Rational preoperative evaluation

Abstract

Summary:Clinical data from two hundred consecutive patients undergoing surgical procedures at the Salt Lake City VA Hospital form the basis of this study. Results of nine commonly ordered preoperative tests (blood count, differential, electrolytes, chemistry panel, urinalysis, prothrombin time, partial thromboplastin time, electrocardiogram, and chest X-ray) were matched with the preoperative history and physical examination and the outcome of surgery in each patient. Each test was examined by (1) the frequency with which it was ordered, (2) the frequency with which it was abnormal, and (3) the frequency with which the abnormal result affected preoperative care. A prevalence ofmedical illness was found in this population, with 47.5% having a major cardiovascular diagnosis, 35.5% a metabolic or endocrine disease, and 28% a major pulmonary diagnosis.A total of 1271 tests were performed, with 477 (35.5%) showing some abnormality. However, only 76 (5.9%) changed the patient's management before surgery. All but five of these abnormalities were predictable from the clinical evaluation and these five were minor. The overall postoperative complication rate was 9%. No complication was attributed to the omission ofa preoperative test. No surgical cases were cancelled during the study period based solely on a preoperative test. We conclude that many preoperative tests can be safely eliminated by ordering only those based on a specific abnormality in the history or physical examination, resulting in more cost-effective surgical care.

Guidelines on the assessment of bleeding risk prior to surgery or invasive procedures

“…Based on the evidence, the practice of indiscriminate coagulation testing is not justifiable, at least for the population of preoperative patients included in this systematic review. Although some defend it as a means of avoiding litigation, it has been demonstrated that 30–95% of unexpected laboratory results from screening tests are either not documented or not pursued further (Muskett & McGreevy, 1986; Johnson & Mortimer, 2002). Therefore, random screening could potentially increase rather than reduce the risk of litigation.…”

Routine preoperative testing: a systematic review of the evidence.

“…Eleven studies were in adults, 18,20,21,23,33,[36][37][38]40,45,46 four of the studies were in children, 28,[30][31][32] four were in both adults and children, 27,41,44,47 and in the remainder of the studies the age of the study population was not specified. 24,26,29,34,35,39,42,43,48 Of the 28 studies, all measured abnormality rates, 18 measured impact on clinical management, 18,20,21,27,28,[30][31][32]34,35,[37][38][39][40]42,45,47,48 and six measured the number of relevant adverse events (for example, respiratory complications) in patients with an abnormal test finding. 20,23,…”

Value of routine preoperative chest x-rays: a meta-analysis

“…Several reports have also considered whether the information obtained from routine preoperative radiographs have had or might have had, any influence on health outcomes. 15,[17][18][19]29 Since this test, when carded out on large numbers of patients, is associated with considerable costs and some health effects, it is important to establish the frequency with which new information of.clinical value is obtained, The present report describes a meta-analysis of published studies and was carried out with the object of estimating this frequency with greater confidence than could be derived from any individual report on its own. Unfortunate.ly, there is insufficient evidence on which to base estimates of how frequently information resulting from routine radiography influences health outcomes.…”