Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Preanesthesia evaluation for noncardiac surgery

BobbieJean Sweitzer, MD, FACP
Section Editor
Natalie F Holt, MD, MPH
Deputy Editor
Marianna Crowley, MD


All patients who undergo anesthesia must have a preanesthesia evaluation by an anesthesia clinician to assess the patient's perioperative risk and readiness for the planned procedure, and to create an anesthetic plan. This topic will discuss the components of preanesthesia evaluation, including risk assessment and appropriate preoperative testing.

Preoperative medical evaluation, medication management, and preoperative evaluation for some specific medical conditions are discussed separately. (See "Preoperative medical evaluation of the adult healthy patient" and "Perioperative medication management" and "Evaluation of cardiac risk prior to noncardiac surgery" and "Management of cardiac risk for noncardiac surgery" and "Evaluation of preoperative pulmonary risk" and "Strategies to reduce postoperative pulmonary complications in adults" and "Perioperative care of the surgical patient with neurologic disease" and "Perioperative management of heart failure in patients undergoing noncardiac surgery" and "Perioperative management of hypertension".)


Goals of preoperative evaluation are to assess the patient's medical status and ability to tolerate anesthesia for the planned procedure, reduce the risks of anesthesia and surgery, and to prepare the patient for the procedure. Adequate preoperative patient evaluation and preparation may improve patient satisfaction, as well as decrease complications, delays, cancellations, costs, and mortality [1-5].


Components of the preanesthesia evaluation process include the following:

Clinical evaluation to identify comorbid conditions, allergies, and previous complications of anesthesia

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Sep 2017. | This topic last updated: Sep 05, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Kluger MT, Tham EJ, Coleman NA, et al. Inadequate pre-operative evaluation and preparation: a review of 197 reports from the Australian incident monitoring study. Anaesthesia 2000; 55:1173.
  2. Blitz JD, Kendale SM, Jain SK, et al. Preoperative Evaluation Clinic Visit Is Associated with Decreased Risk of In-hospital Postoperative Mortality. Anesthesiology 2016; 125:280.
  3. Carlisle J, Swart M, Dawe EJ, Chadwick M. Factors associated with survival after resection of colorectal adenocarcinoma in 314 patients. Br J Anaesth 2012; 108:430.
  4. Ferschl MB, Tung A, Sweitzer B, et al. Preoperative clinic visits reduce operating room cancellations and delays. Anesthesiology 2005; 103:855.
  5. Starsnic MA, Guarnieri DM, Norris MC. Efficacy and financial benefit of an anesthesiologist-directed university preadmission evaluation center. J Clin Anesth 1997; 9:299.
  6. Power LM, Thackray NM. Reduction of preoperative investigations with the introduction of an anaesthetist-led preoperative assessment clinic. Anaesth Intensive Care 1999; 27:481.
  7. van Klei WA, Moons KG, Rutten CL, et al. The effect of outpatient preoperative evaluation of hospital inpatients on cancellation of surgery and length of hospital stay. Anesth Analg 2002; 94:644.
  8. Partridge JS, Harari D, Martin FC, et al. Randomized clinical trial of comprehensive geriatric assessment and optimization in vascular surgery. Br J Surg 2017; 104:679.
  9. Shi Y, Warner DO. Surgery as a teachable moment for smoking cessation. Anesthesiology 2010; 112:102.
  10. Committee on Standards and Practice Parameters, Apfelbaum JL, Connis RT, et al. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology 2012; 116:522.
  11. Reilly DF, McNeely MJ, Doerner D, et al. Self-reported exercise tolerance and the risk of serious perioperative complications. Arch Intern Med 1999; 159:2185.
  12. Girish M, Trayner E Jr, Dammann O, et al. Symptom-limited stair climbing as a predictor of postoperative cardiopulmonary complications after high-risk surgery. Chest 2001; 120:1147.
