ANAESTHESIA II

Anaesthesia II

Preoperative assessment

F J Garca-Miguel, P G Serrano-Aguilar, J Lpez-Bastida

Although anaesthetic and surgical procedures should be individualised for every patient, in practice many preoperative
protocols and routines are used generally. In this article, we aim to emphasise: why preoperative assessment is
important; how it should be done, and by whom; what can be expected; and the importance of test selection based on
patients needs and on scientific evidence of effectiveness. We outline the roles of preoperative medical assessment
in otherwise healthy patients. Clinical history, preoperative questionnaires, physical examination, routine tests,
individual risk-assessment, and fasting policies are investigated by review of published work. Cost of routine
preoperative assessment, the anaesthetists legal responsibility, and patients views in the preoperative process are
also considered. A thorough clinical preoperative assessment of the patient is more important than routine
preoperative tests, which should be requested only when justified by clinical indications. Moreover, this practice
eliminates unnecessary cost without compromising the safety and quality of care. Education and training of medical
doctors should be more scientifically guided, emphasising the relevance of effectiveness, and cost-effectiveness in
clinical decision-making and complemented by audit.
Preoperative assessment is the clinical investigation that
precedes anaesthesia for surgical or non-surgical
procedures, and is the responsibility of the anaesthetist.
The aims of preoperative assessment are to reduce the
risks associated with surgery and anaesthesia, to increase
the quality (thus decreasing the cost) of peroperative care,
to restore the patient to the desired level of function, and
to obtain the patients informed consent for the
anaesthetic procedure.1 This assessment should rely on
the rational use of information from the patients medical
records, clinical interview, physical examination, and
some additional tests.2 Traditionally, a preoperative
consultation with the anaesthetist has facilitated these
goals. Nevertheless, the process of preoperative
assessment has undergone major changes. The increasing
number of day-case surgery procedures has affected the
way in which the anaesthetist assesses patients
preoperatively. Overuse and unexplained variations of
tests for preoperative assessment have been extensively
documented.312 Although most institutions have
established recommendations for the use of laboratory
tests, information is scarce about the ability of such
guidelines to modify and improve the selection of
preoperative tests. It is important to investigate costeffectiveness and efficiency while providing the best
care.35 This article is an update on recent management
issues in preoperative assessment. Our aims are: (1) To
review and assess the evidence related to the health-care
benefits of preoperative assessment; (2) to offer a
reference framework for the practice of preanaesthetic
assessment; and (3) to stimulate research.
Lancet 2003; 362: 174957
Department of Anaesthesiology and Reanimation, Hospital General
de Segovia, Segovia, Spain (F J Garca-Miguel PhD); and Department
of Planning and Evaluation, Servicio Canario de Salud, Canary
Islands, Spain (P G Serrano-Aguilar PhD, J Lpez-Bastida PhD)
Correspondence to: Dr F J Garca-Miguel, Department of
Anaesthesiology and Reanimation, Hospital General de Segovia,
Crta Avila s/n 40002, Segovia, Spain
(e-mail: fgarcia@hgse.sacyl.es)

Preoperative medical assessment

A preoperative assessment is believed to be a basic
element of anaesthetic care. However, we were unable to
find any controlled trials on the clinical effect of provision
of a preanaesthetic review of medical records, or an
adequate physical examination.2 The aim of assessment of
patients before anaesthesia and surgery is to improve the
outcome, by identifying potential anaesthetic difficulties,
identifying existing medical conditions, improving safety
by assessing and quantifying risk, allowing planning of
peroperative care, providing the opportunity for
explanation and discussion, and allaying fear and anxiety.
Good preoperative assessment will help to reduce costs
and increase efficiency of operative theatre time.13

