Utility of preoperative laboratory evaluation in low-risk patients undergoing hysterectomy for benign indications

Progressing Towards Same-Day Discharges After Robotic-Assisted Radical Prostatectomy; Safe and Cost Effective to Discharge Without Routine Blood Tests

Introduction

Changing population demographics and the recent SARS-CoV-2 pandemic have forever changed healthcare, with increasing demands on straining systems. The economic cost is yet to be fully realised, with growing concerns around the current system's ability to accommodate the ageing comorbid population. Consequently, a paradigm shift has taken place in healthcare systems, prioritizing cost accountability. In the absence of established guidelines or robust literature, the use of laboratory tests postoperatively is often guided solely by clinician preference. This study presents a retrospective analysis that investigates the utility and cost implications of routine postoperative investigation following robotic-assisted radical prostatectomies. The findings aim to emphasise the importance of evidence-based practices and cost-effective approaches in postoperative care.

Materials/Methods

A retrospective analysis was performed on all robotic-assisted radical prostatectomies (RARP) identified from a single institution between 29th June 2017 to 28th June 2019. This interval was chosen in an attempt to avoid bias or confounding variables associated with the SRS-CoV-2 pandemic. A single clinician conducted a comprehensive medical record review using unit record numbers corresponding to identified procedural codes. Demographics and variables were recorded, including postoperative test results, hospital length of stay and 30-day readmission rates. Patients were assigned to either 'Routine Postoperative tests' (RPOT) or 'No Routine Postoperative tests' (No RPOT) and a comparative analysis was performed. Using the Australian National Pharmaceutical Benefits Scheme (PBS) pricing guide, total expenditure was calculated.

Results

A total of 319 patients were included in the study with an average of 2.5 tests per patient within the first 24 hours. Routine postoperative tests had no bearing on outcomes, with comparable readmission rates between cohorts, and a significantly shorter length of stay in the "No routine postoperative tests" group when compared to the "Routine Postoperative Tests". A total of 1028 tests were performed within the first 48 hours following surgery with expenditure on routine testing totalling $20,516 based on the Australian PBS pricing schedule. Abnormal results were returned on 96% of patients. In the RPOT group, 18 out of the 20 common interventions occurred from 302 RARP. Among the patients in the RPOT group, eight individuals underwent blood transfusions. However, none of these patients met the hospital-specific criteria for transfusion, which require a hemoglobin level below 70 or symptomatic presentation with a hemoglobin level below 80.

Conclusion

The data suggests routine postoperative laboratory has no bearing on re-admission rates, with patients experiencing significantly shorter hospital stays. Furthermore, our results indicate inefficient use of routine postoperative laboratory, with few clinical interventions, frequent abnormal results, and significant accumulative expenses.

Risk of Reintervention or Postoperative Bleeding after Laparoscopy for Benign Gynecological Disease: A Clinical Prediction Model

OBJECTIVE

The objective of the study was to develop a clinically applicable prediction tool to early seek for postoperative major complications after laparoscopic surgery for benign pathologies.

DESIGN

Retrospective analysis of prospectively collected data was performed.

SETTING

The study was conducted at Tertiary Care University Hospital.

PARTICIPANTS

The participants of this study were reproductive-aged women undergoing laparoscopy for benign conditions.

METHODS

Anamnestic, intraoperative, and postoperative characteristics from January 2019 to December 2021 were retrospectively reviewed. Patients with postoperative complications (reintervention or postoperative bleeding) were matched in a 1:2 ratio with women with same surgical indications without complications. Cases and controls were matched for preoperative hemoglobin, hematocrit, weight, height, body mass index, age, and blood volume. A prediction model was created by inserting multiple independent modifying factors through logistic regression. The receiver operating characteristic (ROC) curve was used to evaluate the predictive accuracy of the model, and the Hosmer-Lemeshow (H-L) test was carried out to evaluate the goodness-of-fit, and a calibration curve was drawn to confirm the predictive performance. A nomogram was depicted to visualize the prediction model.

