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.
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Avoid ordering cardiac stress testing for asymptomatic patients prior to undergoing low to intermediate risk non-cardiac surgery.
Unnecessary cardiac stress testing increases the patient risk profile for the intended surgery by exposing the patient to the inherent complications of the investigation employed. A further consequence may be the invasive treatment of asymptomatic non-critical coronary disease leading to further patient risk and delay of surgery.
Cardiac stress testing should be reserved for symptomatic patients who would normally qualify for the investigation regardless of the need for an operation, and asymptomatic patients at high risk of coronary disease with a significant risk of major adverse cardiac events due to co-morbidity or the high risk nature of the surgery
Supporting evidence
- Devereaux PJ, Sessler DI. Cardiac complications in patients undergoing major noncardiac surgery. N Engl J Med 2015;373:2258-69.
- Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;64:e77-137.
- Kristensen SD, Knuuti J, Saraste A, et al. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J 2014;35:2383-431.
- Wijeysundera DN, Beattie WS, Austin PC, et al. Non-invasive cardiac stress testing before elective major non-cardiac surgery: population based cohort study. BMJ 2010;340:b5526.
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