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Guideline Summary
Guideline Title
Preoperative evaluation.
Bibliographic Source(s)
Danielson D, Bjork K, Card R, Foreman J, Harper C, Roemer R, Stultz J, Sypura W, Thompson S, Webb B. Preoperative evaluation. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012 Jul. 61 p. [36 references]
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Institute for Clinical Systems Improvement (ICSI). Preoperative evaluation. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2010 Jun. 40 p.

FDA Warning/Regulatory Alert

Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which important revised regulatory and/or warning information has been released.

  • November 13, 2013 – Over-the-Counter Topical Antiseptic Products External Web Site Policy: The U.S. Food and Drug Administration (FDA) is requesting label and packaging changes to enhance the safe use of certain over-the-counter (OTC) topical antiseptic products. This request is the result of their ongoing evaluation of infrequent but continuing reports of infections resulting from antiseptic products labeled for preoperative or preinjection skin preparation. When used properly, topical antiseptics are safe and effective products to reduce the number of bacteria on patients' skin prior to surgery or injections. However, most often, contamination of topical antiseptics occurs when organisms are introduced into the product by users. Therefore, health care professionals and patients should follow all label directions to decrease the chances of infection.

Scope

Disease/Condition(s)

Conditions that require elective, non-high-risk operative procedures

Guideline Category
Evaluation
Risk Assessment
Clinical Specialty
Anesthesiology
Family Practice
Internal Medicine
Nursing
Pediatrics
Surgery
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Health Care Providers
Health Plans
Hospitals
Managed Care Organizations
Nurses
Physician Assistants
Physicians
Guideline Objective(s)
  • To describe appropriate evaluation for elective, non-high-risk operative procedures for adult and pediatric patients
  • To increase the percentage of complete preoperative history and physical examinations obtained for patients two years of age and older undergoing elective, non-high-risk surgery and eliminate diagnostic tests performed without clinical indications
  • To increase the percentage of patients two years of age and older undergoing elective, non-high-risk surgery who receive appropriate management of stable comorbidities prior to procedure
  • To eliminate canceled or delayed elective, non-high-risk surgical procedures for patients two years of age and older due to incomplete preoperative history and physical examination and ineffective communication between clinicians
Target Population

Patients two years of age and older under evaluation for elective, non-high-risk operative procedures

Note: Pediatric patients for whom this guideline is intended are those between the ages of 2 and 15 years. Patients over age 15 are considered adults for the purposes of this guideline.

Interventions and Practices Considered
  1. Preoperative health assessment, including medical history, physical examination, and comprehensive medication review
  2. Further evaluation as appropriate if preoperative assessment is abnormal (e.g., electrocardiogram, tests for hemoglobin and potassium, coagulation studies, chest x-ray); pregnancy test if indicated
  3. Determining if patient is considered high risk (cardiac and non-cardiovascular)
  4. Management of stable comorbidities such as diabetes, sleep apnea, and conditions requiring use of beta-blockers, coronary artery stent placement, or anti-platelet therapy
  5. Measures to prevent perioperative infective endocarditis (antibiotic prophylaxis)
  6. Management of medications (drugs to continue and drugs to stop)
  7. Nicotine cessation
  8. Communicating results to facility where procedure will be conducted and patient education (e.g., results of preoperative testing and instructions on fasting requirements, showering and shaving, and venous thromboembolism prophylaxis)
  9. Immediate pre-procedure assessment
Major Outcomes Considered
  • Risk of cardiac or other operative complications
  • Identification of electrocardiographic abnormalities
  • Morbidity and mortality due to surgery

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

A consistent and defined process is used for literature search and review for the development and revision of Institute for Clinical Systems Improvement (ICSI) guidelines. Literature search terms for the current revision of this document include: preoperative and/or preoperative assessment with obstructive sleep apnea, statins, beta-blockers, STOP-bang, medications, NSAIDS, vitamins, supplements, risk, risk factors, surgical site infection, surgical risk, anesthesia risk, comorbidities, and communication. The timeframe used for the new literature search for this revision was 2009-2012.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Quality of Evidence and Strength of Recommendations

Category Quality Definitions Strong Recommendation Weak Recommendation
High Quality Evidence Further research is very unlikely to change the work group's confidence in the estimate of effect. The work group is confident that the desirable effects of adhering to this recommendation outweigh the undesirable effects. This is a strong recommendation for or against. This applies to most patients. The work group recognizes that the evidence, though of high quality, shows a balance between estimates of harms and benefits. The best action will depend on local circumstances, patient values or preferences.
Medium Quality Evidence Further research is likely to have an important impact on the work group's confidence in the estimate of effect and may change the estimate. The work group is confident that the benefits outweigh the risks but recognizes that the evidence has limitations. Further evidence may impact this recommendation. This is a recommendation that likely applies to most patients. The work group recognizes that there is a balance between harms and benefits, based on moderate quality evidence, or that there is uncertainty about the estimates of the harms and benefits of the proposed intervention that may be affected by new evidence. Alternative approaches will likely be better for some patients under some circumstances.
Low Quality Evidence Further research is very likely to have an important impact on the work group's confidence in the estimate of effect and is likely to change. The estimate or any estimate of effect is very uncertain. The work group feels that the evidence consistently indicates the benefit of this action outweighs the harms. This recommendation might change when higher quality evidence becomes available. The work group recognizes that there is significant uncertainty about the best estimates of benefits and harms.

Supporting Literature

In addition to evidence that is graded and used to formulate recommendations, additional pieces of literature will be used to direct the reader to other topics of interest. This literature is not given an evidence grade and is instead used as a reference for its associated topic. These citations are noted by (author, year) and are found in the references section of the original guideline document.

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Guideline Development Process

A work group consisting of 6 to 12 members that includes physicians, nurses, pharmacists, other healthcare professionals relevant to the topic, and an Institute for Clinical Systems Improvement (ICSI) staff facilitator develops each document. Ordinarily, one of the physicians will be the leader. Most work group members are recruited from ICSI member organizations, but if there is expertise not represented by ICSI members, 1 or 2 work group members may be recruited from medical groups, hospitals or other organizations that are not members of ICSI.

The work group will meet for 7 to 8 three-hour meetings to develop the guideline. A literature search and review is performed and the work group members, under the coordination of the ICSI staff facilitator, develop the algorithm and write the annotations and literature citations.

Once the final draft copy of the guideline is developed, the guideline goes to the ICSI members for critical review.

