CADTH RAPID RESPONSE REPORT: SUMMARY OF ABSTRACTS

Pre-operative Internal
Medicine and
Anesthesiology
Consultations for Elective
Surgeries: Clinical
Effectiveness and Guidelines

Service Line: Rapid Response Service

Version: 1.0
Publication Date: July 10, 2018
Report Length: 8 Pages
 Authors: Camille Dulong, Lorna Adcock

Cite As: Pre-operative internal medicine and anesthesiology consultations for elective surgeries: Clinical effectiveness and guidelines. Ottawa: CADTH; 2018
July. (CADTH rapid response report: summary of abstracts).

Acknowledgments:

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SUMMARY OF ABSTRACTS: Pre-operative Internal Medicine and Anesthesiology for Elective Surgeries 2
 Research Questions
1. What is the clinical effectiveness of an internal medical consultation as part of the pre-
operative assessment for adults undergoing elective surgical procedures?
2. What is the clinical effectiveness for an anesthesiology consultation as part of the pre-
operative assessment for adults undergoing elective surgical procedures?

3. What are the evidence-based guidelines regarding pre-operative internal medicine and
anesthesiology consultations for adults undergoing elective surgical procedures?

Key Findings
One systemic review and three non-randomized studies were identified regarding pre-
operative consultations by anesthesiologists or physicians for elective surgeries. No
relevant evidence-based guidelines were identified.

Methods
A limited literature search was conducted on key resources including Ovid Medline,
PubMed, The Cochrane Library, University of York Centre for Reviews and Dissemination
(CRD) databases and a focused Internet search. No methodological filters were applied to
limit retrieval by publication type. The search was limited to English language documents
published between January 1, 2013 and June 22, 2018. Internet links were provided, where
available.

Selection Criteria
One reviewer screened citations and selected studies based on the inclusion criteria
presented in Table 1.

Table 1: Selection Criteria

Population Adult patients undergoing elective surgical procedures (e.g., cataract surgery, joint replacements)

Intervention Q1. Pre-operative internal medicine consultation

Q2. Pre-operative anesthesiology consultation
Q3. Pre-operative internal medicine and anesthesiology consultation
Comparator Q1: Standard of care, no pre-operative internal medicine consultation
Q2: Standard of care, no pre-operative anesthesiology consultation
Q3: None
Outcomes Q1-2: Clinical effectiveness (e.g., decreased pre-operative testing, decreased post-operative
complications), safety (e.g., adverse events before and after surgical procedures)
Q3: Guidelines
Study Designs Health Technology Assessments, Meta-analysis, Systematic Reviews, Randomized Controlled Trials,

SUMMARY OF ABSTRACTS: Pre-operative Internal Medicine and Anesthesiology for Elective Surgeries 3
 Guidelines

Results
Rapid Response reports are organized so that the higher quality evidence is presented first.
Therefore, health technology assessment reports, systematic reviews, and meta-analyses
are presented first. These are followed by randomized controlled trials, and evidence-based
guidelines.

One systematic review and three non-randomized studies were identified regarding pre-
operative internal medicine and anesthesiology consultation for elective surgeries. No
relevant health technology assessments, randomized controlled trials, or evidence-based
guidelines were identified.

Additional references of potential interest are provided in the appendix.

Overall Summary of Findings

One systematic review1 and three non-randomized studies2-4 were identified regarding
various pre-operative internal medicine and anesthesiology consultations prior to various
elective surgeries. Detailed study characteristics are provided in Table 2.

One systemic review1 was identified regarding the effectiveness of pre-operative

consultations by physicians prior to surgery from applicable randomized and non-
randomized studies. The main comparators were pre-operative assessment by
anesthesiologists, existing preoperative assessment processes or no consultations taking
place prior to surgery. Overall, the authors concluded that more research is needed to
understand the overall effects of pre-operative consultations with proper implementation
strategies for valuable informed decision-making.

One non-randomized study2 investigated whether pre-operative consultations were

associated with post-operative complications in patients who received elective abdominal
aortic aneurysm repair surgery. Researchers concluded that there were no major
differences in post-operative complications between those patients who received pre-
operative consultations and those who did not.

The second non-randomized study3 researched the benefits of cardiac consultation prior to
non-cardiac, non-vascular surgery to determine and whether those patients who received a
pre-operative consultation had a higher risk of perioperative cardiovascular events.
Researchers determined that those patients who received a pre-operative consultation did
not change the perioperative outcome of surgery or management of events.

