Preoperative evaluation of the adult patient undergoing non-cardiac

39 Pages·2011·0.43 MB·English

GUIDELINES
Preoperative evaluation of the adult patient undergoing
non-cardiac surgery: guidelines from the European Society
of Anaesthesiology
Stefan De Hert, Georgina Imberger, John Carlisle, Pierre Diemunsch, Gerhard Fritsch, Iain Moppett,
Maurizio Solca, Sven Staender, Frank Wappler and Andrew Smith, the Task Force on Preoperative
Evaluation of the Adult Noncardiac Surgery Patient of the European Society of Anaesthesiology
Thepurposeoftheseguidelinesonthepreoperativeevaluation members ofsubcommittees ofscientific subcommittees and
ofthe adultnon-cardiac surgery patient is topresent individual members oftheESA. Electronic databases were
recommendationsbasedonavailablerelevantclinicalevidence. searchedfromtheyear2000untilJuly2010withoutlanguage
Theultimateaimsofpreoperativeevaluationaretwo-fold.First, restrictions. These searches produced 15425abstracts.
we aimto identify those patientsfor whom theperioperative Relevantsystematic reviews withmeta-analyses, randomised
period may constitute anincreased risk ofmorbidityand
controlled trials, cohort studies, case–control studies and
mortality, aside from therisksassociated with theunderlying
cross-sectional surveys wereselected. The Scottish
disease. Second, this should helpus to design perioperative
IntercollegiateGuidelinesNetworkgradingsystemwasusedto
strategiesthataimtoreduceadditionalperioperativerisks.Very
assessthe levelofevidence andto graderecommendations.
fewwell performed randomised studies on thetopic are
The final draft guideline waspostedon theESA website for
availableandmany recommendations rely heavily on expert
4weeksandthelinkwassenttoallESAmembers,individualor
opinionandareadaptedspecificallytothehealthcaresystemsin
national (thus including mostEuropeannational anaesthesia
individualcountries.Thisreportaimstoprovideanoverviewof
societies). Comments werecollated andthe guidelines
current knowledge on the subjectwith anassessment ofthe
qualityof theevidence inorderto allowanaesthetists all over amendedasappropriate.Whenthefinaldraftwascomplete,the
Europetointegrate – whereverpossible – thisknowledgeinto Guidelines Committee andESA Boardratifiedthe guidelines.
daily patient care.The Guidelines Committee oftheEuropean EurJ Anaesthesiol2011;28:684–722
Society ofAnaesthesiology (ESA) formed a taskforce with Publishedonline14September2011
Appendix1and2areaccessibleontheEuropeanJournal help physicians in the decision making in their clinical
of Anaesthesiology website: http://links.lww.com/EJA/A22. practice.
Clinical practice over Europe varies widely. The way in
which healthcare services are organised and specific
PREAMBLE
national jurisprudence may have a significant impact
Thepurposeoftheseguidelinesistopresentrecommen-
on how this scientific evidence will be implemented in
dations based on available relevant clinical evidence on
thevariousEuropeancountries,despitetheavailabilityof
the topic. The information comes not only from high-
the same scientific information. For instance, a Dutch
quality randomised clinical trials or meta-analyses
study in 4540 adult surgical patients suggested that
but also from cohort studies and even expert opinion
trained nurses were perfectly capable of assessing the
statements. Ultimately, these recommendations should
preoperative health status of surgical patients as com-
paredwithanaesthesiologists,therebyprovidingscienti-
From the Department of Anaesthesiology, Ghent University Hospital, Ghent ficbasisforapotentialplacefornursesinthepreoperative
University, Ghent, Belgium (SDH), Cochrane Anaesthesia Review Group, assessment of patients.1 Yet, in a number of European
Rigshospitalet, Copenhagen, Denmark (GI), Department of Anaesthesia and
Peri-operative Medicine, Torbay Hospital, Torquay, Devon, UK (JC), Service countries nurses are not legally allowed to perform pre-
d’Anesthe´sie Re´animation Chirurgicale, Hoˆpital de Hautepierre, University operative evaluations of patients. Hence, this particular
Hospital of Strasbourg, Strasbourg, France (PD), Department of
Anaesthesiology, Peri-operative Medicine and Intensive Care Medicine, scientific information might result in a recommendation
Paracelsus Medical University, Salzburg, Austria (GF), Divisionof Anaesthesia
andIntensiveCare,UniversityofNottingham,Nottingham,UK(IM),Departmentof
Anaesthesiology, Azienda Ospedaliera di Melegnano, Milan, Italy (MS),
Department of Anaesthesiology and Intensive Care, Spital Ma¨nnedorf, ThisarticleisaccompaniedbythefollowingInvited
Mannedorf, Switzerland (SS), Department of Anaesthesiology and Operative
Intensive Care Medicine, University Hospital Witten/Herdecke, Cologne, Commentary:
Germany (FW) and Department of Anaesthesiology, University of Lancaster,
Lancaster,UK(AS) Riad W, Chung F. Continent-wide anaesthesia
Correspondence to Stefan De Hert, MD, PhD, Professor of Anaesthesiology, guideline:asteptowardssaferpractice.EurJAnaes-
DepartmentofAnaesthesiology,GhentUniversityHospital,GhentUniversity,De thesiol 2011; 28:682–683.
Pintelaan185,B-9000Ghent,Belgium
Tel:[phone];fax:[phone];e-mail:[email protected]
0265-0215(cid:1)2011CopyrightEuropeanSocietyofAnaesthesiology DOI:10.1097/EJA.0b013e3283499e3b
Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
Preoperativeevaluationoftheadultnon-cardiacsurgerypatient 685
toincludenursesinthepreoperativeassessmentinsome Table1 Levelsofevidence
countries, whereas in other countries local legislation
1RR High-qualitymeta-analyses
might preclude such an approach. SystematicreviewsofRCTs
RCTswithaverylowriskofbias
TheEuropeanSocietyofAnaesthesiology(ESA)iscom- 1R Wellconductedmeta-analyses
mittedtotheproductionofhigh-quality,evidence-based SystematicreviewsofRCTs
RCTswithalowriskofbias
clinical guidelines and recommendations. The Guide- 1S Meta-analysessystematicreviewsofRCTs
lines Committee of the ESA defines the topics to be RCTswithahighriskofbias
2RR High-qualitysystematicreviewsofcase–
examined which are then referred to specific Task
controlorcohortstudies
Forces. These Task Forces refine the questions and High-qualitycase–controlorcohortstudies
propose guidelines based on their critical appraisal of withaverylowriskofconfoundingor
biasandahighprobabilitythatthe
the available literature.