Search strategy
We searched for trials in MEDLINE, EMBASE, and HealthSTAR
databases. The databases of the UK Centre for Reviews and
Dissemination (DARE and NHS economic evaluation
database) and the Cochrane Collaboration (The Cochrane
Library) were also used. The search included all published
articles regardless of the language. Terms used in the search
were preoperative evaluation, pre-anaesthetic assessment,
preoperative test, surgical risk, and informed consent. All
relevant studies concerning chest radiograph,
electrocardiogram (ECG), laboratory tests, and legal aspects
were retrieved. Information on preoperative test
recommendations for elective surgery in asymptomatic
patients was mainly obtained from systematic reviews
published for International Health Technology Assessment
Agencies.612 To complete the review on the specific topic of
preoperative testing we accepted the work done by Munro
and colleagues6 and by the National Institute for Clinical
Excellence (NICE)12 as the most comprehensive, and we
extended the search strategy used by Munro and colleagues
from 1997 to 2003. The definition used in this paper for
routine preoperative testing is that of tests ordered for
asymptomatic, apparently healthy individuals, in the absence
of any specific clinical indication, to identify conditions
undetected by clinical history and examination.6

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1749

ANAESTHESIA II

Panel 1: Preoperative questionnaire for adults13

Panel 2: Preoperative questionnaire for children13,23

Have you ever suffered from any of the following? (if yes,
please give details)
Heart disease or any sort
Chest pain, palpitations, or blackouts
High blood pressure
Rheumatic fever
Asthma, bronchitis, or other chest disease
Breathless on exertion at night
Diabetes or sugar in the urine
Kidney or urinary trouble
Convulsions or fits
Anaemia or other blood disorders
Bruising or bleeding problems
Blood clots in the legs or lungs
Jaundice (yellowness)
Indigestion or heartburn
Any other serious illness

1. Has your child had good growth, development, and

exercise tolerance?
2. Has your child been admitted to or frequently attended
hospital?
3. Has your child attended a doctor in the past 4 weeks?
4. Has your child had any of these symptoms in the past
4 weeks: high temperature, rash, cough, cold, sore
throat?
5. Has your child been in contact with an infectious disease
in the past 4 weeks?
6. Does your child have any heart problems?
7. Has your child ever been short of breath while exercising
or been blue around the lips?
8. Does your childs chest ever sound wheezy and whistling?
9. Does your child have any kidney problems?
10. Has your child ever been jaundiced?
11. Does your child bruise easily?
12. Has your child ever had any convulsions or seizures?
13. Does your child, or does anyone in the family, have nerve
or muscle problems?
14. Have your child or family members ever had problems
with anaesthesia?
15. Does your child have any other medical conditions?
16. For female children: has your child started her periods?
If yes, what was the date of her last menstrual period?
17. Is there any chance that your child might be pregnant?

Do you smoke, or you have stopped recently?

(if yes, how many a day?)
Do you drink alcohol (if yes, how much a week?)
Do you have false, capped or crowned teeth?
Do you wear contact lenses or a hearing aid?
Do you have a pacemaker or any implants?
Women
Could you be pregnant?
Are you on the pill or HRT?
What is your approximate weight?
What is your approximate height?
Are you taking any medicines or drugs?
Are you allergic to any drugs or materials?
Please list any previous operations or anaesthetics
Have you, or any member of your family, had any problems
with anaesthetics?
Is there anything else that your anaesthetist or surgeon
should know?

In several studies, specific preoperative outcomes (eg,

cardiac, respiratory) have been reported in patients with
specific pre-existing conditions (eg, hypertension, previous
myocardial infarction, smoking, airway abnormalities).1420
However, since these studies were not controlled trials, they
were not judged to be rigorous enough to provide
unequivocal evidence.
Interview
The preoperative interview is the anaesthetists first
introduction to a patient. This is the most efficient and
productive of the three basic techniques used in
preoperative assessment. The objectives of the interview in
patients who are presumed to be basically healthy is to
detect unrecognised disease that could increase the risk of
surgery above the baseline.21 The preoperative medical
history should focus on the indication for surgical
procedures, allergies, and undesirable side-effects to
medications or other agents, known medical problems,
surgical history, major trauma, and current medications. A
focused review of issues pertinent to the planned anaesthetic
procedures (cardiopulmonary function, homoeostatic
status, possibility of pregnancy, personal or family history of

