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Preoperative tests

About

What is covered

This pathway covers routine preoperative tests for people over 16 who are having elective surgery. It aims to reduce unnecessary testing by advising which tests to offer people before minor, intermediate and major or complex surgery, taking into account specific comorbidities (cardiovascular, renal and respiratory conditions and diabetes and obesity). It does not cover pregnant women or people having cardiothoracic procedures or neurosurgery.

Updates

Updates to this pathway

5 April 2016 Pathway updated upon publication of NICE guideline NG45 on routine preoperative tests for elective surgery.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on routine preoperative tests for people over 16 having elective surgery in an interactive flowchart

What is covered

This pathway covers routine preoperative tests for people over 16 who are having elective surgery. It aims to reduce unnecessary testing by advising which tests to offer people before minor, intermediate and major or complex surgery, taking into account specific comorbidities (cardiovascular, renal and respiratory conditions and diabetes and obesity). It does not cover pregnant women or people having cardiothoracic procedures or neurosurgery.

Updates

Updates to this pathway

5 April 2016 Pathway updated upon publication of NICE guideline NG45 on routine preoperative tests for elective surgery.

Sources

NICE guidance and other sources used to create this interactive flowchart.

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

NICE has produced resources to help implement its guidance on:

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Minor surgery

ASA grade
Test
ASA 1 (a normal healthy patient)
ASA 2 (a patient with mild systemic disease)
ASA 3 (a patient with severe systemic disease) or ASA 4 (a patient with severe systemic disease that is a constant threat to life)
Full blood count
Not routinely
Not routinely
Not routinely
Haemostasis
Not routinely
Not routinely
Not routinely
Kidney function
Not routinely
Not routinely
Consider in people at risk of AKI (see adults having surgery in the NICE pathway on acute kidney injury)
ECG
Not routinely
Not routinely
Consider if no ECG results available from past 12 months
Lung function / arterial blood gas
Not routinely
Not routinely
Not routinely

Intermediate surgery

ASA grade
Test
ASA 1 (a normal healthy patient)
ASA 2 (a patient with mild systemic disease)
ASA 3 (a patient with severe systemic disease) or ASA 4 (a patient with severe systemic disease that is a constant threat to life)
Full blood count
Not routinely
Not routinely
Consider for people with cardiovascular or renal disease if any symptoms not recently investigated
Haemostasis
Not routinely
Not routinely
Consider in people with chronic liver disease
  • If people taking anticoagulants need modification of their treatment regimen, make an individualised plan in line with local guidance
  • If clotting status needs to be tested before surgery (depending on local guidance) use point-of-care testing. Note that currently the effects of direct oral anticoagulants (DOACs) cannot be measured by routine testing
Kidney function
Not routinely
Consider in people at risk of AKI (see adults having surgery in the NICE pathway on acute kidney injury)
Yes
ECG
Not routinely
Consider an ECG for people with cardiovascular, renal or diabetes comorbidities
Yes
Lung function/arterial blood gas
Not routinely
Not routinely
Consider seeking advice from a senior anaesthetist as soon as possible after assessment for people who are ASA grade 3 or 4 due to known or suspected respiratory disease

Major or complex surgery

ASA grade
Test
ASA 1 (a normal healthy patient)
ASA 2 (a patient with mild systemic disease)
ASA 3 (a patient with severe systemic disease) or ASA 4 (a patient with severe systemic disease that is a constant threat to life)
Full blood count
Yes
Yes
Yes
Haemostasis
Not routinely
Not routinely
Consider in people with chronic liver disease
  • If people taking anticoagulants need modification of their treatment regimen, make an individualised plan in line with local guidance
  • If clotting status needs to be tested before surgery (depending on local guidance) use point-of-care testing. Note that currently the effects of direct oral anticoagulants (DOACs) cannot be measured by routine testing
Kidney function
Consider in people at risk of AKI (see adults having surgery in the NICE pathway on acute kidney injury)
Yes
Yes
ECG
Consider for people aged over 65 if no ECG results available from past 12 months
Yes
Yes
Lung function/arterial blood gas
Not routinely
Not routinely
Consider seeking advice from a senior anaesthetist as soon as possible after assessment for people who are ASA grade 3 or 4 due to known or suspected respiratory disease

Glossary

acute kidney injury
American Society of Anesthesiologists
electrocardiogram

Paths in this pathway

Pathway created: March 2014 Last updated: November 2016

© NICE 2017

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