Australian and New Zealand College of Anaesthetists
The Australian and New Zealand College of Anaesthetists (ANZCA) ), including the Faculty of Pain Medicine, is one of Australasia's largest specialist medical colleges and is responsible for the training, examination and specialist accreditation of anaesthetists and pain medicine specialists and for the standards of clinical practice.
1.
Avoid routinely performing preoperative blood investigations, chest X-ray or spirometry prior to surgery, but instead order in response to patient factors, symptoms and signs, disease, or planned surgery.
Preoperative testing aims to provide results that will guide preoperative, intraoperative and postoperative care, particularly results that may change the intended plans. Preoperative laboratory blood investigations in asymptomatic patients undergoing low risk surgery are of little value in detecting abnormalities that will alter patient management and/or improve outcomes. Even when minor abnormalities in laboratory values are detected in asymptomatic patients, adverse outcomes are rare. Clinical history and physical examination should be used to determine the need for laboratory blood testing before low risk surgery; that is, test on the basis of patient and surgical factors.
Similarly, in the absence of positive clinical findings, or significant history, abnormal chest X-ray or spirometry results are uncommon. Positive results, in the absence of symptoms or signs, are unlikely to significantly influence perioperative management. Although the diagnostic yield of preoperative chest X-rays increases with age, most abnormalities reflect chronic disorders and when performed in asymptomatic patients do not impact on anaesthetic management or perioperative outcome. In other words, chest X-ray results are not predictive of postoperative pulmonary complications in most patients. Preoperative chest X-rays may, however, be appropriate prior to cardiac and thoracic surgery and as part of oncological evaluation. There is insufficient evidence to support spirometry as an appropriate tool to stratify risk of postoperative adverse respiratory events. Spirometry may be of value in lung resection surgery, unexplained dyspnoea, and uncertainty about whether known airflow obstruction is optimally reduced. Rather than performing these investigations routinely for surgery, decisions should be individualised, depending on patient history and examination.
Further, for all of these tests, lack of symptoms, signs or known disease increases the likelihood that positive findings are false positives exposing patients to the risks of unnecessary further testing.
Supporting evidence
- Merchant R, Chartrand D, Dain S, et al. Guidelines to the practice of anesthesia – revised edition 2016. Can J Anesth 2016;63:86-112. http://www.cas.ca/English/Page... L, Lindsley K, Tielsch J, et al. Routine preoperative medical testing for cataract surgery. Cochrane Database Syst Rev 2012;3:CD007293.
- Benarroch-Gampel J, Sheffield KM, Duncan CB, et al. Preoperative laboratory testing in patients undergoing elective, lowrisk ambulatory surgery. Ann Surg 2012;256(3):518–28.
- Joo HS, Wong J, Naik VN, Savoldelli GL. The value of screening preoperative chest x-rays: a systematic review. Can J Anesth 2005;52:568–74.
- De Hert S, Imberger G, Carlisle J, et al. Preoperative evaluation of the adult patient undergoing non-cardiac surgery: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol 2011;28(10):684-722.
- Johansson T, Fritsch G, Flamm M, et al. Effectiveness of non-cardiac preoperative testing in non-cardiac elective surgery: a systematic review. British Journal of Anaesthesia 2013;110(6):926-39.
- O’Neill F, Carter E, Pink N, Smith I. Routine preoperative tests for elective surgery: summary of updated NICE guidance. BMJ 2016;353:i3292.
- Smetana GW, Lawrence VA, Cornell JE. Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians. Ann Intern Med 2006;144:581-95.
How this list was made
ANZCA’s Safety and Quality Committee established a working group that developed a preliminary list of 10 anaesthetic-related practices that, based on clinical evidence, may have possible limited benefit, no benefit or may potentially cause harm to patients. Using an on-line survey tool, all ANZCA Fellows and trainees were invited to rank these recommendations and provide relevant comments. This engagement facilitated consensus and informed Fellows and trainees about ANZCA’s involvement with the Choosing Wisely campaign.
Recommendation 1-5
ANZCA’s final list of 5 Choosing Wisely recommendations deliberately supports the clinician’s judgements and emphasises the importance of considering patient and surgical factors in decision making; in particular, as regards the selection of necessary preoperative testing and appropriate facilities for all patients and the expected outcomes and goals of care for the medically frail.
Recommendation 6
The ANZCA Safety and Quality Committee proposed that the college submit a statement to Choosing Wisely Australia as part of analgesic stewardship.
The committee agreed that the existing document development group (DDG) for ANZCA and FPM professional document PS41(G) Position statement on acute pain management would be well-placed to develop the Choosing Wisely recommendation. It was also agreed that an expert group should be formed comprising members with expertise in obstetric anaesthesia, paediatric anaesthesia, and paediatric pain medicine, to provide input to the Choosing Wisely recommendation.
The draft document was circulated for consultation in February 2022 with the following stakeholders: ANZCA national/regional committees, NZ national committee, FPM committees, Australian Society of Anaesthetists (ASA), New Zealand Society of Anaesthetists (NZSA), ANZCA Special Interest Groups (SIG) including Obstetric SIG and Acute Pain SIG, and Society for Paediatric Anaesthesia in New Zealand and Australia (SPANZA). The one-month consultation period finished in March 2022. After consideration of the feedback received during this period, the DDG made further amendments to the CW recommendation. The ANZCA Safety and Quality Committee approved the post consultation version and sent to Choosing Wisely for consideration by the Representative Panel. Feedback obtained from that consultation was then collated and discussed at the Board meeting before some minor amendments were made to clarify the explanation section of the recommendation.Download ANZCA Recommendations
Related recommendations
- 1 Avoid routinely performing preoperative blood investigations, chest X-ray or spirometry prior to surgery, but instead order in response to patient factors, symptoms and signs, disease, or planned surgery.
- 2 Avoid ordering cardiac stress testing for asymptomatic patients prior to undergoing low to intermediate risk non-cardiac surgery.
- 3 Avoid administering packed red blood cells (blood transfusion) to a young healthy patient with a haemoglobin of ≥70g/L who does not have on-going blood loss, unless the patient is symptomatic or haemodynamically unstable.
- 4 Avoid initiating anaesthesia for patients with limited life expectancy, at high risk of death or severely impaired functional recovery, without discussing expected outcomes and goals of care.
- 5 Avoid initiating anaesthesia for patients with significant co-morbidities without adequate, timely preoperative assessment and postoperative facilities to meet their needs.
- 6 Avoid routine prescription of slow-release opioids in the management of acute pain unless there is a demonstrated need, close monitoring is available and a cessation plan is in place