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anaesthetic problems, smoking and drinking habits, and

functional status) has also been shown to be useful.22,23
Questionnaires are an effective way of gleaning basic
background information. Many institutions have developed
questionnaires to improve efficiency in preoperative clinics.
They can be given to the patient at the surgical outpatient
clinic to be completed immediately or taken home and
returned by post. However, questionnaires should not be
seen as a substitute for preoperative interview but as an
additional source of information. The questionnaire is not
supposed to shorten the consultation but to reduce the time
spent asking basic questions, allowing more time to discuss
the actual problem and the operation (panels 1 and 2).13, 2325
Physical examination
A complete physical examination in presumed healthy
individuals includes:2,23 weight and height; main vital signs
blood pressure, pulse (rate and regularity), and respiratory
rate; cardiac and pulmonary examination; anatomical
conditions required for specific anaesthetic procedures,
such as intubation (airway examination), regional
anaesthesia, venous access, etc; and other particular
examinations thought to be of use.
Routine tests
Most patients admitted for elective surgery undergo a range
of routine preoperative tests. These tests, whether or not
guided by the patients clinical needs, have been part of
preoperative clinical practice for many years.7,8,26 The
purposes of routine preoperative testing are: the assessment
of a pre-existing health problem, the identification of
unsuspected medical conditions, the prediction of
preoperative or postoperative complications, the
establishment of a baseline reference for later comparisons,
and the screening of patients opportunistically. This
inappropriate use of resources has been widely
documented,7,2651 especially for the routine chest radiograph,
but besides the small probability of finding a relevant

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ANAESTHESIA II

SBU7

ANDEM9

OSTEBA8

GR10

NCCHTA6

GPAC11

NICE12

Chest radiography

Electrocardiogram

Immigrants from developing

countries without a chest
radiograph during the
previous 12 months
Immigrants from developing
countries who have not
had a chest radiograph
during the previous
12 months

Men older than 5060 years, When the need for

women older than
transfusions is
6070 years
envisioned

Blood count

Haemostasis

Other analyses

Not recommended

Not indicated

If history suggests risk

of haemorrhage; if not
possible to know the
past history; for special
treatments

The cost-effectiveness
of examination
increases with age,
although the age from
which it must be done
is not clear

If anamnesis suggests
coagulation problems,
difficult surgical
homoeostasis, and for
drinkers of more than
500 mL of wine per
day or equivalent
Immigrants from developing Men and women older
Not recommended routinely
If past history suggests
countries who have not had than 60 years
except in children of younger than haemorrhagic disorders;
a chest radiograph during
1 year of age and patients of non- for treatment with oral
the previous 12 months;
white origin, but recommended for anticoagulants
long-term smokers
surgery in which need for
transfusions is expected
Not indicated
Not indicated
Not indicated
If the anamnesis
suggests homoeostasis
disorders
Not indicated
Not indicated
Not indicated
If the anamnesis
suggests homoeostasis
disorders
Not recommended
Men and women younger
Men and women older than
No recommended
than 60 years if asthmatic or 60 years of age undergoing
smoker. Indicated for those
major surgery.
older than 80 years

Blood urea nitrogen or

creatinine and
glycaemia tests for
people older than
40 years

Men older than 4045 years, Minor surgerydo not do

women older than 55 years
routinely except in patients
younger than 1 year, the elderly,
pregnant women, and immigrants
from developing countries, but
recommended for potentially
haemorrhagic surgery
People older than 60 years; Men and women older than
Not recommended routinely
obese individuals with
60 years; those older than
except in newborns, people older
body-mass index greater
40 years without a previous than 60 years, and fertile women,
than 30; smokers of more
ECG
but recommended for potentially
than 20 cigarettes per day
haemorrhagic surgery (more than
500 mL bloodloss)

Creatinine for persons

over 60 years of age

Not indicated

Not indicated

Renal function in
patients older than
40 years undergoing
a major surgery.
Dipstick urine test in
those older than
16 years

SBU=Swedish Council on Technology Assessment in Health Care. ANDEM=Agence Nationale pour le Developpment de lEvaluation Medicale (France). OSTEBA=Office
for Health Technology assessment (Spain). GR=Health Council of the Netherlands. NCCHTA=National Coordinating Centre for Health Technology assessment (UK).
GPAC=Guidelines and Protocols Advisory Committee (USA). NICE=National Institute for Clinical Excellence (UK).

