the preoperative basic health assessment is not specifically required for sedation/analgesia and other minor procedures, a limited preoperative assessment and documentation is required and mandated by the Joint Commission and other organizations [R].

   The preoperative basic health assessment is usually done within 30 days of the planned procedure. However, a review of the current history and focused physical examination will occur at the surgical facility prior to the procedure.

   The patient needs to be aware that the preoperative assessment is not a substitute for preventive services, but the preoperative evaluation may be used as an opportunity to address preventive services.

   This is another opportune time to initiate or augment patient education efforts including the use of the patient preoperative guide. Please see Appendix C, "Preoperative Questionnaire – Adult," and Appendix D, "Preoperative Questionnaire – Pediatric" in the original guideline document (see "Availability of Companion Documents" field).

5. Abnormal Findings Pertinent to Preoperative Evaluation?

   Abnormal findings are results from the preoperative basic health assessment that suggest that further evaluation is needed in order to assess or optimize surgical/anesthesia risk and care. Examples of abnormal findings are a patient taking medication such as a diuretic, suggesting the need for a recent potassium level, the presence of chest pains, or a markedly elevated blood pressure. Examples of abnormal findings in pediatric patients include a current upper respiratory infection or asthma.

   There may be other abnormal findings that, although not relevant to the planned procedure, may be relevant to the patient's general health. The evaluation of these findings would follow standard medical practice and is beyond the scope of the guideline. This type of finding would not necessarily need to delay the procedure.

   Preoperative questionnaires to assist in determining abnormal findings for adult and pediatric patients are attached in Appendix C, "Preoperative Questionnaire—Adults" and Appendix D, "Preoperative Questionnaire—Pediatrics" in the original guideline document.

6. Further Evaluation Performed and Evaluated for Surgical/Anesthesia Risk

   Key Points:

   • Most laboratory and diagnostic tests including electrocardiograms are not necessary for routine procedures unless a specific indication is present. The role of a preoperative electrocardiogram is uncertain. On rare occasions, an electrocardiogram can detect a previously unrecognized myocardial infarction.
   • Electrocardiograms are not indicated, regardless of age, for those patients having cataract surgery.

   Further evaluation may be as simple as asking a few more questions, performing further physical examination, or ordering a laboratory or radiological exam. More in-depth evaluations may be needed such as a consultation or treadmill testing.

   The type and extent of evaluation required should be guided by standard medical practice with consideration of the patient's underlying medical condition and the planned procedure. For example, some practitioners will order a baseline preoperative hemoglobin if significant blood loss is anticipated. Recommendations for this type of testing are beyond the scope of the guideline.

   Abnormal findings might trigger a need for a specific laboratory test. Note that most laboratory tests (e.g., hemoglobin, potassium, coagulation studies, chest x-rays, electrocardiograms) are not routinely necessary unless a specific indication is present.

   Test	Consider Performing if:
   Electrocardiogram	No electrocardiogram within last year in patients (regardless of age) with history of diabetes, hypertension, chest pain, congestive heart failure, smoking, peripheral vascular disease, inability to exercise, or morbid obesity. At time of preoperative evaluation, patient has any intercurrent cardiovascular symptoms or signs and symptoms of new or unstable cardiac disease.
   Coagulation studies	Patient has a known history of coagulation abnormalities or recent history suggesting coagulation problems or is on anticoagulants. Patient needs anticoagulation post-operatively (where a baseline may be needed).
   Hemoglobin	Patient has a history of anemia or history suggesting recent blood loss or anemia.
   Potassium	Patient is taking digoxin, diuretics, angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers.
   Chest x-ray	Patient has signs or symptoms suggesting new or unstable cardiopulmonary disease.

   Refer to the original guideline document for more information on electrocardiogram, coagulation studies, and hemoglobin.

7. High Risk Patient?

   High-risk in this context refers particularly to the risk of cardiac complications in adults and airway complications in pediatric patients. However, noncardiac conditions in adults and cardiac conditions in pediatric patients, along with other conditions such as coagulopathy, severe symptomatic anemia, pregnancy, and anesthesia reactions can be significant problems in selected patients. These conditions also need to be screened for as indicated in the preoperative basic health assessment. The specifics of risk stratification for noncardiac conditions relative to an individual patient are beyond the scope of this guideline.

   The final determination of a patient as high risk occurs after review and analysis of the preoperative basic health assessment and any other adjunctive evaluation that was indicated for surgical/anesthesia risk. The determination is the responsibility of involved providers, including the primary care physician, surgeon, and/or anesthesiologist.