Rating Scheme for the Strength of the Recommendations

See the "Rating Scheme for the Strength of the Evidence" field.

Cost Analysis

The guideline developers reviewed published cost analyses.

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

Critical Review Process

The purpose of Critical Review is to provide an opportunity for the clinicians in the member groups to review the science behind the recommendations and focus on the content of the guideline. Critical review also provides an opportunity for clinicians in each group to come to consensus on feedback they wish to give the work group and to consider changes needed across systems in their organization to implement the guideline.

All member organizations are expected to respond to critical review guidelines. Critical review of guidelines is a criterion for continued membership within the Institute for Clinical Systems Improvement (ICSI).

After the critical review period, the guideline work group reconvenes to review the comments and make changes as appropriate. The work group prepares a written response to all comments.

Approval

Each guideline, order set, and protocol is approved by the appropriate steering committee. There is one steering committee each for Respiratory, Cardiovascular, Women's Health, and Preventive Services. The Committee for Evidence-based Practice approves guidelines, order sets, and protocols not associated with a particular category. The steering committees review and approve each guideline based on the following:

  • Member comments have been addressed reasonably.
  • There is consensus among all ICSI member organizations on the content of the document.
  • Within the knowledge of the reviewer, the scientific recommendations within the document are current.
  • When evidence for a particular recommendation in the guideline has not been well established, the work group identifies consensus statements that were developed based on community standard of practice and work group expert opinion.
  • Either a critical review has been carried out, or to the extent of the knowledge of the reviewer, the changes proposed are sufficiently familiar and sufficiently agreed upon by the users that a new round of critical review is not needed.

Once the guideline, order set, or protocol has been approved, it is posted on the ICSI Web site and released to members for use. Guidelines, order sets, and protocols are reviewed regularly and revised, if warranted.

Revision Process of Existing Guidelines

ICSI scientific documents are revised every 12 to 36 months as indicated by changes in clinical practice and literature. ICSI checks with every work group 6 months before the schedule revision to determine if there have been changes in the literature significant enough to cause the document to be revised earlier or later than scheduled.

ICSI staff working with the work group to identify any pertinent clinical trials, meta-analysis, systematic reviews, or regulatory statements and other professional guidelines conduct a literature search. The work group will meet for 1 to 2 three-hour meetings to review the literature, respond to member organization comments, and revise the document as appropriate.

A second review by members is indicated if there are changes or additions to the document that would be unfamiliar or unacceptable to member organizations. If a review by members is not needed, the document goes to the appropriate steering committee for approval according to the criteria outlined above.

Recommendations

Major Recommendations

Note from the National Guideline Clearinghouse (NGC) and the Institute for Clinical Systems Improvement (ICSI): For a description of what has changed since the previous version of this guidance, refer to Summary of Changes Report – July 2012 External Web Site Policy. In addition, in 2011 ICSI began its transition to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system as a method of assessing the quality of evidence and writing recommendations.

The recommendations for preoperative evaluation are presented in the form of a table with a list of evidence-based recommendations and an algorithm with 11 components, accompanied by detailed annotations. An algorithm is provided in the original guideline document External Web Site Policy at the ICSI Web site for Preoperative Evaluation. Clinical highlights and selected annotations (numbered to correspond with the algorithm) follow.

Quality of evidence (Low Quality, Moderate Quality, and High Quality) and strength of recommendation (Weak or Strong) definitions are repeated at the end of the "Major Recommendations" field).

Clinical Highlights

  • Provide a comprehensive preoperative basic health assessment for all patients undergoing a diagnostic or therapeutic procedure as defined in the guideline. (Annotation #4; Aims #1, 3)
  • Most laboratory and diagnostic tests including electrocardiograms are not necessary with routine procedures unless a specific indication is present. (Annotation #6; Aim #1)
  • Patient education and instruction strongly influence perioperative outcomes (e.g., medication management, apnea screening, nicotine cessation and surgical site infection). (Annotation #8; Aim #2)

Preoperative Evaluation Algorithm Annotations

  1. Decision to Perform Elective Procedure

    The decision to perform an elective procedure is usually made at the time of the surgical or other consultation. There may be exceptions; for example, a non-surgical procedure such as a computed tomography-guided lung biopsy might be arranged by the primary physician after discussion with a radiologist.

    A member of the surgical team explains to the patient the procedure and the need for anesthesia and may obtain and document consent. These issues must be addressed but are not part of this guideline.

    Patient education is essential to assist the patient in preparing for the surgical procedure and to reinforce compliance to preoperative instructions. The "Patient Preoperative Guide," an optional tool, may assist in these efforts. Please refer to Appendix A, "Patient Preoperative Guide," in the original guideline document.

    Patients undergoing high-risk or emergent procedures are beyond the scope of this guideline as a more extensive evaluation and risk assessment may be needed.

    The technical aspects of shared decision-making to proceed with surgery are beyond the scope of this guideline, but are included as a reference in Appendix F, "ICSI Shared Decision-Making Model," of the original guideline document.

  1. High-Risk Procedure?

    High-risk referred to here is primarily surgical procedure-derived risk of cardiac/pulmonary complications. Cardiovascular complications are more common in adults, and pulmonary complications are more common in children. If a procedure presents other specific non-cardiovascular associated high-risk, that risk and its stratification are beyond the scope of this guideline and need to be individually addressed by the surgeon. For example, a neurosurgical procedure may have an inherent elevated hemostasis risk.

    The above scheme only distinguishes between high-risk procedures and non-high-risk procedures. Certainly further refinement is possible as illustrated in one reported study (high-, intermediate- and low-cardiac-risk categories). This guideline work group took the approach of universal precautions, meaning that, if all high-risk procedures are excluded and all patients are adequately evaluated preoperatively, there is questionable gain in further procedural risk stratification.

    Although it is ultimately up to the involved clinicians to determine whether a particular procedure is considered to be high risk, it is generally accepted that most high-risk (greater than five percent combined incidence of cardiac death and non-fatal myocardial infarction) procedures fall into the following categories:

    • Major cardiac and non-cardiac thoracic procedures
    • Aortic and other major vascular procedures
    • Anticipated prolonged surgical procedures (usually greater than four hours) associated with large fluid shifts and/or blood loss (e.g., pancreas resection [Whipple procedure], major spinal surgery)

    In general, the type of anesthesia employed (general anesthesia versus spinal anesthesia) and duration of surgery have not been shown to be independently correlated with risk of complication.

