On This Episode:
This week, Lynn and Garry sit down with guest Dru Riddle to tackle one of the most misunderstood and increasingly problematic concepts in perioperative care: the idea that patients can be “cleared” for anesthesia by non-anesthesia providers. While well-intentioned, this language blurs professional boundaries and creates real risks for patients and anesthesia teams alike.
The conversation dives into the critical distinction between preoperative optimization and anesthesia clearance. Cardiologists, pulmonologists, nephrologists, and other specialists play a vital role in optimizing organ systems and managing comorbidities, but optimization is not clearance. These consultants do not bear responsibility for anesthesia delivery, nor do they possess the specialized training in anesthesia physiology, pharmacology, and pathophysiology required to determine anesthesia-specific risk.
By combining clinical judgment with evidence-based assessment tools, nurse anesthetists continue to lead the way in patient safety, outcomes, and perioperative decision-making.
The goals for this show are to help you be able to:
- Differentiate between preoperative medical optimization and anesthesia clearance.
- Explain why anesthesia providers are uniquely qualified to determine anesthesia-related risk.
- Describe the appropriate role of non-anesthesia consultants in the perioperative period.
- Apply modern risk assessment tools, such as the DASI scale, to evaluate perioperative anesthesia risk.
Important Links:
- The 1099 CRNA Institute
- Earn MAC Dev Credit
- Now you can watch the show on YouTube!
"Preoperative assessment is critical; we must evaluate patients thoroughly."
- Lynn & Garry
References
Ahmed, M. J., & Hartley, M. (2024). Principles of preoperative assessment and enhanced recovery optimization for thoracic anaesthesia. Anaesthesia and Intensive Care Medicine, 25(9), 605–609. https://doi.org/10.1016/j.mpaic.2024.06.002
Alonso, J., Permanyer-Miralda, G., Cascant, P., Brotons, C., Prieto, L., & Soler-Soler, J. (1997). Measuring functional status of chronic coronary patients: Reliability, validity and responsiveness to clinical change of the reduced version of the Duke Activity Status Index (DASI). European Heart Journal, 18(3), 414–419. https://doi.org/10.1093/oxfordjournals.eurheartj.a015260
Aronson, S., Martin, G., Gulur, P., Lipkin, M. E., Lagoo-Deenadayalan, S. A., Mantyh, C. R., Attarian, D. E., Mathew, J. P., & Kirk, A. D. (2020). Preoperative Optimization: A Continued Call to Action. Anesthesia and Analgesia, 130(4), 808–810. https://doi.org/10.1213/ANE.0000000000004492
Aronson, S., Murray, S., Martin, G., Blitz, J., Crittenden, T., Lipkin, M. E., Mantyh, C. R., Lagoo-Deenadayalan, S. A., Flanagan, E. M., Attarian, D. E., Mathew, J. P., & Kirk, A. D. (2020). Roadmap for Transforming Preoperative Assessment to Preoperative Optimization. Anesthesia and Analgesia, 130(4), 811–819. https://doi.org/10.1213/ANE.0000000000004571
Augusto, S. N., Wu, Y., Chaikijurajai, T., Hazen, S. L., & Tang, W. H. W. (2025). Abbreviated Duke Activity Status Index for Risk Stratification in Heart Failure. The American Journal of Cardiology, 237, 54–59. https://doi.org/10.1016/j.amjcard.2024.11.029
Augusto, S. N., Wu, Y., Hazen, S. L., & Tang, W. H. (2024). Comparable Prognostic Value Of Original And Abbreviated Duke Activity Status Index (DASI) Score In Patients With Stable Heart Failure. Journal of Cardiac Failure, 30(1), 289–290. https://doi.org/10.1016/j.cardfail.2023.10.410
Bamgbade, O. A., Oluwole, O., Khalaf, W. M., Namata, C., & Metekia, L. M. (2021). Perioperative care of obstructive sleep apnea patients: A survey of European anesthesiologists. Saudi Journal of Anaesthesia, 15(2), 101–108. https://doi.org/10.4103/sja.sja_1010_20
Bettelli, G., & Audisio, R. A. (Eds.). (2025). Geriatric Surgery and Perioperative Care (First edition.). Academic Press.
