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