Indications for preoperative tests for elective surgery in otherwise healthy patients, extracted from systematic reviews

abnormality in the absence of any clinical indication,33,5257

abnormal findings have a surprisingly small effect on
subsequent anaesthetic and surgical management.54,58,59
Drawbacks to the extensive use of routine preoperative
testing are: patients discomfort; unnecessary waiting times
for some procedures; unnecessary direct costs and emerging
opportunity costs; potential for unnecessary subsequent
tests related to false-positive abnormal findings.1,28,60
The evidence suggests that 6070% of preoperative
testing52,61,62 is unnecessary, if a proper history and physical
examination are done.63 Most studies in which the number
of preoperative tests was reduced without adversely
affecting the patients health results have been retrospective.
However, data from some prospective studies48,64 have
confirmed this finding.
Which tests should be ordered preoperatively for elective
surgery? This question, focused on patients with no
symptoms other than those relevant to the planned
operation, has been repeatedly tackled by health technology
assessment agencies since 1989,612 by means of systematic
reviews of published work and, in some cases, by expert
panels or consensus conferences. The UK National
Institute of Clinical Excellence has published a comprehensive review of the evidence on routine preoperative
testing.12 The table shows information about the indications
for preoperative tests in asymptomatic patients.
Because selective ordering of tests, according to the
patients needs, is safer and more efficient for the patient
and the health-care system, some researchers have
investigated the reasons for the internationally widespread
custom of ordering preoperative tests.7,8,26,65,66 A common

reason is protection from legal liability. However, additional

testing does not seem to provide legal protection; in most
retrospective studies a change in management has been
reported in fewer than 5% of patients with abnormal test
findings.54,58,59
Research has been done to obtain information about
attitudes and opinions of anaesthetists about the use of
preoperative assessment tests.7,26,6567 The pioneer study of
the Swedish Council on Technology Assessment in Health
Care from 19897 quantified the high degree of inappropriate
use of preoperative tests for elective surgery. It also obtained
information on the reasons or motives behind the observed
deviations from evidence-based practice through a national
survey of anaesthetists. 60% of participants agreed with the
statement there is no scientific evidence to support
widespread use of chest radiography or ECG in
asymptomatic patients. Studies in Spain26,65,66 and Italy67
had similar findings; about 70% of anaesthetists agreed that
legal liability purposes are among the reasons for most
preoperative tests requested in asymptomatic patients, and
80% of participants rejected, or judged to be doubtful, the
statement that published work supports routine
preoperative testing.

Preoperative risk assessment

Nowadays anaesthesia is safer than it used to be. In a review
of over 100 000 procedures under general and spinal
anaesthesia, patient and surgical risk factors were much
more important than anaesthetic factors in prediction of
7-day mortality.68 The anaesthetist must be aware of any
medical problem of his or her patient, in order to provide

