[CAVE - A checklist system for preoperative risk evaluation : Guideline-conform cardiopulmonary diagnostics before...

Preoperative evaluation of patient risk is an essential component of patient preparation before surgery. Guidelines provide evidence-based algorithms for preoperative assessment of cardiac risk; however, even experienced physicians correctly apply evidence-based algorithms in only 50% of all cases or less.

A checklist system for guideline-based cardiopulmonary risk evaluation in adult patients undergoing abdominal or visceral surgery (CAVE checklists) was created to assist in preoperative cardiopulmonary risk assessment and increase correct application of evidence-based algorithms before elective visceral surgery.

International guidelines were transformed into a checklist system. These checklists were than evaluated in a department of general and visceral surgery. The main goal was to determine whether preoperative examinations, such as electrocardiograph (ECG), chest-x-ray, spirometry and advanced assessment by a cardiologist, are performed according to evidence-based guidelines. The frequency of recommended as well as unnecessary and missed examinations was assessed.

In this study 541 patients with a median age of 64.5 years (interquartile range: 52-73 years) were examined using the checklist system. Of the patients 90.4% underwent ECG and 98.5% chest-X-ray as recommended in the guidelines. Spirometry was not recommended in any patient and not performed in any case. Advanced assessment by a cardiologist was performed in 45.5% of cases as recommended in the guidelines. When guidelines did not recommend ECG, x‑ray, spirometry or advanced cardiac assessment, 69.4%, 99.6%, 99.3% and 99.8% of patients, respectively, actually did not receive these examinations. Only 2.8% of all patients did not receive an examination that was recommended by the guidelines: 1.5% ECG, 0.2% x‑ray and 1.1% advanced cardiological assessment. None of these patients suffered from postoperative cardiopulmonary complications.

These simple checklists are easy to use and provide a higher degree of evidence-based preoperative cardiopulmonary risk evaluation than previously reported in the literature. Adaptation of the checklists to changing guidelines is easy to perform. Whether the application of these checklists will result in a reduction of morbidity and costs have to be determined in further clinical trials.