RESULTS

Thirty-nine complicated procedures were matched with 78 uncomplicated controls. According to the multivariate logistic regression analysis findings, the prediction model was developed using C-reactive protein (CRP), intraoperative blood loss, and 24 h postoperative urinary volume, therefore a nomogram was generated. The area under the ROC curve of the prediction model was 0.879, depicting good accuracy, the sensitivity was 60.00%, while specificity reached 93.59%. The H-L test (χ2 = 4.45, p = 0.931) and the calibration curve indicated a good goodness-of-fit and prediction stability.

LIMITATIONS

The retrospective design, moderate sensitivity, and study population limit the generalization of the findings, requiring additional research.

CONCLUSIONS

This prediction model based on CRP, intraoperative blood loss, and 24 h postoperative urinary volume might be a potentially useful tool for predicting reintervention and postoperative bleeding in patients undergoing planned gynecological laparoscopy.

Preoperative investigations for elective surgical patients in a resource limited setting: Systematic review

Background

Preoperative investigation for surgical patients is important to check for conditions that may affect surgical outcome. It helps the anesthetist and surgeon to plan perioperative anesthesia and surgical management appropriately. However, 60-70% of laboratory tests before surgery are not really required. This review was conducted to develop evidence-based recommendations on preoperative investigations for patients waiting for surgery in a resource limited setting.

Methods

After formulating the key questions, scope, and eligibility criteria for the articles to be included, advanced search strategy of electronic sources from data bases and websites was conducted. Duplication of literatures was avoided by endnote. Screening of literatures was conducted with proper appraisal. This review was reported in accordance with the preferred reporting items for systematic reviews and meta-analysis (PRISMA) 2020 statement.

Results

A total of 553 articles were identified from data bases and websites using an electronic search. 75 articles were removed for duplication and 223 studies were excluded after reviewing titles and abstracts. At the screening stage, 82 articles were retrieved and evaluated for eligibility. Finally, 46 studies met the eligibility criteria and were included in this systematic review.

Conclusion

and recommendation: Selective laboratory ordering reduces the number and cost of investigations. Preoperative tests should be guided by the patient's clinical history, co-morbidities, and physical examination. Patients with signs or symptoms of certain types of disease should be evaluated with appropriate testing. Therefore, adherence to recommendations of guidelines on preoperative investigation is important for good surgical outcome and patient satisfaction.

Utility of preoperative laboratory testing in ASA 1 & ASA 2 patients undergoing outpatient surgery in the United States

STUDY OBJECTIVE

To assess the utility of preoperative testing in ASA physical status 1 and 2 patients undergoing outpatient surgery across several surgical specialties.

DESIGN

Retrospective cohort study.

PATIENTS

The American College of Surgeons National Surgical Quality Improvement Program database from 2017 to 2018 was queried to extract patients defined as ASA 1 and 2 who underwent outpatient surgeries. A total of 352,775 adult patients underwent outpatient surgery with 186,954 patients had at least one lab drawn within 30 days prior to the surgery.

INTERVENTIONS

ASA physical status 1 and 2 patients who underwent outpatient surgeries.

MEASUREMENTS

The primary independent variable was the utilization of preoperative laboratory testing. The primary outcomes were the occurrence of any medical or surgical complication adverse events within 30 days of discharge. In addition, we also examined hospital readmissions. A P value of 0.025 was used to avoid type I error for each primary outcome.

MAIN RESULTS

In the overall cohort, 186,954 out of 352,775 (53%) of patients had at least one lab test. Hematology was the most common lab test ordered, 172,903 out of 352,755 patients (49%), followed by chemistry (43%), liver function (23%), and coagulation tests (11%). After adjusting for confounding factors, the use preoperative testing was not associated with overall medical complications, OR (95%CI) of 1.09 (1.00 to 1.18), P = 0.05 and overall surgical complications, 1.00 (0.92 to 1.08), P = 0.96 [Bonferroni corrected: medical complications OR (97.5% CI) of 1.09 (0.989 to 1.202), P = 0.0950 and overall surgical complications, 1.00 (0.918 to 1.093), P = 1.00.

CONCLUSION

We detected a low utility of preoperative tests for ASA 1 and 2 patients undergoing a large variety of outpatient procedures. Our results support the elimination of preoperative laboratory test for ASA 1 and 2 undergoing ambulatory surgery.