Relevance of Routine Testing in Low-risk Patients Undergoing Minor and Medium Surgical Procedures

Soares, Danielle de Sousa; Brandão, Roberta Ribeiro Marques; Mourão, Mirla Rossana Nogueira; Azevedo, Vera Lucia Fernandes de; Figueiredo, Alexandre Vieira; Trindade, Eliomar Santana

doi:10.1016/s0034-7094(13)70215-0

Cited by 26 publications

(15 citation statements)

References 13 publications

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“…However, several studies including randomized clinical trials continue to show no difference in outcomes when comparing routine to no preoperative testing (Benarroch-Gampel et al 2012 ; Keay et al 2012 ; Schein et al 2000 ; Sheffield et al 2013 ). Finding changes in tests of clinically healthy or stable patients usually does not alter clinical management during the perioperative period (Soares Dde et al 2013 ). Instead, un-indicated investigations detect minor abnormalities of no clinical relevance which may be unsafe for patients causing unnecessary delay, further scrutiny of false positive or inconsequential findings, and cancellation of surgery and medico-legal liability if not addressed (Kumar and Srivastava 2011 ).…”

Section: Discussionmentioning

confidence: 99%

“…Onuoha et al ( 2014b ) in conjunction with the ASA conducted a survey of clinical anesthesiologists and results indicated that the utilization of low-value services are often driven by external factors other than patient safety such as the lack of control by anesthesiologists over preoperative testing, surgeon preference, patient preference or demand, medico-legal concerns, or postoperative needs. Additional predictors include facility preference, practice tradition, concerns about surgical delay or cancellation, institutional policies and procedures, and the lack of both clear guidelines or the awareness of current evidence with respect to preoperative testing (Benarroch-Gampel et al 2012 ; Brown and Brown 2011 ; Soares Dde et al 2013 ). In a survey of anesthesiologists, the most notable but modifiable challenge was the lack of communication and collaboration by all stakeholders involved in the perioperative care of the patient (Onuoha et al 2014b ).…”

Section: Discussionmentioning

confidence: 99%

“…Ambulatory procedures are often performed in low-risk patients—healthy individuals or those with stable chronic medical conditions—and restricted to procedures of short duration with a low risk of intraoperative surgical complications (Benarroch-Gampel et al 2012 ). Despite existing evidence-based guidelines advising the contrary, a battery of preoperative tests continue to be performed in low-risk patients undergoing low-risk ambulatory surgery (Benarroch-Gampel et al 2012 ; Brown and Brown 2011 ; Fleisher LA 2013 ; Richman 2010 ; Schein et al 2000 ; Soares Dde et al 2013 ; Vogt and Henson 1997 ). Routine preoperative tests when performed in low-risk patients rarely change management and as much as 93 % of these tests are not indicated (Brown and Brown 2011 ).…”

Section: Introductionmentioning

confidence: 99%

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The incidence of un-indicated preoperative testing in a tertiary academic ambulatory center: a retrospective cohort study

et al. 2015

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BackgroundDespite existing evidence and guidelines advocating for appropriate risk stratification, ambulatory surgery in low-risk patients continues to be accompanied by a battery of routine tests prior to surgery. Using a single-center retrospective cohort study, we aimed to quantify the incidence of un-indicated preoperative testing in an academic ambulatory center by utilizing recommendations by the recently developed American Society of Anesthesiology (ASA) “Choosing Wisely” Top-5 list.MethodsWe utilized data from the EPIC medical records of 3111 patients who had ambulatory surgery at the Hospital of the University of Pennsylvania during a 6-month period. Data were abstracted from laboratory studies— complete blood count, electrolyte panel, coagulation studies, and cardiac studies—stress test, and echocardiogram obtained within 30 days prior to surgery. Preoperative tests obtained from each patient were categorized into “indicated” (ASA ≥ 3) and “un-indicated” (ASA 1 and 2) tests, and percentages were reported.ResultsDuring the study period, 52.9 % (95 % confidence interval (CI) 37.6–66.4) of all patients had at least one un-indicated laboratory test performed preoperatively. Further analysis revealed variation in the incidence of preoperative ordering between tests; 73 % of all complete blood counts (CBCs), 70 % of all metabolic panels, and 49 % of all coagulation studies were considered un-indicated by “Top-5 List” criteria. Stated differently, of the patients included in the sample, 51 % of patients received an un-indicated CBC, 41 % an un-indicated metabolic panel, and 16 % un-indicated coagulation studies. Twelve percent of “any un-indicated preoperative test” were obtained from ASA 1 healthy patients. Of the 587 patients less than 36 years old, 331 (56 %) had at least one test that was deemed un-indicated. Forty-one patients had either an echocardiogram or stress test ordered and performed within 30 days of surgery. Of these, eight (19.5 %) studies were un-indicated as determined by chart review.ConclusionsThe incidence of ordering “at least one un-indicated preoperative test” in low-risk patients undergoing low-risk surgery remains high even in academic tertiary institutions. In the emerging era of optimizing patient safety and financial accountability, further studies are needed to better understand the problem of overuse while identifying modifiable attitudes and institutional influences on perioperative practices among all stakeholders involved. Such information would drive the development of feasible interventions.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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The incidence of un-indicated preoperative testing in a tertiary academic ambulatory center: a retrospective cohort study

et al. 2015

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“…The incidence of pathological laboratory findings in otherwise healthy children is low. Furthermore, positive findings do not necessarily produce a change in anesthetic practice . Frequently, preoperative routine blood tests appear to be justified by legal, rather than medical, reasons…”