  1. Preoperative Basic Health Assessment

    Recommendations:

    • A preoperative basic health assessment must be completed for all patients undergoing a diagnostic or therapeutic procedure (exceptions are addressed below) [Low Quality Evidence, Strong Recommendation].
    • Include risk factors for development of surgical site infections as part of the complete preoperative basic health assessment [Low Quality Evidence, Strong Recommendation].

    This guideline follows the basic premise that diagnostic tests (laboratory and x-ray) are not part of the preoperative basic health assessment.

    A complete preoperative basic health assessment includes:

    • Medical History
      • Indication for surgical procedure
      • Allergies and intolerances to medications, anesthesia, or other agents (specify reaction type)
      • Known medical problems
      • Surgical history
      • Trauma (major)
      • Current medications (prescription, over-the-counter medications, herbal and dietary supplements)
      • Risk factors for development of surgical site infection (e.g., smoking, diabetes, obesity, malnutrition, chronic skin disease)
      • Malnutrition is a known risk factor for decreased wound healing and increased surgical site infections. A basic nutritional assessment should be considered on all patients undergoing surgery, with lab verification reserved for those patients felt to be at risk.
      • Focused review of issues pertinent to the planned anesthesia and procedure:
        • Current status of pertinent known medical problems
        • Cardiac status
        • Pulmonary status
        • Functional status (the ability to perform at four or more medical emergency treatments [METs])
        • Hemostasis status (personal or family history of abnormal bleeding)
        • Possibility of severe (symptomatic) anemia
        • Possibility of pregnancy
        • Past personal or family history of anesthesia problems
        • Smoking, alcohol history, and illicit drugs
    • Physical Examination
      • Weight, height, and body mass index
      • Vital signs - blood pressure, pulse (rate and regularity), respiratory rate
      • Cardiac
      • Pulmonary
      • Other pertinent exam

    A sample preoperative form is attached in Appendix B, "Preoperative Forms – Adult and Pediatric," in the original guideline document.

    Basic Health Assessment Applications

    A preoperative basic health assessment as outlined in this guideline is required for all patients undergoing a diagnostic or therapeutic procedure, regardless of setting, except for:

    • Otherwise healthy patients receiving peripheral nerve blocks, local or topical anesthesia, and/or no more than 50% nitrous oxide/oxygen and no other sedative or analgesic agents administered by any route — for example, most dental procedures or excision of simple skin lesions.
    • Patients receiving "sedation/analgesia" (often referred to as "conscious sedation") defined as "a state that allows patients to tolerate unpleasant procedures while maintaining adequate cardiopulmonary function and the ability to respond purposefully to verbal command and/or tactile stimulation." This technique is commonly used for procedures such as endoscopy and bronchoscopy, and may be used for certain surgical procedures. Patient history must be available at the time they receive sedation/analgesia.

    Although the preoperative basic health assessment is not specifically required for sedation/analgesia and other minor procedures, a limited preoperative assessment and documentation is required and mandated by the Joint Commission and other organizations.

    The preoperative basic health assessment is usually done within 30 days of the planned procedure. However, a review of the current history and focused physical examination will occur at the surgical facility prior to the procedure.

    The patient needs to be aware that the preoperative assessment is not a substitute for preventive services, but the preoperative evaluation may be used as an opportunity to address preventive services.

    This is another opportune time to initiate or augment patient education efforts including the use of the patient preoperative guide. Please see Appendix A," Patient Preoperative Guide," in the original guideline document. Refer to the NGC summary of the ICSI Perioperative Protocol.

  1. Abnormal Findings Pertinent to Preoperative Evaluation?

    Abnormal findings are results from the preoperative basic health assessment that suggest that further evaluation is needed in order to assess or optimize surgical/anesthesia risk and care. Examples of abnormal findings are a patient taking medication such as a diuretic, suggesting the need for a recent potassium level; the presence of chest pains; or a markedly elevated blood pressure. Examples of abnormal findings in pediatric patients include a current upper respiratory infection or asthma.

    There may be other abnormal findings that, although not relevant to the planned procedure, may be relevant to the patient's general health. The evaluation of these findings would follow standard medical practice and is beyond the scope of the guideline. This type of finding would not necessarily need to delay the procedure.

    Preoperative questionnaires to assist in determining abnormal findings for adult and pediatric patients are attached in Appendix C, "Preoperative Questionnaire—Adults," and Appendix D, "Preoperative Questionnaire—Pediatrics," in the original guideline document.

  1. Further Evaluation Performed and Evaluated for Surgical/Anesthesia Risk

    Recommendations:

    • If clinical circumstances suggest a potential bleeding problem, clinician should perform coagulation studies [Low Quality Evidence, Strong Recommendation].
    • Perform electrocardiogram for all patients age 65 and over, within one year prior to procedure [Low Quality Evidence, Weak Recommendation].
    • Electrocardiograms are not indicated, regardless of age, for those patients having cataract surgery [High Quality Evidence, Strong Recommendation].
    • Preoperative electrocardiograms are not recommended for patients undergoing other minimal risk procedures, unless medical history/assessment indicate high-risk patient [High Quality Evidence, Strong Recommendation].
    • A preoperative hemoglobin should only be obtained based on the patient's underlying medical condition and the planned procedure [Low Quality Evidence, Strong Recommendation].

    Further evaluation may be as simple as asking a few more questions, performing further physical examination, or ordering a laboratory or radiological exam. More in-depth evaluations may be needed, such as a consultation or cardiac stress testing.

    The type and extent of evaluation required should be guided by standard medical practice with consideration of the patient's underlying medical condition and the planned procedure. For example, some clinicians will order a baseline preoperative hemoglobin if significant blood loss is anticipated. Recommendations for this type of testing are beyond the scope of the guideline.

    Abnormal findings might trigger a need for a specific laboratory or other diagnostic test. Note that most laboratory and diagnostic tests (e.g., hemoglobin, potassium, coagulation studies, chest x-rays, electrocardiograms) are not routinely necessary unless a specific indication is present.

