Recommended approach to pre-anaesthesia assessment before diagnostic or therapeutic surgical and non-surgical procedures requiring anaesthesia care (pre-anaesthesia assessment).
1. General principles
The assessment of a patient’s health status within the framework of the pre-anaesthesia assessment is a specialist consultation carried out by a physician qualified in the field of Anaesthesiology and Intensive Care Medicine (AIM), or under the direct supervision of such a physician.
A physician with specialist qualifications in AIM is authorised to perform pre-anaesthesia assessments for patients of all age groups and is responsible for the assessment.
The physician specialising in AIM determines the scope of any additional examinations and specialist consultations required as part of the pre-anaesthesia assessment.
The pre-anaesthesia assessment must be documented in writing in the patient’s medical records.
Routine biochemical testing in asymptomatic patients is not recommended.
2. Definition and Objectives of the Pre-anaesthesia Assessment
The assessment of a patient prior to the administration of anaesthesia for diagnostic or therapeutic procedures of a surgical or non-surgical nature (hereinafter referred to as the pre-anaesthesia assessment) is an integral part of comprehensive anaesthesia care before any planned anaesthesia or monitored anaesthesia care (also referred to as anaesthesia monitoring).
The scope of the assessment is determined by:
- the patient’s health status,
- the choice of anaesthetic technique,
- the nature and urgency of the planned procedure.
The objectives of the pre-anaesthesia assessment are:
- evaluation of available preoperative assessment results,
- assessment of the patient’s health status and the functional reserve of individual organ systems,
- detection of potential abnormalities based on physical examination findings, biochemical tests or other diagnostic examinations,
- recommendation of any additional diagnostic examinations and specialist consultations, if required,
- recommendation of measures to optimise organ function, if required,
- development of an anaesthesia care plan (including the postoperative analgesia strategy) taking into account the patient’s condition, the type of procedure and the resources available at the healthcare facility,
- providing the patient with information about the planned procedure, the anaesthetic technique and postoperative care, and obtaining informed consent.
3. Components of the Pre-anaesthesia Assessment
3.1 Medical History (Review of Medical Records and Patient Interview)
- general health status, functional capacity and psychological condition
- past and current medical history
- current medication therapy
- allergies
- history of substance use (alcohol, medications, analgesics, recreational drugs, etc.)
- previous anaesthesia history (complications, difficult intubation, etc.)
- previous administration of blood products and any related complications
3.2 Clinical Examination
A basic clinical examination, performed to the extent required, is recommended. Even in so-called asymptomatic patients, it should include at least the following:
- visual inspection
- assessment of the airway (detection of potential signs of difficult intubation)
- assessment of the respiratory system (respiratory rate, signs of respiratory distress/dyspnoea)
- cardiovascular system assessment (blood pressure, pulse, and the condition of the venous system at sites planned for vascular access)
- in the case of a planned regional anaesthetic technique, assessment of the relevant body area in relation to the proposed technique.
3.3 Laboratory Tests, Additional Examinations and Specialist Consultations
- The scope of laboratory tests and specialist consultations should always be determined by the expected clinical value of the results and their potential impact on the anaesthesia care plan.
- An ECG is recommended for all patients over 40 years of age, even in the absence of a history of heart disease.
- Chemical urine testing is recommended for all patients.
Documentation of the pre-anaesthesia assessment in the patient’s medical records should include:
- findings of the patient assessment, including vital signs (blood pressure and heart rate),
- ASA physical status classification,
- recommendations for any additional laboratory tests and/or specialist consultations,
- recommendations for any measures required to optimise organ function,
- documentation of informed consent, or, where applicable, the reason why informed consent is not required,
- the anaesthesia care plan,
- the date and time of the assessment, and the identity of the physician performing the assessment.
4. Patient Informed Consent
Obtaining the patient’s consent to anaesthesia is an essential part of anaesthesia care for planned diagnostic and therapeutic procedures, whether surgical or non-surgical. Informed consent documents that the patient (or their legal representative) has been informed about the nature of the planned care or procedure, including its risks and potential complications. Obtaining informed consent is a prerequisite for providing anaesthesia care for all elective procedures (i.e., procedures that are planned and may be postponed until informed consent has been obtained from the patient or their legal representative, without increasing the risk of deterioration in the patient’s health status or endangering their life). If the urgent nature of a procedure prevents obtaining informed consent, this must be documented and justified in the patient’s medical records by the physician requesting anaesthesia care.
5. Validity of the Pre-anaesthesia Assessment
The pre-anaesthesia assessment is generally considered valid for 1 month, unless a new assessment is required for clinical reasons (e.g., a change in the patient’s health status since the previous assessment). In paediatric patients, the validity period is 2 weeks.
