The case against routine preoperative laboratory testing

Excessive Preoperative Testing in Otolaryngology: A Retrospective Comparison of Primary Care and Perioperative Providers

OBJECTIVE

To assess the association between provider type (primary care provider [PCP] or perioperative provider) and excessive preoperative testing.

STUDY DESIGN

Cross-sectional study.

SETTING

Academic medical center.

METHODS

Electronic medical records of adult patients who obtained an outpatient preoperative assessment and underwent surgery in the Department of Otolaryngology-Head and Neck Surgery during the first 2 weeks of January 2019 (n = 94) were reviewed. Patients receiving preoperative tests beyond those recommended by the guidelines were deemed to have had excessive testing. Descriptive statistics were used to characterize the study population. Simple and multivariate logistic regression were used to analyze the association between the outcome and the predictor variables.

RESULTS

Overall, 44.7% of preoperative evaluations had excessive testing. Patients who had their preoperative evaluation performed by a perioperative provider had 89% lower odds of having excessive preoperative testing compared to those evaluated by a PCP (odds ratio = 0.11, 95% confidence interval: [0.03, 0.37], P < .001). Female sex, younger age, and higher risk of major adverse cardiac events were associated with greater odds of excessive testing.

CONCLUSION

Excessive preoperative testing is more commonly performed by PCPs compared to perioperative providers. These results give preliminary evidence in support of a potential shift in the clinical responsibility of preoperative evaluation from PCPs to perioperative providers in order to reduce excessive testing and promote high-value health care. The next steps include validating these findings, identifying reasons for differential guideline concordance, and intervening accordingly.

[Preoperative evaluation of adult patients before elective, non-cardiothoracic surgery : A joint recommendation of the German Society for Anesthesiology and Intensive Care Medicine, the German Society for Surgery and the German Society for Internal Medicine]

The 70 recommendations summarize the current status of preoperative risk evaluation of adult patients prior to elective non-cardiothoracic surgery. Based on the joint publications of the German scientific societies for anesthesiology and intensive care medicine (DGAI), surgery (DGCH), and internal medicine (DGIM), which were first published in 2010 and updated in 2017, as well as the European guideline on preoperative cardiac risk evaluation published in 2022, a comprehensive re-evaluation of the recommendation takes place, taking into account new findings, the current literature, and current guidelines of international professional societies. The revised multidisciplinary recommendation is intended to facilitate a structured and common approach to the preoperative evaluation of patients. The aim is to ensure individualized preparation for the patient prior to surgery and thus to increase patient safety. Taking into account intervention- and patient-specific factors, which are indispensable in the preoperative risk evaluation, the perioperative risk for the patient should be minimized and safety increased. The recommendations for action are summarized under "General Principles (A)," "Advanced Diagnostics (B)," and the "Preoperative Management of Continuous Medication (C)." For the first time, a rating of the individual measures with regard to their clinical relevance has been given in the present recommendation. A joint and transparent agreement is intended to ensure a high level of patient orientation while avoiding unnecessary preliminary examinations, to shorten preoperative examination procedures, and ultimately to save costs. The joint recommendation of DGAI, DGCH and DGIM reflects the current state of knowledge as well as the opinion of experts. The recommendation does not replace the individualized decision between patient and physician about the best preoperative strategy and treatment.

Preoperative ECG Abnormalities Among Patients Who Underwent Elective Surgical Operations at the Kuwaiti Specialised Hospital, Khartoum, Sudan: A Cross-Sectional Study

BACKGROUND

The presence of preoperative ECG abnormalities has shown wide variation, and its value has been argued; thus, this study aimed to determine preoperative ECG abnormalities among Sudanese patients and their correlates.

MATERIALS AND METHODS

An observational descriptive cross-sectional study was conducted at the Kuwaiti Specialised Hospital, Khartoum, Sudan, from October 2020 to March 2021, including all patients over 40 years of age who planned to undergo elective surgery. Demographic, clinical, and ECG findings were obtained during the pre-anaesthesia check-up. The data were analysed using IBM SPSS software version 28 (IBM Corp., Armonk, NY).

