Utility of Preanesthesia Evaluation Guidelines Within Prolapse Surgery

INTRODUCTION: The American Society of Anesthesiologists (ASA) Practice Advisory for Preanesthesia Evaluation advocates for selective preoperative testing. The ASA guidelines identify clinical risk factors that warrant laboratory testing ahead of surgery to assess the risk of adverse perioperative outcomes. OBJECTIVE: To assess the utility of the ASA Preanesthesia Evaluation clinical risk factors at identifying women at risk of adverse perioperative outcomes after prolapse surgery. METHODS: This is a retrospective cohort study utilizing the 2014 to 2023 American College of Surgeons National Surgical Quality Improvement Program database to analyze the utility of ASA Preanesthesia Evaluation guidelines within prolapse surgery. Women undergoing prolapse surgery were identified using CPT codes. The ASA Preanesthesia Evaluation clinical risk factors determined by the ASA guidelines were: (1) major surgery, (2) extremes of age, and/or (3) specific medical comorbidities. Major surgeries included minimally invasive sacrocolpopexy, sacrospinous ligament suspension, uterosacral ligament suspension, colpocleisis, and vaginal mesh for prolapse repair. Extreme of age was defined as >80, and comorbidities included liver disease, renal dysfunction, bleeding disorders, and endocrine disease. The primary outcome was any 30-day postoperative complication. Preoperative laboratory results and frequency of testing were assessed as secondary objectives, including sodium, BUN, creatinine, hemoglobin, hematocrit, platelet count, PTT, INR, and hemoglobin A1c. Standard group comparisons were performed comparing women who met the ASA clinical risk factors and those who did not. RESULTS: A total of 48,608 women underwent prolapse surgery: 23,625 (48.6%) had at least one ASA clinical risk factor and 24,983 (51.4%) did not. Table 1 displays significant differences between the two groups. Women with ASA clinical risk factors were more likely to be White (71.8% vs 60.8%, p<0.001), Hispanic or Latino ethnicity (11.9% vs 7.8%, p<0.001), have higher ASA functional status (class 3 or 4) (37.1% vs 22.4%, p<0.001), and undergo concomitant hysterectomy (19.1% vs 9.0%, p<0.001) or sling (25.9% vs 22.8%, p<0.001). The median operative time was longer (117 minutes (76–171) vs 74 (49–111), p<0.001) in women with preoperative risk factors. Rates of 30-day postoperative complications and reoperation rates were similar between groups (6.2% vs 6.0%, p=0.32, and 1.2% vs 1.1%, p=0.65); however, women with ASA clinical risk factors were at higher readmission risk (2.4% vs 1.5%, p<0.001). Table 2 displays the frequency and results of preoperative laboratory tests. Most laboratory tests were performed at higher frequency in women with ASA clinical risk factors; however, most laboratory results did not differ clinically between groups. CONCLUSIONS: The clinical risk factors identified by the ASA Preanesthesia Evaluation guidelines were not associated with higher rates of postoperative complications in women undergoing prolapse surgery. Although preoperative laboratory testing was performed more frequently in women meeting ASA clinical risk factors, actual differences in preoperative lab results were not clinically meaningful. These guidelines may not be generalizable to women with prolapse.Table 1Table 2