    Test Consider Performing If:
    Electrocardiogram
    • No electrocardiogram within last year in patients (regardless of age) with history of diabetes, hypertension, chest pain, congestive heart failure, smoking, peripheral vascular disease, inability to exercise, or morbid obesity.
    • At time of preoperative evaluation, patient has any intercurrent cardiovascular symptoms or signs and symptoms of new or unstable cardiac disease.
    Coagulation studies
    • Patient has a known history of coagulation abnormalities or recent history suggesting coagulation problems or is on anticoagulants.
    • Patient needs anticoagulation post-operatively (where a baseline may be needed).
    Hemoglobin
    • Patient has a history of anemia or history suggesting recent blood loss or anemia.
    Potassium
    • Patient is taking digoxin, diuretics, angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers.
    Chest x-ray
    • Patient has signs or symptoms suggesting new or unstable cardiopulmonary disease.
    Pregnancy Test
    • Patient is of child-bearing age and
      1. Is sexually active and history suggests possible pregnancy, e.g., delayed menstruation

        or

      2. Patient is concerned about possible pregnancy

        or

      3. The possibility of pregnancy is uncertain

    Refer to the original guideline document for more information on electrocardiogram, coagulation studies, hemoglobin, and pregnancy.

  1. High-Risk Patient?

    High-risk in this context refers particularly to the risk of cardiac complications in adults and airway complications in pediatric patients. However, non-cardiac conditions in adults and cardiac conditions in pediatric patients, along with other conditions such as coagulopathy, severe symptomatic anemia, pregnancy, and anesthesia reactions can be significant problems in selected patients. These conditions also need to be screened for as indicated in the preoperative basic health assessment. The specifics of risk stratification for non-cardiac conditions relative to an individual patient are beyond the scope of this guideline.

    The final determination of a patient as high risk occurs after review and analysis of the preoperative basic health assessment and any other adjunctive evaluation that was indicated for surgical/anesthesia risk. The determination is the responsibility of involved clinicians, including the primary care physician, surgeon, and anesthesiologist.

    Although it is ultimately the responsibility of involved clinicians to determine whether a particular patient is considered to be at high risk of complication, it is generally accepted that patients at high risk usually fall into the following categories:

    Cardiovascular

    • Unstable coronary syndromes
      • Recent* myocardial infarction
      • Unstable or severe angina

        *Recent can mean less than 30 days if post-myocardial infarction cardiac risk stratification is completed and patient determined to be low-risk; three to six months if formal risk stratification not done.

    • Decompensated congestive heart failure
    • Significant arrhythmias
      • High-grade atrioventricular block
      • Symptomatic ventricular arrhythmias in the presence of underlying heart disease
      • Supraventricular arrhythmias with uncontrolled ventricular rate
    • Severe valvular disease
    • Severe hypertension (diastolic consistently over 110, systolic consistently over 180)
    • Congenital heart abnormalities

    Non-Cardiovascular

    • Pulmonary disease, severe or symptomatic (e.g., chronic obstructive pulmonary disease requiring oxygen, respiratory distress at rest, asthma, cystic fibrosis)
    • Poorly controlled symptomatic diabetes (causing symptoms with attendant risk of hypovolemia)
    • Symptomatic anemia
  1. Management of Stable Comorbidities

    Continuation or cessation of medications in the immediate preoperative period is an essential part of the instructions given to the patient. Controversy exists in this area, although some evidence supports specific instructions in selected situations. The following are the recommendations of the work group. Where those recommendations have the weight of literature or guidelines from a national organization, selected references are noted in the original guideline document.

    Antithrombotic Therapy

    General recommendations regarding antithrombotic therapy are beyond the scope of this document, given the different classes of medications and the variety of situations for which they are used. (This document does, however, make recommendations regarding coronary stents and anti-platelet therapy; see below). For patients on antithrombotic therapy, please refer to the NGC summary of the ICSI guideline Antithrombotic Therapy Supplement for information regarding management.

    Beta-Blockers

    Recommendations:

    • Beta-blockers should be continued throughout the perioperative period for any patient who is already taking beta-blockers [Low Quality Evidence, Strong Recommendation].
    • Vascular surgery patients with a positive stress test should be initiated on beta-blockers in the perioperative period if they are not already taking them [Low Quality Evidence, Strong Recommendation].

    For the remainder of patients undergoing non-cardiac surgery, the use of beta-blockers in the perioperative period remains controversial. This controversy includes the following questions:

    • Which patient/procedure combinations need beta-blockers?
    • When should beta-blockers be initiated?
    • What is the dosage?
    • How long should beta-blockers be continued postoperatively?

    In general, the work group recommends:

    • Consider initiation of beta 1 selective blocker therapy for patients undergoing moderate to high-risk procedure AND who have two or more Revised Cardiac Risk Index (RCRI) factors. Refer to table in the original guideline document for RCRI list.
    • Begin the beta-blocker two weeks or more preoperatively, if possible.
    • Continue postoperatively for a month or more.

    Coronary Artery Stent Placement (Recent) and Anti-platelet Therapy (Aspirin, Clopidogrel, Prasugrel, and Ticlopidine)

    Recommendations:

    • Surgery should be avoided for at least four weeks after bare-metal stent implantation [Low Quality Evidence, Strong Recommendation].
    • Surgery should be avoided for one year after drug-eluting stent implantation [Low Quality Evidence, Strong Recommendation].
    • If surgery cannot be avoided during the above time periods, dual anti-platelet therapy should be continued perioperatively unless strongly contraindicated (i.e., procedures associated with high-risk for clinically significant bleeding, such as intracranial surgery) [Low Quality Evidence, Strong Recommendation].
    • If deemed necessary to discontinue clopidogrel/prasugrel/ticlopidine preoperatively, aspirin should be continued, if at all possible, in the perioperative period in order to reduce cardiac risk [Low Quality Evidence, Strong Recommendation].

    There is clear evidence that premature discontinuation of dual platelet therapy (aspirin combined with clopidogrel, prasugrel or ticlopidine) for any reason after coronary stent placement results in a marked increased risk of myocardial infarction or death. Therefore, a critical part of the preoperative evaluation of a patient who fits this description is a careful assessment of the benefits of the surgery itself and surgical bleeding risk versus the high risk of cardiac events if platelet therapy is reduced or stopped prematurely. Important stent considerations include how long the coronary stent has been in place and whether the stent is a bare-metal stent versus a drug-eluting stent.

    The pre-surgical evaluation of risk in this group of patients may require discussion with cardiology and surgery.

    General principles are as follows:

    • For patients with bare-metal stents, surgery should be avoided for at least four weeks after stenting.
    • For patients with drug-eluting stents, surgery should be avoided for one year after stenting.
    • If surgery cannot be avoided during the above time periods, dual anti-platelet therapy should be continued perioperatively unless strongly contraindicated such as intracranial surgery. Alternatives such as stopping the clopidogrel/prasugrel/ticlopidine and continuing aspirin or stopping all ant-iplatelet therapy may be necessary to reduce bleeding risk but are associated with increased cardiac risk.
    • If anti-platelet therapy is held prior to surgery, it should be restarted as soon as possible following surgery.

