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Published by
The Association of Anaesthetists of Great Britain and Ireland
21 Portland Place, London, W1B 1PY
Telephone 020 7631 1650 Fax 020 7631 4352
info@aagbi.org
www.aagbi.org January 2010
Membership of the working party
(details correct at the start of the working party process)
Dr R Verma Chairman
Prof M Y K Wee Vice President, AAGBI
Dr A Hartle Council Member, AAGBI
Dr V R Alladi Council Member, AAGBI
Dr A-M Rollin Vice President, Royal College of Anaesthetists
Dr G Meakin President, Association of Paediatric Anaesthetists
Dr R Struthers Consultant Anaesthetist, Derriford Hospital
Dr J Carlisle Preoperative Association representative
Dr P Johnston Vice Chairman, GAT
Mrs K Rivett Patient Liaison Group representative
Mr C Hurley Royal College of Nursing representative
This guideline has been seen and approved by the Council of the
AAGBI.
1
Contents
1. Recommendations 3
2. Introduction 5
3. Before planned admission 7
4. After planned admission 15
5. After unplanned admission 18
6. Children and young people 19
7. Tests and investigations 22
8. The patient’s perspective 24
References 26
Appendices 29
To be reviewed by 2015.
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1. Recommendations
This guidance has been designed to help anaesthetists provide
high quality pre-operative assessment services and patient
preparation before surgery. In addition it defines the roles and
responsibilities of anaesthetists both after planned and after
unplanned admissions.
3
Anaesthetic departments must establish clear pathways of
care for unplanned admissions with surgeons, emergency
departments, critical care and theatre personnel.
4
2. Introduction
Preparing a patient for anaesthesia requires an understanding of
the patient’s pre-operative status, the nature of the surgery and
the anaesthetic techniques required for surgery, as well as the
risks that a particular patient may face during this time.
Anaesthetists are in the unique position that they can offer all
of these skills, and the ultimate responsibility for pre-operative
anaesthetic assessment lies with the anaesthetist. Therefore,
anaesthetists should take the lead in organising pre-operative
anaesthetic services.
5
The lead anaesthetist for pre-operative assessment and
evaluation should be given the responsibility to:
6
3. Before planned admission
Pre-operative services should:
* This assumes that all patients have the capacity to take in the information
provided and make an autonomous decision. For those who do not, attempts
must be made to provide appropriate information and readers are referred to
other guidance on consent issued by the AAGBI and GMC.
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Pre-operative systems and communication
Recognising that at least 80% of patients could be treated as
day cases (<24-h stay), The Modernisation Agency High Impact
change No 1 states that day surgery (rather than inpatient
surgery) should be the norm for elective surgery. Booking of
patient as inpatients should therefore be the exception rather
than the rule.
8
Pathologies that predictably progress from medical to surgical
treatment, such as aortic aneurysmal disease and osteoarthrosis,
would be particularly suitable for early attempts at optimising
health.
9
history of a heart murmur, or pulmonary function tests for chest
disease. These protocols should be written by senior anaesthetic
staff and should be regularly reviewed and updated.
10
• Have balanced the pros and cons of different surgical and
non-surgical alternatives.
• Are receiving optimum treatment if they have significant
medical co-morbities.
• Have had their risks assessed with regard to mortality and
common morbidities.
• Have been informed of these risks and had the opportunity
to discuss them.
• Have been informed how to reduce their risks pre-
operatively.
• Have been given the opportunity and time to reduce their
risks.
11
Anaesthetic, critical care and surgical departments should
discuss risk thresholds for:
i. Age
ii. Sex
iii. Socioeconomic status [7]
iv. Aerobic fitness [8-10]
v. Diagnosed ischaemic heart disease (myocardial infarction
and angina)
vi. Diagnosed heart failure
vii. Diagnosed ischaemic brain disease (stroke and transient
ischaemic attacks)
viii. Diagnosed kidney failure [11]
ix. Diagnosed peripheral arterial disease
12
tool for survival prediction in addition to traditional risk factors
such as hypertension, hypercholesterolaemia, smoking, chronic
obstructive pulmonary disease (COPD) and diabetes [8-10].
13
postgraduate personnel. This may necessitate increased clinic
resources with regard to both the time taken and the space for
trainees and students to see patients.
14
4. After planned admission
Anaesthetists are central to ensuring the safety of patients in the
peri-operative period.
15
• Ensure the patient is aware of any risks particular to that
patient or associated with specific anaesthetic procedures.
• Ensure the patient understands the nature of the operation
and is happy to proceed (N.B. see footnote on page 7).
• Confirm the availability of HDU or intensive care unit beds
if appropriate, before proceeding.