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1751

ANAESTHESIA II

anaesthesia in the best possible conditions to maximise

safety and comfort.69 The American Society of
Anaesthesiologists classification was the first systematic
attempt to stratify the risk for patients undergoing
anaesthesia. This classification refers to mortality, based
on the general clinical impression of the severity of
systemic illnesses. The anaesthetist is principally
responsible for choosing a particular anaesthetic
technique or agent, and the selection should be based on
the type of procedure to be undertaken and on the specific
needs and risks of the patient. 69
General versus regional anaesthesia
The decision whether to apply general or regional
anaesthesia is a matter of great debate. Early data
suggested that mortality did not differ between the two
approaches.69,70 However, these studies often did not
include the postoperative period, and did not take into
account other outcomes such as time to discharge, patient
satisfaction, and time taken by the anaesthetist. Regional
anaesthetic techniques have now been improved, so older
studies may no longer be valid.69 Most studies comparing
epidural and general anaesthesia have not been adequately
designed to detect clinical differences, since the incidence
of events was low and small numbers of patients were
investigated. Nevertheless, these studies can make us
aware of any potential differences and how they affect our
decisions about the type of anaesthesia to apply.7174
Results of a meta-analysis including 141 trials and
9559 patients showed that epidural or spinal anaesthesia
reduced mortality, risk of myocardial infarction,
transfusion requirements, incidence of pneumonia, and
respiratory
depression,
compared
with
general
anaesthesia.75 Epidural anaesthesia also reduces the risk of
venous thromboembolism and the likelihood of a
thrombophilic
state,
compared
with
general
anaesthesia.7680 The precise mechanism for this reduction
of risk is not clear. Epidural anaesthesia decreases
intraoperative loss of blood, presumably because of a
reduction in arterial blood pressure and a redistribution of
bloodflow. Additionally, elimination of the need for
positive pressure ventilation reduces venous backpressure
into the surgical field. Finally, sympathetic blockade
results in increased bloodflow to the legs and feet.
Cardiac risk
The overall risk of postoperative cardiac death or major
cardiac complications is less than 6% in patients older
than 40 years undergoing major non-cardiac
operations.8182 However, the risk is not uniform, but is
increased by old age and pre-existing heart disease. The
best approach is to identify patients at high risk so that
appropriate testing and therapeutic measures can be
undertaken to reduce or eliminate the risk.83 Several
multivariate indices of risk have been developed for
patients with known or suspected cardiac disease. All
seem to be similar in their ability to predict cardiac
problems during the operation.8487
In 2002, the American College of Cardiology and the
American Heart Association jointly updated the practice
guidelines on perioperative cardiovascular assessment for
non-cardiac surgery.88 These guidelines incorporate
clinical predictors and functional status into the
preoperative risk assessment algorithm, and show how this
assessment can best be undertaken without submitting the
patient to unnecessary interventions. They emphasise that
preoperative testing should be restricted to circumstances
in which the results will affect management and outcome.
The estimation of preoperative risk should integrate

1752

Panel 3: Similarities and differences between

guidelines of the American College of
Cardiology/American Heart Association
(ACC/AHA) and the American College of
Physicians (ACP)
Similarities
Emergency surgery cases proceed directly to the operating
room without further risk stratification
Both algorithms incorporate Detsky predictors86*
Patients eventually placed into low, intermediate, or high risk
categories
Differences
ACC/AHA preoperative guideline

Presence or absence of coronary artery disease is the

first risk assessment

Clinical predictors derived from Goldman82 and Detsky86

criteria

Patients with poor functional status require stress testing

ACP preoperative guideline
Destky criteria are the first determinants of risk
stratification

Minor clinical predictors derived from Eagle87 and

Vanzetto20 criteria

ACP felt functional status not proved to be useful risk

predictor

Patients undergoing vascular surgery require stress

testing

Adapted with permission from Karnath.90 *Detsky and colleagues

reported ten variables associated with an increased risk for
perioperative cardiac complications in patients undergoing noncardiac
surgery (age older than 70 years, myocardial infarction after 6 months,
etc). Each risk factor was assigned a point score, and patients are
stratified into three risk categories based on their total score.

