American Society of Anesthesiologists

View all recommendations from this society

Released October 12, 2013

Don’t obtain baseline laboratory studies in patients without significant systemic disease (ASA I or II) undergoing low-risk surgery – specifically complete blood count, basic or comprehensive metabolic panel, coagulation studies when blood loss (or fluid shifts) is/are expected to be minimal.

Performing routine laboratory tests in patients who are otherwise healthy is of little value in detecting disease. Evidence suggests that a targeted history and physical exam should determine whether pre-procedure laboratory studies should be obtained. The current recommendation from the 2003 ASA amendment that all female patients of childbearing age be offered pregnancy testing rather than required to undergo testing has provided individual physicians and hospitals the opportunity to set their own practices and policies relating to preoperative pregnancy testing. Some institutions respect the right of a patient to refuse testing after a thorough explanation of the anesthetic risks during pregnancy and the required signing of a waiver. The avoidance of the routine administration of the pregnancy test was therefore excluded from our Top 5 preoperative recommendations.

The risk specifically related to the surgical procedure could however modify the above preoperative recommendation to obtain laboratory studies and when the need arises; the decision to implement should include a joint decision between the anesthesiologists and surgeons. This should be applicable to all outpatient surgery.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

The list started as an academic project of Onyi C. Onuoha, M.D., M.P.H A review of the literature and practice guidelines as approved by the American Society of Anesthesiologists (ASA) was performed to identify an evidence-based list of activities to question within the field of anesthesiology. A multi-step survey of anesthesiologists in both the academic and private sector and ASA Committees of Jurisdiction was performed to generate a “Top 5 List” list of preoperative and intraoperative activities. The final list was endorsed by the ASA and accepted for the Choosing Wisely® campaign. We believe that developing strategies whereby all stakeholders in the perioperative team are involved in the implementation is a means in which anesthesiologists could be engaged in the efforts to reduce over-utilization of low value, non-indicated medical services evident in the U.S. health system today.

ASA’s disclosure and conflict of interest policy can be found at


Committee on Standards and Practice Parameters, Apfelbaum JL, Connis RT, Nickinovich DG; American Society of Anesthesiologists Task Force on Preanesthesia Evaluation, Pasternak LR, Arens JF, Caplan RA, Connis RT, Fleisher LA, Flowerdew R, Gold BS, Mayhew JF, Nickinovich DG, Rice LJ, Roizen MF, Twersky RS. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology. 2012 Mar;116(3):522–38.

Kumar A, Srivastava U. Role of routine laboratory investigations in preoperative evaluation. J Anaesthesiol Clin Pharmacol. 2011;27(2):174–9.

Mollov JL, Twersky RS. (2013). Is routine preoperative pregnancy testing necessary? In L. Fleisher, Evidence-based practice of anesthesiology (3rd ed., pp. 26-30). Philadelphia (PA): Elsevier Saunders.

Soares Dde S, Brandao RR, Mourao MR, Azevedo VL, Figueiredo AV, Trindade ES. Relevance of routine testing in low risk patients undergoing minor and medium surgical procedures. Rev Bras Anestesiol. 2013;63(2):197–201.

Brown SR, Brown J. Why do physicians order preoperative test? A qualitative study. Fam Med. 2011;43(5):338–43.

Czoski-Murray C, Lloyd JM, McCabe C, Claxton K, Oluboyede Y, Roberts J, Nicholls JP, Rees A, Reilly CS, Young D, Fleming T. What is the value of routinely testing full blood count, electrolytes and urea, and pulmonary function test before elective surgery in patients with no apparent clinical indication and in subgroups of patients with common comorbidities: a systematic review of the clinical and cost-effective literature. Health Technol Assess. 2012;16(50):1–159.

Katz RI, Dexter F, Rosenfeld K, Wolfe L, Redmond V, Agarwal D, Salik I, Goldsteen K, Goodman M, Glass PS. Survey study of anesthesiologists’ and surgeons’ ordering of unnecessary preoperative laboratory tests. Anesth Analg. 2011;112(1):207–12.

Keay L, Lindsley K, Tielsch J, Katz J, Schein O. Routine preoperative testing for cataract surgery. Cochrane Database Syst Rev. 2012;3:CD007293.