The following advice is derived from NICE Clinical Guideline NG45 April 2016
It is recommended that you take into account any medications the patient is taking when applying these guidelines.
Please cc a copy of the results to Dr Soet and the hospital medical records department when ordering tests.
ASA Grades Definitions
| ASA grade 1 | A normal healthy person |
| ASA grade 2 | A person with mild systemic disease |
| ASA grade 3 | A person with severe systemic disease |
| ASA grade 4 | A person with severe systemic disease that is a constant threat to life |
Surgery Grades
| Minor | Intermediate | Major or complex |
| E/O skin lesion cystoscopy endoscopy hand day surgery | inguinal hernia repair optical urethrotomy stapedectomy myringoplasty | mastoidectomy craniotomy TURP/TURBT lumbar discectomy thyroidectomy total joint replacement colonic resection implant surgery |
Resting ECG
Surgery Grade
| ASA grade | Minor | Intermediate | Major or complex |
| ASA 1 | Do not routinely offer | Do not routinely offer | Consider for people aged over 65 if no ECG results available from past 12 months |
| ASA 2 | Do not routinely offer | Consider for people with cardiovascular, renal or diabetes comorbidities | Offer |
| ASA3 or ASA4 | Consider if no ECG results available from past 12 months | Offer | Offer |
Resting echocardiography
Do not routinely offer resting echocardiography before surgery.
Consider resting echocardiography if the person has:
1. a heart murmur and any cardiac symptom (including breathlessness, pre-syncope, syncope or chest pain) or
2. signs or symptoms of heart failure.
Before ordering the resting echocardiogram, carry out a resting electrocardiogram (ECG) and discuss the findings with Dr Soet.
Chest X-ray
Do not routinely offer chest X-rays before surgery.
Lung function tests and arterial blood gas analysis
Do not routinely offer lung function tests or arterial blood gas analysis before surgery.
Consider seeking advice from Dr Soet as soon as possible after assessment for people who
1. are ASA grade 3 or 4 due to known or suspected respiratory disease and
2. are having intermediate or major or complex surgery.
Full Blood Count Test
Surgery Grade
| ASA grade | Minor | Intermediate | Major or complex |
| ASA 1 | Do not routinely offer | Do not routinely offer | Offer |
| ASA2 | Do not routinely offer | Do not routinely offer | Offer |
| ASA3 or ASA4 | Do not routinely offer | Consider for people with cardiovascular or renal disease if any symptoms not recently investigated | Offer |
Kidney function tests
Surgery Grade
| ASA grade | Minor | Intermediate | Major or complex |
| ASA 1 | Do not routinely offer | Do not routinely offer | Consider in people at risk of AKI |
| ASA2 | Do not routinely offer | Consider in people at risk of AKI | Offer |
| ASA3 or ASA4 | Consider in people at risk of AKI | Offer | Offer |
Coagulation Profile
Do not routinely offer haemostasis tests before surgery.
Consider haemostasis tests in
1. People with chronic liver disease having intermediate or major or complex surgery.
2. If people taking anticoagulants need modification of their treatment regimen, make an individualized plan in line with local guidance.
3. If clotting status needs to be tested before surgery (depending on local guidance) use point-of-care testing.
Glycated haemoglobin (HbA1c) test in people without diagnosed diabetes
Do not routinely offer HbA1c testing before surgery to people without diagnosed diabetes.
Glycated haemoglobin (HbA1c) test in people with diagnosed diabetes
People with diabetes who are being referred for surgical consultation from primary care should have their most recent HbA1c test results included in their referral information.
Offer HbA1c testing to people with diabetes having surgery if they have not been tested in the last 3 months.
Pregnancy testing
On the day of surgery, sensitively ask all women of childbearing potential whether there is any possibility they could be pregnant.
Make sure women who could possibly be pregnant are aware of the risks of the anaesthetic and the procedure to the fetus.
Document all discussions with women about whether or not to carry out a pregnancy test.
Carry out a pregnancy test with the woman’s consent if there is any doubt about whether she could be pregnant.
Develop locally agreed protocols for checking pregnancy status before surgery.
Make sure protocols are documented and audited, and in line with statutory and professional guidance.