Preoperative screening and risk assessment in the ambulatory

surgery patient
Anil Gupta
Orebro University Hospital, Orebro and University of
Linkoping, Linkoping, Sweden
Correspondence to Anil Gupta, Associate Professor,
Department of Anesthesiology and Intensive Care,
University Hospital, SE 701 85 Orebro, Sweden
Tel: +46 19 6020256; fax: +46 19 127479;
e-mail: anil.gupta@orebroll.se
Current Opinion in Anaesthesiology 2009,
22:705711

Purpose of review
With the rapid increase in the number of sicker patients with multiple co-morbidities and
extremes of age who are undergoing ambulatory surgery, a thorough and detailed
preoperative workup has become increasingly important. Case cancellation on the
morning of surgery should be an exception. Therefore, much attention is focused on the
optimization of the sicker patients. Although the anesthesiologist plays a central role in
the preoperative assessment, a multidisciplinary approach is critical. This review was
done to provide the reader with current trends and practices in preoperative
assessment of the ambulatory surgical patient.
Recent findings
The risk factors that may influence major morbidity, death or hospital admission include
age greater than 85 years, hospital admission within the previous 6 months and
invasiveness of surgery. The American Society of Anesthesiologists physical status
greater than 2 can predict in-hospital adverse events. Routine preoperative
investigations in the healthy patient, including electrocardiogram are, today,
unwarranted and have not been shown to improve outcome.
Summary
Risk management involves the identification of the patient at risk, optimization of
preoperative health status, risk reduction through medical intervention as well as
appropriate perioperative care. Thus, patient outcome can be improved, specifically for
the sicker patients at a higher risk.
Keywords
ambulatory surgery, perioperative care, risk assessment
Curr Opin Anaesthesiol 22:705711
2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
0952-7907

Introduction
With the significant increase in the number of sicker
patients with multiple co-morbidities and extremes of
age who are undergoing ambulatory surgery, a thorough
and detailed preoperative evaluation and optimization
has become increasingly important.
A close communication between the surgeon, anesthesiologist and family physician is essential in order that the
preoperative screening process is efficient and identifies
patients at risk who may benefit from preoperative optimization [1]. In addition, major complications or death,
although rare following ambulatory surgery [2], occur as a
result of multiple factors and it is, therefore, important to
identify those patients who are at risk as well as those
factors that may add to the risk of a perioperative event.
This article outlines the issues relating to preoperative
screening and risk assessment as well as discussing the
0952-7907 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

mechanisms that can be put into place in order to run an

efficient ambulatory surgical practice.

Preoperative assessment
The main purpose of a preoperative assessment is to
identify patients suitable for ambulatory surgery, as
well as to determine and reduce the risks associated
with a detrimental outcome [3]. Appropriate preoperative preparation should reduce cancellation of cases on
the day of surgery [4]. The surgeon is often the first
physician who screens the patient at the time of the
visit to the outpatient facility. Anesthesiologists often
meet the patient on the day of surgery or interview
patients by telephone the day before surgery [5].
Therefore, it is important that the surgeon is familiar
with the prerequirements for anesthesia. However, it is
critical that the anesthesiologist evaluates the sick and
old patient several days before surgery in order to
avoid cancellation.
DOI:10.1097/ACO.0b013e3283301fb3

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706 Ambulatory anaesthesia

Involving patients in the preoperative evaluation and

preparation process is crucial. Many healthcare facilities
have developed detailed information leaflets or brochures
as a way of informing the patient about the operation;
others rely upon procedure-specific videos, which can be
available through the Internet. Such approaches to
patient education are effective but rest largely on the
degree of patients involvement in their surgery.

