NATIONAL INSTITUTE FOR HEALTH AND
CARE EXCELLENCE
SCOPE
1 Guideline title
Preoperative tests: the use of routine preoperative tests for elective surgery
(update).
1.1 Short title
Preoperative tests.
2 The remit
This is an update of 'Preoperative tests' (NICE clinical guideline 3).
See section 4.3.1 for details of which sections will be updated. We will also
carry out an editorial review of all recommendations, for example to ensure
that they comply with NICE’s duties under equalities legislation.
This update is being undertaken as part of the guideline review cycle.
The update was commissioned to include the results of the 2012 Heath
Technology Assessment (HTA 2012) ‘What is the value of routinely testing full
blood count, urea and electrolytes, and pulmonary function tests before
elective surgery in patients with no apparent clinical indication and in
subgroups of patients with common comorbidities: a systematic review of the
clinical and cost-effective literature’. In the areas where new evidence was
identified as part of the NICE review update, full searches will be undertaken.
No additional searches will be undertaken for areas where the NICE review
update found no new evidence. Formal consensus methods will be used, in
addition to the updated evidence reviews, to support the development of
recommendations, including those where no evidence review is to be
conducted.
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3 Need for the guideline
3.1 Incidence
a) Many apparently healthy people are tested preoperatively to check
for undetected conditions that might affect their treatment. In
2012/2013 the NHS in England completed 10.6 million operations,
compared to 6.61 million in 2002/2003. This is an increase of 60%.
3.2 Current practice
a) In 2003 NICE issued guidance for the use of routine preoperative
tests for healthy children and adults, and adults with mild, moderate
and severe comorbidities (cardiovascular, respiratory, renal
disease and obesity), undergoing elective surgery (NICE clinical
guideline 3).
b) A generic preoperative test is defined as an investigation done
before an operation that is recommended for all patients of a
particular type (for example, people in a certain age range or with a
particular comorbidity) that is not directly linked to either the
surgical procedure or the condition for which the operation is for.
c) The American Society of Anesthesiologists (ASA) Physical Status
Classification System is often used by UK anaesthetists to
establish a person’s functional capacity. ASA grades are a simple
scale describing a person’s fitness to be given an anaesthetic for a
procedure. However, the ASA clearly states that it does not
endorse any elaboration of these definitions within the classification
system.
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Table 1. American Society of Anesthesiologists Physical Status
Classification System
ASA grade 1 A normal healthy patient, (that is, without any
clinically important comorbidity and without a
clinically significant past/present medical history)
ASA grade 2 A patient with mild systemic disease
ASA grade 3 A patient with severe systemic disease
ASA grade 4 A patient with severe systemic disease that is a
constant threat to life
ASA grade 5 A moribund patient who is not expected to survive
without the operation
ASA grade 6 A declared brain-dead patient whose organs are
being removed for donor purposes
d) Clinical opinion currently varies on how useful it is to test
apparently healthy people before their operations. There is also
increasing awareness that such tests can alarm people
unnecessarily for little clinical benefit. Evidence shows that
clinicians do not often change how they manage people’s care,
even if tests in relatively healthy people give abnormal results.
Therefore, if preoperative tests are only ordered when healthy
people undergoing surgery have a specific condition or there is a
reasonable suspicion they have that condition, the potential savings
to the NHS could be considerable.
e) Most of the evidence base in NICE clinical guideline 3 (the existing
preoperative tests clinical guideline) was inconclusive. As a result
of new published evidence in the area, NICE has commissioned an
update of the original NICE guideline. In NICE clinical guideline 3 a
traffic light system was developed to show the degree of consensus
reached by the guideline group and whether the test is
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recommended, may be considered or is not recommended (see
table below).This will continue to be used for the updated guideline.
YES Test recommended
NO Test not recommended
CONSIDER The value of carrying out a
preoperative test is not known
(amber area), and may depend
on specific patient
characteristics
f) Since NICE clinical guideline 3 was published in 2003, new
preoperative tests have been developed for use in elective surgery
(for example, non-invasive cardiac stress tests) that may give more
information on the best form of management during surgery and
postoperative complications.
4 The guideline
The guideline development process is described in detail on the NICE website
(see section 6, ‘Further information’).