  13. Hartle A, McCormack T, Carlisle J, et al. The measurement of adult blood pressure and management of hypertension before elective surgery: Joint Guidelines from the Association of Anaesthetists of Great Britain and Ireland and the British Hypertension Society. Anaesthesia 2016; 71:326.
  14. Verdecchia P, Angeli F, Gattobigio R. Clinical usefulness of ambulatory blood pressure monitoring. J Am Soc Nephrol 2004; 15 Suppl 1:S30.
  15. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009; 360:1418.
  16. Jhanji S, Thomas B, Ely A, et al. Mortality and utilisation of critical care resources amongst high-risk surgical patients in a large NHS trust. Anaesthesia 2008; 63:695.
  17. Pearse RM, Moreno RP, Bauer P, et al. Mortality after surgery in Europe: a 7 day cohort study. Lancet 2012; 380:1059.
  18. Weiser TG, Haynes AB, Molina G, et al. Size and distribution of the global volume of surgery in 2012. Bull World Health Organ 2016; 94:201.
  19. Dimick JB, Chen SL, Taheri PA, et al. Hospital costs associated with surgical complications: a report from the private-sector National Surgical Quality Improvement Program. J Am Coll Surg 2004; 199:531.
  20. Pearse RM, Harrison DA, James P, et al. Identification and characterisation of the high-risk surgical population in the United Kingdom. Crit Care 2006; 10:R81.
  21. Schilling PL, Dimick JB, Birkmeyer JD. Prioritizing quality improvement in general surgery. J Am Coll Surg 2008; 207:698.
  22. Khuri SF, Henderson WG, DePalma RG, et al. Determinants of long-term survival after major surgery and the adverse effect of postoperative complications. Ann Surg 2005; 242:326.
  23. Healy MA, Mullard AJ, Campbell DA Jr, Dimick JB. Hospital and Payer Costs Associated With Surgical Complications. JAMA Surg 2016; 151:823.
  24. Sankar A, Johnson SR, Beattie WS, et al. Reliability of the American Society of Anesthesiologists physical status scale in clinical practice. Br J Anaesth 2014; 113:424.
  25. Liu JB, Liu Y, Cohen ME, et al. Defining intrinsic operative risk separate from patient factors for preoperative evaluations. 12th Annual Academic Surgical Congress ASC20170172
  26. Gupta PK, Gupta H, Sundaram A, et al. Development and validation of a risk calculator for prediction of cardiac risk after surgery. Circulation 2011; 124:381.
  27. Bjorgul K, Novicoff WM, Saleh KJ. American Society of Anesthesiologist Physical Status score may be used as a comorbidity index in hip fracture surgery. J Arthroplasty 2010; 25:134.
  28. Han KR, Kim HL, Pantuck AJ, et al. Use of American Society of Anesthesiologists physical status classification to assess perioperative risk in patients undergoing radical nephrectomy for renal cell carcinoma. Urology 2004; 63:841.
  29. Skaga NO, Eken T, Søvik S, et al. Pre-injury ASA physical status classification is an independent predictor of mortality after trauma. J Trauma 2007; 63:972.
  30. 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.
  31. Wolters U, Wolf T, Stützer H, Schröder T. ASA classification and perioperative variables as predictors of postoperative outcome. Br J Anaesth 1996; 77:217.
  32. Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation 1999; 100:1043.
  33. Tsiouris A, Horst HM, Paone G, et al. Preoperative risk stratification for thoracic surgery using the American College of Surgeons National Surgical Quality Improvement Program data set: functional status predicts morbidity and mortality. J Surg Res 2012; 177:1.
  34. Enright PL, Sherrill DL. Reference equations for the six-minute walk in healthy adults. Am J Respir Crit Care Med 1998; 158:1384.
  35. Sinclair RC, Batterham AM, Davies S, et al. Validity of the 6 min walk test in prediction of the anaerobic threshold before major non-cardiac surgery. Br J Anaesth 2012; 108:30.