relationshipiscausal
2R Wellconductedcase–controlorcohort
SeveralEuropeannationalanaesthesiologysocietieshave
studieswithalowriskofconfoundingor
alreadyproducedlocalrecommendationsconcerningpre- biasandamoderateprobabilitythatthe
relationshipiscausal
operative evaluation of the adult non-cardiac surgery
2S Case–controlorcohortstudieswithahighrisk
patients.FollowingarequestbytheESAtoallEuropean ofconfoundingorbiasandasignificantrisk
national societies, national guidelines and recommen- thattherelationshipisnotcausal
3 Non-analyticalstudies(casereports,case
dations from Austria, Belgium, the Czech Republic,
series,etc.)
Finland, the Netherlands, Norway, Slovenia, Sweden 4 Expertopinion
and UK were made available to the Task Force.
RCT,randomisedclinicaltrial.
Veryfewwellperformedrandomisedstudiesonthetopic
areavailableandmanyrecommendationsinthesereports
INTRODUCTION
rely heavily on expert opinion and are adapted specifi-
Thepresentguidelinesdealwiththepreoperativeevalu-
cally to the healthcare systems in the individual
ationoftheadultpatientundergoingelective,non-cardiac
countries. This report aims to provide an overview of
surgery.Theultimateaimsofthisevaluationaretwo-fold.
currentknowledgeonthesubjectwithanassessmentof
First is the identification of those patients for whom the
the quality of the evidence in order to allow anaesthe-
perioperative period may constitute an increased risk of
siologists all over Europe to integrate – wherever
morbidity and mortality, aside from the risks associated
possible – this knowledge in daily patient care.
with the underlying disease. Second, this identification
The potential legal implications may be an area of con- shouldhelptodesignperioperativestrategiesthataimto
cern.2 It cannot be overemphasised that guidelines may reduceadditionalperioperativerisks.
notbeappropriateforallclinicalsituations.Thedecision
Awidevarietyofsurgical proceduresneedcollaboration
whether or not to follow a recommendation from a
with anaesthesiology. As surgical techniques become
guideline must be made by the responsible physician
increasingly complex, the physical fitness required of
on an individual basis, taking into account both the
patients as well as the surgical impact on perioperative
specific conditions of the patient and the available
risk increases. Surgical risk may vary tremendously,
resources. Therefore, deviations from guidelines for
depending on duration of procedure, estimated blood-
specific reasons remain possible and certainly should
loss, estimated fluid shifts and anatomical region.3–6
not be interpreted as a basis for claims of negligence.
Cardiac risk has been described by a three-part classifi-
TheESAGuidelinesCommitteeselectedthesystemfor cationthatdistinguishesbetweenlow-risk,intermediate-
assessing levels of evidence and grading recommen- riskandhigh-riskproceduresaccordingtotheAHA/ACC
dations proposed by the Scottish Intercollegiate Guide-
lines Network (SIGN), as outlined in Tables 1 and 2. Table2 Gradesofrecommendation
Thisselectionwas madebecausethissystemprovidesa A Atleastonemeta-analysis,systematicreviewofRCTsor
thorough categorisation of levels of evidence, including RCTratedas1þþanddirectlyapplicabletothetarget
populationorabodyofevidenceconsistingprincipally
an assessment of quality and also includes observational
ofstudiesratedas1þ,directlyapplicabletothetarget
studies. populationandwithanoverallconsistencyofresults
B Abodyofevidenceincludingstudiesratedas2þþ,directly
TheESA Guidelines Committee supervises and coordi- applicabletothetargetpopulationandwithanoverall
consistencyofresultsorextrapolatedevidencefromstudies
natesthepreparationofnewguidelines.Oncethedocu-
ratedas1þþor1þ
mentwasfinalised,itwassubmittedtooutsidespecialists C Abodyofevidenceincludingstudiesratedas2þ,directly
for review and comments. The document was then applicabletothetargetpopulationandwithanoverall
consistencyofresultsorextrapolatedevidencefrom
revised and finally approved by the ESA Guidelines
studiesratedas2þþ
Committee and the ESA board. After final approval, D Evidencelevel3or4orextrapolatedevidencefromstudies
the ESA is responsible for the publication of the guide- ratedas2þ
lines. A regular update of the guidelines is planned.
RCT,randomisedclinicaltrial.
EuropeanJournalofAnaesthesiology 2011,Vol28No10
Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
686 DeHertetal.
guideline and the guideline of the European Society of overview because these represent specific entities in
Cardiology(ESC).7–9Therefore,inordertostratifyover- which specialised diagnosis, treatment and advice on
allperioperativerisk,itisessentialtoconsiderthenature perioperativesupportandtreatmentarealwaysindicated.
and duration of a surgical procedure.
Pregnancy was deliberately not included in the present
Risk factors are, therefore, not only patient-related and guidelines, as it represents a specific entity with its own
surgery-related but are also organisation-related. Not all associatedphysiologicalchanges,possibleco-morbidities
ofthesecanbecoveredbyrecommendations.Inaddition, and potential risks that deserve separate guidelines.
reliableclinicalevidenceonmanyissuesisscarceandof
The following conditions/factors were assessed:
lowqualityorevenabsent.Therefore,whereverpossible,
recommendations will be provided on the basis of the
(cid:1) Cardiovascular disease
bestavailableevidenceandwhenthisisnotpossible,the
(cid:1) Respiratory disease, smoking and obstructive sleep
recent available evidence will be summarised.
apnoea syndrome (OSAS)
The task force addressed the following fundamental (cid:1) Renal disease
questions: (cid:1) Diabetes mellitus
(cid:1) Obesity
How should a preoperative consultation clinic (cid:1) Coagulation disorders
be organised? (cid:1) Anaemiaandpreoperativebloodconservationstrategies
This organisational aspect is addressed by assessing the (cid:1) The elderly
evidence regarding the following questions: (cid:1) Alcohol misuse and addiction
(cid:1) Allergy
How, when and by whom should patients be
evaluated preoperatively? Howtomanagethefollowingconcurrentmedication:
This first part of this question assessed the evidence (cid:1) Antithrombotic therapy and locoregional anaesthesia
about the different tools available that help to screen (cid:1) Herbal medication
patients preoperatively such as paper or website ques- (cid:1) Psychotropic medications
tionnaire to be completed by patients, interview by a (cid:1) Perioperative bridging of anticoagulation therapy
nurse or a physician and others.
