Excerpt

In 2003, NICE first issued guidance on the use of routine preoperative tests for elective surgery (NICE CG3). The guideline evaluated the practice of routinely performing preoperative diagnostic tests for elective surgery in healthy and comorbid populations.

Much of the evidence in the original guideline was inconclusive and a formal consensus survey about the appropriateness of preoperative testing was conducted to inform the recommendations made by the Guideline Development Group (GDG). Since the guideline was issued there has been a reduction in the ordering of routine tests for young, healthy patients undergoing minor surgery, however there remains a concern that unnecessary tests continue to be requested.

Excessive testing can cause significant anxiety in patients, delays in treatment and unnecessary, costly, and possibly harmful treatments. Moreover, even genuinely abnormal results often do not result in any significant change in perioperative management in relatively healthy patients.

In 2012/13 the NHS in England completed 10.6 million operations compared with 6.61 million in 2002/03: an increase of 60%. Therefore even a small percentage of unnecessary testing can affect large numbers of patients.

Preoperative tests provide a benefit where they yield additional information that cannot be obtained from a patient history and physical examination alone, and also where they:

• help to assess the risk to the patient and inform discussions about the risks and benefits of surgery
• allow the patient's clinical management to be altered, if necessary, in order to reduce possible harm or increase the benefit of surgery
• help to predict postoperative complications
• establish a baseline measurement for later reference where potentially abnormal postoperative test results cannot be adequately interpreted in isolation.⁴⁸

Since the original NICE guideline was issued in 2003, preoperative assessment has changed radically. In the past preoperative tests were requested by junior medical staff in anticipation of, and readiness for, an assessment by an anaesthetist shortly before surgery. Currently most patients are seen well in advance of surgery in a preoperative assessment clinic, where a structured history and targeted examination are performed by experienced nursing staff according to protocols developed by anaesthetists. Early preoperative assessment by nurses can determine the patient’s functional status, which remains a major determinant of perioperative risk, and has been shown to reduce the number of investigations which are requested.

In light of these developments, it is clear that an update to the guideline is required. However a review of newly published evidence highlighted the paucity of high quality studies evaluating the benefit of routine preoperative testing in adults undergoing elective non-cardiac surgery. For this reason a modified Delphi consensus survey was undertaken to re-evaluate the usage of routine preoperative tests amongst clinicians, which helped the GDG update and revise the recommendations made in 2003.

A number of other developments have occurred since 2003 and are reflected in the scope of this update. Random blood glucose has been largely abandoned in the detection and optimisation of diabetes mellitus and replaced by glycated haemoglobin (HbA1c). Several new preoperative tests are increasingly used in patients undergoing elective surgery (for example non-invasive cardiac stress tests, cardiopulmonary exercise testing, polysomnography). It is hoped that these tests may provide more information on the best form of perioperative management and assist the prediction of postoperative complications in certain higher risk patients.

In a final change from the 2003 guideline, children, and patients undergoing cardiothoracic procedures or neurosurgery, are populations not covered by this update because their management is highly specialised and specialist guidance exists elsewhere.

