L. Reuven Pasternak, M.D., Chair
Task Force on Preoperative Evaluation Guidelines

IIn October 2001, the ASA House of Delegates adopted the recommendations of the Task Force on Preanesthesia Evaluation.¹ This advisory followed six years of extensive discussions that included the facilitation of the development of the advisory methodology by the Committee on Practice Parameters with the related movement from the formal Guidelines process to that of the advisory model. The Advisory model was designed to accommodate recommendations whose literature did not meet the rigorous standards of the ASA evidence-based model but whose issues were of sufficient concern to the membership as to warrant expert guidance. During the past year, there has been some considerable discussion about current trends, future directions for this effort and, in one circumstance, debate about one of the specific recommendations.

Debate: Pregnancy Testing
At the time of the adoption of the advisory, members of the Committee on Ethics raised some concerns about the manner in which the issue of pregnancy testing had been presented. There was agreement that the evidence for universal pregnancy testing for all premenopausal females was insufficient and that the weight of evidence argued against such a policy. However, there was some concern on the part of the Committee on Ethics members that the wording of the advisory might be interpreted as actually recommending routine pregnancy testing. Accordingly, a joint working group has proposed for adoption the following change to better reflect the spirit of the advisory and evidence-based model:

“The Task Force recognizes that patients may present for anesthesia with early undetected pregnancy. The Task Force also recognizes that the literature is insufficient to inform patients or physicians on whether anesthesia causes harmful effects on early pregnancy. Pregnancy testing may be offered to female patients of childbearing age and for whom the result would alter the patient’s management.”

Current Trends
During the past year, there has been considerable agreement with several tenets established by the task force:

Testing and Consultation: Testing and consultation are done on the basis of a reasonable expectation that the patient may have an abnormal value and that such a value will have an effect on the decision as to whether and how to provide care during perioperative management.

Availability of Information: There is an obligation on the part of the system in which anesthesia staff work to provide accurate and timely information to permit to appropriate determination of risk and, where necessary, intervention to address those issues.

These trends confirm the well-established goal of restricting testing and consultation only to those tests that are needed. These findings are consistent with those of the American Heart Association/American College of Cardiology (AHA/ACC) recommendations concerning preoperative testing of the cardiac patient undergoing noncardiac surgery.² Of significant interest to the membership was having the sponsored advisory mandating that information be available on a timely basis before surgery to allow for appropriate review.

Future Issues
While there has been agreement on the major issues associated with testing, perhaps the most significant challenges facing us in the evaluation of patients undergoing elective surgery is that of assessing (and modifying) risk and the appropriate system in which to perform this function. The first issue that comes to mind is that of an appropriate risk-stratification methodology. When the Task Force on Preoperative Evaluation first met, it was recognized that the current ASA Physical Status classification system was outdated and inadequate. However, it was decided that revising that system was not within the mandate of that group.

Multiple systems have emerged to try to accommodate the combined issues of surgical and medical co-morbidity. However, most of them such as the APACHE (Acute Physiology and Chronic Health Evaluation) score system are dedicated to a small segment of the surgical population such as critical procedures. Others, including the system currently used by the AHA/ACC and the ASA Task Force on Preanesthesia Evaluation, are simple for use outside of the specialty but do not fully encompass the full spectrum of relevant clinical activity. One attempt to address this issue was formulated at Johns Hopkins in 1990,3 utilizing a classification system for surgical procedures that included five levels of intensity matched against the four levels of the ASA system. Though never field-tested, it met with an enthusiastic response and has been adopted by some preoperative systems. A similar system was suggested as recently as 2002 in an article in the ASA NEWSLETTER.⁴ The ability to properly address risk reduction will depend on the development of a better risk stratification system for patient care.

A final point in development for preoperative testing is that of personnel. While anesthesia staffing is likely to improve, it still will not approach levels that will perhaps allow the staffing of clinics by anesthesiologists in a manner that ensures all patients are seen by physicians. The challenge in developing preoperative systems will continue to be predicated on who needs to be seen, when and by whom.

This activity will await new innovations in information management such as Web-based data, risk-stratification and the performance of appropriate studies to assess which interventions are of true benefit to patient care.

References:

1. American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Practice Advisory for Preanesthesia Evaluation. Anesthesiology. 2002; 96(2):485-496. Available online at: <www.ASAhq.org/publicationsAndServices/preeval.pdf>.

2. American College of Cardiology/American Heart Association Task Force on Practice Guidelines. ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation for Noncardiac Surgery — Executive Summary. Anesth Analg. 2002; 94:1052-1064.

3. Pasternak LR. Preoperative assessment of the ambulatory and same-day admission patient. Welcome Trends in Anesthesiology. 1991; 9(5):3-11.

4. Lema ML. Using the ASA physical status classification may be risky business. ASA Newsl. 2002; 66(9):1,24.

L. Reuven Pasternak, M.D., is Vice-Dean, Bayview Campus, Johns Hopkins University Schools of Medicine and Public Health, Baltimore, Maryland.