English Version of Guideline

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GARI Task Force Preoperative Evaluation

Guideline for preoperative Patient Evaluation

1) Introduction:
These guidelines were compiled and published by the members of the GARI Task Force
on Preoperative Evaluation. The current version may either by obtained directly through
GARI or online at www.oegari.at. The information displayed here serves as preoperative
evaluation of adults undergoing elective surgical intervention. A guideline for
preoperative evaluation of pediatric patients is displayed separately from this expose.
The extent of preoperative examination on the one hand results from the type and
invasiveness of the intervention and on the other hand, from the medical history or clinical
peculiarities of the patients or from a combination of both.
The role of the anesthetist in preoperative patient evaluation is defined by the sole
responsibility in the planning and execution of anaesthesiological treatment.
Type and invasiveness of the surgical treatment
Depending on the effect on physiologic and/or pathophysiologic parameters the following
2 types of surgical treatment are being defined [11]:

minor major
Duration of procedure < 2 hours 2 hours
Estimated blood-loss < 500 ml 500 ml
Anatomic region All except visceral cavities,
diagnostic endoscopic surgery
incl. laparoscopic
cholecystectomy,
laparoscopic herniotomy and
thoracoscopic procedures
without resection
Surgery of thorax and
abdomen including
laparoskopic bowel-surgery
(resection und anastomosis)
and thoracoskopic lobectomy
Pathophysiologic
interactions
Major hemodynamic and
respiratoric changes caused by
the procedure; major
fluidshifts

2) Medical history and clinical examination
a) Anamnesis: The ascertainment is performed according to the anamnesis questionnaire
of the task force ( available on www.oegari.at)[1;7;29;28;31]
b) Clinical examination [14;16]:
Weight, size, calculation of BMI
Measurement of blood pressure, pulse (rate and rhythmic)
Pupils: size, reaction to light, in separate mode and bilateral comparison
Respiratory system:
Mallampati Score (sitting, maximum mouth opening, head in neutral position,
tongue sticking out unvoiced)
Thyreomental distance (distance between thyroid cartilage and point of the
chin at maximum hyperextension of cervix), - should be more then 6 cm [19].
Mandible protrusion test (mandible incisors are adjustable before/atop/behind
maxillar incisors)
GARI Work Group Preoperative Evaluation Gerhard Fritsch
(Members: H. Ferstl, R. Germann, H. Gombotz, B. Gschiel, M. Haisjackl, K. Holaubeck,
B. Horvath, S. Kozek, W. Lingnau, G. Prause, M. Seyr, F. Spiegl, G. Ulber)
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Compilation of dental chart
Inspection of the corresponding anatomic area for preparation of regional
anesthesia and vascular access
Auscultation of lungs and heart
In case of suspicion of neurological disease a cursory neurological examination
shall be performed.
In case of minor surgical intervention and without pathological findings in both the
medical history and the clinical examination no further testing is necessary [2; 7; 13; 14;
16; 30].
From pathologic anamnesis and clinical examination the indication for further
clarification arises (see 3-7).

Stress Anamnesis:
The cardio-respiratory capacity constitutes the essential factor for estimation of the
perioperative risk [1; 11; 29]. As a rule, a close patient interview should suffice. For
objectification machine-aided stress tests are applied.

MET = Metabolic Equivalent Threshold (1 MET = consumption of 3.5ml O
2
/kg body weight/min for men;
consumption of 3.15ml O
2
/kg body weight/min for women = resting metabolic rate; Definition acc. to [1]
CCS = Canadian Cardiovascular Society; NYHA = New York Heart Association

MET = Metabolic Equivalent Threshold (1 MET = consumption of 3.5ml O
2
/kg body weight/min for men;
consumption of von 3.15ml O
2
/kg body weight/min for women = resting metabolic rate; definition acc. to
Ainsworth)
In case of MET < 4 the cardiopulmonary evaluation is to be considered (see 3.and 4.).

MET CCS/NYHA-Classification Medical history
1 IV No exercise possible
Resting dyspnea
2-3 III Walking on the plane (100-150 m
without stopping), minor activities
Shortness of breath under minor
activities
3-4 II Mild shortness of breath caused by
activities, walks 1 flight of stairs
4-5 I Walking in normal speed, climbs 2
flights of stairs, running short distances
5-10 no limitations, minor sporting activities
(playing golf, skiing, hiking)
>10 Competitive sports, endurance sports
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MET = Metabolic Equivalent Threshold (1 MET = demand of 3,5ml O
2
/kg bodyweight/min in men; demand
of 3,15ml O
2
/kg bodyweight/min in women = oxygen-consumption at rest; definition according to
Ainsworth)
MET<4 consider further cardiopulmonar evaluation

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3) Cardio-vascular evaluation
This evaluation aims at identifying patients with an increased perioperative cardio-
vascular risk. This procedure also includes medical history with regard to cardio or
cerebrovascular diseases and an assessment of the individual physical load of the patient.