clinical determinants of risk: those who have had coronary

revascularisation in the previous 5 years, or a favourable
result of either coronary angiography or cardiac stress test
in the preceding 2 years, may be submitted to surgery
without further cardiac assessment. The American
College of Physicians has also published guidelines for
assessment and management of perioperative risk.89 Both
sets of preoperative guidelines are evidence-based.
Similarities and differences between the guidelines are
outlined in panel 3.
Pulmonary risk
Postoperative lung complications contribute substantially
to overall peroperative morbidity and mortality.
Pulmonary complications occur significantly more often
than cardiac complications and are associated with
significantly longer hospital stays.91,92 One broad definition
of postoperative lung complication includes an
identifiable disease or dysfunction that is clinically
relevant and adversely affects the clinical course.9396 This
classification would include several major problems such
as atelectasis, infection (bronchitis and pneumonia),
prolonged mechanical ventilation, respiratory failure,
exacerbation of underlying chronic lung disease, and
bronchospasm.
Risk factors for pulmonary complications can be
grouped as patient-related or procedure-related.
Patient-related factors
Chronic lung disease is the most important patient-related
risk factor for postoperative pulmonary complicationsit
increases the risk of postoperative complications 26 to

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ANAESTHESIA II

6 fold.17,88 Patients with asthma that is well controlled and

with a peak flow measurement of greater than 80% of that
predicted can proceed to surgery with an average risk.97
Current cigarette smokers have an increased risk for
postoperative pulmonary complications, even in the
absence of chronic lung disease. Smokers of more than
20 packs per year have a higher incidence of postoperative
pulmonary complications than those smoking fewer
cigarettes (rate of complications varied from 155% to
55%).98 The relative risk of pulmonary complications in
smokers is four times higher than in people who have not
smoked within the past 2 months.91
Changes related to morbid obesity can accentuate and
increase the risk of postoperative pulmonary
complications. However, there is a clear discrepancy
between different reports. Differences may arise, in part,
because many studies do not adequately distinguish
between obesity itself and comorbid conditions. Despite
controversy, a balanced interpretation of the evidence
suggests that obesity is not a risk factor for postoperative
pulmonary complications and should not affect patient
selection for otherwise high-risk procedures.91,99
The risk due to age alone, once corrected for
comorbidities, seems small, although data are
conflicting.100102
Surgery-related factors
The site of surgery is the most important factor in
predicting the overall risk of postoperative pulmonary
complications. The rate of complications is inversely
related to the distance of the surgical incision from the
diaphragm. Thus, the rate is substantially higher for
thoracic and upper abdominal surgery (1959% and
1617%, respectively) than for lower abdominal surgery
(05%).92,95,101,103
Surgical procedures lasting longer than 34 h are
associated with an increased risk of pulmonary
complications.100,101,104,105 General anaesthesia seems to be
associated with a higher risk of clinically important
pulmonary complications than epidural or spinal
anaesthesia. Regional nerve block is associated with
reduced risk, and should be considered, if possible, for
patients at high risk.75,95,105,106

Preoperative fasting policies

Restricted intake of food and oral fluid before general
anaesthesia has for a long time been judged vital, to
reduce the risk of regurgitation of the gastric contents.
However, preoperative fasting can impair nutrition and
hydration. Anaesthetists concerned with the well-being,
hydration, comfort, and safety of their patient try to
establish safe periods of preoperative fasting without
unnecessary starvation.107,108 Several unsystematic reviews
of the literature109114 have suggested that an overly long
fasting period (such as the traditional nothing by mouth
from midnight) might be unnecessary or even
detrimental to the patient. Any re-assessment of our
fasting policy should be welcome. A number of
associations have published new or revised guidelines
dealing with preoperative fasting inpatients undergoing
elective surgery.108111,113,114 The most comprehensive report
was published in 1999 by the American Society of
Anaesthesiologists,115 which recommended that adults
should have no clear fluids for at least 2 h, and should
take their last light meal at least 6 h before having surgery
with general anaesthesia, regional anaesthesia, or sedation
or analgesia. The routine use of gastrointestinal stimulants
to decrease the risk of pulmonary aspiration in otherwise
healthy patients was discouraged.