Preoperative testing
Thebackgroundforthesecondpartofthequestionwas
Thispartprovidesrecommendationsonthepreoperative
concerned with optimisation of the patient’s condition
tests to use.
when risk factors are present. This implies that patients
should be seen sufficiently in advance to allow for
measures to be instituted. This question assessed the Airway evaluation
information and evidence about whether timing of the This part discusses the modalities for preoperative
preoperative assessment affects outcome. airway evaluation.
The third part of the question evaluated the evidence
Patient information
regarding the qualifications necessary to perform the
This part discusses the evidence concerning possible
preoperative evaluation: nurse, family physician/general
ways to inform the patient about the operation.
practitioner, anaesthesiologist or others?
A number of these questions have been addressed
How should a preoperative assessment of a recently by other task forces and we decided to refer
patient be performed? toexistingguidelinesonspecifictopicssuchaspreopera-
Wedecidedtoapplyastepwiseapproachusinganumber tive testing guidelines, cardiovascular disease and anti-
of successive questions; for each question, the best coagulation.
available evidence was sought and assessed for quality.
This practical aspect is addressed by assessing the METHODS
evidenceabouttheavailableinformationonthefollow- Selection of the task force
ing issues: The Guidelines Committee of the ESA reviewed the
fieldsofexpertiseofthesubcommitteesoftheScientific
Specific clinical conditions in which the patients Committee. The committee decided that the following
should undergo more extensive testing subcommittees were most relevant to preoperative
Every patient should be checked for specific conditions evaluation: Evidence-Based Practice and Quality
that might interfere with anaesthesia and surgery and Improvement; Monitoring and Computing; Respiration;
which should be evaluated further and potentially trea- Circulation; Patient Safety and Airway Management.
ted. Uncommon diseases and endocrinological disorders Thecommitteeaskedthechairsofthosesubcommittees
other than diabetes were not included in the present tonominateonemembertojointhetaskforceandthen
EuropeanJournalofAnaesthesiology 2011,Vol28No10
Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
Preoperativeevaluationoftheadultnon-cardiacsurgerypatient 687
chose the chair of the task force by consensus. ESA evidence and to grade our recommendations.10 We
members with expertise in preoperative evaluation and assigned a level of evidence to each included study
guideline development were co-opted onto the task and graded our recommendation based on the body of
force. In addition, the Cochrane Anaesthesia Review evidence supporting them.
Group provided assistance with literature searching,
critical appraisal and methodological advice.
Review process
The final draft guideline underwent a review process
Development of the guidelines
previouslyagreeduponbytheESAGuidelinesCommit-
To develop the scope of the guidelines, the Task
tee and the Editor-in-Chief of the European Journal of
Forcemetanddefinedaseriesofkeyclinicalquestions
Anaesthesiology.ThedraftwaspostedontheESAwebsite
about how anaesthetic preoperative evaluation should
for 4 weeks and the link was sent to all ESA members,
be conducted. These questions formed the basis for
individual or national (thus including most European
subsequent evidence review and the development of
national anaesthesia societies). We invited comments
recommendations. We assigned a Task Force member
within this 4-week consultation period. We also sent
to take primary responsibility for each question.
sections of the draft for review to scientific subcommit-
We designed search strategies to search for all the pub- tees members and external experts with specific exper-
lished evidence relevant to the key clinical questions. tise in these areas.
Search terms were chosen using the PICO (Population,
We collated the comments from all these sources and
Intervention, Comparison, Outcome) format in consul-
amended the guidelines as appropriate. When the final
tationwiththememberoftheTaskForceresponsiblefor
draftwascomplete,theGuidelinesCommitteeandESA
each key clinical question. We searched Embase and
Board ratified the guidelines.
MEDLINE,usingOvid,fromyear2000untilthepresent.
Wedidnotuselanguagerestrictions.Thesearcheswere
HOW, WHEN AND BY WHOM SHOULD
undertaken between January 2010 and July 2010. Full
PATIENTS BE EVALUATED PREOPERATIVELY?
details of each search, including the search terms used,
Introduction
thedatesthateachsearchwasconductedandthenumber
The original questions ‘how should we screen patients
of abstracts are shown in Appendix 1, http://links.lww.
who need to be evaluated preoperatively by the anaes-
com/EJA/A22.
thesiologist’, ‘at what time should the patient be seen
In total, these searches produced 15425 abstracts. We preoperatively’ and ‘who should examine the patient’
reviewedtheseabstractsandselectedarticlesthatwere have been consolidated into a single chapter. These
relevant to the key clinical questions. Specifically, we items have many intersecting aspects and common
selectedarticlesthatinvestigatedinterventionsthatmay political implications, as they are regulated by different
beimplementedbyananaesthesiologistinthepreopera- requirements in different countries.
tive period. We mainly included studies conducted
We assessed the best available evidence concerning the
in the context of a patient presenting prior to surgery.
following:
We included systematic reviews with meta-analyses,
randomised controlled trials (RCTs), cohort studies,
(cid:1) Thetoolstoscreenpatienthistoryandphysicalstatus
case–control studies and cross-sectional surveys. We
(such as questionnaires, either paper-based or
didnotincludenarrativereviews,editorials,caseseries
electronic-based, to be filled by the patient alone or
or case reports.
inconjunctionwithahealthprofessional;interviewsby
Ourgoalwastoincludeallrelevantandrobustevidence either medical or non-medical health professionals);
in these guidelines. Therefore, in some cases, we (cid:1) the timing of preoperative assessment (including
includedtrialsfromothersources.Were-conductedsome studies looking at preoperative interventions aimed
searches,tocoverspecificclinicalquestionsthatemerged at improving patient outcome);
from the initial searches. We also considered references (cid:1) andtheprofessionalqualificationnecessarytoperform
from included trials, sometimes leading to the inclusion thepreoperativeevaluation(nurse,physicianassistant,
of trials that had been published prior to 10 years ago. family physician/general practitioner, surgeon, anaes-
Finally, other trials were sourced from the personal thesia trainee or anaesthesia specialist).
clinical and academic experience of the Task Force
MEDLINE and Embase for the period 2000 to May
members.
