Practice Guidelines

Routine preoperative tests for elective surgery: summary of updated NICE guidance

BMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i3292 (Published 14 July 2016) Cite this as: BMJ 2016;354:i3292

Infographic: Recommended tests before elective surgery

A visual summary of tests to offer, according to the patient's physical status and the complexity of the planned surgical procedure

  1. Frank O’Neill, senior research fellow1,
  2. Eleanor Carter, trainee specialist advisor, specialty registrar in anaesthesia1 2,
  3. Natalie Pink, project manager1,
  4. Ian Smith, chair of Guideline Development Group, senior lecturer in anaesthesia1 3
  1. 1National Clinical Guideline Centre
  2. 2Cambridge University Hospitals NHS Trust
  3. 3University Hospitals of North Midlands
  1. Correspondence to: N Pink natalie.pink{at}rcplondon.ac.uk

What you need to know

  • Excessive preoperative testing may cause anxiety, delays in treatment, and further unnecessary treatments without influencing outcome or changing perioperative management

  • Include the results of tests undertaken in primary care when referring people for surgical consultation to avoid unnecessary repetition

  • Patients who are relatively healthy or having relatively non-invasive surgery may require few, if any, preoperative tests

  • Before ordering lung function tests or an echocardiogram, consider discussing the patient with an anaesthetist

Routine preoperative investigations are expensive, labour intensive, and of questionable value, especially as they may contribute to morbidity or cause additional delays due to spurious results.1 2 3 4 5 Preoperative assessment clinics are usually based in the hospital where surgery will occur and are run according to local policies and procedures. The number of elective surgeries within the NHS has risen: 10.6 million operations took place in 2012-13 compared with 6.61 million in 2002-03. Even if only a small percentage of tests are unnecessary, large numbers of patients will be affected.

Elective surgeries are those scheduled in advance and excludes medical emergencies. The guidance covers patients over 16 years old. It includes healthy people and those who have one or more of the following comorbidities—cardiovascular, respiratory, renal, diabetes, and obesity—who are having minor, intermediate, or major or complex elective surgery (box 1). Individuals are classified by the severity of disease using the American Society of Anesthesiologists (ASA) classification system (box 2), and extent of surgery to guide testing.

Box 1: Surgery grades and examples

Minor
  • Excising skin lesion

  • Draining breast abscess

Intermediate
  • Primary repair of inguinal hernia

  • Excising varicose veins in the leg

  • Tonsillectomy or adenotonsillectomy

  • Knee arthroscopy

Major or complex
  • Total abdominal hysterectomy

  • Endoscopic resection of prostate

  • Lumbar discectomy

  • Thyroidectomy

  • Total joint replacement

  • Lung operations

  • Colonic resection

  • Radical neck dissection

  • There is no widely accepted and validated system for classifying the stressfulness of operative procedures, so the …

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