Hostname: page-component-cd9895bd7-jkksz Total loading time: 0 Render date: 2024-12-19T16:59:01.300Z Has data issue: false hasContentIssue false
  • English
  • Français

Role of history and physical examination in preoperative evaluation

Published online by Cambridge University Press:  12 July 2005

W. A. van Klei ,
D. E. Grobbee ,
C. L. G. Rutten ,
P. J. Hennis ,
J. T. A. Knape ,
C. J. Kalkman  and
K. G. M. Moons
W. A. van Klei
Affiliation:
University Medical Centre Utrecht, Department of Perioperative Care and Emergency Medicine, Utrecht, The Netherlands Julius Centre for General Practice and Patient Oriented Research, University Medical Centre Utrecht, Utrecht, The Netherlands
D. E. Grobbee
Affiliation:
Julius Centre for General Practice and Patient Oriented Research, University Medical Centre Utrecht, Utrecht, The Netherlands
C. L. G. Rutten
Affiliation:
Weezenlanden Hospital, Isala Clinics, Department Anaesthesiology, Zwolle, The Netherlands
P. J. Hennis
Affiliation:
University Medical Centre Utrecht, Department of Perioperative Care and Emergency Medicine, Utrecht, The Netherlands
J. T. A. Knape
Affiliation:
University Medical Centre Utrecht, Department of Perioperative Care and Emergency Medicine, Utrecht, The Netherlands
C. J. Kalkman
Affiliation:
University Medical Centre Utrecht, Department of Perioperative Care and Emergency Medicine, Utrecht, The Netherlands
K. G. M. Moons
Affiliation:
University Medical Centre Utrecht, Department of Perioperative Care and Emergency Medicine, Utrecht, The Netherlands Julius Centre for General Practice and Patient Oriented Research, University Medical Centre Utrecht, Utrecht, The Netherlands
Get access

Abstract

Summary

Background and objective: Since reports have shown that outpatient preoperative evaluation increases the quality of care and cost-effectiveness, an increasing number of patients are being evaluated purely on an outpatient basis. To improve cost-effectiveness, it would be appealing if those patients who are healthy and ready for surgery without additional testing could be easily distinguished from those who require more extensive evaluation. This paper examines whether published studies provide sufficient data to determine how detailed preoperative history taking and physical examination need to be in order to assess the health of surgical patients and to meet the objective of easy and early distinction.

Methods: A MEDLINE search was conducted from 1991 to 2000 with respect to preoperative patient history and physical examination. Altogether, 213 articles were found, of which 29 were selected. Additionally, 38 cross-references, 7 articles on additional testing and 4 recently published papers were used.

Results: It is questionable to what extent an extensive history is relevant for anaesthesia and long-term prognosis. With respect to physical examination, it seems unreasonable to diagnose valvular heart disease based on cardiac auscultation only, and it is unclear which method should be used to predict the difficulty of endotracheal intubation. The benefits of routine testing for all surgical patients before operation are extremely limited and are not advocated.

Conclusions: The amount of detail of preoperative patient history and the value of physical examination to obtain a reasonable estimate of perioperative risk remains unclear. Although not evidence based, a thorough history taking and physical examination of all patients before surgery seems important until more evidence-based guidelines become available. Diagnostic and prognostic prediction studies may provide this necessary evidence.

Keywords

ECONOMICS, costs and cost analysis, health care costs, direct service costsPATIENT CARE, ambulatory care, preoperative care
Type
Original Article
Information
European Journal of Anaesthesiology , Volume 20 , Issue 8 , September 2003 , pp. 612 - 618
Copyright
2003 European Society of Anaesthesiology