Children have specific preoperative needs.116,117 Infants

need regular feeding in the form of breastmilk, non-human
milk, or infant formula to prevent hunger, thirst,
hypoglycaemia, dehydration, and discomfort. As a group,
the nutritional needs of children are heterogeneous. For
instance, neonates (<1 month) are different from infants
(1 month to 1 year) and, similarly, the needs of the older
child (>1 year) are different from those of younger
children. Guidelines published by the American Society of
Anaesthesiologists recommend a 6 h fast for non-human
milk or infant formulae for neonates and infants, and a less
strict 4 h policy for breastmilk feeding, before procedures
requiring general anaesthesia, regional anaesthesia, or
monitored anaesthetic care.

Patients perspective
The anaesthetists preoperative consultation with the
patient is important to enhance trust and confidence. The
patient should know the anaesthetists name and status. If
the anaesthetist is still in training, the patient will want to
know that his or her levels of competence and experience
are appropriate, and that a senior specialist will be at
hand.13 The preoperative anaesthetic clinic is the place and
time to assess the patients fitness for surgery as well as to
discuss the most appropriate anaesthetic technique in the
light of the patients preferences, clinical state, the
operation itself, and the anaesthetists preferences and
special skills.13,118 This is also the time to help the patient
raise any doubts and questions about aspects of anaesthetic
care, and to obtain the patients explicit consent to what is
agreed. Discussion between anaesthetist and patient
should include how the patient will get to the theatre, if
there is a choice; what will be experienced in the recovery
room, or in ICU, if that is planned; what time the
operation is scheduled, with a prompt explanation if the
time slips; whether a blood transfusion is likely to be given;
how postoperative and postdischarge pain will be managed
and what choices there might be. If the patient is to wake
up with an epidural catheter or a patient-controlled
analgesia machine, intravenous line, oxygen mask, etc,
those too must be explained.3,23
Patients prefer to be seen preoperatively by the same
anaesthetist who will later anaesthetise them.118 Most
anaesthetists agree, and this practice is deemed to be a
marker of high-quality anaesthesia by the UK Association
of Anaesthetists.119,120 Finally, a postoperative visit, however
brief, by the anaesthetist, completes the patients
perception of good quality of care.

Legal issues
As far as medical responsibility is concerned, no specific
rules can be formulated, neither for anaesthetists or any
other medical specialists, nor for the different medical
acts. In October, 1987, the US Congress approved the
duties of preanaesthetic care (last modified in October,
1993), stating that the anaesthetist has a responsibility to
determine the medical condition of the patient, to develop
a plan of anaesthetic care, and to inform the patient or
guardian of this plan. These principles apply to all patients
who are going to undergo anaesthesia or a monitored
anaesthetic procedure121 and can only be modified in
special circumstances, such as an extreme emergency. The
specifications state that preoperative screening tests are
usually useful, but no systematic tests are required for
the pre-anaesthetic assessment.121 Anaesthetists, the
anaesthetic department, and medical institutions should
develop scientifically based guidelines to define the tests to
be used preoperatively. The probable contribution of each
test to the final result of surgery should be assessed

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1753

ANAESTHESIA II

individually. Every anaesthetist should, additionally, ask

for any specific tests, the results of which could affect, in
his or her opinion, the decisions to take, the risks involved,
and the ways to control the anaesthesia and surgery in
every individual case.
In France, a 1974 government circular established the
preoperative anaesthetic consultation as compulsory; the
assessment must be summarised in a preoperative report,
and done far enough in advance to allow time for all the
necessary complementary tests.122
In other countries, there are no similarly defined
regulations. In Spain, failure to do adequate preoperative
tests is judged, in view of recent court cases, to be serious
negligence, unless surgery is urgent and vital. Biochemical
and haematological tests, radiography, and an electrocardiogram have been judged, in legal cases, to be
necessary to show the true condition of the patient and to
eliminate, or at least diminish, the likelihood of treatment
failure or death.123 However, as previously mentioned,
there is much evidence that routine preoperative testing is
done, not for clinical reasons, but to prevent possible legal
claims by the patients.5

