Guidelines for ordering pre-operative spirometry, CXR, transthoracic echocardiogram and cardiac stress tests:

The guidelines below are adapted from both Up to Date and the Choosing Wisely campaign, which has been endorsed by the Australian and New Zealand College of Anaesthetists

• CXR:

  • A CXR may form part of the surgical work-up, however it is not generally useful from an anaesthetic perspective unless you are suspicious of acute pathology (eg effusion, pneumonia)
  • It is not useful for risk stratification above and beyond clinical assessment
  • Should NOT be routine

• Spirometry:

  • In general, it is not useful for risk stratification above and beyond clinical assessment
  • Unlikely to be useful in patients who already have a diagnosis of COPD or other respiratory disease
  • Occasionally useful for assessing response to treatment or diagnosing the cause of dyspnoea, however this is relatively rare
  • Is part of the work-up of a patient having lung-resection surgery, however this is considered separately
  • Should NOT be routine

• TTE:

  • Indicated if the patient is having intermediate or high-risk surgery and has had an abnormal TTE or confirmed cardiac disease (eg cardiac failure, pulmonary hypertension, aortic stenosis) and no TTE in the last 2 years
  • May also be indicated if the patient has undiagnosed shortness of breath or clinical evidence of undiagnosed cardiac disease (eg a new murmur, new atrial fibrillation, new or worsening signs of cardiac failure)
  • A resting echocardiogram is not a useful investigation for assessing suspected undiagnosed ischaemic heart disease

• Cardiac stress tests:

  • Stress echocardiograms and stress thalliums should not be ordered without discussion with either the Anaesthesia Consultant in PAC-Anaesthesia, the Clinical Lead Anaesthetist or the PMU consultant. Coronary angiograms (including CTCA) should not be ordered without discussing first with a cardiologist.