    Preoperative Management of Chronic Medications

    The work group acknowledges there is very little evidence surrounding the management of chronic medications perioperatively. Decisions about medications to be administered or held around the time of surgery are driven instead by case reports, expert opinion, and pharmacokinetic principles. A table has been developed for health care clinicians to help guide decisions about preoperative medication management (see Appendix E, "Drugs to Stop/Drugs to Continue," in the original guideline document).

    It is extremely important to obtain a complete and accurate list of all of the patient's medications, both prescription and non-prescription (making sure to include herbal or "natural" medicines). Optimally, this would occur at least a week before surgery.

    As medication management is driven largely by expert opinion, communication with the consulting anesthesiologist may be warranted if there are specific questions or concerns related to continuing or discontinuing medications around the time of surgery.

    Drugs to Continue

    Recommendations:

    • Clinicians should complete a thorough medication review (including all prescription, non-prescription and herbal or "natural" medicines) with the patient at least one week before surgery if at all possible [Low Quality Evidence, Strong Recommendation].
    • Medications contributing to the patient's current state of medical homeostasis should be continued (i.e., neuro/psych medications, anti-arrhythmic agents, human immunodeficiency virus [HIV] medications, statins, antihypertensives) with the exception of the medication groups listed below in "Drugs to Stop" [Low Quality Evidence, Strong Recommendation].

    In general, most prescription drugs can be continued up to the time of procedure, and will not interfere with any anesthetic plan. The drugs to be continued should certainly include medications where discontinuation puts the patient at risk. Anti-Parkinson's drugs, anti-seizure medications, anti-hypertensives, statins, cardiac rhythm drugs, and all analgesics fall into this category. The possible exceptions to the above are the angiotensin-converting enzyme (ACE) inhibitors and the angiotensin receptor blockers, although cessation of these remains controversial.

    Factors for Consideration

    Many of the drugs typically continued in order to sustain medical homeostasis in the patient are not continued without risk, especially considering potential drug interactions with anesthesia agents. Factors to consider are the following points if the patient is taking any of the medications listed. See the table on page 19 of the original guideline document for factors to consider if the patient is taking any of the medications listed in the table.

    Drugs to Stop

    Recommendations:

    • Medications that do not contribute to the medical homeostasis of the patient should be discontinued in preparation for surgery (i.e., non-prescription medications, herbal or "natural" medicines and over-the-counter supplements) [Low Quality Evidence, Weak Recommendation].
    • Medications that may increase risk of adverse outcomes perioperatively should generally be discontinued according to pharmacokinetic principles (i.e., non-steroidal anti-inflammatory drugs [NSAIDs], angiotensin converting enzyme inhibitor [ACEI]/angiotensin receptor blocker [ARB], diabetes medications, anticoagulants, osteoporosis agents, hormone therapy) [Low Quality Evidence, Weak Recommendation].
    • Inadvertent administration of medications the night before or morning of surgery is not typically an indication for cancellation of surgical procedures [Low Quality Evidence, Weak Recommendation].

    Those drugs with a potential to cause harm to the patient in the perioperative period should be discontinued. For example, NSAIDS and other anticoagulants increase bleed risk perioperatively. Some herbal supplements can prolong bleeding time, as well as increase blood pressure. The effects of many herbal supplements are unknown, as the actual composition of each product varies widely (these products are not regulated by the U.S. Food and Drug Administration). Hormone replacement therapies and some osteoporosis agents may promote clot development perioperatively. Optimal time frame for discontinuation before surgery depends on the pharmacokinetic profile of the medication, as well as individual patient factors. In general, it takes a drug approximately five half-lives to be completely eliminated from the system.

    There is currently controversy surrounding the potential risk of bleeding associated with the use of omega-3 fatty acids. The risk of bleeding is theoretical, and stems from the biochemical role of omega-3 fatty acids in eicosanoid metabolism. A summary reviewed research including patients undergoing major vascular surgery, currently taking omega-3 fatty acids, with or without additional anticoagulants. The results of this summary led the author to conclude that omega-3 fatty acids do not increase the risk of significant clinical bleeding episodes. Based on the information provided by this summary, inadvertent administration of omega-3 fatty acids the night before or the day of surgery does not warrant cancellation of the scheduled procedure.

    Diabetic medications and antithrombotics are dealt with elsewhere in this document. Non-prescription drugs, supplements and vitamins can be held the morning of surgery.

    Prevention of Perioperative Infective Endocarditis

    Recommendations:

    • Patients diagnosed with certain cardiac conditions and undergoing specified procedures should receive appropriate antibiotic prophylaxis [Low Quality Evidence, Strong Recommendation].

    Cardiac conditions for which antibiotic prophylaxis is recommended:

    • Prosthetic cardiac valve or prosthetic material used for cardiac valve repair
    • Previous infective endocarditis
    • Cardiac transplantation recipients who develop valvulopathy
    • Congenital heart disease (CHD)
      • Unrepaired cyanotic CHD, including palliative shunts and conduits
      • Completely repaired congenital heart defect with prosthetic material or device, placed by surgery or by catheter intervention, during the first six months after the procedure
      • Repaired CHD with residual defects at site or adjacent to site of a prosthetic patch or prosthetic device

    For patients with any of these conditions, prophylaxis is recommended only before:

    • All dental procedures that involve manipulation of gingival tissue or of the periapical region of teeth, or perforation of oral mucosa
    • An invasive procedure of the respiratory tract that involves incision or biopsy of respiratory tract mucosa, including tonsillectomy and adenoidectomy, and
    • Any surgical procedures that involve infected skin or musculoskeletal structures.