Methods for preoperative assessment

The methods by which a preoperative assessment can be
done include physician-based, nurse-based, standardized questionnaires or Internet-based health questionnaires. There is no single system that is ideal under all
circumstances. Instead, it is often the existence of
co-morbidities that should be the guiding factor as to
the optimal method for preoperative assessment, and
each hospital needs to have local policies. The family
physician can often be an important bridge between the
patient and surgeon and anesthesiologist in preoperative
optimization.
Physician-based assessment

Physician-based assessment has the advantage of obtaining a good medical history as well as direct assessment of
the patients physical status. However, it is expensive and
may be reserved for patients in the American Society of
Anesthesiologists (ASA) physical status 3 as well as for
those with special needs such as neonates, physically or
mentally handicapped, and those with on-going systemic
infections.
Nurse-based assessment

Patients in the ASA physical status 12 and children are

usually ideal for nurse-based assessment. It is important,
however, that the nurses are trained and follow physicianwritten guidelines for preoperative assessment and
patient education [6] and, whenever uncertain, have
the possibility to discuss the case with a physician. This
approach should allow substantial cost-savings without
compromising patient care [7].
Standardized and Internet-based health questionnaires

Many patients can be screened using questionnaires.

This approach is cost-effective. However, such questionnaires should be user-friendly. Nevertheless, there
is a concern that use of questionnaires relies on the
patients own ability to discriminate between health and
disease, which may lead to misinterpretation and, therefore, lack the ability to identify some patients at risk.
In addition, some important anesthesia-related issues
such as risk of regurgitation and aspiration may be
missed as insignificant by the patient, and surgeons
or family physicians may not be able to assess difficult
intubation.

Timing of preoperative assessment

When should the patient be assessed depends on
patients clinical condition and the invasiveness of the
surgery [1]. In order for the assessment to be cost-effective, patients with ASA physical status 12 may be
assessed on the day of surgery. Even well controlled
ASA physical status 3 patients may be examined on
the morning of surgery, provided the preoperative
workup has been complete and adequate. All other
patients including those who have recently acquired
respiratory tract infections or have new symptoms should
be examined at a Preoperative Anesthesia Clinic (PAC)
in order to reduce cancellations on the day of surgery as
well as avoid perioperative complications and improve
efficiency of the ambulatory facility [7]. In this patient
population, sufficient time should be available to perform
further investigations and optimization.

Patient selection
The risks associated with ambulatory surgery are primarily due to patient-related medical co-morbidities and,
sometimes, surgical complications. Rarely is anesthesia
the primary cause of morbid events, although it could be a
contributory factor. The statistically significant predictors
of death within 7 days of outpatient surgery include age
greater than 85 years, male sex, having surgery initially
performed in an outpatient hospital and having prior
inpatient hospital admissions [8]. Factors associated with
an increased risk of hospital admission have been identified to include age greater than 65 years, operating time
more than 120 min, cardiac diagnoses, peripheral vascular disease, cerebrovascular disease, malignancy, HIVpositive status and general anesthesia [9]. Smokers, obese
patients and patients with asthma are at two-fold to fivefold higher risk of developing perioperative respiratory
events in ambulatory surgical centers [10]. Therefore,
careful patient selection in the preoperative anesthesia
clinic may reduce the risk of unanticipated events.
The criteria for accepting patients for day surgery have
increasingly become liberal with older and sicker patients
undergoing ambulatory surgery. Thus, not only ASA 12
patients but also stable ASA 3 patients are now acceptable
for day surgery. Similarly, the previous criterion for
admitting obese patients (BMI >35 kg/m2) is being
stretched to include BMI 4050 kg/m2 [11] and sometimes even higher in hospitals with experienced staff.
Although at an increased risk for bronchospasm and
desaturation, obese patients have not been shown to
be at an increased risk for unanticipated admission [12].
Children less than 36 months postgestation were previously not considered suitable for day surgery, but today,
a postconceptional age of more than 5260 weeks is