The functional capacity of an organism is the more important value than ischemic
changes in the repolarization phase in ECG. Not until then the indication for further
diagnostics should be performed.
The guidelines of the ACC and AHA as well as the Revised Cardiac Risk Index acc. to Lee
serve as practical support and the classification of the New York Heart Association
(NYHA) resp. the Cardiovascular Society (CCS) (s. section on risk-scores)
a) Further diagnostic investigation for preoperative clarification ONLY in case of
stable chest pain, Angina pectoris and high operative risk
instable angina
respiratory distress of unknown cause
history of myocardial infarction in the anamnesis (if MET 4 only resting
ECG)
State after revascularization (if MET 4 only resting ECG)
b) Should further preoperative clarification be necessary, the following tests are
recommended:
12-chanel resting ECG
Obligation in case of positive cardiac anamnesis, especially before larger
surgical treatment.
Cave: A resting ECG without pathological findings does NOT exclude a
coronary heart disease.
Chest X-ray:
only in combination with positive clinical examination findings, reduced
capacity, spirometry and blood gas analysis [18]
Stress ECG, Spiroergometry:
with planned high operative risk AND anamnestic reduced capacity < 4 METS
(noted athero-sclerotic vascular disease or continuing physical lack of exercise
due to orthopedic disease).

Exercise tolerance is an existing risk factor independent of the ST-segment
depression.
If bicycle ergonomics is not possible
(a) Maybe arm turner ergometry
(b) Pharmacological exercise, stress-echocardiography (Dipyridamol,
Dobutamin, Dobutamin with atropine)
(c) Myocardial scintigraphy
Echocardiography:
Clinical evidence for acute cardiac insufficiency or valvular defect
(Quantification of valvular function pressure gradient)
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Cave: Echocardiography in resting does not provide any additional information
for a foretelling of preoperative cardiac complications
Coronary angiography, coronary revascularization:
An effective myocardial revascularization is the adequate means for lowering
the perioperative risk, especially with instable angina, isolated LAD stenosis or
3-vessel disease. By means of stress-echocardiographically proven cardiac
wall movement disorders (also of all 5 segments) are NOT an indication.
Cave: Complications with CABG or PTCA neutralize advantages! Depending
on the type of stent (platelet aggregation inhibitors) it is advisable not to
perform any operation up to 1 year!
c) Special Risk
Valvular heart disease
Aortic valve stenosis is another considerable risk factor for perioperative
complications. There is an independent relative risk (RR) of 5.2 with
gradients of 25 to 50 mmHg and 6.8 for gradients > 50 mmHg.
Mitral valve stenosis also increases the perioperative risk. Besides carefully
performed auscultation an echocardiography should be performed in case
of suspicion.
Other valvular defects and prosthetic mitral valve replacement: the extent
of the cardiac insufficiency is predictive. Antimicrobial endocarditis
prophylaxis is also necessary after valve replacement.
Heart failure: no evidence-based management. Too strong drainage is to be
avoided. Beta blockers are NO acute perioperative option.
Cardiac heart rhythm disturbance: no independent risk. Coronary cardiac
disease and heart failure are the main pathologies.
Arterial hypertension is not an independent perioperative risk until a blood
pressure value of >180/>110 mmHg is reached. No cancellation of surgery!
Pulmonary hypertension: NO interventions. Perioperative antibiotic
prophylaxis.
Hypertrophic cardiomyopathy: perioperative danger of exacerbation of the
dynamic efflux obstruction. NO additional clarification. Volume substitute
therapy and alpha-adrenergic substances
Antibiotic prophylaxis in order to avoid endocarditis
perioperative necessary for patients with:
(a) prosthetic valvular transplants
(b) complex congenital cyanotic organic heart defects
(c) already suffered endocarditis
(d) systemic or pulmonary conduits (Ross, Bentall)

