Continent-wide anaesthesia guideline

This invited commentary accompanies the following article: De Hert S, Imberger G, Carlisle J, et al. Preoperative evaluation of the adult patient undergoing non-cardiac surgery: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol 2011; 28:684–722. The aim of an anaesthesia guideline is to improve the efficiency of anaesthesia care providers by using the latest evidence-based medical knowledge to simplify and/or eliminate unnecessary steps. Physicians are expected to be familiar with clinical guidelines, but should note that they are advisory in nature and are there to help with safer decision making, something which might vary according to the patient's condition and the available resources. Practice guidelines should be revised periodically to accommodate newly published data. In 2007, the Anaesthesiology Board of European Union of Medical Specialists published guidelines for the safety and quality of anaesthesia.1 A more recent milestone was the Helsinki Declaration on Patient Safety in Anaesthesiology published in June 2010. This represented a European consensus on measures to improve patient care and it set out a framework for good practice.2 In order to constrain costs and standardise practice across Europe, the European Society of Anaesthesiologists (ESA) took a giant step forward by committing to the development of evidenced-based clinical guidelines and recommendations. In this issue, the unique specific task force, led by Professor Stefan De Hert, has published an outstanding guideline for the preoperative evaluation of adult patients undergoing elective non-cardiac surgery.3 Their recommendations are very comprehensive.3 They cover a wide range of topics that include cardiovascular disease, respiratory disease, obstructive sleep apnoea (OSA), renal disease, diabetes, obesity, coagulation disorders, anaemia, the elderly patient, alcohol addiction and allergy. They also cover concurrent medication, and preoperative testing. In addition, there is a very useful section on airway evaluation. Swift proliferation and promotion of various guidelines are very beneficial for the anaesthesia community. Clinical practice recommendations prepared by experts in the field increase confidence in guidelines and make them an excellent source of information for physicians. Benefits of guidelines are improvements in healthcare quality and in the validation and optimisation of health expenditure.4 One disadvantage is that they can potentially be misused by hospital administrators and others as a means by which the quality of care can be judged. For many clinical issues, the randomised controlled trials that might best guide practice are lacking, and consequently some guidelines are based mainly on expert opinion. These opinions may vary from one country to another, depending on local clinical experience; this is another limitation of clinical guidelines. OSA is a good example for the importance of guidelines. The syndrome has prevalence between 2 and 4% in the general population.5 Surgical patients may have undiagnosed OSA with the associated risk of increased perioperative complications.6 Postoperatively, OSA patients may require extra monitoring, prolonged oxygen therapy or ICU admission. Many anaesthesiologists are not familiar with how best to deal with these vulnerable patients, especially in the emergency situation. The availability of guidelines will help clinicians make safe decisions and formulate a postoperative management plan. In this context, a task force from the American Society of Anesthesiologists (ASA) has published a practice guideline for the preoperative screening of OSA patients.7 Chung et al.6 developed a simple OSA screening tool, the STOP-Bang questionnaire which is useful for identifying and stratifying risk of suspected or known OSA patients, especially for busy caregivers. At present, it is the most commonly used screening tool for OSA. The cost of healthcare is rapidly increasing and there is a need to contain expenditure. By definition, one of the goals of guidelines is to eliminate unnecessary employment of resources and build a more efficient and cost-effective healthcare system. The role of preoperative evaluation in constraining cost is clear from a recent study. In a randomised controlled trial of 1061 patients undergoing day surgery, no preoperative testing was done with no increase in perioperative adverse events.8 This practice led to a substantial cost reduction of $38.5 per patient.8 The ASA task force on pre-anaesthetic evaluation gives some support to this approach by clearly stating that testing should only be done when additional information will improve the safety of anaesthetic processes, overriding any inconvenience and the cost of the investigations.9 In this context, the new guideline gives appropriate advice on the place of laboratory testing, ECG and chest radiograph before surgery,3 with the authors recommending specific investigations for each clinical condition based on the history and physical examination. The current practice guidelines and recommendations are necessary steps in the integration and standardisation of anaesthesia practice across Europe and eventually worldwide. The adoption of newly developed clinical guidelines into practice requires education of healthcare professionals through presentation at conferences and publication in journals. This will increase awareness of the advantages of a particular guideline. It has been shown that adherence to guidelines is considerably influenced by factors such as compatibility with the local environment, personal experience, scientific beliefs, the influence of peers and the physician's attitude towards new practice.10 The degree of confidence in the guideline developers, the requirements of the new skills and the clarity of the recommendations can also affect the decision of anaesthesiologists to follow or ignore the guidelines.10 The implementation of these recommendations on preoperative evaluation of non-cardiac patients will be very useful in establishing continent-wide uniform practice and may influence practice in the rest of the world. Acknowledgement The authors declare no support from any organisation for the submitted work, no financial ties with any organisations that might have an interest in the submitted work and no other relationships or activities that could have influenced the submitted work. This article was checked and accepted by the Editors, but was not sent for external peer-review.

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