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Preoperative screening and risk assessment Gupta 707

considered not to be associated with greater risk or poor

outcome, provided there have been no adverse episodes
such as apnea during the operation [12,13]. Children with
ongoing upper respiratory tract infection (URI) were
previously denied surgery, but anesthesiologists today
are more liberal, although not in uniform agreement, on
this issue [14]. There is, however, an increased risk of
minor desaturation, coughing and bronchospasm in children with recent and current URI [15] and it may, therefore, be wise to delay surgery by 4 weeks following an
episode of severe URI [12].
Diabetic patients have not been shown to be at an
increased risk of postoperative complications following
ambulatory surgery [16]. Regional anesthesia is beneficial
in diabetic patients, provided there is no evidence of
neuropathy, due to a better control of blood glucose.
Patients with stable coronary artery disease do not appear
to be at a higher risk of perioperative complications
following ambulatory surgery [17]. Patients suffering
from reactive airway disease (asthma and chronic obstructive pulmonary disease) are at higher risk for minor
perioperative events following ambulatory surgery [18].
Obstructive sleep apnea (OSA) syndrome has been a
cause of much debate and discussion over the last few
years and, although no evidence-based guidelines are
available, individual patient assessment is necessary
[19]. In one retrospective analysis of data, the preoperative diagnosis of OSA was not a risk factor for either
unanticipated hospital admission or for other adverse
events among patients undergoing outpatient surgical
procedures [20]. This subject has been extensively
reviewed recently, but data are not restricted to the
outpatient population [19].
Needless to say, an adult should preferably be at home
with the patient during the first 24 h after surgery,
specifically when performing intra-abdominal surgery
or ENT surgery under general anesthesia because of
the potential risk for major or serious bleeding complications. Additionally, patients who are expected to have
severe postoperative pain, potential risk of bleeding in a
closed space, live more than 30 min away from a hospital
with emergency facilities or have previously had major
anesthesia-related complications should be reconsidered
for suitability as out-patients.

Preoperative investigations
In general, routine preoperative investigations in otherwise healthy patients do not predict outcome, reduce
hospital admissions or re-admissions or prevent adverse
events [2123]. They can also be financially unsound in a
healthcare system starved of resources. When indicated,
however, preoperative investigations can reduce risks

through optimization of health status. For instance,

plasma brain natriuretic peptide (BNP) can be used as
a bedside test to exclude left ventricular dysfunction in
otherwise healthy patients with symptoms of recentonset breathlessness or undue tiredness. BNP has been
shown to predict perioperative events in cardiac patients
undergoing noncardiac surgery [24,25]. Similarly, HbA1c
values may be used to assess poorly controlled diabetes
mellitus over the previous few months, although its
benefits in patients undergoing ambulatory surgery are
lacking. Routine ECG in older patients continues to be
done in many hospitals, but this too can be questioned
[26,27]. Importantly, therapy-directed investigations
should be performed in order to reduce risks associated
with anesthesia or surgery. A recent publication addresses
and recommends tests that may be considered appropriate prior to surgery depending on the complexity of the
surgery in relation to the medical status of the patient
[28].

Risk assessment
In general, risks of major complications following ambulatory surgery are low. Warner et al. [2] found that two
patients of more than 35 000 operated for ambulatory
surgery had a myocardial infarction following home discharge and another two patients died following road
traffic accidents, which probably had no relationship to
the surgery or anesthetic. In older patients (>65 years),
mortality within 7 days appears to be much higher, 41 of
100 000 [8]. A novel index for risk-identification has been
developed for prediction of in-hospital admission following outpatient surgery [9]. This scoring system has the
advantage of simplicity but needs further assessment in
prospective studies before it can be recommended for
routine use. Risks associated with anesthesia and surgery
is often related to the underlying co-morbidity in the
patient, the type of surgery or anesthetic administered as
well as the facility in which the procedure is performed
(e.g. ambulatory surgery center versus office-based
surgery).

Patient-related risk factors

A large majority of patients who die or suffer from major
injury, do so because of the underlying diseases that are
either poorly treated or because of a known poor outcome
as a consequence of these diseases. Patient factors that
are known to be associated with major cardiac complications in noncardiac surgery include cardiac failure,
ischemic heart disease, renal insufficiency, insulindependent diabetes mellitus and a history of stroke
[29]. Patients with a myocardial infarction are today
advised to wait for 46 weeks before elective surgery.
For a more thorough discussion of this and related issues
in cardiac patients undergoing noncardiac surgery, the

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708 Ambulatory anaesthesia

Figure 1 Algorithm for the perioperative management of the ambulatory surgery patient

Preoperative assessment in the PAC

ASA 12A
(ASA 2A: optimally
managed)

ASA 2B: not

optimally managed

ASA 3A: Optimally

managed

Optimize
medication

Preoperative
medication

ASA 3B: (not

optimally managed))

Continue
medication

Consult appropriate
physician for
optimization

Choose appropriate
anesthetic technique

Yes
Is surgery
appropriate as day
case?

