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Anaesthesia II
Preoperative assessment
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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ANAESTHESIA II
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
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ANAESTHESIA II
SBU7
ANDEM9
OSTEBA8
GR10
NCCHTA6
GPAC11
NICE12
Chest radiography
Electrocardiogram
Blood count
Haemostasis
Other analyses
Not recommended
Not indicated
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
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
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ANAESTHESIA II
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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References
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5
The future
First, the public and patients are willing to play a more
active role in the decision-making process on their own
health.127129 Some health-care systems are working to
empower citizens and patients to improve the value of their
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