A pre-anesthesia evaluation reviews a patient’s history, current disease status, and planned surgery before anesthesia. The history drives the plan, and testing should confirm it, not replace it. Here is why that difference matters for patients, surgeons, and facilities.

The preoperative assessment is one of the most critical components of the anesthetic encounter. One of the important parts of the evaluation is the gathering of a complete and accurate medical history. From this medical history, anesthesia providers generally will order laboratory tests. The balance of evaluation and testing is critical to provide meaningful information and manage costs as well. It seemed more common 20 years ago that patient evaluation was often just testing. Every patient got an EKG, a chest X-ray, and full blood work. This is why many preoperative departments are called Pre-Anesthesia Testing.

Why the Medical History Matters More Than the Test Panel

The longer that I practice, the more I realize that a good medical history is the most important part of the patient record. We want to understand the patient’s situation and perform focused testing only when it confirms or updates a diagnosis, or when the result will alter our anesthetic plan. We no longer perform screening background testing or get tests just to have the result on the chart. We treat the patient, not the chart. Practicing “legal” or “defensive” medicine is costly and is of little benefit. There is certainly morbidity associated with over testing. We have all seen a patient’s surgery cancelled for an abnormal lab number. The patient then gets routed to a medicine service and a day or two later is back for the required surgery with a negative workup. That cost time and money.

Pre-Anesthesia Evaluation vs. Pre-Anesthesia Testing

LifeLinc renamed our pre-anesthesia testing process to Pre-Anesthesia Evaluation just to stress the fact that it is about evaluation and not just testing. As providers, we should think clinically about testing and not just work from a checklist. There are certain surgeries that will require particular lab work, but the patient should be individualized regarding other testing. Testing is done to check the status of existing disease and establish parameters which would affect the anesthetic plan. The real focus of the evaluation stage is deciding if a patient’s disease process is stable or is changing. If the patient has experienced changes in symptomatology recently, then other medical consultation is warranted before elective surgery is performed.

Why a Clearance Letter Rarely Helps

Referring a patient to a medical service for evaluation prior to anesthesia should be accompanied with a question. Why do you want the consult? It is poor practice to ask for “clearance” letters as a permission slip to undergo anesthesia. These are very rarely helpful, and don’t seem to alter the anesthesia plan. You are the expert in anesthesia and are the person best able to judge a patient’s readiness for surgery. Specific questions like “Can you optimize this out-of-control blood pressure” or “Please evaluate increasing angina” are clinically focused reasons for consultation and tend to yield better responses. “Please clear for surgery” usually yields such deep gems as, “Maintain blood pressure.” They are rarely helpful.

When Is Preoperative Testing Actually Needed?

Never forget to think like a clinician with your patient. Don’t become just a technician. There are recommended testing rubrics out there that you can base your ordering on but individualizing a plan is always best. Remember, if you order a test, you are responsible for looking at the result. Don’t order tests that you don’t follow up on.

What Our Data Taught Us About Type and Screens

Lastly, look at your data and notice patterns that might help you become more focused and efficient. In one of our practices, we had ordered a type and screen for a particular surgery because that surgery had always been associated with blood loss. Over time the surgical techniques improved, and we compared the number of patients with type and screens that actually got transfused. The number was so small that we were able to do away with the type and screen for that surgery. We now only get the type and screen when specific hemoglobin/hematocrit parameters are met. This saved several thousand type and screen tests in this one hospital.

Take a good history and base any testing on the patient’s medical history and the needs of the surgery that is scheduled. Emphasize evaluation and utilize testing as confirmation data and you will become a better clinician.

References

1. Ganguli I, Lupo C, Mainor AJ, et al. Prevalence and Cost of Care Cascades After Low-Value Preoperative Electrocardiogram for Cataract Surgery in Fee-for-Service Medicare Beneficiaries. JAMA Internal Medicine. 2019;179(9):1211-1219.

2. American Society of Anesthesiologists Committee on Standards and Practice Parameters. Practice Advisory for Preanesthesia Evaluation. Anesthesiology. 2012;116(3):522-538.

About the author: Greg Thompson, MD, brings over two decades of clinical anesthesia practice and managerial experience to LifeLinc. A board-certified anesthesiologist, Greg has practiced in a variety of clinical settings from ambulatory surgery centers to tertiary care teaching hospitals.