Proceed to surgery

Postoperative
assessment

No
Yes

Consider whether patient should be

admitted

Admit patient

No

Home discharge

Please note that American Society of Anesthesiologists (ASA) classification into A and B is a modification from the original and takes into account
whether the patient is optimally managed or not. PAC, Preoperative Anesthesia Clinic.

reader is referred to the recently published guidelines

[30]. To the above list of patient-related risk factors can
be added chronic obstructive lung disease requiring
oxygen therapy at home, morbid obesity with a BMI
more than 50 kg/m2, severe bronchial asthma that is
poorly controlled on drugs and some rare diseases that
are not encountered daily [12,17]. These patients may be
optimally managed, yet have an increased risk of perioperative complications. A general approach to preoperative assessment and optimization is shown in
Fig. 1. The key issues that need to be considered on a
case-to-case basis are as follows:
(1) Does the surgery reduce long-term morbidity or
mortality?
(2) If yes, does hospital admission improve outcome?

(3) If not, is the patient optimally managed for comorbidities?

(4) If not, optimize first and reconsider the appropriateness of day surgery. If yes, proceed to surgery.

Surgery-related risk factors

The type and magnitude of surgery per se can be a risk
factor and, therefore, it is important to consider whether
the planned surgical procedure is appropriate for day
case. The interaction between patient-related and
surgery-related factors may significantly increase the risk
in any given patient. There is no uniform agreement on
the grades or types of surgery [28,30]. The grade or type
of surgery in relation to patient-risk factors often guides
physicians whether day surgery can be performed in a

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Preoperative screening and risk assessment Gupta 709

Table 1 Should surgery be performed as day case
Patient-related factors
Surgery-related factors
Low risk
Intermediate risk
High risk

Low risk
Yes
Probably yesa
No

Intermediate risk
a

Probably yes
Probably noa
No

High risk
No
No
No

Should surgery be performed as ambulatory or not. The suggested decision support assessment is based on personal experience. For surgery-related
risk, please see [30]. Patient-related risk is based on American Society of Anesthesiologists (ASA) classification: low risk, ASA 12; intermediate risk,
ASA 3; high risk, ASA 45.
a
Availability of resources, expertise and local traditions should be the deciding factors.

given patient [28]. Table 1 reflects one approach to

patient management; however, each case should be
decided on its own merits.
Low-risk surgery

One with a cardiac risk of less than 1%, low-risk surgery

includes procedures performed on superficial organs,
such as eye surgery, ambulatory surgery, plastic surgery,
inguinal herniorrhaphy, simple mastectomy, among
others.
Intermediate-risk surgery

One with a cardiac risk of 15%, intermediate-risk

surgery includes head and neck surgery, intraperitoneal
and intrathoracic surgery, orthopedic surgery and prostate
surgery.
High-risk surgery

One with a known cardiac risk of more than 5%, this type
of surgery includes procedures with large fluid shifts such
as esophageal, liver and pancreatic surgery. These
patients should preferably be admitted to the hospital
for 24 h and not be sent home on the same evening,
except in specialist centers.

Anesthesia-related factors
Complications related directly to anesthesia technique in
day surgery today are extremely rare, which could reflect
well tolerated anesthetic practice, better drugs as well as
improved perioperative patient care. Factors that remain
of direct concern to anesthesiologists include the risk
of aspiration, difficult tracheal intubation and complications of regional anesthetic techniques including nerve
injuries.
Preoperative assessment can identify some of these risks.
Therefore, it is important to identify patients at risk and
prevent these risks. For instance, patients with hiatus
hernia and gastro-esophageal reflux may benefit from the
use of a proton-pump inhibitor (PPI), omeprazole, preoperatively in order to increase gastric pH and reduce
volume. However, the advantage of routine use of PPIs in
these patients should be weighed against the potential
risks of increased infection. Similarly, identification of a