    Regimens for antibiotics: these are to be given as a single dose 30 to 60 minutes prior to procedure (pediatric dosing is in parentheses):

    • Amoxicillin – 2 g oral (50 mg/kg)
    • Ampicillin – 2 g intramuscular or intravenous (50 mg/kg)
    • Cefazolin or ceftriaxone – 1 g intramuscular or intravenous (50 mg/kg)
    • Cephalexin – 2 g oral (50 mg/kg)
    • Clindamycin – 600 mg oral; intramuscular or intravenous (20 mg/kg)
    • Azithromycin or clarithromycin – 500 mg oral (15 mg/kg)

    Diabetic Management

    Recommendations:

    • Individual patient evaluation and instruction should occur prior to surgery to avoid extremes in glucose levels [Low Quality Evidence, Strong Recommendation].
    • Doses of long-acting insulins (glargine, NPH, etc.) may be decreased by up to 50% preoperatively [Low Quality Evidence, Strong Recommendation].
    • Oral diabetic agents should be held preoperatively [Low Quality Evidence, Strong Recommendation].
    • Short-acting, sliding scale insulin should be used to treat high blood glucose values in patients holding their normal anti-diabetic medications [Low Quality Evidence, Strong Recommendation].

    Given the complexities and wide variety of methodologies employed to achieve glycemic control, individual patient evaluation and instruction are required prior to surgery to avoid extremes in glucose levels.

    Hypoglycemia can lead to harmful effects including cardiac rhythm problems and cognitive deficits. Hypoglycemia is difficult to detect in the sedated patient.

    Hyperglycemia can lead to problems with electrolytes, acidosis, and fluid balance and is associated with poor wound healing, increased risk of infection, as well as higher mortality in hospitalized patients.

    The optimal glucose range needs further investigation.

    General principles are as follows:

    • Mild hyperglycemia is preferable to hypoglycemia.
    • Patients should not take oral hypoglycemics on the day of the procedure.
    • Patient should not take short-acting insulin bolus the morning of procedure.
    • Long-acting or intermediate insulin may be used to cover basal insulin needs; 50% to 100% of usual dose is often reasonable.
    • Insulin pumps should be continued but only to provide basal insulin coverage.
    • The details of the insulin recommendations are influenced by the insulin sensitivity of the patient, the timing of the procedure, the length of the procedure, and how long the patient will need to take nothing by mouth following the procedure.

    Sleep Apnea

    Recommendations:

    • Clinicians should remind patients who have been formally diagnosed with obstructive sleep apnea and have an oral appliance or continuous positive airway pressure equipment to bring their appliance or equipment with them on the operative day [High Quality Evidence, Strong Recommendation].
    • Clinicians should screen patients for sleep apnea or sleep apnea symptoms and communicate to surgical team [Low Quality Evidence, Strong Recommendation].

    Obstructive sleep apnea increases the patient's risk for intra- and postoperative complications. Patients with a diagnosis of obstructive sleep apnea often have oral appliances or continuous positive airway pressure equipment and should be reminded to bring those appliances or equipment on the operative day, for use during the recovery from anesthesia or sedation.

    Some patients may not have a diagnosis of obstructive sleep apnea confirmed by polysomnography studies, but are presumed to have obstructive sleep apnea based on the preoperative history and physical examination. Quick and inexpensive surrogates for polysomnography studies are not new and have several variants. Patients who score high on these indices may need to be treated in the perioperative period as though they have a formal diagnosis of obstructive sleep apnea. This information should be communicated to the surgeon and anesthesiologist before the patient undergoes any procedure involving general anesthesia, monitored anesthesia care, conscious sedation or the administration of narcotics.

    Nicotine Cessation

    Recommendations:

    • Patients should always be strongly encouraged to quit nicotine use [Low Quality Evidence, Strong Recommendation].

    This work group recognizes that there has been confusion and concern related to nicotine cessation shortly before surgery in terms of increasing postoperative pulmonary complications which arose from misinterpretation of initial studies. Current literature and this work group consensus is that patients should always be strongly encouraged to abstain from nicotine at any time before surgery.

    If patients are using nicotine replacement therapy, this should be continued perioperatively.

    For certain procedures, e.g., vascular or orthopedic, the surgeon may require absolute nicotine cessation for at least three months prior to surgery, but that is beyond the scope of this document.

  1. Communicate Results and Instructions to Facility and Patient

    The goal of the preoperative assessment is to identify and manage medical conditions that may impact perioperative morbidity and mortality. Accurate communication of preoperative findings and recommendations to the patient, the surgical facility, and the clinicians directly involved in the surgery is an important component of decreasing morbidity and mortality. During the communication process, preoperative clinicians should avoid specific anesthesia recommendations and avoid "clearing" a patient for surgery. "Patient is medically optimized" is a more accurate reflection of the work done during the preoperative process.

    The results must be communicated to the location where the procedure will be conducted prior to the date of the scheduled procedure. The report should include a complete summary of the assessment, any adjunctive evaluation, and any specific recommendations.

    Sample preoperative forms for relaying preoperative assessment information for adult and pediatric patients are attached in Appendix B, "Preoperative Forms – Adult and Pediatric," in the original guideline document.

    Patient Education

    Preoperative patient education is the shared responsibility of all clinicians. This education should include both general and procedure specific information, including the results of any preoperative testing, along with specific recommendations or instructions prior to surgery.

    When providing patient education, adequate attention to the patient's reading level, potential visual impairments (provide large print materials) and other potential learning barriers is a critical component for preparing them for surgery.

    Preoperative Showering/Shaving

    Patients should be given instructions on how to decrease their risk of surgical site infection. These include:

    • Instructions not to shave or remove any hair at or near the surgical site
    • Instructions for general cleansing of the skin the night before or morning of surgery. The work group is aware of studies supporting the use of 2% chlorhexidine cloths wiped on the surgical site the night before and morning of surgery for some specific procedures, such as total joint procedures.

    Preoperative Fasting Recommendations (Nothing by Mouth)

    Preoperative fasting guidelines have been revised and simplified over the last decade. The American Society of Anesthesiologists Task Force on Preoperative Fasting has issued practice guidelines that follow a "2, 4, 6, 8 hour" rule applying to all ages:

    • The fasting period for clear liquids, including water, fruit juices without pulp, carbonated beverages, clear tea and coffee is recommended to be two hours or longer prior to surgery.
    • The fasting period for breast milk is recommended to be four hours or longer prior to surgery.
    • The fasting period for formula, non-human milk and light meals (such as toast) is recommended to be six hours or longer prior to surgery.
    • The fasting period for fried and fatty foods or meat may be eight hours or longer, as these foods may prolong gastric emptying time. The amount and type of food should be taken into account to determine an appropriate fasting period.

    Patients should be educated and informed of fasting requirements sufficiently in advance of the procedure.

