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Table 2 Risk stratification, GRADE level of evidence and strength of recommendation by clinical specialties

From: The quality of clinical practice guidelines for preoperative care using the AGREE II instrument: a systematic review

General requirements
 1. Preoperative evaluation
 Pediatric patients receiving anesthesia Very low Strong for
 Emergency surgeries in pediatric patients Very low Strong against
 All patients who are undergoing diagnostic or therapeutic procedures Very low Weak for
 Patients with ASA 1 or 2 without surgical or obstetric history (preanesthetic evaluation, including physical examination, the day of the procedure). Very low Weak for
 Patient with significant medical, surgical, or obstetrical history (anesthesiologist assessment) Very low Weak for
 In case of bleeding or complication history of previous alloimmunization, it is recommended to evaluate the blood type. Very low Weak for
 2. Informed consent (Ideally written)
 Provide information on risks and benefits related to obstetric anesthesia and analgesia. Very low Weak for
 3. Complete laboratory
 Patients undergoing low-risk surgery independently of their ASA score Very low Strong against
 Patients undergoing intermediate-risk surgery Very low Strong against
 Patients with renal or cardiovascular disease undergoing intermediate-risk surgery that has not been recently evaluated Very low Weak for
 Patients undergoing high-risk surgery Very low Strong for
 Patients with preeclampsia or other preceding or a suspect of hemostatic disorder, it is recommended to apply platelet count, liver function test, and evaluation of coagulation Very low Weak for
 In case of bleeding or complication history of previous alloimmunization, it is recommended to evaluate the blood type. Very low Weak for
 Patients with liver failure Very low Strong for
 In anticoagulated patients (e.g., consume Warfarin) Low Strong for
 Patients with potential risk of bleeding undergoing intermediate or high-risk surgery Very low Strong for
 Routinely Very low Strong against
 4. Hematocrit and hemoglobin
 In pediatric patients with possible bleeding Low Strong for
 In pediatric patients routinely perform minor surgery Low Strong against
 Patients with anemia or blood disease or liver disease; when you suspected of anemia or other chronic disease during clinical examination. In medium or high-risk surgeries, anticipated transfusion requirement Low Strong for
 Patients requiring intermediate or major surgery, and bleeding risk of transfusion requirement Low Strong for
 Patients over 40 years Low Weak for
 Patients with a history of hematological or liver disease Low Strong for
 5. Hemostasis/coagulation tests
 Pediatric patients with negative history Low Strong against
 Patients with a history of bleeding Low Strong for
 Patients with liver failure Very low Strong for
 In anticoagulated patients (e.g., consume Warfarin) Low Strong for
 Patients with potential risk of bleeding undergoing intermediate or high-risk surgery Very low Strong for
 Routinely Very low Strong against
 6. Urinalysis
 Routinely before surgery Very low Weak against
 Urine or culture if diagnosing a urinary infection can influence surgery decisions Very low Weak for
 7. Glucose
 Routinely to pediatric patients Low Strong against
 Diabetic patients Low Strong for
 8. Glycated hemoglobin (HbA1c) test
 Diabetic patient without Hb1Ac within 3 months Very low Weak for
 Patients without diabetes Very low Weak against
 9. Assessment of risk factors for surgical site infection
 Assessment of smoking, diabetes, obesity, malnutrition, and chronic skin disease Low Strong for
 10. Kidney function tests
 For minor surgery in ASA 1/2 patients or intermediate-risk surgery in ASA 2 patients Very low Weak against
 For complex or major surgery in ASA 1 patients at risk of acute kidney injury (AKI) Very low Weak for
 In intermediate-risk surgery in ASA 2 patients at risk of AKI. In patients with increased risk surgery performed Very low Weak for
 ASA 3/4 patients: at risk of AKI in low-risk surgery or just higher-risk surgery Very low Weak for
 11. Sickle cell disease/trait test
 Routinely Very low Weak against
 Assess personal of family history of sickle cell anemia Very low Weak against
 Contact a specialized service providing treatment to a confirmed case Very low Weak for
 12. Chest X-ray
 Routinely in healthy people Low Strong against
 Patients with a history or diagnostic tests suggesting cardiorespiratory disease Moderate Weak for
 Patients over 40 years, patients undergoing non-low-risk surgery Low Weak for
 Patients undergoing non-low-risk surgery or mainly intrathoracic or intraabdominal surgery Moderate Weak for
 13. Pregnancy testing
 Performed in women of childbearing age Very low Weak for
  Test the day of surgery in women of childbearing age.
  In pregnant women, ensure that surgery and anesthesia does not threaten the fetus life.
  Document all discussions with women about whether to carry out a pregnancy test.
  Carry out the pregnancy test under the possibility of pregnancy.