This scope defines what the guideline will (and will not) examine, and what the
guideline developers will consider. The scope is based on the referral from the
Department of Health.
The areas that will be addressed by the guideline are described in the
following sections.
4.1 Population
4.1.1 Groups that will be covered
Groups that will be covered Rationale
a) Adults and young people As in the original NICE guideline.
(older than 16 years) ASA
grade 1.
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b) Adults and young people As in the original NICE guideline.
ASA grade 2.
Cardiovascular, respiratory and renal
c) Adults and young people diseases were included as
ASA grade 3 and above. comorbidities in the original NICE
guideline.
Systemic comorbidities for ASA
grades 2, 3 and 4 include: Evidence shows that people with
cardiovascular issues, respiratory obesity may need different
issues, renal disease, obesity and preoperative tests because of the
diabetes. associated risk of complications
during operations.
Clinical experts at the stakeholder
workshop supported the point that
people with diabetes may need
different preoperative tests because
of the associated risk of
complications during operations.
d) Patients having the As in the original NICE guideline.
following types of elective
surgery:
Grade 1 (minor, such as
removal of a skin lesion or
drainage of a breast
abscess).
Grade 2 (intermediate, such
as primary repair of an
inguinal hernia, removal of
varicose veins in the leg,
removal of the tonsils or
knee arthroscopy).
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Grade 3 (major, such as a
full hysterectomy, partial
removal of the prostate
using an endoscope,
removal of part of a
damaged disc from the
spine or removal of the
thyroid).
Grade 4 (major+, such as
total joint replacement, lung
operations, removal of part
of the lower intestine,
removal of cancerous lymph
nodes from the neck,
neurosurgery or heart
surgery).
4.1.2 Groups that will not be covered
Groups that will not be covered Rationale
a) All children and young The clinical considerations and the
people (0–16 years old). pattern of pathology are different to
those for adults.
Children are treated in specialist
centres.
b) Pregnant women. No recommendations were made for
this group in the original NICE
guideline.
Relatively few pregnant women will
have elective non-obstetric surgery.
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c) Adults with ASA grade 2 or The evidence and stakeholder
above, with comorbidities opinion has not supported including
other than cardiovascular, any comorbidities other than those
respiratory, renal, diabetes already listed.
or obesity.
4.2 Setting
a) All settings in which NHS care is received or commissioned.
4.3 Management
4.3.1 Key issues that will be covered
Areas from the original guideline that will be updated
The proposed method of update is by systematic evidence review and, where
appropriate, by formal consensus survey. This guideline will cover the
prognostic clinical value of the following preoperative tests:
Preoperative tests Description and rationale for prioritising
topic
a) Full blood count As in the original NICE guideline and the
(haemoglobin, HTA 2012. Results will be incorporated and
white blood cell updated with new evidence.
count and platelet
Amber-coded recommendations in the
count).
original NICE guideline indicated uncertainty
about the suitability of the test, suggesting a
further survey to review the consensus
position is needed.
Obesity and diabetes are included as
comorbidities of interest after new evidence
was found in the review for updating the
guideline.
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b) Kidney function As in the HTA 2012. Results will be
tests (urea, incorporated and updated with evidence.
estimated
Amber-coded recommendations in the
glomerular filtration
original NICE guideline which were not
rate and electrolyte
included in the HTA 2012 (see above).
tests).
Obesity and diabetes are now included as
comorbidities of interest in this update (see
above).
c) Pulmonary function As in the HTA 2012. Results will be
tests (also incorporated and updated with evidence.
including blood gas
Amber-coded recommendations in the
analysis).
original NICE guideline which were not
covered in the HTA 2012 (see above).
Evidence may show that specific pulmonary
tests can predict postoperative
complications for adults with respiratory
disease.
d) Resting New evidence shows the limited value of an
electrocardiogram ECG in changing the best form of
(ECG). management.