  36. ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med 2002; 166:111.
  37. Colson M, Baglin J, Bolsin S, Grocott MP. Cardiopulmonary exercise testing predicts 5 yr survival after major surgery. Br J Anaesth 2012; 109:735.
  38. Wilson RJ, Davies S, Yates D, et al. Impaired functional capacity is associated with all-cause mortality after major elective intra-abdominal surgery. Br J Anaesth 2010; 105:297.
  39. James S, Jhanji S, Smith A, et al. Comparison of the prognostic accuracy of scoring systems, cardiopulmonary exercise testing, and plasma biomarkers: a single-centre observational pilot study. Br J Anaesth 2014; 112:491.
  40. Dillon ST, Vasunilashorn SM, Ngo L, et al. Higher C-Reactive Protein Levels Predict Postoperative Delirium in Older Patients Undergoing Major Elective Surgery: A Longitudinal Nested Case-Control Study. Biol Psychiatry 2017; 81:145.
  41. Kristensen SD, Knuuti J, Saraste A, et al. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J 2014; 35:2383.
  42. Schein OD, Katz J, Bass EB, et al. The value of routine preoperative medical testing before cataract surgery. Study of Medical Testing for Cataract Surgery. N Engl J Med 2000; 342:168.
  43. riskcalculator.facs.org/RiskCalculator/ (Accessed January 14, 2017).
  44. Oresanya LB, Lyons WL, Finlayson E. Preoperative assessment of the older patient: a narrative review. JAMA 2014; 311:2110.
  45. Cologne KG, Keller DS, Liwanag L, et al. Use of the American College of Surgeons NSQIP Surgical Risk Calculator for Laparoscopic Colectomy: how good is it and how can we improve it? J Am Coll Surg 2015; 220:281.
  46. Arce K, Moore EJ, Lohse CM, et al. The American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator Does Not Accurately Predict Risk of 30-Day Complications Among Patients Undergoing Microvascular Head and Neck Reconstruction. J Oral Maxillofac Surg 2016; 74:1850.
  47. O'Neill AC, Bagher S, Barandun M, et al. Can the American College of Surgeons NSQIP surgical risk calculator identify patients at risk of complications following microsurgical breast reconstruction? J Plast Reconstr Aesthet Surg 2016; 69:1356.
  48. Vaziri S, Wilson J, Abbatematteo J, et al. Predictive performance of the American College of Surgeons universal risk calculator in neurosurgical patients. J Neurosurg 2017; :1.
  49. Glance LG, Lustik SJ, Hannan EL, et al. The Surgical Mortality Probability Model: derivation and validation of a simple risk prediction rule for noncardiac surgery. Ann Surg 2012; 255:696.
  50. Mashour GA, Moore LE, Lele AV, et al. Perioperative care of patients at high risk for stroke during or after non-cardiac, non-neurologic surgery: consensus statement from the Society for Neuroscience in Anesthesiology and Critical Care*. J Neurosurg Anesthesiol 2014; 26:273.
  51. Gupta H, Gupta PK, Fang X, et al. Development and validation of a risk calculator predicting postoperative respiratory failure. Chest 2011; 140:1207.
  52. Gupta H, Gupta PK, Schuller D, et al. Development and validation of a risk calculator for predicting postoperative pneumonia. Mayo Clin Proc 2013; 88:1241.
  53. Arozullah AM, Khuri SF, Henderson WG, et al. Development and validation of a multifactorial risk index for predicting postoperative pneumonia after major noncardiac surgery. Ann Intern Med 2001; 135:847.
  54. Brueckmann B, Villa-Uribe JL, Bateman BT, et al. Development and validation of a score for prediction of postoperative respiratory complications. Anesthesiology 2013; 118:1276.
  55. Canet J, Gallart L, Gomar C, et al. Prediction of postoperative pulmonary complications in a population-based surgical cohort. Anesthesiology 2010; 113:1338.