difficult airway and appropriate management would

reduce the risk of hypoxia and even death. Patients with
diabetes mellitus and peripheral neuropathy could be at
an increased risk of nerve injuries when performing
regional blocks, which should, therefore, be considered
carefully in the individual patient and risks weighed
against the possible benefits. Outcome data on regional
anesthesia in diabetic patients undergoing ambulatory
surgery are, however, lacking in the literature. Careful
consideration to spinal or epidural analgesia should be
made in patients taking anticoagulants and antiplatelet
drugs, which has been thoroughly reviewed by Horlocker
et al. [31]. Several patient-experienced outcomes such as
postoperative nausea, vomiting and pain have a major
impact on the quality of life following ambulatory
surgery. It is important to identify the patient at risk of
these complications and take appropriate steps to reduce
these risks [3234].

Risk management
Reducing the perioperative risk for the patient is the
primary responsibility of all physicians and, therefore,
every effort should be made to assess the risks involved
and use documented and evidence-based methods to
reduce these risks in the individual case. The use of
checklists as a part of the patient safety program initiated
by the World Health Organization has been shown to
improve outcome [35] and should be implemented
in all ambulatory centers. In many patients, risk reduction incorporates preoperative optimization, which may
involve a multidisciplinary team including a surgeon and
an anesthesiologist, and even a family practitioner or
other specialists. Some therapies that may be of value
in reducing perioperative complications could include:
weight reduction before surgery in the morbidly obese
[36], cessation of smoking (48 weeks before planned
surgery) in the chronic smoker [37], continuation of
antiplatelet drugs and statins in patients with recently
implanted coronary stents [30], PPIs in order to reduce
volume and increase pH of gastric contents [38], and
finally beta-blockers in the cardiac patient undergoing
noncardiac surgery [30]. For a more thorough review of
this subject, the reader is referred to some recent articles
published in the literature [5,39]. A summary of some of

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710 Ambulatory anaesthesia

Table 2 The risk factors believed to affect outcome
Risk factor

The risk

Recommendation

Reference

Age <52 weeks, postgestational

Age >85 years
Weight (BMI >50 kg/m2)

Apnea periods
Unanticipated admission
Desaturation, bronchospasm

[13]
[9]
[12]

ASA physical status >2

Ongoing upper respiratory
infection
Smoking

In-hospital adverse postoperative outcomes

Coughing, broncho-laryngospasm

Admit patient for observation

Consider admission following surgery
Not recommended for day surgery except
in specialized centers
Admit for overnight observation
Individual assessment; consider postponing
surgery
If possible, stop smoking 48 weeks before
surgery; no smoking on day of surgery
Admit for observation in upper grades
obstructive sleep apnea, those needing
opiates postoperatively
Continue aspirin and statins
Delay elective surgery by 3 months for
bare-metal stents and >1 year for
drug-eluting stents

Obstructive sleep apnea

Infections, delayed healing,

desaturation
Difficult tracheal intubation

Patients with coronary stents

Stent occlusion

[22]
[15]
[37]
[17]
[30]

Some of the recommendations are based on single studies and not on guidelines or consensus opinion. ASA, American Society of Anesthesiologists.

these important risks has been presented in Table 2. It is

important to state that a thorough preoperative assessment combined with risk-reduction strategies and optimized perioperative care is often the key to a successful
outcome in the individual patient.

Conclusion
Preoperative screening and risk assessment involves
using routines in a multidisciplinary environment. Using
checklists should reduce interindividual differences
among physicians and nurses. Patients should be
involved in their own management to improve outcome
by active participation. Although day surgery has been
shown to be safe, an increasing number of elderly, sicker
patients who are operated today as day surgical cases
imply a potentially increasing risk in the future. These
risks should be periodically evaluated and incumbent
risks eliminated.

References and recommended reading

Papers of particular interest, published within the annual period of review, have
been highlighted as:

of special interest
 of outstanding interest
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