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Areas not in the original guideline that will be included in the update
As for the table above, the proposed method of update is by systematic
evidence review and, where appropriate, by formal consensus survey. This
guideline will cover the prognostic clinical value of the following preoperative
tests:
Preoperative tests Population/type Description and
of surgery rationale for
prioritising topic
e) Cardiopulmonary ASA grade 2 or Evidence shows this
exercise test above undergoing test can identify causes
(CPET). grade 3 and 4 of exercise intolerance
surgery. (such as obesity, heart
and pulmonary disease)
and predict
postoperative
complications for adults
undergoing non-cardiac
surgery.
f) Non-invasive ASA grade 2 or Evidence shows
cardiac testing: above undergoing echocardiography can
grade 3 and 4 potentially predict
- resting
surgery. postoperative
echocardiography
complications for adults
with coronary heart
disease and restricted
mobility from non-
cardiac causes.
g) Polysomnography ASA grade 2 or There is evidence that
(to detect above (with this test may guide
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obstructive sleep comorbid obesity) management for adults
apnoea [OSA]). undergoing grade with obesity and OSA
3 and 4 surgery. during operations.
h) HbA1c (glycated ASA grade 1 (over Evidence shows the
haemoglobin). 40 years old), 2 potential role of
and above hyperglycaemia on the
undergoing grade risk of postoperative
3 and 4 surgery. infections and
cardiovascular
complications for high
risk groups (such as
people with cardiac
disease, diabetes or
obesity).
Areas from the original guideline that will be covered by a formal
consensus survey (no systematic evidence review)
No evidence was found for the tests listed below in the NICE update review,
but the opinion from the stakeholder workshop was that clinical practice and
experience of use is likely to have changed since the original NICE guideline
was published in 2003. NICE will carry out a formal consensus survey to
explore current practice in these areas:
i) haemostasis tests
j) chest X-ray
k) urine tests
l) pregnancy tests
m) sickle cell disease/trait tests.
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4.3.2 Issues that will not be covered
Areas from the original guideline that will be removed
a) Children (ASA grade 1).
b) Cardiovascular surgery.
c) Neurosurgery.
d) Random blood glucose tests
Areas not covered by the original guideline or the update
e) Computed tomography scan of the thorax.
f) Haemoglobin electrophoresis.
g) Blood cross-matching.
h) Screening tests for methicillin-resistant Staphylococcus aureus
(MRSA), Clostridium difficile (C.Diff), vancomycin-resistant
enterococci (VRE), carbapenem-resistant Enterobacteriacaea
(CRE), carbapenem-resistant Klebsiella pneumoniae (CRKP) and
other superbug hospital acquired infections.
i) Preoperative clinical assessment (including history taking, physical
examination and advice on the assessment and wider clinical
management of people’s conditions before surgery or during follow-
up) and the optimal setting for preoperative testing.
4.4 Main outcomes
a) All-cause mortality.
b) Change in healthcare management (for example cancellation of
surgery).
c) Complications related to surgery or anaesthesia.
d) Length of hospital stay after an operation.
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e) Hospital readmission.
f) Adverse events caused by testing.
g) Health related quality of life.
h) Intensive care / high dependency unit admission.
4.5 Economic aspects
Developers will take into account both clinical and cost effectiveness when
making recommendations involving a choice between alternative
interventions. A review of the economic evidence will be conducted and
analyses will be carried out as appropriate. The preferred unit of effectiveness
is the quality-adjusted life year (QALY), and the costs considered will usually
be only from an NHS and personal social services (PSS) perspective. Further
detail on the methods can be found in The guidelines manual.
4.6 Status
4.6.1 Scope
This is the final scope.
4.6.2 Timing
The development of the guideline recommendations will begin in May 2014.
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5 Related NICE guidance
5.1 Published guidance
5.1.1 NICE guidance to be updated
This guideline will update and replace the following NICE guidance:
Preoperative tests: the use of routine preoperative tests for elective surgery
NICE clinical guideline 3 (2003).
5.1.2 Other related NICE guidance
Patient experience in adult NHS services: improving the experience of care for
people using adult NHS services NICE clinical guideline 138 (2012).
5.2 Guidance under development
No other related guidance is under development.
6 Further information
Information on the guideline development process is provided in the following
documents, available from the NICE website:
How NICE clinical guidelines are developed: an overview for stakeholders
the public and the NHS: 5th edition
The guidelines manual.
Information on the progress of the guideline will also be available from the
NICE website.
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