   Although it is ultimately the responsibility of involved providers to determine whether a particular patient is considered to be at high risk of complication, it is generally accepted that patients at high risk usually fall into the following categories:

   Cardiovascular

   • Unstable coronary syndromes
     • Recent* myocardial infarction
     • Unstable or severe angina

       *Recent can mean less than 30 days if post myocardial infarction cardiac risk stratification is completed and patient determined to be low-risk; 3 to 6 months if formal risk stratification not done.

   • Decompensated congestive heart failure
   • Significant arrhythmias
     • High grade atrioventricular block
     • Symptomatic ventricular arrhythmias in the presence of underlying heart disease
     • Supraventricular arrhythmias with uncontrolled ventricular rate
   • Severe valvular disease
   • Severe hypertension (diastolic over 110, systolic over 180)
   • Congenital heart abnormalities

   Non-Cardiovascular

   • Pulmonary disease, severe or symptomatic (e.g., chronic obstructive pulmonary disease requiring oxygen, respiratory distress at rest, asthma, cystic fibrosis)
   • Poorly controlled symptomatic diabetes (causing symptoms with attendant risk of hypovolemia)
   • Symptomatic anemia

8. Management of Stable Comorbidities

   Antithrombotic Therapy

   General recommendations regarding antithrombotic therapy are beyond the scope of this document, given the different classes of medications and the variety of situations for which they are used. (This document does however make recommendations regarding coronary stents and antiplatelet therapy; see below). For patients on antithrombotic therapy, please refer to the NGC summary of the ICSI guideline Antithrombotic Therapy Supplement for information regarding management.

   Beta-Blockers

   Patients on chronic beta-blocker therapy should continue their medication up to and including the day of surgery. If beta-blocker therapy is stopped prior to surgery, patients may be at increased risk for complications postoperatively [R].

   Coronary Artery Stent Placement (Recent) and Antiplatelet Therapy (Aspirin, Clopidogrel and Ticlopidine)

   There is clear evidence that premature discontinuation of dual platelet therapy (aspirin combined with clopidogrel (Plavix®) or ticlopidine (Ticlid®) for any reason after coronary stent placement results in a marked increased risk of myocardial infarction or death [R]. Therefore, a critical part of the preoperative evaluation of a patient who fits this description is a careful assessment of the benefits of the surgery itself and surgical bleeding risk versus the high risk of cardiac events if platelet therapy is reduced or stopped prematurely. Important stent considerations include: how long the coronary stent has been in place and whether the stent is a bare-metal stent versus a drug-eluting stent.

   The presurgical evaluation of risk in this group of patients may require discussion with cardiology and surgery.

   General principles are as follows:

   • For patients with bare-metal stents, surgery should be avoided for the first four to six weeks after stenting.
   • For patients with drug-eluting stents, surgery should be avoided for one year after stenting.
   • If surgery cannot be avoided during the above time periods, dual platelet therapy should be continued perioperatively unless strongly contraindicated. Alternatives such as stopping the clopidogrel/ticlopidine and continuing aspirin or stopping all antiplatelet therapy may be necessary to reduce bleeding risk but are associated with increased cardiac risk.
   • If antiplatelet therapy is held prior to surgery, it should be restarted as soon as possible following surgery [R].

   Diabetic Management

   Given the complexities and wide variety of methodologies employed to achieve glycemic control, individual patient evaluation and instruction are required prior to surgery.

   General principles are as follows:

   • No oral hypoglycemics on the day of surgery
   • Usually 1/3 to 1/2 of patient's routine morning insulin dosage may be administered

   Sleep Apnea

   Obstructive sleep apnea increases the patient's risk for intra- and postoperative complications [C]. Patients with a diagnosis of obstructive sleep apnea often have oral appliances or continuous positive airway pressure equipment and should be reminded to bring those appliances or equipment on the operative day, for use during the recovery from anesthesia or sedation.

   Some patients may not bear a diagnosis of obstructive sleep apnea confirmed by polysomnography studies, but are presumed to have obstructive sleep apnea based on the preoperative history and physical examination. This information should be communicated to the surgeon and anesthesiologist before the patient undergoes any procedure involving general anesthesia, monitored anesthesia care, conscious sedation or the administration of narcotics. Refer to the NGC summary of the ICSI guideline Diagnosis and Treatment of Obstructive Sleep Apnea in Adults.

   Smoking Cessation

   Smoking cessation is an important intervention for the overall health of patients, and surgery may provide the impetus for patients to quit. Patients who quit smoking prior to surgery do not risk postoperative complications related to smoking cessation [D]. With the exception of improved wound healing for head and neck surgeries [D], there is no strong evidence to recommend smoking cessation prior to surgery as a means to achieve improved outcomes and reduce postoperative complications.

