ABSTRACT
The preoperative visit is one of the cornerstones of good anesthetic practice. It gives the anesthetist an opportunity to assess the patient, optimize medical treatment, discuss anesthetic management, gain consent, and decide upon appropriate anesthetic equipment before the patient arrives in theater (Table 1). In the past, preoperative assessment was often performed in a haphazard fashion. Inexperienced junior members of the surgical team were tasked with organizing an assessment of fitness for surgery. A large number of investigations were ordered to satisfy ‘‘testhungry’’ anesthetists and prevent cancellations. These tests were often unnecessary and frequently ignored. The lack of evidence for the benefits of these ‘‘routine’’ preoperative tests and their excessive cost led to the development of more structured assessment processes in the form of clinical guidelines (1). Many of these are dependent upon expert opinion and, even in the case of National Institute for Clinical Excellence (NICE) guidelines, consensus cannot always be reached. This confusion is the result of a dearth of well-constructed studies to enable evidence-based recommendations. Where studies into preoperative investigations have been conducted, they are usually aimed at risk stratification. While this information is clearly of benefit, there is little data on the ability of preoperative tests to change practice
Table 1 Goals of Preoperative Assessment
Identification of medical conditions Initiation of further investigations Optimization of medical treatment Formulation of an anesthetic plan in terms of: Regional vs. general anesthesia, or both Premedication Monitoring Intravenous access Airway management Postoperative management
Discussion of risks and gaining informed consent
and improve outcome. Consequently, conflicting advice in preoperative assessment guidelines is widespread. This variation may be influenced by differences in the physiological and psychological characteristics of the local population, the medicolegal environment, and socioeconomic factors. In the guideline for cardiac assessment produced by the American College of Cardiology and American Heart Association, a much larger array of tests are recommended for patients with ischemic heart disease than would be expected in standard British practice (2).