The third non-randomized study4 determined the efficiency of preoperative consultations of

surgeons and anesthesiologists prior to cardiac surgery. The researchers concluded that
the majority of patients undergoing a pre-operative consultation did not change therapy type
or procedural practices.

SUMMARY OF ABSTRACTS: Pre-operative Internal Medicine and Anesthesiology for Elective Surgeries 4
Table 2: Summary of Findings

Author Patient Type of Type of Outcomes Results

Population consultation surgery Measured
Pham (2017)1 Patients over 18 Preoperative Not specified Length of hospital RCT (1 study)
years of age medical stay, perioperative - hospital length of stay was
undergoing consultations by mortality or reduced in patients with
elective surgery an internal morbidity, costs pre-operative
medicine and quality of life consultations
physician or - patient satisfaction was
generalist for similar among groups
elective surgical before and after hospital
patients. admission
- similar proportion of
patients did not undergo
surgery for a medical
consultation

Non-RCT (3 studies)
- no difference in surgical
cancellations or length of
hospital stay between
those patients receiving
anesthetic consultation
and those receiving
medical consultation
- The odd of complications
was greater in those
patients who received a
consultation on the day of
surgery compared to
those who received a
consultation prior to
surgery day.
Boniakowski 469 adult Consultation with Elective 30 day morbidity, - 80 patients had pre-
(2017)2 patients cardiologist abdominal aortic consult specific operative medical
undergoing aneurysm repair morbidity and consultations
elective mortality - Majority of consultations
abdominal aortic were with cardiologist
aneurysm repair - No difference in post-
surgery complications
among patients receiving
consultations and those
who did not.
Dogan (2017)3 Patients over 18 Consultation with Intermediate non- Changes in pre- - 75% of patients in
years of age cardiologist cardiac, non- operative therapy treatment group did not
who have known vascular surgery or change therapy
cardiac disease recommendations, - 2.8% did not receive
and undergoing surgery delays, surgery due to
noncardiac, complication rates consultation
nonvascular - Complication rates were
surgery similar in treatment and

SUMMARY OF ABSTRACTS: Pre-operative Internal Medicine and Anesthesiology for Elective Surgeries 5
 control groups
Treatment
group: 700
patients

Control group:
1,200 patients
Groot (2017)4 Patients over 18 Consultation with Not specified Consultation - 61% of patients had no
years of age cardiologist or reasons, change change in therapy
undergoing anesthesiologist in therapy - Cardiac murmurs was the
elective non- most common
cardiac surgery consultation reason

(n=24,274)

Non-RCT: non-randomized controlled trial; RCT: Randomized Controlled trial

References Summarized
Health Technology Assessments
No literature Identified

Systematic Reviews and Meta-analyses

1. Pham CT, Gibb CL, Fitridge RA, Karnon JD. Effectiveness of preoperative medical
consultations by internal medicine physicians: a systematic review. BMJ Open. 2017
Dec 03;7(12):e018632.
PubMed: PM29203506

Randomized Controlled Trials

No literature Identified

Non-Randomized Studies
2. Boniakowski AE, Davis FM, Phillips AR, Robinson AB, Coleman DM, Henke PK. The
effects of preoperative cardiology consultation prior to elective abdominal aortic
aneurysm repair on patient morbidity. Vascular. 2017 Aug;25(4):390-395.
PubMed: PM28059000

3. Dogan V, Biteker M, Ozlek E, Ozlek B, Basaran O, Yildirim B, et al. Impact of pre-

operative cardiology consultation prior to intermediate-risk surgical procedures.
European Journal of Clinical Investigation. 2017 Aug 07.
PubMed: PM28783209

4. Groot MW, Spronk A, Hoeks SE, Stolker RJ, van Lier F. The preoperative cardiology
consultation: indications and risk modification. Netherlands Heart Journal. 2017
Nov;25(11):629-633.
PubMed: PM28567710

Guidelines and Recommendations

No literature identified

SUMMARY OF ABSTRACTS: Pre-operative Internal Medicine and Anesthesiology for Elective Surgeries 6
 Appendix — Further Information
Previous CADTH Reports
5. Timing of pre-operative testing and assessment: guidelines [Internet]. Ottawa: CADTH;
2016 [cited 2018 Jul 5]. (CADTH Rapid response report: summary of abstracts).
Available from: https://www.cadth.ca/timing-pre-operative-testing-and-assessment-
guidelines-0

Non-Randomized Studies
Elective surgery not specified in abstract
6. Davis FM, Park YJ, Grey SF, Boniakowski AE, Mansour MA, Jain KM, et al. The
clinical impact of cardiology consultation prior to major vascular surgery. Annals of
Surgery. 2018 Jan;267(1):189-195.
PubMed: PM29240607

