Last updated January 11, 2022

Preanesthesia Evaluation

Summary of Advisory Statements

Preanesthesia History and Physical Examination

Impact

The assessment of anesthetic risks associated with the patient's medical conditions, therapies, alternative treatments, surgical and other procedures, and of options for anesthetic techniques is an essential component of basic anesthetic practice.
  • Benefits may include, but are not limited to, the safety of perioperative care, optimal resource use, improved outcomes, and patient satisfaction.

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Timing

An assessment of readily accessible, pertinent medical records with consultations, when appropriate, should be performed as part of the preanesthetic evaluation before the day of surgery for procedures with high surgical invasiveness.
  • For procedures with low surgical invasiveness, the review and assessment of medical records may be done on or before the day of surgery by anesthesia staff.

  • The information obtained may include, but should not be limited to, (1) a description of current diagnoses; (2) treatments, including medications and alternative therapies used; and (3) determination of the patient's medical condition(s).

  • The timing of such assessments may not be practical with the current limitation of resources provided in specific healthcare systems or practice environments.

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An initial record review, patient interview, and physical examination should be performed before the day of surgery for patients with high severity of disease.
  • For patients with low severity of disease and undergoing procedures with high surgical invasiveness, the interview and physical exam should also be performed before the day of surgery.

  • For patients with low severity of disease undergoing procedures with medium or low surgical invasiveness, the initial interview and physical exam may be performed on or before the day of surgery.

  • At a minimum, a focused preanesthetic physical examination should include an assessment of the airway, lungs, and heart, with documentation of vital signs.

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It is the obligation of the healthcare system to, at a minimum, provide pertinent information to the anesthesiologist for the appropriate assessment of the severity of medical condition of the patient and invasiveness of the proposed surgical procedure well in advance of the anticipated day of procedure for all elective patients.
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Selection and Timing of Preoperative Tests

Routine Preoperative Testing
  • Preoperative tests should not be ordered routinely.

  • Preoperative tests may be ordered, required, or performed on a selective basis for purposes of guiding or optimizing perioperative management.

    • The indications for such testing should be documented and based on information obtained from medical records, patient interview, physical examination, and type and invasiveness of the planned procedure.

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Preoperative Testing in the Presence of Specific Clinical Characteristics
  • There is insufficient evidence to identify explicit decision parameters or rules for ordering preoperative tests on the basis of specific clinical characteristics.

  • Consideration of selected clinical characteristics may assist the anesthesiologist when deciding to order, require, or perform preoperative tests. The following clinical characteristics may be of merit, although the anesthesiologist should not limit consideration to the characteristics suggested below.

  • Electrocardiogram

    • Important clinical characteristics may include cardiocirculatory disease, respiratory disease, and type or invasiveness of surgery.

    • The Task Force recognizes that ECG abnormalities may be higher in older patients and in patients with multiple cardiac risk factors.

    • An ECG may be indicated for patients with known cardiovascular risk factors or for patients with risk factors identified in the course of a preanesthesia evaluation. Age alone may not be an indication for ECG.

  • Preanesthesia Cardiac Evaluation Other than ECG

    • Preanesthesia cardiac evaluation may include consultation with specialists and ordering, requiring, or performing tests that range from noninvasive passive or provocative screening tests (e.g. , stress testing) to noninvasive and invasive assessment of cardiac structure, function, and vascularity (e.g. , echocardiogram, radionucleotide imaging, cardiac catheterization).

    • Anesthesiologists should balance the risks and costs of these evaluations against their benefits.

    • Clinical characteristics to consider include cardiovascular risk factors and type of surgery.

  • Preanesthesia Chest Radiographs

    • Clinical characteristics to consider include smoking, recent upper respiratory infection, COPD, and cardiac disease.

      • The Task Force recognizes that chest radiographic abnormalities may be higher in such patients but does not believe that extremes of age, smoking, stable COPD, stable cardiac disease, or resolved recent upper respiratory infection should be considered unequivocal indications for chest radiography.

  • Preanesthesia Pulmonary Evaluation Other than Chest X-ray

    • Preanesthesia pulmonary evaluation other than chest x-ray may include consultation with specialists and tests that range from noninvasive passive or provocative screening tests (e.g. , pulmonary function tests, spirometry, pulse oximetry) to invasive assessment of pulmonary function (e.g. , arterial blood gas).

      • Anesthesiologists should balance the risks and costs of these evaluations against their benefits.

      • Clinical characteristics to consider include type and invasiveness of the surgical procedure, interval from previous evaluation, treated or symptomatic asthma, symptomatic COPD, and scoliosis with restrictive function.

  • Preanesthesia Hemoglobin or Hematocrit

    • Routine hemoglobin or hematocrit is not indicated.

