NICE Guidance

This National Institute for Health and Care Excellence (NICE) guidance is the current, unaltered NICE guidance at time
of publication. BJUI publishes selected NICE guidance relevant to urologists to extend their distribution and promote best
practice.

Routine preoperative tests for elective surgery

© NICE (2016) Routine preoperative tests for elective surgery

Overview The tests covered by this guideline are:

This guideline covers routine preoperative tests for people • chest X-ray
aged over 16 who are having elective surgery. It aims to • echocardiography (resting)
reduce unnecessary testing by advising which tests to offer • electrocardiography (ECG; resting)
people before minor, intermediate and major or complex • full blood count (haemoglobin, white blood cell count and
surgery, taking into account specific comorbidities platelet count)
(cardiovascular, renal and respiratory conditions and diabetes • glycated haemoglobin (HbA1c) testing
and obesity). It does not cover pregnant women or people • haemostasis tests
having cardiothoracic procedures or neurosurgery. • kidney function (estimated glomerular filtration rate,
electrolytes, creatinine and sometimes urea levels)
Who is it for? • lung function tests (spirometry, including peak expiratory
flow rate, forced vital capacity and forced expiratory
• Healthcare professionals volume) and arterial blood gas analysis
• People having elective surgery, their families and carers • polysomnography
This guideline updates and replaces NICE guideline CG3 • pregnancy testing
(published June 2003). • sickle cell disease/trait tests
• urine tests.
Recommendations The recommendations were developed in relation to the
following comorbidities:
People have the right to be involved in discussions and make
informed decisions about their care, as described in your care • cardiovascular
[http://www.nice.org.uk/about/nice-communities/public- • diabetes
involvement/your-care]. • obesity
• renal
We expect you to take our guidance into account. But you
• respiratory.
should always base decisions on the person you are working
with. Recommendations relevant for all types of surgery
Making decisions using NICE guidelines [http://www.nice.org. A colour poster version of these recommendations can be
uk/about/what-we-do/our-programmes/nice-guidance/nice- downloaded from tools and resources [http://www.nice.org.
guidelines/using-NICE-guidelines-to-make-decisions] explains uk/guidance/ng45/resources].
how we use words to show the strength (or certainty) of our
1.1 Communication
recommendations, and has information about prescribing
medicines (including off-label use), professional guidelines, 1.1.1 When offering tests before surgery, give people
standards and laws (including on consent and mental information in line with recommendations (including
capacity), and safeguarding. those on consent and capacity) made in the NICE
guideline on patient experience in adult NHS services
Guidance on consent for young people aged 16–17 is
[http://www.nice.org.uk/guidance/cg138].
available from the reference guide to consent for examination
1.1.2 Ensure that the results of any preoperative tests
or treatment [http://www.gov.uk/government/publications/refe
undertaken in primary care are included when
rence-guide-to-consent-for-examination-or-treatment-second-
referring people for surgical consultation.
edition] (Department of Health).

© NICE 2016. All rights reserved and subject to NICE ‘Notice of Rights’.
BJU Int 2018; 121: 12–16 BJU International © 2018 BJU International | doi:10.1111/bju.14079
wileyonlinelibrary.com Published by John Wiley & Sons Ltd. www.bjui.org
 Routine preoperative tests for elective surgery

1.2 Considering existing medicines 1.8 Chest X-ray

1.2.1 Take into account any medicines people are taking 1.8.1 Do not routinely offer chest X-rays before surgery.
when considering whether to offer any preoperative
1.9 Echocardiography
test.
1.9.1 Do not routinely offer resting echocardiography
1.3 Pregnancy tests
before surgery.
1.3.1 On the day of surgery, sensitively ask all women of 1.9.2 Consider resting echocardiography if the person has:
childbearing potential whether there is any
possibility they could be pregnant. • a heart murmur and any cardiac symptom (including
breathlessness, pre-syncope, syncope or chest pain) or
1.3.2 Make sure women who could possibly be pregnant
are aware of the risks of the anaesthetic and the • signs or symptoms of heart failure.
procedure to the fetus. Before ordering the resting echocardiogram, carry out a
1.3.3 Document all discussions with women about resting electrocardiogram (ECG) and discuss the findings with
whether or not to carry out a pregnancy test. an anaesthetist.
1.3.4 Carry out a pregnancy test with the woman’s
consent if there is any doubt about whether she Recommendations for specific surgery grades
could be pregnant. (minor, intermediate, and major or complex) and
1.3.5 Develop locally agreed protocols for checking ASA grades
pregnancy status before surgery.
1.3.6 Make sure protocols are documented and audited, The following recommendations are specific to surgery grade
and in line with statutory and professional guidance. and ASA grade.