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Health Council of the Netherlands, Committee on Preoperative Evaluation.Preoperative Evaluation 1997/2.The Hague, the Netherlands: Health Council of the Netherlands, 1997.
Adriaensen H, Baele P, Camu F, et al. Recommendations on pre-anesthetic evaluation of patients put forward jointly with the BSAR and the BPASAR. The Belgian Society of Anesthesia and Reanimation and the Belgian Professional Association of Specialists in Anesthesia and Reanimation. Acta Anaesthesiol Belg 1998; 49: 47–50.Google Scholar
Roizen MF. Preoperative evaluation. In: Miller RD, ed. Anaesthesia.New York, USA: Churchill Livingstone, 2000: 824–883.
Frost EA. Outpatient evaluation: a new role for the anesthesiologist. Anesth Analg 1976; 55: 307–310.Google Scholar
Fischer SP. Development and effectiveness of an anesthesia preoperative evaluation clinic in a teaching hospital. Anesthesiology 1996; 85: 196–206.Google Scholar
Pollard JB, Zboray AL, Mazze RI. Economic benefits attributed to opening a preoperative evaluation clinic for outpatients. Anesth Analg 1996; 83: 407–410.Google Scholar
Pollard JB, Garnerin P. Use of outpatient preoperative evaluation to decrease length of stay for vascular surgery. Anesth Analg 1997; 85: 1307–1311.Google Scholar
van Klei WA, Moons KGM, Rutten CLG, et al. Effect of outpatient preoperative evaluation on cancellation of surgery and length of hospital stay. Anesth Analg 2002; 94: 644–649.Google Scholar
Pollard JB, Olson L. Early outpatient preoperative anesthesia assessment: does it help to reduce operating room cancellations? Anesth Analg 1999; 89: 502–505.Google Scholar
Cassidy J, Marley RA. Preoperative assessment of the ambulatory patient. J Perianesth Nurs 1996; 11: 334–343.Google Scholar
Rutten CLG, Post D, Smelt WLH. Outpatient preoperative examination by the anesthesiologist I. Fewer items of service and preoperative hospital days. Ned Tijdschr Geneeskd 1995; 139: 1028–1032.Google Scholar
Vaghadia H, Fowler C. Can nurses screen all outpatients? Performance of a nurse based model. Can J Anaesth 1999; 46: 1117–1121.Google Scholar
Van Klei WA, Moons KGM, Rutten CLG, Knape JTA, Grobbee DE. Preoperative outpatient investigation by the anesthesiologist in young adults: the case history and physical examination suffice, the short questionnaire of the Netherlands Health Council does not. Ned Tijdschr Geneeskd 2000; 144: 1389–1393.Google Scholar
Almany SL, Mileto L, Kahn JK. Preoperative cardiac evaluation. Assessing risk before noncardiac surgery. Postgrad Med J 1995; 98: 171–172.Google Scholar
Brorsson B, Arvidsson S. The effect of dissemination of recommendations on use. Preoperative routines in Sweden, 1989–91. Int J Technol Assess Health Care 1997; 13: 547–552.Google Scholar
Van Aken H, Rolf N. Preoperative evaluation and preparation. The view of the anesthetist. Anaesthesist 1997; 46 (Suppl. 2): S80–S84.Google Scholar
McCallion J, Krenis LJ. Preoperative cardiac evaluation. Am Fam Physician 1992; 45: 1723–1732.Google Scholar
Mangano DT. Perioperative cardiac morbidity. Anesthesiology 1990; 72: 153–184.Google Scholar
Narr BJ, Warner ME, Schroeder DR, Warner MA. Outcomes of patients with no laboratory assessment before anesthesia and a surgical procedure. Mayo Clin Proc 1997; 72: 505–509.Google Scholar
Coriat P, Kieffer E. Preoperative risk stratification in vascular surgical patients. Acta Anaesthesiol Scand Suppl. 1996; 109: 127–130.Google Scholar
Prause G, Ratzenhofer-Comenda B, Pierer G, Smolle-Juttner F, Glanzer H, Smolle J. Can ASA grade or Goldman's cardiac risk index predict peri-operative mortality? Anaesthesia 1997; 52: 203–206.Google Scholar
Lee A, Lum ME, Perry M, Beehan SJ, Hillman KM, Bouman A. Risk of unanticipated intraoperative events in patients assessed at a preanaesthetic clinic. Can J Anaesth 1997; 44: 946–954.Google Scholar
Wolters U. ASA classification and perioperative variables as predictors of postoperative outcome. Br J Anaesth 1996; 77: 217–222.Google Scholar
Arvidsson S, Ouchterlony J, Nilsson S, et al. The Gothenburg study of perioperative risk. I. Preoperative findings, postoperative complications. Acta Anaesthesiol Scand 1994; 38: 679–690.Google Scholar
