Pre-operative evaluation of the adult patient undergoing elective noncardiac surgery

This Invited Commentary accompanies the following article: De Hert S, Staender S, Fritsch G, et al. Pre-operative evaluation of adults undergoing elective noncardiac surgery. Updated guideline from the European Society of Anaesthesiology. Eur J Anaesthesiol 2018; 35:407–464. The worldwide surgical volume has been estimated at 313 million operations for 2012, corresponding to a 33% increase compared with the volume reported for 2004.1 Based on burden of disease estimations, the number of procedures required to address this burden is in the order of 5000 to 5500 procedures/100 000 across European regions.2 In-hospital mortality in patients undergoing elective surgery amounted to 0.5% and morbidity to 17%.3 Current demographic development and the resulting increase in disease burden can be expected to further aggravate these alarming figures. Guidelines are intended to support clinicians and other stakeholders in management decisions in defined situations based on high-quality evidence with the final goal to improve clinical practice.4 Pre-operative evaluation is a crucial component of the daily tasks of anaesthesiologists to adequately estimate peri-operative risk with the goals of complying with patients’ information obligations, and planning peri-operative management and resources to improve peri-operative outcome. In this issue of the European Journal of Anaesthesiology, De Hert et al.5 present an update of the first European guidelines on pre-operative evaluation of the adult patient undergoing elective noncardiac surgery. The expert panel of the European Society of Anaesthesiology (ESA) task force on pre-operative evaluation defined specific research questions within broad topic clusters and conducted systematic literature searches that resulted in over 34 000 hits for the period between 2010 and May 2016. The members of the task force selected, appraised the quality of and extracted information from over 2500 articles to formulate their recommendations covering clinical and organisational topics related to the pre-operative evaluation of patients undergoing elective noncardiac procedures. Finally, stakeholders were offered the possibility to comment on the final draft. The tremendous effort resulted in the expansion of several sections compared with the 2011 guidelines,6 in particular with regard to cardiac medication, coagulation disorders, pre-operative anaemia and patient blood management, risk stratification scores and biomarkers. A section on neurological disease was added. Finally, the updated guidelines also highlight the relevance of the assessment of frailty, functional status, polymedication and cognitive and sensory impairment in the geriatric population. In addition to their methodological validity, the stress on frail patients burdened by major comorbidities, that is the patients whose anaesthesiologists are and will be increasingly confronted with in their daily practice, indicates that clinical relevance of the topic was the key principle guiding the selection of topics to be covered and specific questions to be asked in these guidelines. In spite of the impressive quantity of data analysed by the members of the task force, the majority of the recommendations had to be inferred from evidence classified as ‘moderate-quality’ or even ‘low-quality’. Further, for a relevant number of diagnostic or therapeutic approaches, the available evidence indicated limited benefit and therefore resulted in ‘weak recommendations’, requiring clinical and situative judgement even in the presence of high-quality or moderate-quality data. Finally, as highlighted in the preamble of the guidelines, the implementation of some of the recommendations may be restricted by country-specific legal requirements in spite of available evidence. In summary, the updated guideline from the ESA on the pre-operative evaluation of the adult patient undergoing elective noncardiac surgery will not provide absolute practice directives; rather it represents a valid and valuable framework to support deliberate decision-making by individual end-users, to give direction to care improvement at institutional or even national level and to further research efforts. Acknowledgements relating to this article Assistance with the commentary: none. Financial support and sponsorship: none. Conflicts of interest: none. Comment from the Editor: this article was checked and accepted by the editors, but was not sent for external peer review.