1.4 Sickle cell disease or sickle cell trait tests Surgery grades
1.4.1 Do not routinely offer testing for sickle cell disease Surgery grades Examples
or sickle cell trait before surgery.
1.4.2 Ask the person having surgery if they or any
Minor
• excising skin lesion

member of their family have sickle cell disease. • draining breast abscess

1.4.3 If the person is known to have sickle cell Intermediate

• primary repair of inguinal hernia
disease and has their disease managed by a • excising varicose veins in the leg
specialist sickle cell service, liaise with this team • tonsillectomy or adenotonsillectomy
before surgery. • knee arthroscopy

1.5 HbA1c testing for people without diagnosed diabetes Major or complex
• total abdominal hysterectomy

1.5.1 Do not routinely offer HbA1c testing before surgery • endoscopic resection of prostate

to people without diagnosed diabetes. • lumbar discectomy

• thyroidectomy
1.6 HbA1c testing for people with diabetes • total joint replacement

1.6.1 People with diabetes who are being referred for • lung operations

surgical consultation from primary care should have • colonic resection

their most recent HbA1c test results included in • radical neck dissection

their referral information.

1.6.2 Offer HbA1c testing to people with diabetes having
surgery if they have not been tested in the last ASA grades
3 months.
The ASA (American Society of Anesthesiologists) Physical
1.7 Urine tests Status Classification System [http://www.asahq.org/resources/c
1.7.1 Do not routinely offer urine dipstick tests before linical-information/asa-physical-status-classification-system] is
surgery. a simple scale describing fitness to undergo an anaesthetic.
1.7.2 Consider microscopy and culture of midstream The ASA states that it does not endorse any elaboration of
urine sample before surgery if the presence of a these definitions. However, anaesthetists in the UK often
urinary tract infection would influence the decision qualify (or interpret) these grades as relating to functional
to operate.

© NICE 2016. All rights reserved and subject to NICE ‘Notice of Rights’.
BJU International © 2018 BJU International 13
NICE Guidance

capacity – that is, comorbidity that does not (ASA 2) or that Table 2 (continued)
does (ASA 3) limit a person’s activity. Test ASA grade

ASA 1 A normal healthy patient ASA 1 ASA 2 ASA 3 or ASA 4

ASA 2 A patient with mild systemic disease Kidney Not Consider in Yes
ASA 3 A patient with severe systemic disease function routinely people at
ASA 4 A patient with severe systemic disease that is a constant threat to life risk of AKI2
ECG Not Consider for Yes
routinely people with
Key to recommendations in tables
cardiovascular,
[Yes] Offer the test renal or
diabetes
[Not routinely] Do not routinely offer the test comorbidities
Lung function/ Not Not Consider seeking
[Consider] Consider the test (the value of carrying out the test may depend on arterial blood routinely routinely advice from a
specific patient characteristics) gas senior anaesthetist
as soon as possible
after assessment for
people who are ASA
Table 1 Minor surgery
grade 3 or 4 due to
Test ASA grade known or suspected
respiratory disease
ASA 1 ASA 2 ASA 3 or ASA 4