Arvidsson S, Ouchterlony J, Sjostedt L, et al. Predicting postoperative adverse events. Clinical efficiency of four general classification systems. Acta Anaesthesiol Scand 1996; 40: 783–791.Google Scholar
Menke H. Präoperative Risikoeinschätzung mit der ASA-Klassification. Eine prospectieve Untersuchung zu Morbidität und Letalität in verschiedenen ASA-Klassen bei 2937 Patienten mit allgemeinchirurgischen Operationen. Chirurg 1992; 63: 1029–1034.Google Scholar
Arbous, MS. Anesthesia-related risk factors for perioperative severe morbidity and mortality.Thesis Utrecht University, Utrecht, The Netherlands, 1998.
Schein OD, Katz J. The value of routine preoperative testing before cataract surgery. N Engl J Med 2000; 342: 168–175.Google Scholar
Roizen MF, Coalson D, Hayward RS, et al. Can patients use an automated questionnaire to define their current health status? Med Care 1992; 30: MS74–MS84.Google Scholar
Lutner RE, Roizen MF, Stocking CB, et al. The automated interview versus the personal interview. Do patient responses to preoperative health questions differ? Anesthesiology 1991; 75: 394–400.Google Scholar
Vacanti CJ, Vanhouten RJ, Hill RC. A statistical analysis of the relationship of physical status to postoperative mortality in 68 388 cases. Anesth Analg 1970; 49: 564–566.Google Scholar
Fowkes FGR, Lunn JN, Farrow SC. Epidemiology in anaesthesia III: mortality risk in patients with coexisting physical disease. Br J Anaesth 1982; 54: 819–825.Google Scholar
Escolano F. Drug allergy in a population of surgical patients. Rev Esp Anestesiol Reanim 1998; 45: 425–430.Google Scholar
Van Klei WA, Rutten CLG, Moons KGM, Lo B, Knape JTA, Grobbee DE. Limited effect of a recommendation of the Netherlands Health Council: preoperative evaluation clinics in the Netherlands. Ned Tijdschr Geneeskd 2001; 145: 25–29.Google Scholar
Griffith KE. Preoperative assessment and preparation. Int Anesthesiol Clin 1994; 32: 17–36.Google Scholar
Mohr DN, Lavender RC. Preoperative pulmonary evaluation. Identifying patients at increased risk for complications. Postgrad Med 1996; 100: 241–248.Google Scholar
El Ganzouri AR, McCarthy RJ, Tuman KJ, Tank EN, Invankovich AD. Preoperative airway assessment: predictive value of a multivariate risk index. Anesth Analg 1996; 82: 1197–1204.Google Scholar
Wilson ME, Spiegelhalter D, Robertson JA, Lesser P. Predicting difficult intubation. Br J Anaesth 1988; 61: 211–216.Google Scholar
Mallampati SR, Gatt SP, Gugino LD. A clinical sign to predict difficult tracheal intubation: a prospective study. Can J Anaesth 1985; 32: 429–434.Google Scholar
Goldman L. Cardiac risk in noncardiac surgery. Ann Intern Med 1983; 98: 504–513.Google Scholar
Goldman L. Cardiac risk in noncardiac surgery: an update. Anesth Analg 1995; 80: 810–820.Google Scholar
Larsen SF, Olesen KH, Jacobsen E. Prediction of cardiac risk in non-cardiac surgery. Eur Heart J 1987; 8: 179–185.Google Scholar
Detsky AS, Abrams HB, McLaughlin JR. Predicting cardiac complications in patients undergoing noncardiac surgery. J Gen Intern Med 1986; 1: 211–219.Google Scholar
Stoelting R, Dierdorf S. Anesthesia and Co-existing Disease.New York, USA: Churchill Livingstone, 1993: 21–35.
Torsher LC, Shub C, Rettke SR, Brown DL. Risk of patients with severe aortic stenosis undergoing noncardiac surgery. Am J Cardiol 1998; 81: 448–452.Google Scholar
St. Clair EW, Oddone EZ, Waugh RA, Corey GR, Feussner JR. Assessing house staff diagnostic skill using a cardiology patient simulator. Ann Intern Med 1992; 117: 751–756.Google Scholar
Roldan CH, Shively BK, Crawford MH. Value of the cardiovascular physical examination for detecting valvular heart disease in asymptomatic subjects. Am J Cardiol 1996; 77: 1327–1331.Google Scholar
Weidenbener CJ, Kraus MD, Waller BF, Taliercio CP. Incorporation of screening echocardiography in the preparticipation exam. Clin J Sports Med 1995; 5: 86–89.Google Scholar
Stewart BF, Siscovick D, Lind BK, et al. Clinical factors associated with calcific aortic valve disease. Cardiovascular Health Study. J Am Coll Cardiol 1997; 29: 630–634.Google Scholar
Otto CM, Lind BK, Kitzman DW, Gersh BJ, Siscovick DS. Association of aortic-valve sclerosis with cardiovascular mortality and morbidity in the elderly. N Engl J Med 1999; 341: 142–147.Google Scholar
Singh JP, Evans JC, Levy D, et al. Prevalence and clinical determinants of mitral, tricuspid, and aortic regurgitation (the Framingham Heart Study). Am J Cardiol 1999; 83: 897–902.Google Scholar