2010 were searched (a few articles that appeared
TheexpertiseoftheTaskForceguidedtheselectionof latein1999arealsocaptured).Abstractsfrom584refer-
trialstobeincluded,includingasubjectiveassessmentof ences in MEDLINE and 523 in Embase were reviewed.
therelevanceofastudy.Onceselected,wereviewedthe Thirty-eight studies were included initially, but only
trials with regard to their quality and applicability. We 28 were finally selected for quality and relevance to
used the SIGN grading system to assess the level of the topic.
EuropeanJournalofAnaesthesiology 2011,Vol28No10
Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
688 DeHertetal.
Existing evidence Trained nurses and physicians in training have been
There exists a variety of methods for preoperative data shown to be equivalent in assessing patients pre-
collection (level of evidence: 3).11 A standardised pre- operatively, both in adult (level of evidence: 1þ)33
operative questionnaire has been demonstrated to be and paediatric (level of evidence: 1þ) populations.34
valid in detecting medically compromised patients in Interobserver reliability estimates between a nurse
the dental surgery setting (level of evidence: 2þ),12 to and an anaesthetist were similar to those previously
possess a high degree of specificity for 12 common co- demonstrated between two anaesthetists (level of
morbid conditions in cataract patients13 (level of evi- evidence: 3).35 Studies on a nurse-based model for
dence:2þ)andtobeabletodetect,coupledwithspecific screening all outpatients in a university-affiliated
confirmatory tests, impaired haemostasis (level of evi- tertiaryhospitaldaycareunithaveshowngoodnegative
dence: 2þ).14 However, preoperative questionnaire predictive value, moderate specificity and variable
design is critical and crucial for the rate and accuracy sensitivity (level of evidence: 2þ).1,36 The role of
of completion (level of evidence: 2(cid:2)).15 the pharmacy can be very helpful in reducing post-
operative medication discrepancies with the previous
As technology has evolved, so preoperative question-
medical regimen (level of evidence: 1(cid:2),37 level of
naireshavebeentransferredtocomputer-basedsystems
evidence: 2(cid:2)38).
or personal digital assistants (PDAs): touch screen
computer technology has been demonstrated an accu- A recent study39 (level of evidence: 3) reported on the
rateandefficientplatformforpatientself-administered questionsofwhetherthesameanaesthesiologyspecialist
preoperative questionnaires16 (level of evidence: 1(cid:2)) should evaluate the patient and subsequently provide
and assessment with the help of PDAs has been anaesthesiaservicetothem:althoughthisisthepreferred
suggested as being more complete than without (level model of scientific and professional anaesthesia organis-
of evidence: 3).17 In addition, computer-based self- ations throughout the world, and patients frequently
assessment increases detection rates of alcohol use requestforsuchanapproach,thereisverylittleevidence
disorders (AUDs) (level of evidence: 3).18 However, to support it.
such disorders deserve a more elaborated preoperative
evaluation with additional diagnostic tools (level of
Recommendations
evidence: 1(cid:2)).19 We found only one contrary study20
(1) Preoperative standardised questionnaires may be
(level of evidence: 3) in which a short questionnaire
helpful in improving anaesthesia evaluation in
proposedbytheDutchHealthCouncilwasnotfoundto
a variety of situations (grade of recommendation:
be useful in practice.
D).
Thereisessentiallynoevidenceregardingtheeffectof (2) If a preoperative questionnaire is implemented,
timing of preoperative evaluation on patient outcome. great care should be taken in its design (grade of
Thereexistsanumberofstudiesreportingtheeffectof recommendation: D), and a computer-based version
preoperative interventions, notably smoking cessation, should be used whenever possible (grade of recom-
alcohol abstinence, optimisation of medical condition mendation: C).
and weight loss, on outcome, The effects of these (3) Preoperative evaluation should be carried out
interventions are treated in more detail elsewhere, with sufficient time before the scheduled proce-
but as these interventions take time to implement, it dure to allow for the implementation of any
is logical to infer that evaluation should be carried out advisable preoperative intervention aimed at
with sufficient lead time to promote and implement improving patient outcome (grade of recommen-
them. dation: D).
(4) Preoperative assessment should at least be com-
Particularly, medical optimisation is linked to reduced
pletedbyananaesthetist(gradeofrecommendation:
mortality and morbidity after major vascular surgery
D),butthescreeningofpatientscouldbecarriedout
(level of evidence: 3),21 even if timing is not specified.
effectively either by trained nurses (grade of
Smoking cessation has definitely shown to be beneficial
recommendation: C) or anaesthesia trainees (grade
(levelofevidence:1þ),22evenifanoptimaldurationhas
of recommendation: D).
not been identified (level of evidence: 2þþ);23 the
(5) A pharmacy personnel member may usefully be
majority of studies put it between 4 and 8 weeks (level
included in preoperative assessment, in order to
ofevidence:1(cid:2),24,25levelofevidence:1þ26,27),whereas
reduce discrepancies in postoperative drug orders
shorterperiodshaveless(levelofevidence:1(cid:2))28,29ornil
(grade of recommendation: C).
effect (level of evidence: 1(cid:2)).30
(6) Thereisinsufficientevidencetorecommendthatthe
Short lasting alcohol abstinence (1 week) has not been preferred model is that a patient should be seen by
showntobebeneficial(levelofevidence:2(cid:2)),31whereas the same anaesthetist from preoperative assessment
longer (1 month) abstinence has demonstrated positive through to anaesthesia administration (grade of
effects (level of evidence: 1(cid:2)).32 recommendation: D).