9. Communicate Results and Instructions to Facility and Patient

   The results must be communicated to the location where the procedure will be conducted prior to the date of the scheduled procedure. The report should include a complete summary of the assessment, any adjunctive evaluation, and any specific recommendations.

   Preoperative forms for relaying preoperative assessment information for adult and pediatric patients are attached in Appendix B, "Preoperative Forms – Adult and Pediatric" in the original guideline document (see "Availability of Companion Documents" field).

   Patient Education

   Preoperative patient education is a shared responsibility of providers. This education should include both general and procedure specific information, including the results of any preoperative testing, along with specific recommendations or instructions prior to surgery.

   Preoperative Fasting Recommendations (Nothing by Mouth [NPO])

   Preoperative fasting guidelines have been revised and simplified over the last decade. The American Society of Anesthesiologists Task Force on Preoperative Fasting has issued practice guidelines that follow a "2, 4, 6 hour" rule applying to all ages:

   • The fasting period for clear liquids, including water, fruit juices without pulp, carbonated beverages, clear tea and coffee is recommended to be two hours or longer prior to surgery.
   • The fasting period for breast milk is recommended to be four hours or longer prior to surgery.
   • The fasting period for formula, non-human milk and light meals such as toast and clear liquids is recommended to be six hours or longer prior to surgery.
   • The fasting period for fried and fatty foods or meat may be longer, as these foods may prolong gastric emptying time. The amount and type of food should be taken into account to determine an appropriate fasting period.

   Patients should be educated and informed of fasting requirements sufficiently in advance of the procedure [R].

10. Immediate Pre-Procedure Assessment

    The immediate pre-procedure assessment is completed when the patient arrives for the procedure. The purpose is to assure that all necessary information is available and that the patient's medical condition is stable (i.e., he/she continues to be a low-risk patient). The nature of this review is beyond the scope of the guideline but is defined by the Joint Commission and other regulatory agencies.

Definitions:

Conclusion Grades

Grade I: The evidence consists of results from studies of strong design for answering the question addressed. The results are both clinically important and consistent with minor exceptions at most. The results are free of any significant doubts about generalizability, bias, and flaws in research design. Studies with negative results have sufficiently large samples to have adequate statistical power.

Grade II: The evidence consists of results from studies of strong design for answering the question addressed, but there is some uncertainty attached to the conclusion because of inconsistencies among the results from the studies or because of minor doubts about generalizability, bias, research design flaws, or adequacy of sample size. Alternatively, the evidence consists solely of results from weaker designs for the question addressed, but the results have been confirmed in separate studies and are consistent with minor exceptions at most.

Grade III: The evidence consists of results from studies of strong design for answering the question addressed, but there is substantial uncertainty attached to the conclusion because of inconsistencies among the results of different studies or because of serious doubts about generalizability, bias, design flaws, or adequacy of sample size. Alternatively, the evidence consists solely of results from a limited number of studies of weak design for answering the question addressed.

Grade Not Assignable: There is no evidence available that directly supports or refutes the conclusion.

Classes of Research Reports:

1. Primary Reports of New Data Collection:

   Class A:

   • Randomized, controlled trial

   Class B:

   • Cohort study

   Class C:

   • Non-randomized trial with concurrent or historical controls
   • Case-control study
   • Study of sensitivity and specificity of a diagnostic test
   • Population-based descriptive study

   Class D:

   • Cross-sectional study
   • Case series
   • Case report
2. Reports that Synthesize or Reflect upon Collections of Primary Reports:

   Class M:

   • Meta-analysis
   • Systematic review
   • Decision analysis
   • Cost-effectiveness analysis

   Class R:

   • Consensus statement
   • Consensus report
   • Narrative review

   Class X:

   • Medical opinion

A detailed and annotated clinical algorithm is provided for Preoperative Evaluation.

ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675; e-mail: icsi.info@icsi.org; Web site: www.icsi.org.

ICSI's conflict of interest policy and procedures are available for review on ICSI's website at www.icsi.org.

Electronic copies: Available from the Institute for Clinical Systems Improvement (ICSI) Web site.

Print copies: Available from ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675; Web site: www.icsi.org; e-mail: icsi.info@icsi.org.

• Preoperative evaluation. Executive summary. Bloomington (MN): Institute for Clinical Systems Improvement, 2008 Jul. 1 p. Electronic copies: Available from the Institute for Clinical Systems Improvement (ICSI) Web site.
• ICSI pocket guidelines. May 2007 edition. Bloomington (MN): Institute for Clinical Systems Improvement, 2007.

Print copies: Available from ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675; Web site: www.icsi.org; e-mail: icsi.info@icsi.org.

Additionally, Appendices A-D in the original guideline document include patient preoperative guides and questionnaires for adult and pediatric populations.

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