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Preoperative tests overview

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Preoperative tests

About

What is covered

This pathway covers tests that are carried out when someone is due to have planned (elective) surgery. They may be performed by doctors or nurses in hospitals, preoperative assessment clinics or, in some cases, in GP surgeries or health centres.
The pathway makes recommendations on the circumstances in which the tests should be done, not done, or considered – for example, whether a certain test is recommended may depend on the patient's age or how serious the planned operation is.
The appropriateness of testing depends on the characteristics of patients, for example their age, comorbidities and the type of surgery planned. Therefore, the recommendations are set out in tables, which include the type of surgery, common chronic illnesses and age.

How to use this pathway

The recommendations in this pathway are in the form of 'look-up' tables. The tables are set out by surgery grade and ASA grade, with age categories shown across the top of each table. For a patient with more than one comorbidity, follow the recommendations in all relevant tables.

Using the tables

Recommendations on tests are categorised as follows:
'No': Test not recommended
'Consider': Test to be considered (the value of carrying out a preoperative test is not known, and may depend on specific patient characteristics)
'Yes': Test recommended

Updates

Updates to this pathway

3 September 2014 2014 Minor maintenance updates.

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Short Text

The use of routine preoperative tests for elective surgery

What is covered

This pathway covers tests that are carried out when someone is due to have planned (elective) surgery. They may be performed by doctors or nurses in hospitals, preoperative assessment clinics or, in some cases, in GP surgeries or health centres.
The pathway makes recommendations on the circumstances in which the tests should be done, not done, or considered – for example, whether a certain test is recommended may depend on the patient's age or how serious the planned operation is.
The appropriateness of testing depends on the characteristics of patients, for example their age, comorbidities and the type of surgery planned. Therefore, the recommendations are set out in tables, which include the type of surgery, common chronic illnesses and age.

How to use this pathway

The recommendations in this pathway are in the form of 'look-up' tables. The tables are set out by surgery grade and ASA grade, with age categories shown across the top of each table. For a patient with more than one comorbidity, follow the recommendations in all relevant tables.

Using the tables

Recommendations on tests are categorised as follows:
'No': Test not recommended
'Consider': Test to be considered (the value of carrying out a preoperative test is not known, and may depend on specific patient characteristics)
'Yes': Test recommended

Updates

Updates to this pathway

3 September 2014 2014 Minor maintenance updates.

Sources

NICE guidance

The NICE guidance that was used to create the pathway.
Preoperative tests. NICE clinical guideline 3 (2003)

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Education and learning

NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.
Preoperative tests: clinical guideline poster

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.
Routine tests carried out before a planned surgical operation

Pathway information

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Supporting information

Characterisation of mild and severe comorbidity, corresponding to ASA grades 2 and 3, for cardiovascular, respiratory and renal comorbidities

ASA grade 2 : 'A patient with mild systemic disease'
ASA grade 3 : 'A patient with severe` systemic disease
Cardiovascular disease
Current angina
Occasional use of glyceryl trinitrate spray (2–3 times per month). Does not include patients with unstable angina who would be ASA 3
Regular use of glyceryl trinitrate spray (2–3 times per week) or unstable angina
Exercise tolerance
Not limiting activity
Limiting activity
Hypertension
Well controlled using a single anti-hypertensive medication
Not well controlled, requiring multiple anti-hypertensive medications
Diabetes
Well controlled, no obvious diabetic complications
Not well controlled, diabetic complications (e.g. claudication, impaired renal function)
Previous coronary revascularisation
Not directly relevant – depends on current signs and symptoms
Not directly relevant – depends on current signs and symptoms
Respiratory disease
Chronic obstructive airways disease/chronic obstructive pulmonary disease
Productive cough; wheeze well controlled by inhalers; occasional episodes of acute chest infection
Breathlessness on minimal exertion (for example, stair climbing, carrying shopping); distressingly wheezy much of the time; several episodes per year of acute chest infection
Asthma
Well controlled by medications/inhalers; not limiting life-style
Poorly controlled; limiting life-style; on high dose of inhaler/oral steroids; frequent hospital admission on account of asthma exacerbation
Renal disease
Elevated creatinine (creatinine > 100 µmol/litre and < 200 µmol/litre); some dietary restrictions
Documented poor renal function (creatinine > 200 µmol/litre); regular dialysis programme, (peritoneal or haemodialysis)
Further examples are available in appendix 2 of the full guideline

Glossary

American Society of Anesthesiologists
ASA (American Society of Anesthesiologists) grades are a simple scale describing fitness to undergo an anaesthetic. The ASA clearly states that it does not endorse any elaboration of these definitions. However, anaesthetists in the UK often qualify (or interpret) these grades as relating to functional capacity – that is, comorbidity that does not (ASA grade 2) or that does (ASA grade 3) limit a patient's activity.
For example, excision of lesion of skin; drainage of breast abscess.
For example, primary repair of inguinal hernia; excision of varicose vein(s) of leg; tonsillectomy/adenotonsillectomy; knee arthroscopy..
For example, total abdominal hysterectomy; endoscopic resection of prostate; lumbar discectomy; thyroidectomy.
For example, total joint replacement; lung operations; colonic resection; radical neck dissection.
ASA (American Society of Anesthesiologists) grade 1 means a normal healthy patient (without any clinically important comorbidity and without a clinically significant past/present medical history).
ASA (American Society of Anesthesiologists) grade 2 means a patient with mild systemic disease.
ASA (American Society of Anesthesiologists) grade 3 means a patient with severe systemic disease.
ASA (American Society of Anesthesiologists) grade 4 means a patient with severe systemic disease that is a constant threat to life.
Electrocardiogram

Paths in this pathway

Pathway created: March 2014 Last updated: September 2014

© NICE 2015

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