    Venous Thromboembolism Prophylaxis

    Patients should be notified preoperatively that preventive measures regarding venous thromboembolism prophylaxis might be taken, which could include compression stockings, pneumatic boots/leggings and chemoprophylaxis. Special protocols may be necessary in certain circumstances, e.g., prior coronary stenting, history of deep vein thrombosis/pulmonary embolism, prior cardiac valve replacement and coagulopathy. Refer to the NGC summary of the ICSI guideline Venous Thromboembolism Prophylaxis.

  1. Immediate Pre-Procedure Assessment

    The immediate pre-procedure assessment is completed when the patient arrives for the procedure. The purpose is to assure that all necessary information is available and that the patient's medical condition is stable (i.e., he/she continues to be a non-high-risk patient). The nature of this review is beyond the scope of the guideline but is defined by the Joint Commission and other regulatory agencies.

Definitions:

Quality of Evidence and Strength of Recommendations

Category Quality Definitions Strong Recommendation Weak Recommendation
High Quality Evidence Further research is very unlikely to change the work group's confidence in the estimate of effect. The work group is confident that the desirable effects of adhering to this recommendation outweigh the undesirable effects. This is a strong recommendation for or against. This applies to most patients. The work group recognizes that the evidence, though of high quality, shows a balance between estimates of harms and benefits. The best action will depend on local circumstances, patient values or preferences.
Medium Quality Evidence Further research is likely to have an important impact on the work group's confidence in the estimate of effect and may change the estimate. The work group is confident that the benefits outweigh the risks but recognizes that the evidence has limitations. Further evidence may impact this recommendation. This is a recommendation that likely applies to most patients. The work group recognizes that there is a balance between harms and benefits, based on moderate quality evidence, or that there is uncertainty about the estimates of the harms and benefits of the proposed intervention that may be affected by new evidence. Alternative approaches will likely be better for some patients under some circumstances.
Low Quality Evidence Further research is very likely to have an important impact on the work group's confidence in the estimate of effect and is likely to change. The estimate or any estimate of effect is very uncertain. The work group feels that the evidence consistently indicates the benefit of this action outweighs the harms. This recommendation might change when higher quality evidence becomes available. The work group recognizes that there is significant uncertainty about the best estimates of benefits and harms.

Supporting Literature

In addition to evidence that is graded and used to formulate recommendations, additional pieces of literature will be used to direct the reader to other topics of interest. This literature is not given an evidence grade and is instead used as a reference for its associated topic. These citations are noted by (author, year) and are found in the references section of the original guideline document.

Clinical Algorithm(s)

A detailed and annotated clinical algorithm for preoperative evaluation is provided in the original guideline document External Web Site Policy.

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for selected recommendations (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Decreased morbidity and mortality due to surgery
  • Elimination of canceled or delayed surgical procedures
  • Appropriate preoperative history taking and elimination of diagnostic tests performed without clinical indications
  • Appropriate management of stable comorbidities prior to surgery
Potential Harms

Not stated

Contraindications

Contraindications

Dual anti-platelet therapy is strongly contraindicated for procedures associated with high-risk for clinically significant bleeding, such as intracranial surgery.

Qualifying Statements

Qualifying Statements
  • The information contained in this Institute for Clinical Systems Improvement (ICSI) Health Care Guideline is intended primarily for health professionals and other expert audiences.
  • This ICSI Health Care Guideline should not be construed as medical advice or medical opinion related to any specific facts or circumstances. Patients and families are urged to consult a health care professional regarding their own situation and any specific medical questions they may have. In addition, they should seek assistance from a health care professional in interpreting this ICSI Health Care Guideline and applying it in their individual case.
  • This ICSI Health Care Guideline is designed to assist clinicians by providing an analytical framework for the evaluation and treatment of patients, and is not intended either to replace a clinician's judgment or to establish a protocol for all patients with a particular condition.
  • It is understood that the scope of this document is related to the period of time prior to the patient arriving at the hospital for surgery; however, it is recognized that the content and management of patients preparing for surgery preoperatively is also closely associated with the content and management of patients in the perioperative period.

Implementation of the Guideline

Description of Implementation Strategy

Once a guideline is approved for general implementation, a medical group can choose to concentrate on the implementation of that guideline. When four or more groups choose the same guideline to implement and they wish to collaborate with others, they may form an action group.

In the action group, each medical group sets specific goals they plan to achieve in improving patient care based on the particular guideline(s). Each medical group shares its experiences and supporting measurement results within the action group. This sharing facilitates a collaborative learning environment. Action group learnings are also documented and shared with interested medical groups within the collaborative.

Currently, action groups may focus on one guideline or a set of guidelines such as hypertension, lipid treatment, and tobacco cessation.

Detailed measurement strategies are presented in the original guideline document to help close the gap between clinical practice and the guideline recommendations. Summaries of the measures are provided in the National Quality Measures Clearinghouse (NQMC).

Implementation Recommendations

Prior to implementation, it is important to consider current organizational infrastructure that address the following:

  • System and process design
  • Training and education
  • Culture and the need to shift values, beliefs and behaviors of the organization.

The following system changes were identified by the guideline work group as key strategies for health care systems to incorporate in support of the implementation of this guideline.

  • Develop a reliable, standardized system to obtain complete preoperative history and physical examinations and appropriate preoperative testing to eliminate unwarranted variation. (See Appendix B, "Preoperative Forms – Adult and Pediatric," Appendix C, "Preoperative Questionnaire – Adult," and Appendix D, "Preoperative Questionnaire – Pediatric," in the original guideline document).
  • Establish a reliable mechanism to communicate completed preoperative history and physical examinations, associated test results, and instructions to procedure location and patient prior to procedure. (See Appendix A, "Patient Preoperative Guide," and Appendix B, "Preoperative Forms – Adult and Pediatric," in the original guideline document).
  • Develop a comprehensive patient-centered approach to education and appropriate procedure preparation.
Implementation Tools
Chart Documentation/Checklists/Forms
Clinical Algorithm
Patient Resources
Quality Measures
Quick Reference Guides/Physician Guides
Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.
Related NQMC Measures

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Danielson D, Bjork K, Card R, Foreman J, Harper C, Roemer R, Stultz J, Sypura W, Thompson S, Webb B. Preoperative evaluation. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012 Jul. 61 p. [36 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
1997 Sep (revised 2012 Jul)
Guideline Developer(s)
Institute for Clinical Systems Improvement - Nonprofit Organization
Guideline Developer Comment