EuropeanJournalofAnaesthesiology 2011,Vol28No10
Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
Preoperativeevaluationoftheadultnon-cardiacsurgerypatient 689
HOW SHOULD PREOPERATIVE ASSESSMENT (3) Significant arrhythmias
BE PERFORMED? (a) High-grade atrioventricular block
Specificclinicalconditionsinwhichthepatients (b) Symptomatic ventricular arrhythmias
should undergo more extensive testing (c) Supraventricular arrhythmias with uncontrolled
Cardiovascular disease ventricular rate (>100beatsmin(cid:2)1 at rest)
Introduction (d) Symptomatic bradycardia
Perioperativecardiaccomplicationscan occurinpatients (e) Newly recognised ventricular tachycardia
with documented or asymptomatic ischaemic heart dis- (4) Severe valvular disease
ease,ventriculardysfunctionandvalvularheartdisease.It (a) Severeaorticstenosis(meanpressuregradient>
has been estimated that in non-cardiac surgery, major 40mmHg, area<1cm2 or symptomatic)
perioperative cardiac events may occur in up to 4% of (b) Symptomatic mitral stenosis
cardiacpatientsand1.4%ofanunselectedpatientpopu-
Clinical risk factors are as follows:
lation.40Preoperativeidentificationofpatientsat riskfor
developing perioperative cardiac problems and possible (1) History of ischaemic myocardial disease
medical optimisation of the condition may potentially (2) Current stable or history of heart failure
improveoutcome. (3) History of cerebrovascular disease
(4) Diabetes (insulin dependent)
(5) Renal failure (serum creatinine, SCr>2mgdl(cid:2)1)
Existing evidence
In2007,theAmericanCollegeofCardiology(ACC)and We decided to follow the latter guidelines on preopera-
the American Heart Association (AHA) updated their tive cardiac risk assessment and perioperative cardiac
2002 guidelines on perioperative cardiovascular evalu- managementinnon-cardiacsurgery.Forthesethereader
ationandcarefornon-cardiacsurgery.7Thiswasfollowed is referred to the website www.escardio.org/guidelines
by a new update in 2009 with regard to new insights in and/or to either of the articles8,42. With regard to pre-
perioperative b-blocking therapy following the publi- operativetreatmentwithb-blockersandstatins,itshould
cation of the POISE study (level of evidence: 1þ).9,41 benotedthattheseguidelinesunderscoretheimportance
Also in 2009, the ESC published guidelines for pre- of carefully titrating the dose which implies that treat-
operative cardiac risk assessment and perioperative car- ment should ideally be started between 30 days and at
diac management in non-cardiac surgery which were least1weekbeforesurgery.Therefore,theseguidelines
endorsed by the ESA.8 A key component in the pre- should be interpreted within the constraints of logistics
operativeassessmentistheevaluationofthepresenceof and infrastructure that allow patients to be seen suffi-
activeorunstablecardiacconditions(seebelow),surgical ciently far in advance of surgery.
risk factors (Table 3), functional capacity of the patient
[<4 or >4 metabolic equivalents (METs)] and the pre- Recommendations
sence of cardiac risk factors (see below). The decisions (1) If active cardiac disease is suspected in a patient
regarding further testing and possible treatment should scheduledforsurgery,thepatientshouldbereferred
be taken in close cooperation with the cardiologist. to a cardiologist for assessment and possible treat-
ment (grade of recommendation: D).
Active cardiac conditions that necessitate further evalu- (2) In patients currently taking b-blocking or statin
ation and treatment before non-cardiac surgery are as therapy, this treatment should be continued peri-
follows: operatively (grade of recommendation: A).
(1) Unstable coronary syndromes Respiratory disease, smoking and obstructive sleep
(a) Unstable or severe angina apnoea syndrome
(b) Recent myocardial infarction (MI) (within Introduction
30 days) Postoperative pulmonary complications are a significant
(2) Decompensated heart failure postoperative risk. Most important complications are
Table3 Surgicalriskestimates
Highrisk(cardiacrisk>5%) Intermediaterisk(cardiacrisk1–5%) Lowrisk(cardiacrisk<1%)
Aorticsurgery Abdominal Breast
Majorvascularsurgery Carotid Dental
Peripheralvascularsurgery Peripheralarterialangioplasty Endocrine
Endovascularaneurysmrepair Eye
Headandnecksurgery Gynaecological
Majorneurologic/orthopaedic Reconstructive
Pulmonary Minororthopaedic
Majorurologic Minorurologic
EuropeanJournalofAnaesthesiology 2011,Vol28No10
Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
690 DeHertetal.
atelectasis, pneumonia, respiratory failure and exacer- Onestudy(publishedin2000)lookedat460patientswho
bation of chronic lung disease. Established risk factors underwentabdominalsurgery.Theauthorsreportedthat
are age [odds ratio for postoperative pulmonary compli- apredictedFEV1oflessthan61%,andaPaO2lessthan
cations 2.09 (confidence interval, CI 1.70–2.58) for 9.3kPa (70mmHg), the presence of ischaemic heart
patients aged 60–69 years and 3.04 (CI 2.11–4.39) for disease and advanced age, each were independent risk
ages 70–79, both compared with patients younger than factors for postoperativepulmonary complications (level
60 years of age]; chronic obstructive lung disease (odds of evidence: 2(cid:2)).47
ratio 1.79, CI 1.44–2.22); cigarette use (odds ratio 1.26,
CI 1.01–1.56); congestive heart failure (odds ratio 2.93, Chestradiography
CI 1.02–8.43); functional dependence [for total func- Chest radiographs are ordered frequently as part of a
tional dependence, odds ratio 2.51 (CI 1.99–3.15) and routine preoperative evaluation. The evidence is poor
for partial dependence, odds ratio 1.64 (CI 1.36–2.01)]; and the related articles again mostly date before 2000
andahigherASAclassificationandprolongeddurationof and, therefore, were not addressed in this review. How-
surgery (odds ratio 2.14, CI 1.33–3.46).43,44 ever, chest radiographs are not predictive of postopera-
tive pulmonary complications in a high percentage of
Additional risk factors (type of surgery, weight loss,
patients. A change in management or cancellation
cerebral vascular disease, long-term steroid use as well
of elective surgery was reported in only a fraction of
asalcoholuse)havebeenidentifiedandincludedinarisk
patients.48,49
indexforpredictingpostoperativepneumoniaaftermajor
non-cardiac surgery (level of evidence: 2(cid:2)).45 A meta-analysis in 2006 on the value of routine preo-
perative testing identified eight studies published
Toguidethepreoperativeevaluationprocess,thefollow-
between 1980 and 2000 in which the corresponding
ing questions were addressed:
authors looked at the impact of chest radiographs on a
changeonperioperativemanagement.Inonly3%ofthe
(1) How should respiratory disease and OSAS be
casesinthesestudies,thechestradiographinfluencedthe
assessed?