  56. Kor DJ, Lingineni RK, Gajic O, et al. Predicting risk of postoperative lung injury in high-risk surgical patients: a multicenter cohort study. Anesthesiology 2014; 120:1168.
  57. Nadelson MR, Sanders RD, Avidan MS. Perioperative cognitive trajectory in adults. Br J Anaesth 2014; 112:440.
  58. Saczynski JS, Marcantonio ER, Quach L, et al. Cognitive trajectories after postoperative delirium. N Engl J Med 2012; 367:30.
  59. Kat MG, Vreeswijk R, de Jonghe JF, et al. Long-term cognitive outcome of delirium in elderly hip surgery patients. A prospective matched controlled study over two and a half years. Dement Geriatr Cogn Disord 2008; 26:1.
  60. Flinn DR, Diehl KM, Seyfried LS, Malani PN. Prevention, diagnosis, and management of postoperative delirium in older adults. J Am Coll Surg 2009; 209:261.
  61. Marcantonio ER, Goldman L, Mangione CM, et al. A clinical prediction rule for delirium after elective noncardiac surgery. JAMA 1994; 271:134.
  62. Robinson TN, Raeburn CD, Tran ZV, et al. Postoperative delirium in the elderly: risk factors and outcomes. Ann Surg 2009; 249:173.
  63. Jones TS, Dunn CL, Wu DS, et al. Relationship between asking an older adult about falls and surgical outcomes. JAMA Surg 2013; 148:1132.
  64. Chow WB, Rosenthal RA, Merkow RP, et al. Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J Am Coll Surg 2012; 215:453.
  65. Howell SJ, Sear JW, Foex P. Hypertension, hypertensive heart disease and perioperative cardiac risk. Br J Anaesth 2004; 92:57.
  66. Roshanov PS, Rochwerg B, Patel A, et al. Withholding versus Continuing Angiotensin-converting Enzyme Inhibitors or Angiotensin II Receptor Blockers before Noncardiac Surgery: An Analysis of the Vascular events In noncardiac Surgery patIents cOhort evaluatioN Prospective Cohort. Anesthesiology 2017; 126:16.
  67. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol 2014; 64:e77.
  68. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:e57.
  69. Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2016; 67:e27.
  70. Jørgensen ME, Torp-Pedersen C, Gislason GH, et al. Time elapsed after ischemic stroke and risk of adverse cardiovascular events and mortality following elective noncardiac surgery. JAMA 2014; 312:269.
  71. Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics--2015 update: a report from the American Heart Association. Circulation 2015; 131:e29.
  72. Ackland GL, Moran N, Cone S, et al. Chronic kidney disease and postoperative morbidity after elective orthopedic surgery. Anesth Analg 2011; 112:1375.
  73. Mathew A, Devereaux PJ, O'Hare A, et al. Chronic kidney disease and postoperative mortality: a systematic review and meta-analysis. Kidney Int 2008; 73:1069.
  74. Chertow GM, Lazarus JM, Christiansen CL, et al. Preoperative renal risk stratification. Circulation 1997; 95:878.
  75. Buchleitner AM, Martínez-Alonso M, Hernández M, et al. Perioperative glycaemic control for diabetic patients undergoing surgery. Cochrane Database Syst Rev 2012; 9:CD007315.
  76. Akhtar S, Barash PG, Inzucchi SE. Scientific principles and clinical implications of perioperative glucose regulation and control. Anesth Analg 2010; 110:478.
  77. Malone DL, Genuit T, Tracy JK, et al. Surgical site infections: reanalysis of risk factors. J Surg Res 2002; 103:89.
  78. Moitra VK, Greenberg J, Arunajadai S, Sweitzer B. The relationship between glycosylated hemoglobin and perioperative glucose control in patients with diabetes. Can J Anaesth 2010; 57:322.
  79. Weinberg AD, Brennan MD, Gorman CA, et al. Outcome of anesthesia and surgery in hypothyroid patients. Arch Intern Med 1983; 143:893.
