Guidance

Recommendations

Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about 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.

The tests covered by this guideline are:

  • chest X‑ray

  • echocardiography (resting)

  • electrocardiography (ECG; resting)

  • full blood count (haemoglobin, white blood cell count and platelet count)

  • glycated haemoglobin (HbA1c) testing

  • haemostasis tests

  • kidney function (estimated glomerular filtration rate, electrolytes, creatinine and sometimes urea levels)

  • lung function tests (spirometry, including peak expiratory flow rate, forced vital capacity and forced expiratory volume) and arterial blood gas analysis

  • polysomnography

  • pregnancy testing

  • sickle cell disease/trait tests

  • urine tests.

The recommendations were developed in relation to the following comorbidities:

  • cardiovascular

  • diabetes

  • obesity

  • renal

  • respiratory.

1.1 Communication

1.1.2

Ensure that the results of any preoperative tests undertaken in primary care are included when referring people for surgical consultation.

1.2 Considering existing medicines

1.2.1

Take into account any medicines people are taking when considering whether to offer any preoperative test.

1.3 Pregnancy tests

1.3.1

On the day of surgery, sensitively ask all women of childbearing potential whether there is any possibility they could be pregnant.

1.3.2

Make sure women who could possibly be pregnant are aware of the risks of the anaesthetic and the procedure to the fetus.

1.3.3

Document all discussions with women about whether or not to carry out a pregnancy test.

1.3.4

Carry out a pregnancy test with the woman's consent if there is any doubt about whether she could be pregnant.

1.3.5

Develop locally agreed protocols for checking pregnancy status before surgery.

1.3.6

Make sure protocols are documented and audited, and in line with statutory and professional guidance.

1.4 Sickle cell disease or sickle cell trait tests

1.4.1

Do not routinely offer testing for sickle cell disease or sickle cell trait before surgery.

1.4.2

Ask the person having surgery if they or any member of their family have sickle cell disease.

1.4.3

If the person is known to have sickle cell disease and has their disease managed by a specialist sickle cell service, liaise with this team before surgery.

1.5 HbA1c testing for people without diagnosed diabetes

1.5.1

Do not routinely offer HbA1c testing before surgery to people without diagnosed diabetes.

1.6 HbA1c testing for people with diabetes

1.6.1

People with diabetes who are being referred for surgical consultation from primary care should have their most recent HbA1c test results included in their referral information.

1.6.2

Offer HbA1c testing to people with diabetes having surgery if they have not been tested in the last 3 months.

1.7 Urine tests

1.7.1

Do not routinely offer urine dipstick tests before surgery.

1.7.2

Consider microscopy and culture of midstream urine sample before surgery if the presence of a urinary tract infection would influence the decision to operate.

1.8 Chest X‑ray

1.8.1

Do not routinely offer chest X‑rays before surgery.

1.9 Echocardiography

1.9.1

Do not routinely offer resting echocardiography before surgery.

1.9.2

Consider resting echocardiography if the person has:

  • a heart murmur and any cardiac symptom (including breathlessness, pre‑syncope, syncope or chest pain) or

  • signs or symptoms of heart failure.

    Before ordering the resting echocardiogram, carry out a resting electrocardiogram (ECG) and discuss the findings with an anaesthetist.

Recommendations for specific surgery grades (minor, intermediate, and major or complex) and ASA grades

The following recommendations are specific to surgery grade and ASA grade.

Surgery grades

Minor

Examples:

  • excising skin lesion

  • draining breast abscess

Intermediate

Examples:

  • primary repair of inguinal hernia

  • excising varicose veins in the leg

  • tonsillectomy or adenotonsillectomy

  • knee arthroscop

Major or complex

Examples:

  • total abdominal hysterectomy

  • endoscopic resection of prostate

  • lumbar discectomy

  • thyroidectomy

  • total joint replacement

  • lung operations

ASA grades

The American Society of Anesthesiologists (ASA) Physical Status Classification System is a simple scale describing fitness to undergo an anaesthetic. The ASA states that it does not endorse any elaboration of these definitions. However, anaesthetists in the UK often qualify (or interpret) these grades as relating to functional capacity – that is, comorbidity that does not (ASA 2) or that does (ASA 3) limit a person's activity.

ASA 1: A normal healthy patient

ASA 2: A patient with mild systemic disease

ASA 3:A patient with severe systemic disease

ASA 4:A patient with severe systemic disease that is a constant threat to life

Table 1 Minor surgery
Test ASA 1 ASA 2 ASA 3 or ASA 4
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 recommendation in the NICE guideline 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

AKI, acute kidney injury

Key to recommendations

[Yes] Offer the test

[Not routinely] Do not routinely offer the test

[Consider] Consider the test (the value of carrying out the test may depend on specific patient characteristics)

Table 2 Intermediate surgery
Test ASA 1 ASA 2 ASA 3 or ASA 4
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 recommendation in the NICE guideline on acute kidney injury)

Yes
ECG

Not routinely

Consider 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

AKI, acute kidney injury

Key to recommendations

[Yes] Offer the test

[Not routinely] Do not routinely offer the test

[Consider] Consider the test (the value of carrying out the test may depend on specific patient characteristics)

Table 3 Major or complex surgery
Test ASA 1 ASA 2 ASA 3 or ASA 4
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 recommendation in the NICE guideline 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

AKI, acute kidney injury

Key to recommendations

[Yes] Offer the test

[Not routinely] Do not routinely offer the test

[Consider] Consider the test (the value of carrying out the test may depend on specific patient characteristics)