    • Clinical characteristics to consider as indications for hemoglobin or hematocrit include type and invasiveness of procedure, patients with liver disease, extremes of age, and history of anemia, bleeding, and other hematologic disorders.

  • Preanesthesia Coagulation Studies

    • Clinical characteristics to consider for ordering selected coagulation studies include bleeding disorders, renal dysfunction, liver dysfunction, and type and invasiveness of procedure.

      • The Task Force recognizes that anticoagulant medications and alternative therapies may present an additional perioperative risk.

      • The Task Force believes that there were not enough data to comment on the advisability of coagulation tests before regional anesthesia.

  • Preanesthesia Serum Chemistries (i.e. , Potassium, Glucose, Sodium, Renal and Liver Function Studies)

    • Clinical characteristics to consider before ordering preanesthesia serum chemistries include likely perioperative therapies, endocrine disorders, risk of renal and liver dysfunction, and use of certain medications or alternative therapies.

      • The Task Force recognizes that laboratory values may differ from normal values at extremes of age.

  • Preanesthesia Urinalysis

    • Urinalysis is not indicated except for specific procedures (e.g. , prosthesis implantation, urologic procedures) or when urinary tract symptoms are present.

  • Preanesthesia Pregnancy Testing

    • Patients may present for anesthesia with early undetected pregnancy.

      • The Task Force believes that the literature is inadequate to inform patients or physicians on whether anesthesia causes harmful effects on early pregnancy.

      • Pregnancy testing may be offered to female patients of childbearing age and for whom the result would alter the patient's management.

  • Timing of Preoperative Testing

    • The current literature is not sufficiently rigorous to permit an unambiguous assessment of the clinical benefits or harms of the timing for preoperative tests.

      • There is insufficient evidence to identify explicit decision parameters or “rules” for ordering preoperative tests on the basis of specific patient factors.

    • Test results obtained from the medical record within 6 months of surgery generally are acceptable if the patient's medical history has not changed substantially.

      • More recent test results may be desirable when the medical history has changed, or when a test results may play a role in the selection of a specific anesthetic technique (e.g. , regional anesthesia in the setting of anticoagulation therapy).

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Summary and Conclusions

Content of the preanesthetic evaluation includes, but is not limited to, (1) readily accessible medical records, (2) patient interview, (3) a directed preanesthesia examination, (4) preoperative tests when indicated, and (5) other consultations when appropriate. At a minimum, a directed preanesthetic physical examination should include an assessment of the airway, lungs, and heart.
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Timing of the preanesthetic evaluation can be guided by considering combinations of surgical invasiveness and severity of disease.
  • Limitations in resources available to a specific healthcare system or practice environment may affect the timing of the preanesthetic evaluation.

  • The healthcare system is obligated to provide pertinent information to the anesthesiologist for the appropriate assessment of the invasiveness of the proposed surgical procedure and the severity of the patient's medical condition well in advance of the anticipated day of procedure for all elective patients.

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Routine preoperative tests (i.e. , tests intended to discover a disease or disorder in an asymptomatic patient) do not make an important contribution to the process of perioperative assessment and management of the patient by the anesthesiologist.
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Selective preoperative tests (i.e. , tests ordered after consideration of specific information obtained from sources such as medical records, patient interview, physical examination, and the type or invasiveness of the planned procedure and anesthesia) may assist the anesthesiologist in making decisions about the process of perioperative assessment and management.
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Decision-making parameters for specific preoperative tests or for the timing of preoperative tests cannot be unequivocally determined from the available scientific literature.
  • Specific tests and their timing should be individualized and based upon information obtained from sources such as the patient's medical record, patient interview, physical examination, and the type and invasiveness of the planned procedure.

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Recommendation Grading

Overview

Title

Preanesthesia Evaluation

Authoring Organization

Publication Month/Year

March 1, 2012

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

Assess the currently available evidence pertaining to the healthcare benefits of preanesthesia evaluation, offer a reference framework for the conduct of preanesthesia evaluation by anesthesiologists, and stimulate research strategies that can assess the healthcare benefits of a preanesthesia evaluation.

Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Infant, Older adult

Health Care Settings

Ambulatory, Hospital, Outpatient

Intended Users

Nurse anesthetist, nurse, medical assistant

Scope

Assessment and screening, Prevention, Management

Diseases/Conditions (MeSH)

D000758 - Anesthesia, D011315 - Preventive Medicine, D011314 - Preventive Health Services

Keywords

Preanesthesia, Pre-anesthesia checkup, PAC

Source Citation

Practice Advisory for Preanesthesia Evaluation: An Updated Report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology 2012;116(3):522-538.