management, even though 23.1% of preoperative chest
(2) Willoptimisationand/ortreatmentalteroutcomeand
radiographs in that sample were abnormal (level of evi-
ifso,whatinterventionandatwhattimeshoulditbe
dence: 1þ).44
doneinthepresenceofrespiratorydisease,smoking
and OSAS? Inasystematicreviewfrom2005,thediagnosticyieldof
chest radiographs increased with age. However, most of
To answer these questions, MEDLINE and Embase for
the abnormalities consisted of chronic disorders such as
the period 2000 to June 2010 were searched: abstracts
cardiomegalyandchronicobstructivepulmonarydisease
from 390 references in MEDLINE and 490 references
(up to 65%). The rate of subsequent investigations was
inEmbasewerereviewed.Allcomparativestudiesinves-
highly variable (4–47%). When further investigations
tigating an intervention or assessment with regard to
were performed, the proportion of patients who had a
preoperative optimisation of respiratory disease were
change in management was low (10% of investigated
selected. Cardiac surgery studies and studies related
patients). Postoperative pulmonary complications were
to thoracic surgery or lung reduction surgery were
alsosimilarbetweenpatientswhohadpreoperativechest
excluded.
radiographs (12.8%) and patients who did not (16%)
(level of evidence: 1þ).50
Existing evidence
Howshouldrespiratorydiseaseandobstructivesleepapnoea
Assessmentofpatientswithobstructivesleepapnoeasyndrome
syndromebeassessed?
OSAS has been identified as an independent risk factor
Spirometry
for airway management difficulties in the immediate
Many studies on spirometry and pulmonary function
postoperative period.44 In a cohort study from 2008, it
tests relate to lung resection surgery or cardiac surgery
was been demonstrated that patients classified as OSAS
and have been published mainly more than 10 years
riskhavemoreairway-obstructiveeventspostoperatively
ago; therefore, they have been excluded from this
review. andmoreperiodsofdesaturations(SpO2lessthan90%)in
the first 12h postoperatively (level of evidence: 2þ).51
Spirometry has value in diagnosing obstructive lung Dataarescarce regardingtheoverallpulmonarycompli-
disease, but it has not been shown to translate into cation rate. One case–control study with matched
effective risk prediction for individual patients. In patients undergoing hip or knee replacement surgery
addition, there are no data indicating a prohibitive reported that serious complications after surgery, such
threshold for spirometric values below which the risk as unplanned days in ICU, tracheal reintubations and
for surgery would be unacceptable. Changes in clinical cardiac events, occurred significantly more often in
managementduetofindingsfrompreoperativespirome- patientswithOSAS(24%comparedwith9%ofmatched
try were also not reported.46 control patients) (level of evidence: 2þ).52 A recent
EuropeanJournalofAnaesthesiology 2011,Vol28No10
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Preoperativeevaluationoftheadultnon-cardiacsurgerypatient 691
cohort study also reported that postoperative cardio- nutritional status. This may be detrimental for two
respiratory complications were associated with a score reasons. First, muscle mass may be diminished. This
indicating the existence of OSAS (level of evidence: may lead to an early loss of muscle strength following
2þ).53 onlyafew days ofimmobilisation orassisted ventilation
inICUs.Second,serumalbuminconcentrationsareoften
OSAS patients have been identified as having a higher
reduced. This can lead to severe problems with oncotic
risk of difficult airway management (level of evidence:
pressure and fluid shifts. A low serum albumin level
2þ).54 The American Society of Anesthesiologists
(<30gl(cid:2)1) has been found to be an independent risk
addressed this issue in 2006 with practice guidelines
factor for postoperative pulmonary complications (level
including assessment of patients for possible OSAS
of evidence: 2þ).61 In some cases (urgent or emergency
before surgery and suggested careful postoperative
operations), an improvement in the nutritional status is
monitoring for those suspected to be at high risk.55
often impossible. In scheduled elective surgery on the
Therefore, the question of how to correctly identify
contrary, improvements in nutritional status may be of
patientswithOSASoratriskforOSASisofimportance.
benefit. However, there are only limited and conflicting
Ofthe25eligiblestudiesonthattopicpublishedbetween data in this regard in the non-cardiothoracic surgery
2000 and June 2010, 10 dealt with measures to correctly literature in the last 10 years under review (level of
identify patients with risk factors for OSAS. The ‘gold evidence: 2(cid:2)).62,63
standard’ for diagnosis of sleep apnoea is an overnight
sleepstudy(polysomnography).However,suchtestingis Smokingcessation
time consuming, expensive and unsuitable for screening Smoking is a known risk factor for impaired wound-
purposes. The literature indicates that the most widely healing and postoperative surgical sites of infection. A
usedscreeningtoolfordetectingsleepapnoeaistheBerlin RCT of smoking cessation in 120 patients found a sig-
questionnaire (level of evidence: 2(cid:2)).53,56,57 Overnight nificantly reduced incidence of wound-related compli-
pulseoximetrymaybeanadditionalalternativetodetect cations in the intervention (smoking cessation) group
sleepapnoea(levelofevidence:2þþ).58 (5 vs. 31%, P¼0.001) (level of evidence: 1(cid:2)).23
In 27 eligible studies, 17 articles addressed the issue of
Willoptimisationand/ortreatmentalteroutcomeandifso, preoperativesmokingcessation.Aspectssuchasduration
whatinterventionandatwhattimeshoulditbedoneinthe
ofcessationnecessary,methodstomotivatecessationand
presenceofrespiratorydisease,smokingandobstructive
impactoncomplicationswerecovered.InaRCT(smok-
sleepapnoea?