(e) acquired valvular disease (AVS)
(f) Mitral valve collapse with MI
(g) Non-cyanotic organic heart defects (exception ASD II)
(h) hypertrophic (obstructive) CMP
with the following planned operations:
(a) dental, oral intervention, ENT area, rigid bronchoscopy
(b) septic abortion interruption
(c) surgical treatment at the genitourinary tract (cytoscopy, TURP,
hysteroscopy, etc.)
(d) Esophagus dilatation, sclerosing of esophagus varices
Which antibiotics, which procedure:
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(a) Oral: Amoxicillin 2.0 g (children 50 mg/kg body weight) 1 hour prior
to planned surgical treatment
(b) i.v.: Amoxicillin or Ampicillin 2.0 g (children 50 mg/kg body weight)
30 minutes prior to planned surgical treatment, 6 hrs. after;
combination with Gentamicin 1.5 mg/kg urogenital with proven
MRSA: Vancomycin 1 g over 60 minutes before.
(c) Penicillin allergy: Clindamycin 600 mg (children 20 mg/kg body
weight) or Azithromycin or Clarithromycin 0.5 g, 1 hr. before surgical
treatment, 6 hrs. after.
No prophylaxis for patients with:
(a) isolated ASD II
(b) 6 months after ASD, VSD, PDB
(c) prolapse of mitral valve without mitral regurgitation
(d) Accidental cardiac murmur, sclerosis of the aortic valve(vmax < 2 m/s)
(e) physiological mitral regurgitation without morphology and cardiac
murmur
(f) physiological tricuspidal regurgitation or regurgitation of pulmonary
valve without morphology and cardiac murmur

4) Pulmonary Evaluation [13;16;18;23]
From an intraoperative point of view, respiratory problems only play a minor role, whilst
in the postoperative phase they range high on the list of the most frequent complications.

Pulmonary examination:
a) History of preexisting pulmonary desease:
Obstructive (bronchial asthma, COPD)
Restrictive (pulmonary fibrosis, st. p. lobectomy/pneumectomy)
Neuro muscular (Myasthenia)
b) Clinical examination:
Inspection
Percussion
Auscultation
c) Evaluation of pulmonary function (with positive anamnesis, large upper abdomen
resp. intrathoracic interventions)
Spirometry (small lung function test; measures vital capacity , the maximum air
flow (PEF) and 1-second-volume (Tiffeneau, FEV1)
Static lung volume (additionally measures residual volume, total lung capacity)
Other tests
Maximum breathing capacity (maximum minute ventilation): evaluates
functional ventilation disorder
Diffusion measuring (DLCO): measures the actual diffusion capacity
independent of circulation (cardiac output)
Provocative test (allergic asthma)
d) Spiroergometry (see also: cardiovascular evaluation): determines the cardiopulmonary
and metabolic capacity. Indication in case of intra-thoracic resp. massive respiratory
strenuous interventions and simultaneous impediments MET< 4.

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5) Preoperative Coagulation Diagnostics
The basis of preoperative clarification of coagulation is an exact survey of the coagulation
anamnesis [7; 28] according to the recommendation of the task force on Perioperative
Coagulation by GARI under www.oegari.at. Co-morbidity and co-medication are included
in the wider evaluation algorithm (see fig.). Basically, all patients with uncertain pathological
laboratory-confirmed coagulation monitoring should have to be seen by coagulation-
experienced physicians, able to arrange for continuative analysis according to findings (e.g.
single factor analyses, detailed platelet function analytics).

Exemplary Constellation of Findings:
Patients with healthy organs without specific risk consideration in the bleedings
anamnesis: No laboratory analysis (LoE Grade A) [7; 9; 21; 28]. Also prior to tonsillectomy
and adenotomy the risk of bleeding is unforeseeable and not avoidable through laboratory
tests alone [21]. Thus, in case of insuspicient bleeding anamnesis no laboratory test is
necessary.
But: should, due to language barrier, impairment of consciousness or lack of compliance,
patients be not able to adequately answer the questionnaire on bleeding, the laboratory
coagulation test shall be performed as with patients with noticeable bleeding anamnesis (with
clinical bleeding symptoms).