7. Stitgen A, Poludnianyk K, Dulaney-Cripe E, Markert R, Prayson M. Adherence to

preoperative cardiac clearance guidelines in hip fracture patients. Journal of
Orthopaedic Trauma. 2015 Nov;29(11):500-3.
PubMed: PM26165267

8. Thilen SR, Bryson CL, Reid RJ, Wijeysundera DN, Weaver EM, Treggiari MM.
Patterns of preoperative consultation and surgical specialty in an integrated healthcare
system. Anesthesiology. 2013 May;118(5):1028-37.
PubMed: PM23503373

Qualitative Studies
9. Vetter TR, Boudreaux AM, Ponce BA, Barman J, Crump SJ. Development of a
preoperative patient clearance and consultation screening questionnaire. Anesthesia
and Analgesia. 2016 Dec;123(6):1453-1457.
PubMed: PM27529323

10. Mendes FF, Machado EL, de Oliveira M, Brasil FR, Eizerik G, Teloken P. Preoperative
evaluation: screening using a questionnaire. Brazilian Journal of Anesthesiology. 2013
Jul-Aug;63(4):347-51.
PubMed: PM24565242

Pre-operative consultation not specified in abstract

11. Dakik HA, Kobrossi S, Tamim H. The yield of routine pre-operative cardiovascular
evaluation in stable patients scheduled for elective non-cardiac surgery. International
Journal of Cardiology. 2015;186:325-7.
PubMed: PM25880321

12. Shillcutt SK, Walsh DP, Thomas WR, Lyden E, Brakke TR, Ellis SJ, et al. The
implementation of a Preoperative Transthoracic Echocardiography Consult Service by
anesthesiologists. Anesthesia and Analgesia. 2017 Nov;125(5):1479-1481.
PubMed: PM28640783

SUMMARY OF ABSTRACTS: Pre-operative Internal Medicine and Anesthesiology for Elective Surgeries 7
 13. Cohn SL. Preoperative evaluation for noncardiac surgery. Annals of Internal Medicine.
2016 Dec 06;165(11):ITC81-ITC96.
PubMed: PM27919097

14. Lakshminarasimhachar A, Smetana GW. Preoperative evaluation: estimation of

pulmonary risk. Anesthesiology Clinics. 2016 Mar;34(1):71-88.
PubMed: PM26927740

Guidelines and Recommendations – Systematic Methods Not Described

15. Deutsche Gesellschaft fur Anasthesiologie und I, Deutsche Gesellschaft fur Innere M,
Deutsche Gesellschaft fur C, Zwissler B. Preoperative evaluation of adult patients
before elective, noncardiothoracic surgery : joint recommendation of the German
Society of Anesthesiology and Intensive Care Medicine, the German Society of
Surgery, and the German Society of Internal Medicine. Anaesthesist. 2017 Nov 02.
PubMed:PM29098342

16. Dobson G, Chong M, Chow L, Flexman A, Kurrek M, Laflamme C, et al. Guidelines to

the practice of anesthesia - revised edition 2018. Canadian Journal of Anesthesia
[Internet], 2018 [cited 2018 Jul 5]; 65:76-104. Available from:
http://www.cas.ca/English/Page/Files/97_Guidelines-2018.pdf
See section: Pre-anesthetic period, page 83

Review Articles
17. Lambrinos, A. Preoperative consultations: a rapid review [Internet]. Toronto: Health
Quality Ontario; 2014 March [cited 2018 Jul 5]. Available from:
http://www.hqontario.ca/Portals/0/Documents/evidence/rapid-reviews/pre-op-consult-
140305-en.pdf
See section: Results of Rapid Review, page 9

Additional References
18. Patel NJ, Paterick ZR, Schmidt M, Jamil Tajik A, Paterick TE. Cardiology consultation
for non-cardiac surgery: medical and legal explorations for clinicians. International
Journal of Cardiology. 2018 Sep 15; 267:74-76.
PubMed: PM29859708

19. Thilen SR, Wijeysundera DN, Treggiari MM. Preoperative consultations.

Anesthesiology Clinics . 2016 Mar;34(1):17-33.
PubMed: PM26927736

20. Probasco J, Sahin B, Tran T, Chung TH, Rosenthal LS, Mari Z, et al. The preoperative
neurological evaluation. Neurohospitalist. 2013 Oct;3(4):209-20.
PubMed: PM24198903

SUMMARY OF ABSTRACTS: Pre-operative Internal Medicine and Anesthesiology for Elective Surgeries 8