RESULTS

The study included a total of 304 patients with a mean age of 60±14 years, a male predominance of 210 (69.1%) patients, the presence of hypertension (HTN) in 65 (21.4%), and diabetes mellitus (DM) in 58 (19.1%) patients. The study showed that 235 (77%) patients had at least one ECG abnormality. However, 62 (20.4%) were diagnosed as having normal ECG variations; the most commonly diagnosed abnormality was ischemic heart disease (IHD) (32.5%), followed by sinus tachycardia (39, 12.8%). The QRS complex abnormalities were the most common (100, 32.9%), with M-shaped QRS (RSR pattern) being the most common single ECG abnormal sign (65, 21.4%). The ECG abnormalities showed no significant association with age (p-value = 0.24), gender (p-value = 0.16), DM (p-value = 0.77), HTN (p-value = 0.35), asthma (p-value = 0.35), or the grade of surgery (p-value = 0.52). However, the diagnosis of IHD was associated with the presence of HTN (p-value = 0.001).

CONCLUSION

Incidental preoperative ECG abnormalities are common among Sudanese patients undergoing elective surgery, affecting more than three-quarters of them and being of diagnostic value as they led to the diagnosis of ischemic heart disease in nearly one-third of patients. Hypertensive patients may benefit from routine preoperative ECG testing, as ECG signs of ischemic heart disease are more common among hypertensive patients.

Beyond guideline knowledge: a theory-based qualitative study of low-value preoperative testing

BACKGROUND

Choosing Wisely Canada and most major anesthesia and preoperative guidelines recommend against obtaining preoperative tests before low-risk procedures. However, these recommendations alone have not reduced low-value test ordering. In this study, the theoretical domains framework (TDF) was used to understand the drivers of preoperative electrocardiogram (ECG) and chest X-ray (CXR) ordering for patients undergoing low-risk surgery ('low-value preoperative testing') among anesthesiologists, internal medicine specialists, nurses, and surgeons.

METHODS

Using snowball sampling, preoperative clinicians working in a single health system in Canada were recruited for semi-structured interviews about low-value preoperative testing. The interview guide was developed using the TDF to identify the factors that influence preoperative ECG and CXR ordering. Interview content was deductively coded using TDF domains and specific beliefs were identified by grouping similar utterances. Domain relevance was established based on belief statement frequency, presence of conflicting beliefs, and perceived influence over preoperative test ordering practices.

RESULTS

Sixteen clinicians (7 anesthesiologists, 4 internists, 1 nurse, and 4 surgeons) participated. Eight of the 12 TDF domains were identified as the drivers of preoperative test ordering. While most participants agreed that the guidelines were helpful, they also expressed distrust in the evidence behind them (knowledge). Both a lack of clarity about the responsibilities of the specialties involved in the preoperative process and the ease by which any clinician could order, but not cancel tests, were drivers of low-value preoperative test ordering (social/professional role and identity, social influences, belief about capabilities). Additionally, low-value tests could also be ordered by nurses or the surgeon and may be completed before the anesthesia or internal medicine preoperative assessment appointment (environmental context and resources, beliefs about capabilities). Finally, while participants agreed that they did not intend to routinely order low-value tests and understood that these would not benefit patient outcomes, they also reported ordering tests to prevent surgery cancellations and problems during surgery (motivation and goals, beliefs about consequences, social influences).

CONCLUSIONS

We identified key factors that anesthesiologists, internists, nurses, and surgeons believe influence preoperative test ordering for patients undergoing low-risk surgeries. These beliefs highlight the need to shift away from knowledge-based interventions and focus instead on understanding local drivers of behaviour and target change at the individual, team, and institutional levels.

Rationalising pre-operative trauma bloods can lead to significant cost savings

BACKGROUND

A full set of pre-operative bloods is being done on nearly all trauma patients who are admitted to our institute for surgery-regardless of variables such as patient age, injury sustained, or co-morbidities. This leads to unnecessary bloods being taken.

AIMS

The primary aims are (1) to calculate the costs associated with routine pre-operative bloods and (2) to examine how much money could be saved by retrospectively applying a more pragmatic pre-operative bloods policy.

METHODS

Trauma theatre cases over a 5-week period were identified with their pre-operative bloods and post-operative transfusions. Labour, material, and processing costs were estimated for each test. An updated pre-operative blood schedule was proposed and applied retrospectively to see if cost savings could be found.

RESULTS

Of the 173 orthopaedic procedures performed, 109 (63%) had a group and screen or crossmatch pre-operatively. Fifteen (8.6%) required a post-operative blood transfusion. One hundred and twenty-eight (74%) patients had a full blood count, and renal profile taken pre-operatively. A full set of bloods costs approximately €51.23 to take and process. When the updated pre-operative blood guidelines were retrospectively applied, it would have led to cost savings of €2496 over the 5-week period of this audit, and if extrapolated up to 1 year, could lead to potential annual savings of €25,960.

CONCLUSIONS

We have demonstrated that an excessive amount of unnecessary pre-operative bloods have been taken using the current blood schedule. A pragmatic pre-operative blood schedule can lead to significant actual cost savings.