Patients with noticeable bleeding anamnesis with clinical bleeding symptoms: In case of
unknown coagulation disorder the determination of PTZ, aPTT, fibrinogen and platelet-count,
as well as the clarification of the primary hemostasis capacity (PHK; e.g. by Willebrand
Syndrome, platelet malfunction) is to be carried out (LoE Grade A)[7;21;28]. PHK may be
collected with determination of the von Willebrand Factor Antigens (vWF: Ag), the
Ristocetin cofactor (vWF: RCo) and platelet function analytics as e.g. Platelet Function
Analyzer (PFA-100) or aggregometry (e.g. Multiplate).
In case of known coagulation disorder (e.g. hemophilia, von Willebrand Syndrome) further
diagnostic clarification and coagulation therapy (haemostasiology, Internal Medicine,
pediatrics, medical laboratory) is to be performed.
* surgery on spinal chord, cerebrum and retina
Neuraxial blockade in connection with cathether except obstretics, central venous lines infra-, supraclavicular
# known impaired coagulation e.g. hemophelia
www.oegari.at, Task Force on AGPG

aPTT=activated partial Thromboplastintime; Fibr=Fibrinogen; POCT=Point-of-care testing (e.g. ROTEM);
PHC=primary hemostatic capacity i.e. vWF:Ag, vWF:RCo, PFA-100 (aggregometry); PT=Prothrombintime; ThC=platelet count
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Patients with noticeable bleeding anamnesis caused by intake of anticoagulants: On the
basis of an individual risk-benefit consideration (individual medicine) the perioperative
continuation or discontinuing of anticoagulants shall be determined interdisciplinary [7; 20;
28]. In case of clear cardiac indication or recent cerebral ischaemia the surgical intervention
shall be performed by continuously administering Aspirin. For recommendations with loco-
regional anesthesia when using anticoagulant therapy: see www.oegari.at.
Medication management in case of dual anti-platelet therapy (LoE Grade A): Due to the high
risk of stent thrombosis Clopidogrel is not to be discontinued with cardiac drug-eluting stents
for 12 months, with cardiac bare-metal stent for at least one month (elective interventions
should be delayed accordingly). Interventions shall be performed under continued
administering of aspirin.

Warning: Attention is especially directed towards a possible (sustainable) bleeding inducing
effect. Additionally, a drug monitoring is recommended (LoE Grade C) with

interventions without preoperative therapy-free period.
reduced elimination (e.g. severe renal insufficiency with Hirudin or low molecular
weight heparin: aPTT)

drugs with clinically relevant increase bleeding quantity (e.g. Hirudin: aPTT or ecarin
tests; Danaparoid: anti-Xa-activity; Clopidogrel plus Aspirin: aggregation with specific
agonist-activation; oral anticoagulation: International Normalized Ratio INR)
Drug interaction of von anticoagulants and other substances (e.g. analgesics, herbal
medicines, antidepressants and anticonvulsants) are to be taken into account (LoE Grade
C).

Patients with noticeable thrombosis anamnesis: A diligent perioperative thrombosis
prophylaxis is recommended (LoE Grade A), as well depending on the individual - a pre- or
postoperative visit to a coagulation-experienced physicians for further clarification of the
thrombophilia.

*
)
Intervention specific bleeding risk: The intervention per se does not constitute an
indication for preoperative coagulation analysis [21; 26]. In fact, a blood-saving surgical
technique is required (e.g. CUSA, microscopy) and intra-operatively in case of imminent or
manifest high haemorrhage a coagulation testing as rational basis for the coagulation therapy
should be collected. For this purpose, intra-operatively PTZ, aPTT, fibrinogen (Degree A) and
platelet count are to be determined. In addition or alternatively, a point-of-care functional
coagulation monitoring is recommended as diagnostically valuable (rotational
thrombelastometry ROTEM, maybe in addition a blood platelets function test, e.g. with
Multiplate) (LoE Grade B).
Exceptions from these intervention-specific recommendations arise in case of interventions
with hazardous localization of a potential source of bleeding (e.g. ZNS, retina) (LoE Grade
C). Invasive anesthesiologic interventions should be performed as a-traumatically as possible.
Although a (spinal) bleeding with unobtrusive bleeding anamnesis is rather very unlikely and
cannot be predicted or avoided by means of coagulation testing, it may nevertheless be
performed in addition to the assessment of the bleeding anamnesis for the planning of the
anesthesiologic management (e.g. selection of block techniques and inlet)

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6) Preoperative Laboratory Diagnostic
The laboratory diagnostic shall be adjusted to the individual patient anamnesis and to the
individual situation of the intervention and the routine laboratory findings subject to age
group shall be abandoned in favor of an individualized laboratory requirement.
[2;8;13;14;16;23;25;27;30].
a) A blood count analysis is recommended in case of:
Interventions with possibly considerable bleedings (>500ml), from which the
necessity of transfusions arises.
Older patients (>75 years), having to undergo larger inventions [33]
Anemia in the anamnesis
Increased cardiac risk [11]
Chronic renal dysfunction (Hb + number of blood platelets)
Bleedings in the anamnesis
Liver dysfunction (Hb + number of blood platelets)

b) An examination of the serum electrolyte is recommended in case of:
severe interventions
clinic or anamnesis based indication of renal dysfunction or diabetes mellitus.

