Practice advisories are not concrete guidelines, but rather a source to assist in clinical decision making. Although supported by scientific evidence, the same rigor is not applied to these advisories as would be to standards or guidelines due to insufficient number of adequately controlled studies.
The definition of preanesthesia evaluation is subjective, but encompasses an anesthesiologist’s preparation before various procedures, including but not limited to reviewing the patient’s medical records, consulting additional specialties, and performing the preoperative evaluation.
The preanesthesia history and physical examination includes evaluation of pertinent medical records, patient interview, and physical examination. Baseline evaluation should include examination and analysis of airway, heart, lungs, and vital signs. Additional information such as relevant diagnosis with severity, treatments, and prognosis are beneficial to evaluate as well. The purpose of preoperative tests is to elucidate unknown patient pathology, verify and further characterize known patient pathology, and to assist in formulating an individualized clinical plan for the patient. Routine ordering of preoperative tests should be avoided. Rather ordering indicated tests are recommended, especially if aberrant results necessitate a change in anesthetic management for the patient. For highly invasive surgeries, preanesthesia evaluation is recommended before the day of procedure. For minimally invasive surgery, evaluation is recommended before or on the day of procedure.
SPECIFIC RECOMMENDATIONS FROM THE AMERICAN SOCIETY OF ANESTHESIOLOGISTS
Electrocardiogram—May be useful in patients with previously known or newly discovered cardiac risk factors, cardiac pathology, respiratory pathology, and high risk or invasive surgery. Although electrocardiogram abnormalities may increase in older patients, age alone may not be an indication for electrocardiogram.
Cardiac evaluation other than electrocardiogram—It is advisable to consult with relevant specialties, consider cardiac risk factors, understand type and invasiveness of procedure, and compare risks and benefits of additional assessment before ordering tests, including but not limited to echocardiography, cardiac stress test, and cardiac catheterization.
Chest radiography—Consideration of recently resolved respiratory tract infection, stable chronic obstructive pulmonary disease (COPD), stable cardiac disease, smoking, and extremes of age may indicate justification for chest radiography during preanesthesia evaluation; however, the previous risk factors are not definite indications.
Pulmonary evaluation other than chest radiography—Before tests are performed to elucidate extent of pulmonary pathology (including but not limited to pulmonary function tests, pulse oximetry, and arterial blood gas), it is advisable to consult relevant specialties, evaluate pulmonary pathology, pulmonary risk factors, type and invasiveness of procedure, and compare risks and benefits of tests. The date of prior evaluation, asthma, COPD, and scoliosis should also be considered.
Hemoglobin/hematocrit measurement—Consideration of type and invasiveness of procedure, extremes of age, liver pathology, history of anemia, and bleeding diathesis may encourage obtaining hemoglobin and hematocrit levels; however, routine hemoglobin and hematocrit are not indicated.
Coagulation studies—Consideration of liver pathology, renal pathology, bleeding diathesis, and type and invasiveness of procedure may indicate justification for selected coagulation studies. Additional perioperative risks may be associated ...