Full blood count Not routinely Not routinely Not routinely AKI, acute kidney injury. 1Note that currently the effects of direct oral anticoagulants
Haemostasis Not routinely Not routinely Not routinely (DOACs) cannot be measured by routine testing. 2See recommendation 1.1.8 of the
Kidney function Not routinely Not routinely Consider in NICE guideline on acute kidney injury [http://www.nice.org.uk/guidance/cg169/chapte
r/1-Recommendations#assessing-risk-factors-in-adults-having-surgery].
people at risk of AKI1
ECG Not routinely Not routinely Consider if no ECG
results available from Table 3 Major or complex surgery
past 12 months
Test ASA grade
Lung function/ Not routinely Not routinely Not routinely
arterial blood gas ASA 1 ASA 2 ASA 3 or
ASA 4
1
AKI, acute kidney injury. See recommendation 1.1.8 of the NICE guideline on acute
kidney injury [http://www.nice.org.uk/guidance/cg169/chapter/1-Recommendations#a Full blood count Yes Yes Yes
ssessing-risk-factors-in-adults-having-surgery]. Haemostasis Not routinely Not Consider in people
routinely with
chronic liver
disease
Table 2 Intermediate surgery
Test ASA grade
• If people taking
anticoagulants
ASA 1 ASA 2 ASA 3 or ASA 4 need
modification of
Full blood Not Not routinely Consider for people their
count routinely with cardiovascular treatment
or renal disease if regimen,
any symptoms not make an
recently individualised
investigated plan in line with
Haemostasis Not Not routinely Consider in people local
routinely with chronic liver guidance
disease ● If clotting status
• If people taking needs
anticoagulants to be tested
need modification before
of their treatment surgery
regimen, make (depending on
an individualised local guidance)
plan in line with use
local guidance point-of-care
• If clotting status testing1
needs to be tested
Kidney function Consider in Yes Yes
before surgery
people at risk of
(depending on
AKI2
local guidance)
ECG Consider for Yes Yes
use point-of-care
people aged over 65
testing1
if no ECG results
available from past
12 months

© NICE 2016. All rights reserved and subject to NICE ‘Notice of Rights’.
14 BJU International © 2018 BJU International
 Routine preoperative tests for elective surgery

Table 3 (continued) 2 Identify a lead with an interest in the topic to champion

Test ASA grade the guideline and motivate others to support its use and make
ASA 1 ASA 2 ASA 3 or
service changes, and to find out any significant issues locally.
ASA 4 3 Carry out a baseline assessment against the
Lung function/ Not routinely Not Consider seeking recommendations to find out whether there are gaps in
arterial blood routinely advice from a current service provision.
gas senior 4 Think about what data you need to measure
anaesthetist as
soon as possible improvement and plan how you will collect it. You may
after assessment want to work with other health and social care
for people who organisations and specialist groups to compare current
are ASA grade 3
or 4 due to practice with the recommendations. This may also help
known or identify local issues that will slow or prevent
suspected implementation.
respiratory
disease 5 Develop an action plan, with the steps needed to put the
guideline into practice, and make sure it is ready as soon
AKI, acute kidney injury. 1Note that currently the effects of direct oral anticoagulants
(DOACs) cannot be measured by routine testing. 2See recommendation 1.1.8 of the
as possible. Big, complex changes may take longer to
NICE guideline on acute kidney injury [http://www.nice.org.uk/guidance/cg169/chapte implement, but some may be quick and easy to do. An
r/1-Recommendations#assessing-risk-factors-in-adults-having-surgery]. action plan will help in both cases.
6 For very big changes include milestones and a business
Putting this guideline into practice case, which will set out additional costs, savings and
NICE has produced tools and resources [http://www.nice.org. possible areas for disinvestment. A small project group
uk/guidance/ng45/resources] to help you put this guideline could develop the action plan. The group might include the
into practice. guideline champion, a senior organisational sponsor, staff
involved in the associated services, finance and information
Putting recommendations into practice can take time. How professionals.
long may vary from guideline to guideline, and depends on 7 Implement the action plan with oversight from the lead
how much change in practice or services is needed. and the project group. Big projects may also need project
Implementing change is most effective when aligned with management support.
local priorities. 8 Review and monitor how well the guideline is being
Changes recommended for clinical practice that can be done implemented through the project group. Share progress
quickly – like changes in prescribing practice – should be with those involved in making improvements, as well as
shared quickly. This is because healthcare professionals relevant boards and local partners.
should use guidelines to guide their work – as is required by NICE provides a comprehensive programme of support and
professional regulating bodies such as the General Medical resources to maximise uptake and use of evidence and
and Nursing and Midwifery Councils. guidance. See our into practice [http://www.nice.org.uk/about/
Changes should be implemented as soon as possible, unless what-we-do/into-practice] pages for more information.
there is a good reason for not doing so (for example, if it Also see Leng G, Moore V, Abraham S, editors (2014)
would be better value for money if a package of Achieving high quality care – practical experience from
recommendations were all implemented at once). NICE. Chichester: Wiley.
Different organisations may need different approaches to
implementation, depending on their size and function. Context
Sometimes individual practitioners may be able to respond to In 2003, NICE first issued guidance on the use of routine
recommendations to improve their practice more quickly preoperative tests for people having elective surgery. Many
than large organisations. apparently healthy people are tested before surgery to check
Here are some pointers to help organisations put NICE for undetected conditions that might affect their treatment.
guidelines into practice: This can provide a benefit where test results yield additional
information that cannot be obtained from a patient history
1 Raise awareness through routine communication channels, and physical examination alone. However, excessive
such as email or newsletters, regular meetings, internal staff preoperative testing can cause significant anxiety, delays in
briefings and other communications with all relevant treatment and unnecessary, costly and possibly harmful
partner organisations. Identify things staff can include in treatments when false positive results are obtained. Even
their own practice straight away. genuinely abnormal results often do not result in any

