What is the recommended pre-surgical assessment method?

Pre-Surgical Assessment Method

The recommended pre-surgical assessment method prioritizes a focused clinical history and physical examination over routine laboratory testing, with the timing and extent of evaluation determined by surgical invasiveness and patient disease severity. 1, 2

Core Assessment Components

History and Physical Examination

• A thorough clinical history and targeted physical examination are more important than routine preoperative tests and should form the foundation of all pre-surgical evaluations 3, 4, 5
• The focused physical examination must include assessment of the airway (100% consensus), pulmonary examination with lung auscultation (88% consensus), and cardiovascular examination (81% consensus) 1
• Document vital signs as part of the minimum physical examination 1
• Review current diagnoses, all medications (including alternative therapies), and determine the patient's medical condition from accessible medical records 1

Timing Based on Surgical Invasiveness

High Surgical Invasiveness:

• Complete medical record assessment, patient interview, and physical examination must be performed prior to the day of surgery by anesthesia staff 1
• This applies regardless of patient disease severity 1

Medium Surgical Invasiveness:

• Initial assessment of medical records should be done prior to surgery day (58% consultant consensus), though may be acceptable on or before surgery day (61% ASA member consensus) 1

Low Surgical Invasiveness:

• Initial assessment may be performed on or before the day of surgery (69% consultant consensus, 59% ASA member consensus) 1

Timing Based on Patient Disease Severity

High Severity of Disease:

• Initial record review, patient interview, and physical examination must be completed prior to the day of surgery regardless of surgical invasiveness 1

Low Severity of Disease:

• For high surgical invasiveness: assessment prior to surgery day 1
• For medium or low surgical invasiveness: assessment may occur on or before surgery day 1

Cardiovascular Evaluation

Electrocardiography (ECG)

• ECG is indicated for patients with signs or symptoms of cardiovascular disease 2
• Perform ECG for patients undergoing high-risk surgery 2
• Perform ECG for patients undergoing intermediate-risk surgery who have additional risk factors (coronary heart disease, structural heart disease, heart failure, cerebrovascular disease, diabetes, or renal impairment) 1, 2
• ECG is not indicated for asymptomatic patients undergoing low-risk surgery 1, 2
• Consider ECG for patients with cardiovascular risk factors even in lower-risk procedures 1

Functional Capacity Assessment

• Patients with good functional capacity (≥4 METs or ability to climb ≥2 flights of stairs) can generally proceed to surgery without further cardiac testing 2
• Identify active cardiac conditions requiring evaluation before surgery: unstable coronary syndromes, decompensated heart failure, significant arrhythmias, severe valvular disease 2

Pulmonary Assessment

• Chest radiography is not performed routinely for asymptomatic, otherwise healthy patients 2
• Chest radiography is indicated for patients with new or unstable cardiopulmonary signs or symptoms 2
• Consider chest radiography for patients at risk of postoperative pulmonary complications only if results would change perioperative management 2

Laboratory Testing (Selective, Not Routine)

Complete Blood Count (CBC)

• Obtain CBC for patients with diseases that increase risk of anemia (liver disease, hematologic disorders) 2
• Obtain CBC for patients with history of anemia or recent blood loss 2
• Perform CBC when significant perioperative blood loss is anticipated 2
• CBC is indicated for patients undergoing cardiovascular surgery and specific high-risk procedures 2

Electrolytes and Renal Function

• Reserve electrolyte and creatinine testing for patients at risk of electrolyte abnormalities or renal impairment 1, 2
• Test patients taking medications that predispose to electrolyte abnormalities: diuretics, ACE inhibitors, ARBs, NSAIDs, digoxin 1, 2
• Test patients with hypertension, heart failure, chronic kidney disease, complicated diabetes mellitus, or liver disease 2
• Electrolyte measurement is recommended for all patients with known renal conditions and those undergoing neurosurgery or cardiovascular surgery 1

Glucose Testing

• Perform random glucose testing for patients at high risk of undiagnosed diabetes mellitus 2
• In patients with diagnosed diabetes, A1C testing is recommended only if results would change perioperative management 2
• Universal screening is not justified given the low incidence (0.5%) of occult diabetes in the presurgical population 2

Coagulation Studies

• Reserve coagulation testing (PT, aPTT, platelet count) for patients with history of bleeding or medical conditions predisposing to coagulopathy (e.g., liver disease) 2
• Test patients taking anticoagulants 2
• Indiscriminate preoperative coagulation testing is not warranted due to low prevalence of inherited coagulopathies 2

Urinalysis

• Routine urinalysis is not performed for asymptomatic patients 2
• Urinalysis is indicated for patients undergoing urologic procedures or implantation of foreign material (e.g., prosthetic joint, heart valve) 2

Special Population: Lung Cancer Resection

For patients being considered for lung cancer resection, a structured physiologic assessment is required 1:

• Begin with cardiovascular evaluation and spirometry to measure FEV1 and DLCO 1
• Calculate predicted postoperative (PPO) lung functions 1
• If % PPO FEV1 and % PPO DLCO are both ≥60%, the patient is at low risk and no further tests are indicated 1
• If either % PPO FEV1 or % PPO DLCO are 30-60% predicted, perform low technology exercise test (stair climbing ≥22m or shuttle walk ≥400m indicates low risk) 1
• Cardiopulmonary exercise test is indicated when PPO FEV1 or PPO DLCO <30% or when low technology exercise test performance is unsatisfactory 1
• Peak oxygen consumption (VO2peak) <10 mL/kg/min or 35% predicted indicates high risk of mortality and long-term disability 1
• VO2peak >20 mL/kg/min or 75% predicted indicates low risk 1

Special Population: Cataract Surgery

• Routine preoperative laboratory testing is not indicated for cataract surgery 6
• The operating ophthalmologist should perform the preoperative assessment 6
• Directed testing may be recommended only for specific surgical candidates with medical problems 6
• Consider preoperative medical evaluation by primary care physician for patients with COPD, poorly controlled hypertension, recent MI, unstable angina, poorly controlled CHF, or poorly controlled diabetes 6

Common Pitfalls to Avoid

• Avoid ordering routine tests for all patients regardless of clinical indication - this increases cost without improving safety or quality of care 2, 3
• Do not rely on cardiac auscultation alone to diagnose valvular heart disease 7
• Do not perform extensive testing on healthy patients undergoing low-risk procedures 1, 2
• Ensure adequate time for assessment - the healthcare system must provide pertinent information to the anesthesiologist well in advance of the anticipated procedure day for all elective patients 1
• Testing should be based on patient's clinical history, comorbidities, physical examination findings, and perioperative risk assessment rather than performed routinely 2