Cost of routine preoperative assessment

The broad use of routine preoperative tests generates costs
in several ways: the cost of the tests, the cost of follow-up
tests to ascertain the importance of any abnormal findings,
the need for additional consultations, and delays in
surgery.1 The costs are not negligible, and can be
substantially reduced through appropriate selective
ordering of preoperative diagnostic tests. Economic
analyses on preoperative assessment have been undertaken
in Sweden, Spain, the UK, and the USA,7,8,49,124,125 reaching
estimates of savings that could be achieved if evidencebased protocols were implemented. In Sweden the annual
costs generated by preoperative investigations were
estimated to be 726 million Swedish crowns (SEK),
including one inpatient day in 75% of all patients
undergoing surgery. With restricted criteria for
preoperative investigations, the potential savings in the
long term were calculated as SEK 100200 million per
year in 1989 (or roughly $167 000$334 000).7 In Spain
(Basque Country, 1992), the potential estimated reduction
in yearly costs of preoperative testing, according to
different uses of a scientific based protocol8 for healthy
patients needing elective surgery, was US$286 million in
1998.126 The same procedure, applied to healthy patients
undergoing elective surgery in the regional public health
system of the Canary Islands, Spain, estimated a potential
cost reduction of 213324 million in 2000 (equivalent
to $226344 million).124 Investigators from a local study
in the UK estimated conservatively that 50 000 ($83 000)
could be saved per year;49 extrapolation to all hospitals in
the National Health Service could result in savings of
several million pounds. In the USA, it has been estimated
that by ordering no laboratory tests except those indicated
by the history or physical examination, almost $100 could
be saved per patient. Since 29 million patients undergo
some form of surgical procedure annually in USA, about
$29 billion dollars could be saved in total.125 Evidence
suggests that the number of preoperative tests in hospitals
could be reduced without affecting patients outcomes,
and with substantial concomitant reduction in costs.

involvement in making decisions. Information technologies

are powerful instruments for bringing information to
patients and citizens. However, these issues also raise
questions: who is going to lead the processclinicians,
public or patients, health-care administrators, or other
institutions? Who will facilitate the cost-effective selection
of preoperative tests?
Second, there is a strong need for improvement and
increase in research and audit about preoperative
assessment. As NICE pointed out in their recent
publication,12 there is no empirical evidence for the benefits
of preoperative testing in the healthy or asymptomatic
population, since there are few comparative studies on
alternative strategies for testing. Meanwhile, the costs and
results of alternative strategies for preoperative testing
could be monitored in different groups of patients. If
safety, effectiveness, and cost-effectiveness are going to be
the leading principles in decision-making in preoperative
testing, research is needed to identify the best test strategy
and the best methods in every surgical condition. The poor
quality of study design, execution, and reporting also limit
the validity and usefulness of the available noncomparative studies. We propose that future research
projects should include a prospective case-series
investigating the effect on clinical management of routine
testing in patients older than 60 years, and a randomised
trial of outcomes and costs, etc, in patients who do or do
not have the full set of routine preoperative tests. Further
analysis of the existing evidence could include: estimates of
the predictive values or likelihood ratios for different tests
in respect of postoperative events, from studies that
contain adequate data; meta-analysis of pooled results
from existing studies and economic modelling of the
probable resource costs and patients outcomes in current
practice, by use of best estimates of test performance.
Professional societies should take the initiative to
implement and assess a continuing education system that
would effectively bring updated scientific information to
clinicians, allowing them to improve their knowledge and
use the results of research. However, the complexity of
medical decision-making on this topic means that we need
more than better research, education, training, and
scientific based guidelines. How do we address the issues
of fear and the practice of defensive medicine, and the
need for a comprehensive strategy to bring together
scientific societies, health-care administrators, public
representatives, and judicial organisations?
We thank Diego Reverte and Eduardo Tello for their valuable assistance
in the preparation of this manuscript

Conflict of interest statement

None declared.

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3
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5

The future
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active role in the decision-making process on their own
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