16
recommendations for optimisation in the patient’s medical
notes.
• Take steps to allow surgery to proceed safely at a future
date.
• Address deficiencies in the system to reduce the number of
late cancellations.
17
5. After unplanned admission
Patients requiring anaesthesia after unplanned admission are at
higher risk of medical errors and peri-operative complications
[13]. These patients are often cared for by junior staff.
18
6. Children and young people
Children and young people have special healthcare needs
because they are physically and emotionally different from
adults, and need the constant care and support of their parents
or guardians [14].
Before admission
A clear explanation of the proposed surgery and admission
procedures should be given to the parents and the child at the
initial outpatient clinic visit.
19
delivery and the presence of congenital and acquired disease
particularly those affecting the airway or the cardiovascular
system. A history of previous anaesthetics and family history of
anaesthetic problems should be obtained. Sickle-cell screening
should be performed in susceptible populations. The airway
should be assessed and the presence of any loose, usually
deciduous, teeth noted.
After admission
The child should be admitted to a children’s ward or the day
surgery unit staffed by medical and nursing staff trained in
dealing with children and their families. The décor should
be suitable for children, and toys, books, videos and a play
therapist should be available.
20
competent minor to refuse treatment. In such cases, much will
depend on the judgement of the doctor as to whether the child
is competent or not, taking into account the importance or
urgency of the proposed operation. In all cases it is important
that staff know who has parental responsibility [18].
21
7. Tests and investigations
Routine pre-operative investigations are expensive, labour-
intensive and of questionable value, especially as they may
contribute to morbidity or cause additional delays due to
spurious results.
22
comorbidity and complexity of the surgery.
Anaemia ( < 12 g.dl-1 for women and < 13 g.dl-1 for men
should be investigated and treated before planned surgery,
using haematinics such as oral/intravenous iron rather than
transfusion. The urgency and nature of surgery, plus patient-
specific factors, will determine the balance between reversing
anaemia and proceding with surgery. The aim, to avoid peri-
operative blood transfusion, is best achieved when hospital
pre-operative services work with other departments and primary
care.
23
8. The patient’s perspective
This document defines the objectives of pre-operative
assessment, emphasising the need to:
24
It is extremely important that adequate explanation is given
by anaesthetists and other staff should it become necessary to
postpone surgery. In addition to the impact on the patient’s
medical condition, it is likely to cause considerable disruption
to both their work and their home life.
25
References
1. NHS Institute for Innovation and Improvement. Quality and
Service Improvement Tools. http://wwwnodelaysachiever.
nhs.uk/ServiceImprovement/Tools/IT130_PreOpAssessment.
htm (accessed 01/10/09)
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9. Older P, Hall A, Hader R. Cardiopulmonary exercise testing
as a screening test for perioperative management of major
surgery in the elderly. Chest 1999; 116: 355-62.
13. Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner
MJ. Risk factors for retained instruments and sponges after
surgery. New England Journal of Medicine 2003; 348: 229-
53.
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17. Hogg C, Cooper C. Meeting the needs of children and
young people undergoing surgery. London: Action for Sick
Children, 2004.
21. Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007
Guidelines on perioperative cardiovascular evaluation and
care for noncardiac surgery. Journal of the American
College of Cardiology 2007; 50: 1707-32.
28
Appendices
1. Fasting guidelines in adults and children
2. Survival prediction
3. Surgical severity
4. ASA physical status
5. Systemic disease
29
Appendix 1
Fasting guidelines for adults and children
(RCN pre-operative fasting guidelines, 2005)
Adults
Children
30
Post-operative resumption of oral intake in healthly children:
Chewing gum
* This is AAGBI guidance and is not taken from the RCN fasting guidelines.
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Appendix 2
Survival prediction
Age. The risk of dying doubles every 7 years from the age of
10 so that by 90 years the monthly mortality risk is 5000 times
the risk at the age of 10. Life tables for the United Kingdom,
its constituent countries and individual health authorities are
updated at www.gad.gov.uk
Sex. Men are 1.7 times more likely to die than women the
same age.
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Appendix 3
Surgical severity (from NICE pre-operative
testing)
Grade 1 examples: diagnostic endoscopy or laparoscopy,
breast biopsy.
33
Appendix 4
ASA physical status
ASA grade 1 A normal healthy patient: i.e. without any
clinically important comorbidity and without a
clinically significant past/present medical history.
34
Appendix 5
Systemic disease (from NICE pre-operative
testing)
Cardiovascular disease: ‘mild’
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21 Portland Place, London, W1B 1PY
Tel: 020 7631 1650
Fax: 020 7631 4352
Email: info@aagbi.org
www.aagbi.org