Very low Strong for
Cardiovascular requirements
 14. Electrocardiography:
 In neonates and/or children of 6 months Low Weak for
 Healthy people undergoing minor surgery Low Strong against
 Perform in cases of clinical suspicion Low Weak for
 People over 65 undergoing minor or intermediate surgery Very low Strong against
 People with cardiovascular disease Low Weak for
 People with a morbidity undergoing intermediate or major surgery High Strong for
 15. Effort electrocardiography
 Patients undergoing surgeries of intermediate or high risk of complications, including arterial vascular surgery (without severe cardiovascular perioperative conditions) Low Weak for
 Patients undergoing low-risk surgery Low Strong against
 Patients undergoing intermediate-risk surgery Low Strong against
 16. Resting echocardiography
High-risk surgery
  Patient with suspected moderate or severe valvular involvement without evaluation in the last year or with worsening of symptoms Low Strong for
  Patient with heart failure or symptoms suggestive of heart problems, without assessment in the past year, undergoing cardiac surgery Low Weak for
  Symptomatic patients with stent grafts who go to surgery and who have no evaluation in the last year Low Strong for
  Asymptomatic patients Low Weak for
Low, intermediate or uncertain surgical risk
  Routine test in asymptomatic patients without suspect of heart failure or severe valvular disease Very low Weak against
 17. Effort echocardiography
 Routinely to assess cardiac risk Low Strong against
 18. Tomographic coronary angiography
 Routinely to assess cardiac risk Moderate Strong against
 19. Assessment of left ventricular function
 Patients suspected to have valvular disease with important clinical manifestations or undergoing liver transplantation Low Weak for
 Patients with heart failure without ventricular function assessment Low Weak against
 Patients undergoing high-risk surgery Moderate Weak for
 Obese patients (BMI ≥ 40) undergoing bariatric surgery Low Weak for
 Routinely Moderate Strong against
 20. Natriuretic peptide
 Patients undergoing cardiac surgery High Weak for
 Patients over 55 years with at least one cardiovascular risk factor undergoing non-cardiac surgery Low Weak for
 21. Brain natriuretic peptide (BNP) or NT-proBNP
 Patients over 65 years or patients between 45 and 64 years with significant cardiovascular disease or score (revised cardiac risk index (RCRI) ≥ 1 Moderate Strong for
 22. Troponin
 Troponin prior to vascular surgery Moderate Weak for
 Troponin as a preoperative marker of cardiovascular risk and mortality in non-cardiac surgery Low Weak for
 23. Coronary angiography
 The indications of angiography and coronary revascularization are those of non-surgical context Moderate Strong for
 Urgent angiography in patients with myocardial infarction without ST elevation requiring elective non-cardiac surgery or with a computed tomography (CT) with multiple cuts showing serious injury of the left coronary trunk Low Weak for
 Urgent or early invasive strategy for patients with NSTEMI requiring elective non-cardiac surgery High Strong for
 Patients with recent coronary disease at high clinical risk, functional class III-IV in the last 6 months, or patients with severe valve disease and concomitant coronary heart disease Low Strong for
 Patients with non-high-risk criteria (Annex 5) and functional or pharmacological stress tests showing myocardial ischemia Low Weak against
 Patients with or without stable coronary disease functional class I-II without evidence of ischemia by stress tests, or those with severe coronary disease according CT multislice (excluding injury of left coronary trunk) clinically stable without ischemia, or in patients whose non-cardiac surgery cannot be delayed more than 2 weeks due to the underlying disease Low Strong against
 24. Noninvasive test for myocardial ischemia
 Patients undergoing intermediate or high-risk surgery (without severe cardiovascular perioperative conditions) and those undergoing arterial vascular surgery Moderate Weak for
 Intermediate or high-risk patients with poor functional capacity undergoing intermediate-risk surgery Moderate Weak against
 Patients undergoing low-risk surgery Low Strong against
 Low-risk patients undergoing low or intermediate-risk surgery Low Strong against
Pulmonary requirements
 25. Polysomnography
 In patients requiring continuous positive airway pressure (CPAP) High Strong for
 Patients presumed to have obstructive sleep apnea (OSA) based on the preoperative history and physical examination Low Weak for
 26. Lung function tests
 Spirometry in patients undergoing non-high-risk surgery Very low Strong against
 Arterial blood gas analysis in patients undergoing non-high-risk surgery Very low Strong against
 Assessment by medical senior anesthesiologist after confirming respiratory illness or suspected in patients ASA 3/4 undergoing high-risk surgery Very low Weak for
High risk surgery requirements
 27. Stress testing
 In high-risk patients with unknown functional capacity Moderate Weak against
 Patients with major criteria of high cardiovascular risk (Annex 5) Low Strong against
 For high-risk patients and moderate to good (≥ 4 METs to 10 METs) functional capacity Low Weak against
 For high-risk patients and poor (< 4 METs) or unknown functional capacity, if it will change management. Low Weak against
 Patients with low risk and a poor (< 4METs) or unknown functional capacity, who have angina or dyspnea functional class I-II Low Weak for
 Patients with low clinical risk criteria established in Annex 5, who are asymptomatic and with good functional class Low Weak against
 Routinely for patients undergoing low-risk noncardiac surgery Moderate Strong against
 28. Stress test image   
 For high-risk surgery patients with two or more clinical risk factors and low functional capacity Low Strong for
 For intermediate and high-risk patients with one or two clinical risk factors and poor functional capacity (< 4MET) Very Low Weak against
 For low-risk patients regardless of the clinical state of patient Very low Strong against
Special situations or considerations
 29. Cardiopulmonary stress test
 Cardiopulmonary exercise testing to improve the estimation of cardiac risk Low Strong against
 High-risk patients with unknown functional capacity Moderate Weak against
 30. Pharmacological stress test
 Patients undergoing non-cardiac surgery who have poor functional capacity (< 4 METS) dobutamine stress test Moderate Weak for
 Routinely in asymptomatic patients who are at low-risk surgery Moderate Strong against
 31. Prokinetic and other interventions
 Routine use of antacids, metoclopramide, or H2-receptor antagonists before elective surgery in non-obstetric patients High Strong against
 H2-receptor antagonists the night before and the morning of elective cesarean section Moderate Strong for
 Intravenous H2-receptor antagonist before emergency cesarean section; supplemented with 30 ml of sodium citrate if general anesthesia is planned Moderate Strong for
  1. The presented level of evidence and recommendation strength comes from the EB-CPG with the highest overall and methodological rigor AGREE-II score. The level of evidence and recommendation strength by EB-CPG is presented in the online supplemental material 6.a