O'Keefe JH, Shub C, Rettke SR. Risk of non-cardiac surgical procedures in patients with aortic stenosis. Mayo Clin Proc 1989; 64: 400–405.Google Scholar
Jaffe WM, Roche AHG, Coverdale HA, McAlister HF, Ormiston JA, Greene ER. Clinical evaluation versus Doppler echocardiography in the quantitative assessment of valvular heart disease. Circulation 1988; 78: 267–275.Google Scholar
Hoffmann A, Burckhardt D. Evaluation of systolic murmurs by Doppler ultrasonography. Br Heart J 1983; 50: 337–340.Google Scholar
Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia 1984; 39: 1105–1111.Google Scholar
Rose DK, Cohen MM. The airway: problems and predictions in 18 500 patients. Can J Anaesth 1994; 41: 372–383.Google Scholar
Oates JD, Macleod AD, Oates PD, Pearsall FJ, Howie JC, Murray GD. Comparison of two methods for predicting difficult intubation. Br J Anaesth 1991; 66: 305–309.Google Scholar
Frerk CM. Predicting difficult intubation. Anaesthesia 1991; 46: 1005–1008.Google Scholar
Tse JC, Rimm EB, Hussain A. Predicting difficult endotracheal intubation in surgical patients scheduled for general anesthesia: a prospective blind study. Anesth Analg 1995; 81: 254–258.Google Scholar
Yamamoto K, Tsubokawa T, Shibata K, Ohmura S, Nitta S, Kobayashi T. Predicting difficult intubation with indirect laryngoscopy. Anesthesiology 1997; 86: 316–321.Google Scholar
Karkouti K, Rose DK, Ferris LE, Wigglesworth DF, Meisami-Fard D, Lee H. Inter-observer reliability of ten tests used for predicting difficult tracheal intubation. Can J Anaesth 1996; 43: 554–559.Google Scholar
Macario A, Roizen MF, Thisted RA, Kim S, Orkin FK, Phelps C. Reassessment of preoperative laboratory testing has changed the test-ordering patterns of physicians. Surg Gynecol Obstet 1992; 175: 539–547.Google Scholar
Narr BJ, Hansen TR, Warner MH. Preoperative laboratory screening in healthy Mayo patients: cost-effective elimination of tests and unchanged outcomes. Mayo Clin Proc 1991; 66: 155–159.Google Scholar
Perez A. Value of routine preoperative tests: a multicentre study in four general hospitals. Br J Anaesth 1995; 74: 250–256.Google Scholar
Tait AR, Parr HG, Tremper KK. Evaluation of the efficacy of routine preoperative electrocardiograms. J Cardiothorac Vasc Anesth 1997; 11: 752–755.Google Scholar
Haug RH, Reifeis RL. A prospective evaluation of the value of preoperative laboratory testing for office anesthesia and sedation. J Oral Maxillofac Surg 1999; 57: 16–20.Google Scholar
Goldberger AL, O'Konski M. Utility of the routine electrocardiogram before surgery and on general hospital admission: critical review and new guidelines. Ann Intern Med 1986; 105: 552–557.Google Scholar
Munro J, Booth A, Nicholl J. Routine preoperative testing: a systematic review of the evidence. Health Technol Assess 1997; 1: 1–63.Google Scholar
Van Klei WA, Moons KGM, Rheineck Leyssius AT, Knape JTA, Rutten CLG, Grobbee DE. A reduction in type and screen: preoperative prediction of RBC transfusions in surgery procedures with intermediate transfusion risks. Br J Anaesth 2001; 87: 250–257.Google Scholar
Van Klei WA, Moons KGM, Rheineck Leyssius AT, et al. Validation of a clinical prediction rule to reduce preoperative type and screen procedures. Br J Anaesth 2002; 89: 221–225.Google Scholar
Van Klei WA, Rheineck Leyssius AT, Grobbee DE, Moons KGM. Identifying patients for blood conservation strategies. Br J Surg 2002; 89: 1176–1182.Google Scholar
Saklad M. Grading of patients for surgical procedures. Anesthesiology 1941; 2: 281–284.Google Scholar
American Society of Anesthesiologists. New classification of physical status. Anesthesiology 1963; 24: 111.
Owens WD, Felts JA, Spitznagel EL. ASA physical status classifications: a study of consistency for rating. Anesthesiology 1978; 49: 239–243.Google Scholar
Wilson ME, Williams NB, Baskett PJF. Assessment of fitness for surgical procedures and the variability of anaesthetists' judgement. BMJ 1980; 280: 509.Google Scholar
Haynes SR, Lawler PGP. An assessment of the consistency of ASA physical status classification allocation. Anaesthesia 1995; 50: 195–199.Google Scholar
Bellhouse CP. Predicting difficult intubation. Anaesthesia 1992; 47: 440–441.Google Scholar