Long-term medication with:
ACE-inhibitor, angiotensin II-antagonists
Diuretics (high-ceiling diuretics, spironolactone)
Corticoids
Digitalis - only determination of potassium in serum
Antidepressants
Liver dysfunction
c) An examination of the serum creatinine and GFR (computed)[32] is indicated in
case of:
clinic or anamnesis based indication of a renal dysfunction
clinic or anamnesis based indication of diabetes mellitus
severe intervention [8]
systemic corticoid therapy
increased cardiac risk [8;11]
intended intra-operative administration of contrast agent
Cirrhosis of the liver
d) Liver function parameters (GPT, bilirubin, PTZ or INR)
indications of liver dysfunctions
e) Measurement of blood sugar is indicated in case of:
Noted diabetes mellitus
additional HBA 1C in case of planned severe intervention
current fasting blood glucose on day of operation
every severe intervention
systemic corticoid therapy
f) Examination of blood group and antibody diagnostic test is recommended in case of
expected transfusion indigent loss of blood. In consideration of geographic and
logistic peculiarities this indication is to be posed generously.
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The perioperative risk is difficult to display by means of laboratory values [8; 30]. Best
appropriate are the results of the kidney function test and sodium [8]. With minor surgical
interventions and geriatric patients no correlation exists between laboratory tests and
perioperative complications [30].

The following table represents a summary of the recommended preoperative laboratory tests:

*
see 1)

Rare diseases (esp. rare endocrinical diseases) as well as the clarification of blood
coagulation are not included in this algorithm and are dealt with in the
corresponding chapters.

In case of difficult ascertainment of anamnesis (e.g. language barriers) or geriatric
patients a broad preoperative laboratory diagnostics is recommended.

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Cardiovascular, MET < 4
+ +
Respiratory System Lee-Index 3; CCS 3
+ +
Liver positive history for liver disease
+ + +
Cirrhosis
+ + + + + + + +
Kidneys positive history for kidney diseases
+ + + +
Endocrine Disorders DM
+ + + (+)
clinically relevant disorder of the thyroid gland
+ +
Hematology and known hematological desease
+ + +
Onkology malignancy
+ + +
ongoing chemotherapy
+ + + +
Medication ACE-inhibitors; AT II-Antagonists, Digitalis, Diuretics
+ + +
antidepressant therapy
+ +
corticosteroids
+ + +
Type of Surgery* minor surgery

major surgery
+ + + + + +
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7) Recommended assessment of patients with endocrinologic desease

8) Perioperative medication management [3;5;6]

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GARI Task Force Preoperative Evaluation

Administration:
Dr. Gerhard Fritsch
Universittsklinik fr Ansthesie, perioperative Medizin und
allgemeine Intensivmedizin PMU Salzburg
Mllner Hauptstrasse 48
5020 Salzburg

e-mail: g.fritsch@salk.at

Members:

Dr. Harald Ferstl AKH Linz; Scores

Dr. Gerhard Fritsch Universittsklinikum LKH Salzburg; Labor

Prim. Univ. Doz. Dr. Reinhard Germann KH Feldkirch; Anamnese und klinische
Untersuchung

Prim. Univ. Prof. Dr. Hans Gombotz; AKH Linz

Dr
in
. Bernadette Gschiel LKH Klagenfurt; properatives Medikamentenmanagement

Univ. Prof. Dr. Markus Haisjackl; Jemen

Prim. Dr. Karl Holaubeck; KH Zwettl; endokrinologische Vorerkrankungen

Dr
in
.
.
Brigitte Horvath; KH Wiener Neustadt

Univ. Prof
in
. Dr
in
. Sibylle Kozek; Medizinische Universitt Wien; properative
Gerinnungsdiagnostik

Univ. Prof. Dr. Werner Lingnau; Medizinische Universitt Innsbruck; kardiovaskulre
Evaluierung

Univ. Prof. Dr. Gerhard Prause; Medizinische Universitt Graz; pulmonale Evaluierung

Prim
a
. Dr
in
. Michaela Seyr; KH Krems; Kinderleitlinie

Prim. Dr. Franz Spiegl; KH Gssing; properative Eigenblutspende

Dr. Gerald Ulber; KH der BHB Eisenstadt

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GARI Task Force Preoperative Evaluation

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