Chan, S. H., So, V. C., & Irwin, M. G. (2020). Preoperative cardiac optimization. Anaesthesia and Intensive Care Medicine, 21(10), 493–497. https://doi.org/10.1016/j.mpaic.2020.07.008
Dion, J. M. M., Campbell, R. J., Nguyen, P., & Beyea, J. A. (2022). Preoperative anesthesiology consult utilization in Ontario – a population‐based study. Journal of Evaluation in Clinical Practice, 28(1), 151–158. https://doi.org/10.1111/jep.13595
El-Kefraoui, C., Rajabiyazdi, F., Pecorelli, N., Carli, F., Lee, L., Feldman, L. S., & Fiore, J. F. (2021). Prognostic value of the Duke Activity Status Index (DASI) in patients undergoing colorectal surgery. World Journal of Surgery, 45(12), 3677–3685. https://doi.org/10.1007/s00268-021-06256-4
Goodman, B. A., Pichel, A., & Danjoux, G. R. (2022). Risk modification and preoperative optimization of vascular patients. Anaesthesia and Intensive Care Medicine, 23(4), 202–205. https://doi.org/10.1016/j.mpaic.2022.02.003
Greenberg, J. A., Zwiep, T. M., Sadek, J., Musselman, R. P., Moloo, H., Malcolm, J. C., Mullen, K. A., & McIsaac, D. I. (2021). Clinical practice guideline: evidence, recommendations and algorithm for the preoperative optimization of anemia, hyperglycemia and smoking. Canadian Journal of Surgery, 64(5), E491–E509. https://doi.org/10.1503/cjs.011519
Hoballah, J. J., Kaafarani, H. M., & Tsoulfas, G. (Eds.). (2024). Principles of Perioperative Safety and Efficiency (1st ed. 2024.). Springer International Publishing. https://doi.org/10.1007/978-3-031-41089-5
Jindal, P., Patil, V., Pradhan, R., Mahajan, H. C., Rani, A., & Pabba, U. G. (2023). Update on preoperative evaluation and optimisation. Indian Journal of Anaesthesia, 67(1), 39–47. https://doi.org/10.4103/ija.ija_1041_22
Kieninger, M., Eissnert, C., Seitz, M., Judemann, K., Seyfried, T., Graf, B., & Sinner, B. (2018). Analysis and options for optimization of preoperative assessment for anesthesia at a university hospital. Der Anaesthesist, 67(2), 93. https://doi.org/10.1007/s00101-017-0392-3
Leong, D. W., Zarrini, P., Cook-Wiens, G., Elgendy, I., Reis, S. E., Handberg, E. M., Bittner, V., Reichek, N., Sopko, G., Pepine, C. J., Bairey Merz, C. N., & Wei, J. (2018). Abstract 13301: Decreased Functional Capacity Using the Duke Activity Status Index (DASI) Predicts Development of Heart Failure in Women With Ischemia and No Obstructive Coronary Artery Disease (INOCA): Results from the Women’s Ischemia Syndrome Evaluation (WISE) Long-Term Follow-Up. Circulation (New York, N.Y.), 138(Suppl_1 Suppl 1), A13301–A13301.
Ljungqvist, O., Francis, N. K., & Urman, R. D. (Eds.). (2020). Enhanced Recovery After Surgery : A Complete Guide to Optimizing Outcomes (1st ed. 2020.). Springer International Publishing. https://doi.org/10.1007/978-3-030-33443-7
Metzner, M., Mayson, K., Schierbeck, G., & Wallace, T. (2024). The implementation of preoperative optimization in British Columbia: a quality improvement initiative: Preoperative optimization in British Columbia. Canadian Journal of Anesthesia, 71(12), 1672–1684. https://doi.org/10.1007/s12630-024-02870-7
Nathan, N. (2020). The Evolution of Perioperative Medicine: Transforming Preoperative Assessment to Optimization. Anesthesia and Analgesia, 130(4), 803–803.
