Evidence-Based Practice of Anesthesiology

Chapter 2: Update on Preprocedure Testing

 Preop CXR:
o no difference in postop complications/outcome in pts who received preop CXR (most
abnormalities were chronic, no effect on periop outcome or anesthetic management;
exception: acute CHF, acute pneumonia)
o ASA Task Force: although CXR abnormalities are more frequent in older pts who have
COPD, stable cardiac dx, smoke, or resolved URI, there is no evidence that results of
CXR change outcome/management of pt
 Preop PFT:
o In some cases, preop PFT can predict mortality/long term ventilation – severe scoliosis, MG,
multiple sclerosis with restrictive disease, pts with AAA + severe COPD
 Preop UA/Culture: not recommended routinely in asymptomatic patients
o ASA Task Force: preanestheisa UA not recommended except procedures such as
prosthesis implantation and urologic procedures where UTI sx exist
 Preop Coags: no routine screening b/c no impact on management/outcome. Can order targeted
studies in patients where coagulation dysfunction expected.
 Preop Hct/CBC: Anesthesia Task Force says routine hct not warranted; consider type of surgery, age,
hx of liver dx, anemia, bleeding, other heme disorders
 Preop CMP/Glucose: ASA Task Force – consider renal dysfunction, liver dysfunction, meds before
ordering (Inc Cr > 2 can inc cardiac complications postop) as well as insulin dependent DM).
 In institutions that do not require pregnancy history, menstrual history is critical

Chapter 3: Preop Screening Clinic

 Preop testing = inc patient satisfaction, dec lab testing unnecessarily, dec day of cancellations, OR
delays; esp important in complex conditions/surgeries
 At minimum, preop lab testing should be directed by anesthesiologists (dec testing)

Chapter 4: Preop 12-Lead EKG

 Ideal preop screening test: inexpensive, high positive and negative predictive values, add to info from
history/PX, change periop decision making to prevent periop complications
 Extensive preop testing can lead to false positives, expensive/invasive workups, unnecessary delays
and cancellations
 Patient factors suggesting EKG: known hx/risk factors for CVD, poor functional status, new physical
exam findings suggestive of CVD
 Patient population data:
o Asymptomatic patients – most studies show that routine EKG changes management or
predictors adverse outcome in <2% of patients
o Risk factors – certain diseases predict adverse periop cardiovascular complications 
ischemic heart disease, CHF, cerebrovascular disease, DM, CKD.
o Five major risk factors for periop ischemia – CAD, HTN, DM, use of digoxin, LVH on EKG
o LVH or ST segment depression on EKG better predicted postop cardiac mortality than
clinical risk factors (myocardial ischemia, infarction, angina, or DM)
o Cardiovascular mortality inc in higher riks surgery (Esp vascular surgery)
 ASA Task Force: consider significant cardiovascular disease, respiratory dx, and type of invasiveness
of surgery for EKG order. Or indicated in pts with known cardiovascular risk factors (within 6 mos of
surgery).
 Also in pts with low/unknown functional capacity undergoing intermediate or high risk sx. Or patients
who are taking meds that can affect EKG result.
 ACC/AHA Guidelines: (within 30d of surgery)
o Class I (benefit > risk): at least one clinical risk factor (ischemic heart dsiaese, prior CHF,
cerebrovascular dx, DM, renal insufficiency) undergoing vascular surgery (evidence: B)
 o Class I: known CAD, PAD, CVA undergoing intermediate risk procedures (intraperitoneal,
intrathoracic, carotid endoarterectomy, head and neck, ortho, prostate) (Evidence: C)
o Class IIa (benefit > risk but more studies needed): reasonable in pts with no clinical risk
factors undergoing vascular surgery (Evidence: B)
o Class IIb (benefit = or > risk): may be reasonable in pts with at least one clinical risk
factor undergoing intermediate risk surgery (Evidence B)
o Class III (risk > benefit or not indicated): asymptomatic persons undergoing low risk
procedures

Chapter 5: Routine Preop Pregnancy Testing

 Introduction:
o Concerns about anesthesia in pregnant women include: 1) trigger preterm labor 2)
teratogenic effects of drugs intraop 3) alterations in uteroplacental blood flow, maternal
hypoxia, acidosis 4) questionable CNS defects
o Potential of teratogenicity and intrauterine fetal death in first trimester. Inc riks of
spontaneous abortion in women undergoing GA during 1 st/2nd trimester.
o Premature labor more likely in 3rd trimester.
 Mandatory pregnancy testing in childbearing age is institution based. ASA Task Force – pt should
be offered by not required to undergo test. Literature is inadequate to inform patients on whether
anesthesia causes harmful effects early in pregnancy.