Organizations participating in the Institute for Clinical Systems Improvement (ICSI): Affiliated Community Medical Centers; Allina Medical Clinic; Aspen Medical Group; Baldwin Area Medical Center; Brown Clinic; Center for Diagnostic Imaging/Medical Scanning Consultants; CentraCare; Central Lakes Medical Clinic; Chippewa County – Montevideo Hospital & Clinic; Cuyuna Regional Medical Center; Essentia Health; Fairview Health Services; Family HealthServices Minnesota; Family Practice Medical Center; Fergus Falls Medical Clinic; Gillette Children's Specialty Healthcare; Grand Itasca Clinic and Hospital; Hamm Clinic; HealthEast Care System; HealthPartners Central Minnesota Clinics; HealthPartners Medical Group & Regions Hospital; Hennepin County Medical Center; Hennepin Faculty Associates; Howard Young Medical Center; Hudson Physicians; Hutchinson Area Health Care; Hutchinson Medical Center; Integrity Health Network; Lake Region Healthcare Corporation; Lakeview Clinic; Mankato Clinic; MAPS Medical Pain Clinics; Marshfield Clinic; Mayo Clinic; Mercy Hospital and Health Care Center; Midwest Spine Institute; Minnesota Association of Community Health Centers; Minnesota Gastroenterology; Multicare Associates; New Richmond Clinic; North Central Heart Institute; North Clinic; North Memorial Health Care; Northwest Family Physicians; Obstetrics and Gynecology Specialists; Olmsted Medical Center; Park Nicollet Health Services; Planned Parenthood Minnesota, North Dakota, South Dakota; Quello Clinic; Raiter Clinic; Rice Memorial Hospital; Ridgeview Medical Center; River Falls Medical Clinic; Riverwood Healthcare Center; South Lake Pediatrics; Southside Community Health Services; Stillwater Medical Group; University of Minnesota Physicians; Winona Health

ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675; e-mail: icsi.info@icsi.org; Web site: www.icsi.org External Web Site Policy.

Source(s) of Funding

The Institute for Clinical Systems Improvement's (ICSI's) work is funded by the annual dues of the member medical groups and five sponsoring health plans in Minnesota and Wisconsin.

Guideline Committee

Committee on Evidence-Based Practice

Composition of Group That Authored the Guideline

Work Group Members: David Danielson, MD (Work Group Leader) (Mayo Clinic) (Anesthesiology); Randall Card, MD (Cuyuna Regional Medical Center) (Family Medicine); William Sypura, MD (Fairview Health Services) (Family Medicine); Jerry Stultz, MD (HealthPartners Medical Group and Regions Hospital) (Pediatrics); Steven Thompson, PA-C (Mayo Clinic) (Anesthesiology); Rebekah Roemer, PharmD, BCPS (Park Nicollet Health Services) (Pharmacy); Kevin Bjork, MD (Stillwater Medical Group and Lakeview Hospital) (Surgery); Beth Webb, RN, BA (Institute for Clinical Systems Improvement [ICSI]) (Clinical Systems Improvement Facilitator); Joann Foreman, RN, BAN (ICSI) (Project Manager); Cindy Harper (ICSI) (Systems Improvement Coordinator)

Financial Disclosures/Conflicts of Interest

Disclosure of Potential Conflicts of Interest

Kevin Bjork, MD, Work Group Member
Surgery – Stillwater Medical Group & Lakeview Hospital
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: Breast Care PI Committee for Lakeview Health
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Randall Card, MD, FAAP, Work Group Member
Family Medicine – Cuyuna Regional Medical Center
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

David Danielson, MD, Work Group Leader
Anesthesiology – Mayo Clinic
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Rebekah Roemer, PharmD, BCPS - Work Group Member
Pharmacy – Park Nicollet Health Services
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Jerry Stultz, MD, Work Group Member
Pediatrics – Health Partners Medial Group and Regions Hospital
National, Regional, Local Committee Affiliations:
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: Reviewed image charts for TREC Med information retrieval project through Oregon Health and Science University

William Sypura, MD, Work Group Member
Family Medicine – Fairview Health Services
National, Regional, Local Committee Affiliations:
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Steven Thompson, PA-C, Work Group Member
Anesthesiology – Mayo Clinic
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Institute for Clinical Systems Improvement (ICSI). Preoperative evaluation. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2010 Jun. 40 p.

Guideline Availability

Electronic copies: Available from the Institute for Clinical Systems Improvement (ICSI) Web site External Web Site Policy.

Print copies: Available from ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675; Web site: www.icsi.org External Web Site Policy; e-mail: icsi.info@icsi.org.

Availability of Companion Documents

The following is available:

Print copies: Available from ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675; Web site: www.icsi.org External Web Site Policy; e-mail: icsi.info@icsi.org.

Additionally, a preoperative form and questionnaire for both adult and pediatric patients and a shared decision-making model are available in the appendices of the original guideline document External Web Site Policy.

Patient Resources

A patient preoperative guide is available in the appendices of the original guideline document External Web Site Policy.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This summary was updated on December 4, 2002. The updated information was verified by the guideline developer on December 24, 2002. This summary was updated by ECRI on May 3, 2004, and September 18, 2006. This summary was updated by ECRI Institute on October 28, 2008. This summary was updated by ECRI Institute on January 5, 2010 following the U.S. Food and Drug Administration advisory on Plavix (Clopidogrel). This summary was updated by ECRI Institute on May 17, 2010 following the U.S. Food and Drug Administration advisory on Plavix (clopidogrel). This NGC summary was updated by ECRI Institute on November 10, 2010. This NGC summary was updated by ECRI Institute on November 12, 2012. This summary was updated by ECRI Institute on March 6, 2014 following the U.S. Food and Drug Administration advisory on Over-the-Counter Topical Antiseptic Products.

Copyright Statement

This NGC summary (abstracted Institute for Clinical Systems Improvement [ICSI] Guideline) is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

The abstracted ICSI Guidelines contained in this Web site may be downloaded by any individual or organization. If the abstracted ICSI Guidelines are downloaded by an individual, the individual may not distribute copies to third parties.

If the abstracted ICSI Guidelines are downloaded by an organization, copies may be distributed to the organization's employees but may not be distributed outside of the organization without the prior written consent of the Institute for Clinical Systems Improvement, Inc.

All other copyright rights in the abstracted ICSI Guidelines are reserved by the Institute for Clinical Systems Improvement, Inc. The Institute for Clinical Systems Improvement, Inc. assumes no liability for any adaptations or revisions or modifications made to the abstracts of the ICSI Guidelines.

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