Pether, J. (2020). What is the Status Concerning Preoperative Anesthesia Risk Assessment, the View from a Swedish Nurse Anesthetist Perspective? -A National Web-Based Survey. Journal of Anesthesia & Intensive Care Medicine, 10(5). https://doi.org/10.19080/JAICM.2020.10.555797
Pook, M., Elhaj, H., El Kefraoui, C., Balvardi, S., Pecorelli, N., Lee, L., Feldman, L. S., & Fiore, J. F. (2022). Construct validity and responsiveness of the Duke Activity Status Index (DASI) as a measure of recovery after colorectal surgery. Surgical Endoscopy, 36(11), 8490–8497. https://doi.org/10.1007/s00464-022-09145-6
Riedel, B., Li, M. H.-G., Lee, C. H. A., Wijeysundera, D. N., Ho, K. M., Wallace, S., Thompson, B., Ellis, M., Kerridge, R. K., Brannan, J., Pretto, J., Beauchamp, N., Allen, S., Melville, A., Murmane, A., Kenchington, K., Stonell, C., Steele, K., Tronstad, O., … Wijeysundera, H. C. (2021). A simplified (modified) Duke Activity Status Index (M-DASI) to characterise functional capacity: a secondary analysis of the Measurement of Exercise Tolerance before Surgery (METS) study. British Journal of Anaesthesia : BJA, 126(1), 181–190. https://doi.org/10.1016/j.bja.2020.06.016
Ron, D., Gunn, C. M., Havidich, J. E., Ballacchino, M. M., Burdick, T. E., & Deiner, S. G. (2024). Preoperative Communication Between Anesthesia, Surgery, and Primary Care Providers for Older Surgical Patients. Joint Commission Journal on Quality and Patient Safety, 50(5), 326–337. https://doi.org/10.1016/j.jcjq.2024.01.006https://doi.org/10.1213/ANE.0000000000004695
Sevinyan, L., Tailor, A., Williams, P., Prabhu, P., & Madhuri, T. K. (2020). 622 Applicability of duke activity scale index (DASI) in perioperative prediction of postoperative complications for gynaeoncology patients. International Journal of Gynecological Cancer, 30(Suppl 4), A134–A135. https://doi.org/10.1136/ijgc-2020-ESGO.233
Sevinyan, L., Tailor, A., Williams, P., Prabhu, P., & Madhuri, K. (2020). 165 Applicability of duke activity scale index (DASI) in perioperative prediction of postoperative complications for gynaeoncology patients. International Journal of Gynecological Cancer, 30(Suppl 3), A72–A72. https://doi.org/10.1136/ijgc-2020-IGCS.143
Silvapulle, E., Darvall, J., & De Silva, A. (2025). Association between the Duke Activity Status Index and complications after noncardiac surgery: A systematic review. Journal of Clinical Anesthesia, 103, Article 111808. https://doi.org/10.1016/j.jclinane.2025.111808
Stone, R., Carey, E., Fader, A. N., Fitzgerald, J., Hammons, L., Nensi, A., Park, A. J., Ricci, S., Rosenfield, R., Scheib, S., & Weston, E. (2021). Enhanced Recovery and Surgical Optimization Protocol for Minimally Invasive Gynecologic Surgery: An AAGL White Paper. Journal of Minimally Invasive Gynecology, 28(2), 179–203. https://doi.org/10.1016/j.jmig.2020.08.006
Williams, F. R., Quinlan, J., Freer, A., Morrison, B., Sitch, A., Hockey, F., Klas, N., Towey, J., Perera, T. P. R., Rajoriya, N., Lord, J. M., & Armstrong, M. J. (2024). Duke Activity Status Index and Liver Frailty Index predict mortality in ambulatory patients with advanced chronic liver disease: A prospective, observational study. Alimentary Pharmacology & Therapeutics, 59(4), 547–557. https://doi.org/10.1111/apt.17834
Wijeysundera, D. N., Shulman, M. A., Croal, B. L., Granton, J. T., Grocott, M. P. W., Farrington, C., Wallace, S., Thompson, B., Ellis, M., Borg, B., Pretto, J., Godsall, G., Beauchamp, N., Allen, S., Wright, E., Malherbe, J., Sivakumar, H., Kenchington, K., Kirabiyik, Y., … Wijeysundera, H. C. (2018). Assessment of functional capacity before major non-cardiac surgery: an international, prospective cohort study. The Lancet (British Edition), 391(10140), 2631–2640. https://doi.org/10.1016/S0140-6736(18)31131-0
Wijeysundera, D. N., Beattie, W. S., Abbott, T. E. F., Ackland, G. L., Mazer, C. D., Pearse, R. M., Cuthbertson, B. H., Wallace, S., Thompson, B., Borg, B., Brannan, J., Beauchamp, N., Allen, S., Ismail, H., Riedel, B., Melville, A., Kenchington, K., Gurunathan, U., Stonell, C., … Oh, P. (2020). Integration of the Duke Activity Status Index into preoperative risk evaluation: a multicentre prospective cohort study. British Journal of Anaesthesia : BJA, 124(3), 261–270. https://doi.org/10.1016/j.bja.2019.11.025
Wong, S. P., Zietlow, K. M., McDonald, S. R., Barbeito, A., Colon-Emeric, C. S., Lagoo-Deenadayalan, S. A., Loyack, N., & Heflin, M. T. (2020). Delaying Elective Surgery in Geriatric Patients: An Opportunity for Preoperative Optimization. Anesthesia and Analgesia, 130(1), e14–e18. https://doi.org/10.1213/ANE.0000000000004335
