Title: Preoperative evaluation of adult patients undergoing elective non-cardiac surgery in Lithuanian hospitals

Author(s): Jaremko I. 1, Stremaityte V. 2, Gudaityte J. 1
Institute(s):	1. Lithuanian University of Health Sciences, Department of Anaesthesiology, Kaunas, Lithuania, 2. Vilnius University, Department of Emergency Medicine, Vilnius, Lithuania

Background and Goal of Study: The aim of this study was to assess the extent of preoperative evaluation of adult patients undergoing elective non-cardiac surgery in Lithuanian hospitals (LH) compared to ESA guidelines [1].

Materials and Methods: The prospective study was approved by local Ethics Committee. LH containing surgery departments were included. A questionnaire according to ESA preoperative evaluation guidelines [1] was formed and mailed to 42 hospitals. Questionnaires were answered by qualified anaesthesiologists. Answers were received from 30 hospitals (response rate 71.4%).

Results and Discussion: 
1. Preoperative assessment should at least be completed by an anaesthetist (D), but the screening of patients could be carried out effectively by either trained nurses (C) or anaesthesia trainees (D). In 100% of LHs is done by anaesthesiologist.
2. Pre-operative evaluation should be carried out with sufficient time before the scheduled procedure to allow for the implementation of any advisable pre-operative intervention aimed at improving patient outcome (D). In 39.2% of LHs pre-operative assessment is done <2h before the surgery.
3. Pre-operative standardized questionnaires may be helpful in improving anaesthesia evaluation in a variety of situations (D). 76.6% of LHs uses standardized questionnaires.
4. Screening for DMV and difficult intubation should be conducted, whenever feasible, in all patients potentially requiring airway management for anaesthesia (A). No single predictive sign for difficult airway management is sufficient by itself and the pre-anaesthesia assessment needs the combination of different validated evaluation criteria (A)	96.6% screening is done.  In LHs history of previous anaesthesia's evaluated 96.6%, assessment of Mallampati class - 96.6%, thyromental distance - 72.4%, head and neck mobility - 75.9%, length of neck - 82.8% thickness of neck - 3.4%, interincisor distance (mouth opening) - 100%, jaw protrusion - 86.2%, BMI - 75.9%, age - 58.6%, snoring and sleep apnoea - 51.7%, sex - 31%.
5. Pre-operative assessment of obese patients includes at least clinical evaluation, Berlin or STOP questionnaire, ECG, polysomnography and/or oximetry. (D) Laboratory examination is indicated in obese patients in order to detect pathological glucose/HbA1C concentrations and anaemia (D). Clinical evaluation is done in 100% of LHs, Berlin/STOP questionnaires - 3.3%, ECG - 90%, polysomnography/oximetry - 6.6%, glucose/HbA1C - 96.6%.
6. Routine use of coagulation tests is not recommended unless there are specific risk factors in the history (D). In 86.6% of LHs coagulation tests is done routinely.
7. Smoking cessation before surgery is recommended. It must start early (at least 6 to 8 weeks prior surgery, 4 weeks at a minimum) (B). Smoking cessation 6-8 weeks before operation is recommended in 10% of LH.
8. In patients currently taking b-blocking or statin therapy, this treatment should be continued peri-operatively (A). 72.4% of LHs continued this therapy.
9. Patients should be asked explicitly about their intake of herbal drugs (D), Herbal medicines should be discontinued 2 weeks prior to surgery (D). In 44.8% of LHs anaesthesiologists asked abuot herbal drugs, but only in 20.6% stopped.

Conclusion(s): 
1.	Preoperative evaluation in Lithuanian hospitals is done by a doctor anaesthesiologist, mostly 2 hours or less before the surgery, using standardized questionnaires.
2.	Patients with comorbidities and/or taking medication before surgery are evaluated and prepared according to the ESA recommendations in most of LHs. However, some recommendations related to smoking cessation, the assessment of obese patients, usage of herbal preparations, are performed in a small number of LHs.
3.	Airway evaluation is done in most of LHs according to ESA recommendations.

References: 1. 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.