Contents

• National Clinical Guideline Centre
• Acknowledgements
• 1. Guideline summary
  • 1.1. Full list of recommendations
  • 1.2. Key research recommendations
  • 1.3. How this clinical guideline was updated
• 2. Introduction
• 3. Development of the guideline
  • 3.1. What is a NICE clinical guideline?
  • 3.2. Remit
  • 3.3. Who developed this guideline?
  • 3.4. General principles
• 4. Methods
  • 4.1. Developing the review questions and outcomes
  • 4.2. Health technology assessment (HTA) update
  • 4.3. Delphi consensus survey
  • 4.4. Summary of methodological approach for each preoperative test
  • 4.5. Searching for evidence
  • 4.6. Evidence of effectiveness
  • 4.7. Evidence of cost-effectiveness
  • 4.8. Developing recommendations
• 5. Resting electrocardiography
  • 5.1. Introduction
  • 5.2. Review question (intervention): What is the clinical- and cost-effectiveness of using resting electrocardiography (ECG) as a preoperative test in improving patient outcomes in adults and young people undergoing non-cardiac elective surgery?
  • 5.3. Clinical evidence
  • 5.4. Review question (prognostic): Does resting ECG predict prognosis (patient outcomes after surgery) in adults and young people undergoing non-cardiac elective surgery?
  • 5.5. Clinical evidence
  • 5.6. Economic evidence
  • 5.7. Evidence statements
  • 5.8. Delphi survey results
  • 5.9. Recommendations and link to evidence
• 6. Resting echocardiography
  • 6.1. Introduction
  • 6.2. Review question (intervention): What is the usefulness of resting echocardiography as a preoperative test in altering perioperative management for adults and young people with mild to severe comorbidities undergoing major or complex elective surgery?
  • 6.3. Clinical evidence
  • 6.4. Economic evidence
  • 6.5. Evidence statements
  • 6.6. Recommendations and link to evidence
• 7. Cardiopulmonary exercise testing (CPET)
  • 7.1. Introduction
  • 7.2. Review question (intervention): What is the clinical- and cost-effectiveness of using cardiopulmonary exercise test (CPET) as a preoperative test in improving patient outcomes in adults and young people with mild to severe comorbidities undergoing major or complex non-cardiac elective surgery?
  • 7.3. Clinical evidence
  • 7.4. Review question (prognostic): Does cardiopulmonary exercise testing (CPET) predict prognosis (patient outcomes after surgery) in adults and young people with mild to severe comorbidities undergoing major or complex non-cardiac elective surgery?
  • 7.5. Clinical evidence
  • 7.6. Economic evidence
  • 7.7. Evidence statements
  • 7.8. Recommendations and link to evidence
• 8. Chest X-ray
  • 8.1. Introduction
  • 8.2. Delphi survey results
  • 8.3. Economic evidence
  • 8.4. Recommendations and link to evidence
• 9. Polysomnography
  • 9.1. Introduction
  • 9.2. Review question (intervention): What is the clinical- and cost-effectiveness of using polysomnography as a preoperative test (to detect obstructive sleep apnoea) in improving patient outcomes in adults and young people with obesity undergoing major or complex elective non-cardiac surgery?
  • 9.3. Clinical evidence
  • 9.4. Review question (prognostic): Does polysomnography predict prognosis (patient outcomes after surgery) in adults and young people with obesity undergoing major or complex elective non-cardiac surgery?
  • 9.5. Clinical evidence
  • 9.6. Economic evidence
  • 9.7. Evidence statements
  • 9.8. Recommendations and link to evidence
• 10. Lung function tests
  • 10.1. Introduction
  • 10.2. Health technology assessment 2012
  • 10.3. Review question (intervention): What is the usefulness of lung function tests in predicting outcome or altering perioperative management for adults and young people undergoing any type of elective surgery?
  • 10.4. Clinical evidence
  • 10.5. Review question (prognostic): Do lung function tests (also including blood gas analysis) predict prognosis (patient outcomes after surgery) in adults and young people ASA 1–4 undergoing any type of elective non-cardiac surgery?
  • 10.6. Clinical evidence
  • 10.7. Economic evidence
  • 10.8. Evidence statements
  • 10.9. Delphi survey results
  • 10.10. Recommendations and link to evidence
• 11. Full blood count test
  • 11.1. Introduction
  • 11.2. Health technology assessment 2012
  • 11.3. Review question (intervention): What is the usefulness of full blood count (haemoglobin, white blood cell count and platelet count) in predicting outcome or altering perioperative management for adults and young people undergoing any type of elective surgery?
  • 11.4. Clinical evidence
  • 11.5. Review question (prognostic): Do full blood count tests (haemoglobin, white blood cell count and platelet count) predict prognosis (patient outcomes after surgery) in adults and young people ASA 1–4 undergoing any type of elective non-cardiac surgery?
  • 11.6. Clinical evidence
  • 11.7. Economic evidence
  • 11.8. Evidence statements
  • 11.9. Delphi survey results
  • 11.10. Recommendations and link to evidence
• 12. Kidney function tests
  • 12.1. Introduction
  • 12.2. Health technology assessment 2012
  • 12.3. Review question (intervention): What is the usefulness of kidney function tests (urea, estimated glomerular filtration rate and electrolyte tests) in predicting outcome or altering perioperative management for adults and young people undergoing any type of elective non-cardiac surgery?
  • 12.4. Clinical evidence
  • 12.5. Review question (prognostic): Do kidney function tests (urea, estimated glomerular filtration rate and electrolyte tests) predict prognosis (patient outcomes after surgery) in adults and young people ASA 1–4 undergoing any type of elective non-cardiac surgery?
  • 12.6. Clinical evidence
  • 12.7. Economic evidence
  • 12.8. Evidence statements
  • 12.9. Delphi survey results
  • 12.10. Recommendations and link to evidence
• 13. Haemostasis tests
  • 13.1. Introduction
  • 13.2. Delphi survey results
  • 13.3. Economic evidence
  • 13.4. Recommendations and link to evidence
• 14. Glycated haemoglobin (HbA1c) test
  • 14.1. HbA1c testing in people with diabetes
  • 14.2. HbA1c testing in people without diagnosed diabetes
• 15. Sickle cell disease or sickle cell trait tests
  • 15.1. Introduction
  • 15.2. Delphi survey results
  • 15.3. Economic evidence
  • 15.4. Recommendations and link to evidence
• 16. Urinalysis
  • 16.1. Introduction
  • 16.2. Delphi survey results
  • 16.3. Economic evidence
  • 16.4. Recommendations and link to evidence
• 17. Pregnancy testing
  • 17.1. Introduction
  • 17.2. Delphi survey results
  • 17.3. Economic evidence
  • 17.4. Recommendations and link to evidence
• 18. Reference list
• 19. Acronyms and abbreviations
• 20. Glossary
• Appendices
  • Appendix A. Scope
  • Appendix B. Declarations of interest
  • Appendix C. Clinical review protocols
  • Appendix D. Economic review protocol
  • Appendix E. Clinical article selection
  • Appendix F. Economic article selection
  • Appendix G. Literature search strategies
  • Appendix H. Clinical evidence tables
  • Appendix I. GRADE tables
  • Appendix J. Forest plots
  • Appendix K. Excluded clinical studies
  • Appendix L. Delphi survey method and results
  • Appendix M. Economic considerations for Delphi
  • Appendix N. Research recommendations
  • Appendix O. CG3 Full guideline (2003)
  • Appendix P. NICE technical team

Developed by the National Guideline Centre, hosted by the Royal College of Physicians

Disclaimer: Healthcare professionals are expected to take NICE clinical guidelines fully into account when exercising their clinical judgement. However, the guidance does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of each patient, in consultation with the patient and, where appropriate, their guardian or carer.