  80. Schmitt H, Buchfelder M, Radespiel-Tröger M, Fahlbusch R. Difficult intubation in acromegalic patients: incidence and predictability. Anesthesiology 2000; 93:110.
  81. Goodnough LT, Shander A, Spivak JL, et al. Detection, evaluation, and management of anemia in the elective surgical patient. Anesth Analg 2005; 101:1858.
  82. Musallam KM, Tamim HM, Richards T, et al. Preoperative anaemia and postoperative outcomes in non-cardiac surgery: a retrospective cohort study. Lancet 2011; 378:1396.
  83. Dunkelgrun M, Hoeks SE, Welten GM, et al. Anemia as an independent predictor of perioperative and long-term cardiovascular outcome in patients scheduled for elective vascular surgery. Am J Cardiol 2008; 101:1196.
  84. Wu WC, Schifftner TL, Henderson WG, et al. Preoperative hematocrit levels and postoperative outcomes in older patients undergoing noncardiac surgery. JAMA 2007; 297:2481.
  85. Banz VM, Jakob SM, Inderbitzin D. Review article: improving outcome after major surgery: pathophysiological considerations. Anesth Analg 2011; 112:1147.
  86. Sørensen LT. Wound healing and infection in surgery. The clinical impact of smoking and smoking cessation: a systematic review and meta-analysis. Arch Surg 2012; 147:373.
  87. Turan A, Mascha EJ, Roberman D, et al. Smoking and perioperative outcomes. Anesthesiology 2011; 114:837.
  88. http://www.choosingwisely.org.
  89. https://www.aagbi.org/sites/default/files/preop2010.pdf.
  90. Boisen ML, Collins RA, Yazer MH, Waters JH. Pretransfusion testing and transfusion of uncrossmatched erythrocytes. Anesthesiology 2015; 122:191.
  91. Friedman BA, Oberman HA, Chadwick AR, Kingdon KI. The maximum surgical blood order schedule and surgical blood use in the United States. Transfusion 1976; 16:380.
  92. Frank SM, Rothschild JA, Masear CG, et al. Optimizing preoperative blood ordering with data acquired from an anesthesia information management system. Anesthesiology 2013; 118:1286.
  93. Palmer T, Wahr JA, O'Reilly M, Greenfield ML. Reducing unnecessary cross-matching: a patient-specific blood ordering system is more accurate in predicting who will receive a blood transfusion than the maximum blood ordering system. Anesth Analg 2003; 96:369.
  94. O'Neill F, Carter E, Pink N, Smith I. Routine preoperative tests for elective surgery: summary of updated NICE guidance. BMJ 2016; 354:i3292.
  95. Lamont T, Coates T, Mathew D, et al. Checking for pregnancy before surgery: summary of a safety report from the National Patient Safety Agency. BMJ 2010; 341:c3402.
  96. Hennis PJ, Meale PM, Grocott MP. Cardiopulmonary exercise testing for the evaluation of perioperative risk in non-cardiopulmonary surgery. Postgrad Med J 2011; 87:550.
  97. Wijeysundera DN, Beattie WS, Austin PC, et al. Non-invasive cardiac stress testing before elective major non-cardiac surgery: population based cohort study. BMJ 2010; 340:b5526.
  98. Swart M, Carlisle JB. Case-controlled study of critical care or surgical ward care after elective open colorectal surgery. Br J Surg 2012; 99:295.
  99. Ankuda CK, Block SD, Cooper Z, et al. Measuring critical deficits in shared decision making before elective surgery. Patient Educ Couns 2014; 94:328.
  100. Flierler WJ, Nübling M, Kasper J, Heidegger T. Implementation of shared decision making in anaesthesia and its influence on patient satisfaction. Anaesthesia 2013; 68:713.
  101. http://www.asahq.org/publicationsAndServices/standards/09.html.
Topic Outline