ingcessation4weekspriorsurgeryvs.controlgroupwith
Incentivespirometryandchestphysicaltherapy
no smoking cessation), an intention-to-treat analysis
Most of the relevant studies deal with physical therapy
showed that the overall complication rate in the control
after the operation. Although relevant from a clinical
group was 41% and in the intervention group 21%
point of view, a systematic review from 2009 could not
(P¼0.03). Relative risk reduction for the primary out-
show a benefit from incentive spirometry on postopera-
come of any postoperative complication was 49% and
tive pulmonary complications after upper abdominal
number-needed-to-treatwasfive(95%CI3–40)(levelof
surgery, as the methodological quality of the included
studies was only moderate and RCTs were lacking.59 evidence: 1(cid:2)).64
When it comes to preoperative optimisation, there are
Theauthorsofasystematicreviewfrom2006concluded
only limited data on possible effects of chest physical
that 6–8 weeks cessation of smoking has a beneficial
therapy or incentive spirometry for optimisation in non-
effect on complications such as wound healing (level of
cardiothoracicsurgery.Inarandomisedtrialof50patients evidence: 1(cid:2)).23 Smoking cessation 4 weeks prior to
scheduled for laparoscopic cholecystectomy, patients in
surgery also has an effect on the overall rate of post-
one group were instructed to carry out incentive spiro- operative complications (level of evidence: 1(cid:2)).27,64
metry repeatedly for 1 week before surgery, whereas in
Short-term cessation (2–3 weeks before scheduled
the control group, incentive spirometry was carried out
surgery)didnotshowareductioninoverallcomplications
onlyduringthepostoperativeperiod.Lungfunctiontests
and wound healing in colorectal resection surgery,
wererecorded at thetime ofpre-anaestheticevaluation,
although this was a small study (level of evidence:
onthedaybeforethesurgery,postoperativelyat6,24and 1(cid:2)).29Nevertheless,short-termcessationhasabeneficial
48h, and at discharge. Significant improvement in lung
effectontheamountofcarboxyhaemoglobinand,there-
function tests were seen at all study time points after
fore,shouldberecommendedinordertoimproveoxygen
preoperativeincentivespirometrycomparedwithpatients transport capacity (level of evidence: 2þ).65
inthecontrolgroup(levelofevidence:2þ).60
Different methods to motivate patients to stop smoking
Nutrition have been used. In almost all of the studies, some kind
Patients with severe pulmonary disease and many of nicotine replacement therapy was added to letters
other causes may present for surgery with a very poor of recommendations, physician guidance or teaching
EuropeanJournalofAnaesthesiology 2011,Vol28No10
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692 DeHertetal.
programmes.Nosinglemethodprovedtobesuperiorto requireparticularattentionfromtheattendingphysician,
the others (level of evidence: 1(cid:2)).66 as they are prone to perioperative complications.67,70–74
Several co-morbidities such as chronic heart disease,
Optimisationinobstructivesleepapnoeasyndrome chronic obstructive lung disease, peripheral occlusive
The goal of preoperative preparation is to improve or vascular disease and obesity have a major influence on
optimiseanOSASpatient’sperioperativephysicalstatus the development of AKI6,75 and have to be taken into
which includes preoperative continuous positive airway consideration when preparing patients for surgery.
pressure (CPAP) or bi-level positive airway pressure;
In addition, the type of surgery may influence the
preoperative use of oral appliances for mandibular
outcome of patients with impaired renal func-
advancement;orpreoperativeweightloss.Thereisinsuf-
tion.68,72,73,76,77Patientswith pre-existing renalimpair-
ficient literature to evaluate the impact of any of these
mentareatriskofcomplications,particularlywhenthey
measures on perioperative outcomes, although expert
undergo vascular procedures such as carotid endarter-
opinion recommends these interventions (level of evi-
ectomy (level of evidence: 2þ).70,73,76,77 In such cases,
dence: 4).55
theimpairmentofrenalfunctionhasdirectrelationship
to severity and number of complications.73,76 Although
Recommendations
there is conflicting evidence concerning mortality,
(1) Preoperativediagnosticspirometryinnon-cardiothor-
pre-existing renal impairment can be worsened in
acicpatientscannotberecommendedtoevaluatethe
patients undergoing endovascular abdominal aneurysm
risk of postoperative complications (grade of recom-
repair.67,78,79Evenamoderatepreoperativeelevationof
mendation:D).
SCr is associated with adverse outcomes such as com-
(2) Routine preoperative chest radiographs rarely alter
plications and death in patients undergoing general
perioperativemanagementofthesecases.Therefore,
surgery (level of evidence: 3).72
it cannot be recommended on a routine basis (grade
of recommendation: B). In order to define the severity of AKI, the RIFLE
(3) Preoperative chest radiographs have a very limited classification of the Acute Kidney Injury Network can
valueinpatientsolderthan70yearswithestablished be applied.80 RIFLE is categorised into five risk classes
risk factors (grade of recommendation: A). derived from either urine output, increase of SCr or
(4) PatientswithOSASshouldbeevaluatedcarefullyfor decreaseinglomerularfiltrationrate(GFR),respectively.
a potential difficult airway and special attention is
advisedintheimmediatepostoperativeperiod(grade
Existing evidence
of recommendation: C).
Howshouldtheconditionbeassessed?
(5) Specific questionnaires to diagnose OSAS can be
Themedicalhistoryisusuallythefirststepinpreopera-
recommended when polysomnography is not avail-
tive assessment of patients scheduled for surgery. For
able (grade of recommendation: D).
patientsatriskofAKI,severalco-morbiditiesareknown
(6) Use of CPAP perioperatively in patients with OSAS
toberiskfactors.Kheterpaletal.developedascorethat
may reduce hypoxic events (grade of recommen-
predictsworseningofrenalimpairmentandtheincidence
dation: D).
of AKI requiring dialysis in a study with prospectively
(7) Incentivespirometrypreoperativelycanbeofbenefit
collected data from 75952 patients. The following risk
in upper abdominal surgery to avoid postoperative
factors were identified: intraperitoneal surgery (relative
pulmonarycomplications(gradeofrecommendation:
risk 3.3, 95% CI 2.4–4.7); moderate renal insufficiency
D).
(relative risk 3.2, 95% CI 2.8–3.7); mild renal insuffi-
(8) Correction of malnutrition may be beneficial (grade
ciency(relativerisk3.1,95%CI2.5–3.9);ascites(relative
of recommendation: D).
risk3.0,95%CI2.2–4.0);activecongestiveheartfailure
(9) Smokingcessationbeforesurgeryisrecommended.It
(relative risk 2.0, 95% CI 1.4–3.0); emergency surgery
muststartearly(atleast6–8weekspriortosurgery,4
(relativerisk1.9,95%CI1.5–2.3),ageofatleast56years
weeksataminimum)(gradeofrecommendation:B).
(relative risk 1.7, 95% CI 1.4–2.2); diabetes requiring
Ashort-termcessationisonlybeneficialtoreducethe
insulin therapy (relative risk 1.7, 95% CI 1.3–2.3); hy-
amountofcarboxyhaemoglobininthebloodinheavy
pertension (relative risk 1.5, 95% CI 1.2–1.9); male sex
smokers (grade of recommendation: D).