© NICE 2016. All rights reserved and subject to NICE ‘Notice of Rights’.
BJU International © 2018 BJU International 15
NICE Guidance

significant change in perioperative management in relatively

1 Polysomnography
healthy people.
a) Does preoperative screening of people who are at risk of
Since 2003 there has been a reduction in the ordering of
obstructive sleep apnoea with polysomnography identify
routine tests for young, healthy people having minor surgery
those at higher risk of postoperative complications?
(What is the value of routinely testing full blood count,
b) Does treating obstructive sleep apnoea perioperatively
electrolytes and urea, and pulmonary function tests before
improve outcomes?
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- Why this is important
effective literature, Czoski-Murray C et al. 2012). However, Obstructive sleep apnoea is a common condition, particularly
there remains a concern that some unnecessary tests continue in people who are obese, and is associated with adverse
to be requested. According to Hospital Episode Statistics postoperative outcomes. However, it is frequently
2012–13 (Health and Social Care Information Centre) the undiagnosed before surgery. Work is ongoing to examine
NHS in England completed 10.6 million operations compared whether obstructive sleep apnoea is associated with a variety
with 6.61 million in 2002–03 (Hospital Episode Statistics of postoperative outcomes (morbidity, mortality, quality of
2002–03 Health and Social Care Information Centre), an life) in specific surgical populations. However, there is
increase of 60%. Therefore even a small percentage of currently no robust evidence or any ongoing trials studying
unnecessary preoperative testing can affect a large number of whether preoperative assessment and diagnosis of obstructive
people. sleep apnoea leads to preoperative intervention or improved
Over the past 12 years preoperative assessment has postoperative outcomes.
changed radically. Most people are now seen well in
advance of surgery in a preoperative assessment clinic, 2 Glycated haemoglobin testing
where a structured history and targeted examination are Does optimisation of HbA1c in people with poorly controlled
performed by experienced nursing staff. Some preoperative diabetes improve surgical outcomes?
tests have been abandoned in favour of others (for
example random blood glucose in favour of HbA1c), while Why this is important
new tests have been developed that are increasingly being
Diabetes is the most common metabolic disorder in the UK
used in some people having elective surgery (for example
and people with diabetes increasingly need surgical
non-invasive cardiac stress tests, cardiopulmonary exercise
procedures. Diabetes leads to increased morbidity, length of
test and polysomnography).
stay and inpatient costs. Evidence suggests that doctors often
fail to identify high-risk patients before surgery and do not
More information provide perioperative interventions to control HbA1c levels.
You can also see this guideline in the NICE pathway on However, the impact of optimising HbA1c levels before
preoperative tests [http://pathways.nice.org.uk/pathways/ surgery has not been assessed in a randomised clinical trial.
preoperative-tests].
To find out what NICE has said on topics related to this Update information
guideline, see our web page on surgical care [http://www.nice. This guideline is an update of NICE guideline CG3
org.uk/guidance/service-delivery–organisation-and-staffing/ (published June 2003) and will replace it.
surgical-care].
New recommendations and 1 research recommendation have
See also the guideline committee’s discussion and the been added for the following tests that were not included in
evidence reviews (in the full guideline [http://www.nice.org. the original guideline:
uk/Guidance/NG45/evidence]), and information about
how the guideline was developed [http://www.nice.org.uk/ • echocardiography (resting)
Guidance/NG45/documents], including details of the • HbA1c testing
committee. • polysomnography.
Copyright
Recommendations for research © NICE [2016]. All rights reserved and subject to NICE
The guideline committee has made the following ‘Notice of Rights’. Available from https://www.nice.org.uk/
recommendations for research. guidance/ng45. All NICE guidance is subject to regular review
and may be updated or withdrawn. NICE accepts no
responsibility for the use of its content in this publication.

© NICE 2016. All rights reserved and subject to NICE ‘Notice of Rights’.
16 BJU International © 2018 BJU International