Section: Choosing Wisely In Pediatric Anesthesia: 10 Dos and Don′tsmentioning

confidence: 99%

Choosing Wisely in pediatric anesthesia: An interpretation from the German Scientific Working Group of Paediatric Anaesthesia (WAKKA)

Becke

Eich

Höhne

et al. 2018

Pediatric Anesthesia

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Inspired by the Choosing Wisely initiative, a group of pediatric anesthesiologists representing the German Working Group on Paediatric Anaesthesia (WAKKA) coined and agreed upon 10 concise positive ("dos") or negative ("don'ts") evidence-based recommendations. (i) In infants and children with robust indications for surgical, interventional, or diagnostic procedures, anesthesia or sedation should not be avoided or delayed due to the potential neurotoxicity associated with the exposure to anesthetics. (ii) In children without relevant preexisting illnesses (ie, ASA status I/II) who are scheduled for elective minor or medium-risk surgical procedures, no routine blood tests should be performed. (iii) Parental presence during the induction of anesthesia should be an option for children whenever possible. (iv) Perioperative fasting should be safe and child-friendly with shorter real fasting times and more liberal postoperative drinking and enteral feeding. (v) Perioperative fluid therapy should be safe and effective with physiologically composed balanced electrolyte solutions to maintain a normal extracellular fluid volume; addition of 1%-2.5% glucose to avoid lipolysis, hypoglycemia, and hyperglycemia, and colloids as needed to maintain a normal blood volume. (vi) To achieve safe and successful airway management, the locally accepted airway algorithm and continued teaching and training of basic and alternative techniques of ventilation and endotracheal intubation are required. (vii) Ultrasound and imaging systems (eg, transillumination) should be available for achieving central venous access and challenging peripheral venous and arterial access. (viii) Perioperative disturbances of the patient's homeostasis, such as hypotension, hypocapnia, hypothermia, hypoglycemia, hyponatremia, and severe anemia, should not be ignored and should be prevented or treated immediately. (ix) Pediatric patients with an elevated perioperative risk, eg, preterm and term neonates, infants, and critically ill children, should be treated at institutions where all caregivers have sufficient expertise and continuous clinical exposure to such patients. (x) A strategy for preventing postoperative vomiting, emergence delirium, and acute pain should be a part of every anesthetic procedure.

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“…We assume that a normal test value is set arbitrarily based on 95% confidence interval; therefore up to 5% of normal individuals may have a value outside of the reference interval. Moreover, if we consider that tests are independent of each other, then the greater the number the tests ordered, the greater the chance of obtaining a result outside of the reference interval in a healthy patient ( 4 ). Screening tests in an asymptomatic population should only be done in patients with a significant and prevalent condition.…”

Section: Introductionmentioning

confidence: 99%

Utility of routine laboratory preoperative tests based on previous results: Time to give up

et al. 2017

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IntroductionThe usefulness and cost-effectiveness of routine laboratory preoperative tests (POTs) have been challenged recently. In fact, the American Society of Anesthesiologists (ASA) Task Force has stated that test results obtained from the medical record within 6 months of surgery generally are mostly acceptable. The aim of our study was to evaluate the degree of utility of POTs and their clinical benefit based on this recommendation.Material and methodsWe studied retrospectively every routine POT request from 8 randomly selected weeks in 2016. Every POT contained glucose, creatinine, haemoglobin and coagulation tests (PT-INR). Each pathological result for these tests was registered and classified as “expected” (if previous pathological result within 6 months existed for that test) or “unexpected” (if previous pathological result within 6 months did not exist for that test). Results of ASA physical status classification (a system for assessing the fitness of patients before surgery) and changes in patient management after POTs were retrieved from medical history as well.ResultsA total of 4516 tests (from 1129 patients) were analysed and 498 results were found pathological (11%). Of these, 403 were expected (8.9%) and 95 unexpected (2.1%). There was not any change in anaesthetic management for any patient due to these findings.ConclusionsRoutine POTs are an inefficient and low-value service. POTs have to be always ordered selectively after a previous consideration of specific information obtained from several sources (medical records, interviews, examinations, type of surgery) and only if the information obtained will result in changes in the management of the patient.

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Relevance of Routine Testing in Low-risk Patients Undergoing Minor and Medium Surgical Procedures

Cited by 26 publications

References 13 publications

The incidence of un-indicated preoperative testing in a tertiary academic ambulatory center: a retrospective cohort study

The incidence of un-indicated preoperative testing in a tertiary academic ambulatory center: a retrospective cohort study

Choosing Wisely in pediatric anesthesia: An interpretation from the German Scientific Working Group of Paediatric Anaesthesia (WAKKA)

Utility of routine laboratory preoperative tests based on previous results: Time to give up

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