(relativerisk1.4,95%CI1.2–1.7);anddiabetesrequiring
oral medication (relative risk 1.3, 95% CI 1.0–1.7). The
Renal disease
five preoperative risk classes that can be used for pre-
Introduction
operative risk stratification for perioperative AKI are
Postoperative acute kidney injury (AKI) is associated
listed in Table 4 (level of evidence: 2þþ).6
with prolonged hospital stay, increased morbidity and
mortality.67–69 The identification of patients at risk and SCriswidelyusedfortheassessmentofrenalfunctionin
their optimised preparation for non-cardiac surgery is of clinical practice. Although there is evidence of its
majorimportance.Patientswithimpairedrenalfunction accuracy to predict adverse renal outcome such as
EuropeanJournalofAnaesthesiology 2011,Vol28No10
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Preoperativeevaluationoftheadultnon-cardiacsurgerypatient 693
Table4 Preoperativeriskclasses surgery.Severalstudieshaveinvestigatedtheeffectsof
N-acetylcysteine and fenoldapam on the development
Relativeriskfor
Numberof thedevelopment of postoperative AKI.93–98 Only the combination of
Riskclass riskfactors ofAKI(95%CI) N-acetylcysteine and fenoldapam reduces the decline
ofrenalfunctionaftercardiacsurgery(levelofevidence:
ClassI 0–2
ClassII 3 4.0(2.9–5.4) 1(cid:2)).94 Two studies concerning preoperative statin
ClassIII 4 8.8(6.6–11.8)
therapy and postoperative renal impairment have been
ClassIV 5 16.1(11.9–21.8)
ClassV 6andmore 46.3(34.2–62.6) identified.97,98 Both were retrospective association stu-
dies in patients undergoing cardiac surgery. Argalious
AKI,acutekidneyinjury;CI,confidenceinterval.DatafromKheterpaletal.6 etal.98foundnobenefitforpatientstreatedwithstatins
in comparison to patients who did not receive statin
AKI,70,71,77,79itrepresentsanindirectparameterofrenal therapy. In contrast, Virani et al.97 found a reduction in
function, as it is influenced by many non-renal factors postoperative renal impairment for patients pretreated
such as BMI, age and sex. Both GFR and creatinine withstatins.Thiseffectwasrestrictedtothesubgroupof
clearance (CrCl) (either calculated by the formula of patients undergoing isolated coronary artery bypass
Cockroft and Gault or the MDRD formula) are able to surgery.Patientshavingvalvesurgeryoracombination
improve the diagnostic accuracy over SCr alone. of coronary artery bypass surgery and valve surgery
did not benefit. Thus, it remains unclear whether pre-
MDRD formula81
operative statin therapy influences postoperative renal
GFR (mlmin(cid:2)1)(cid:3)1.73m(cid:2)2¼186(cid:3)Scr(cid:2)1.154(cid:3)age(cid:2)0.203 function.
(years)(cid:3)0.742 (iffemale)(cid:3)1.212(ifAfrican–American)
Cockroft and Gault formula82 Recommendations
(1) The risk index of Kheterpal et al.6 is useful for the
GFR¼ð140(cid:2)ageÞ(cid:3)ðweightinkilogramsÞ identification of patients at risk for postoperative
renal impairment (grade of recommendation: C).
(cid:3)0:85ðiffemaleÞ=ð72(cid:3)SCrÞ
(2) Calculated GFR is superior to SCr for the identifi-
cationofpatientswithpre-existingrenalimpairment
GFR is a better predictor of impaired renal function in
(grade of recommendation: C).
patients undergoing major surgery when renal disease
(3) Urineoutputshouldbemonitoredcarefullythrough-
isstillsubclinical(levelofevidence:2þ).83Inastudyof out the perioperative phase and adequate fluid
852 consecutive patients undergoing major vascular
management provided in order to avoid worsening
surgery, the calculated CrCl according to the Cockroft
of pre-existing renal failure for patients at risk for
and Gault formula was found to be superiorto assessing
postoperativerenalimpairment(gradeofrecommen-
SCr alone.84 These findings were confirmed in patients
dation: D).
undergoing cardiac surgery.85,86
Diabetes mellitus
Futurebiomarkers Introduction
A series of newly developed biomarkers such as neutro-
Diabetes mellitus is a common co-morbidity in patients
phil gelatinase-associated lipocalin (NGAL), cystatin C
presenting to anaesthetists for elective and emergency
(CyC),liver-typefattyacid-bindingprotein,interleukin-
surgery. Impaired glucose tolerance, either iatrogenic or
18andkidneyinjurymolecule-1 aregaining importance
asaprecursortoformallydiagnoseddiabetes,isprobably
in clinical settings. NGAL is a marker of tubular stress
more common than formally diagnosed diabetes. Both
with an earlier rise in urine than in serum after tubular
type1(insulindeficiency)andtype2(insulinresistance)
injury.Incasesofworseningrenalfunction,NGALlevels
diabetesare well recognised asrisk factors for microvas-
precede the rise of SCr for more than 24h. NGAL has
cular and macrovascular disease, resulting in end-organ
been investigated only in the setting of cardiac surgery
damage, notably to heart, brain and kidneys. Patients
andintensivecarepatientsasyet,buttheresultsofthese
withdiabetesaremorelikelytopresentforsurgerythan
trialsarepromising.87–92ThelevelofCyCisdetermined thosewithout.99Furthermore,elevatedbloodglucosein
byglomerularfiltrationandnotbytubularstress.Itisnot
the perioperative period is a risk factor for surgical site
influencedbyage,sex,race,musclemass,infection,liver infection100 and diabetic patients are at greater risk for
disease or inflammatory disease unlike SCr. postoperativeheartfailure.101BothtypeIandIIdiabetic
patientshaveahigherrateofdifficultlaryngoscopythan
Whatinterventionshouldbedonebytheanaesthesiologistin non-diabetic patients.102,103
thepresenceofthespecificcondition(andatwhattime)?
Until now, data on the prophylactic treatment of AKI Thefollowingquestions,therefore,needtobeaddressed.
in patients undergoing non-cardiac surgery have been First, should the preoperative assessment be used for
lacking.Thereisgrowingevidenceinthefieldofcardiac unselective or targeted screening for the presence of
EuropeanJournalofAnaesthesiology 2011,Vol28No10
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