The role of routine laboratory tests after unilateral total knee arthroplasty

Background

Recent studies suggest that routine laboratory tests are not required within 1 day after partial knee arthroplasty. In this study, we evaluated the utility of routine postoperative laboratory tests after initial unilateral total knee arthroplasty (TKA) in an Asian population. In addition, we explored risk factors associated with abnormal test results.

Methods

Clinical data of patients who underwent original unilateral TKA between 2015 and 2020 were retrospectively analyzed. Patient characteristics and laboratory test results were recorded. Multivariate binary logistic regression analysis was performed to identify risk factors associated with 3 abnormal laboratory results.

Results

A total of 713 patients, who underwent relevant laboratory tests within 3 days of TKA surgery, were enrolled. Among them, 8.1%, 9.9%, and 3.4% patients with anemia, hypoalbuminemia, and abnormal serum potassium levels required clinical intervention after surgery. Binary logistic regression analysis revealed that preoperative hemoglobin levels, estimated blood loss, and age were independent risk factors of postoperative blood transfusion in TKA patients. On the other hand, preoperative albumin levels, intraoperative blood loss, and operation time were risk factors associated with postoperative albumin supplementation. In addition, lower body mass index (BMI) and preoperative hypokalemia were potential risk factors of postoperative potassium supplementation.

Conclusion

Considering that more than 90% of abnormal postoperative laboratory tests do not require clinical intervention, we believe that routine laboratory tests after surgery have little significance in patients with primary unilateral TKA. However, postoperative laboratory testing is necessary for patients with established risk factors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05509-0.

Challenges in the Diagnosis and Management of Non-Severe Hemophilia

(1) Background: Mild and moderate hemophilia, synonymous with non-severe hemophilia (NSH), are of constant interest for the clinicians. Bleeding occurs usually after trauma, injury, surgery, or inhibitor development, sometimes leading to a shift of the clinical phenotype from mild to severe, even with life-threatening and unexpected outcomes. (2) Methods: We performed a retrospective observational study conducted on 112 persons with congenital coagulopathies, 26 of them with NSH, admitted to our clinic in the period 2000 to 2022. For the diagnosis, we used laboratory studies (complete blood cell count, coagulation assays, biochemistry, thromboelastography, genetic tests) and imaging investigations (X-ray, ultrasound, CT, MRI). We selected four cases confronted with pitfalls of diagnosis and evolution in order to illustrate the sometimes provocative field of NSH. (3) Results: Confronted with challenging cases with under-, missed or delayed diagnosis and severe consequences, we aimed at presenting four such selected cases with mild or moderate hemophilia, real pitfalls in our clinical activity. (4) Conclusions: In the field of NSH, if not timely recognized, tending sometimes to remain ignored by caregivers and patients themselves, we can be confronted with challenging diagnostic situations and life-threatening bleeds.

Pre-Anesthetic Medical Evaluations: Criteria Considerations for Telemedicine Alternatives to Face to Face Visits

Background

The number of pre-anesthetic medical evaluations (PAMEs) being conducted in primary care is increasing. Due to the COVID-19 pandemic, the use of telemedicine has surged, providing a feasible way to conduct some of these visits. This study aimed to identify patient-related factors where a face to face (FTF) evaluation is indicated, measured by the need for pre-operative testing.

Methods

A retrospective chart review was conducted on patients age ≥ 18 years who had a PAME between January 2019–June 2020 at a rural primary care clinic in Southeast Minnesota. Data collected included age, gender, Charlson Comorbidity Index Score, medications, revised cardiac risk index (RCRI), smoking status, exercise capacity, body mass index, and pre-operative testing. Logistical regression modeling for odds ratios of outcomes was performed.

Results

254 patients were included, with an average age of 64.1 years; 43.7% were female. Most were obese (mean BMI 31.6), non-smoking (93.7%) with excellent functional capacity (87.8% ≥ 5 METs). 76.8% of the planned surgeries were intermediate or high risk. 35.0% (n = 89) of visits resulted in medication adjustments and 76.7% (n = 195) in pre-operative testing. Age ≥ 65 years, ≥7 current medications, and diabetes all significantly increased the odds of requiring pre-operative testing (P < .05).

Conclusions

This study was able to identify patient-related factors that increased the likelihood of requiring pre-operative testing. Patients who are age ≥ 65 years, ≥7 current medications, and those with diabetes could be scheduled for a FTF evaluation. Others could be scheduled for a telemedicine visit to minimize health-care exposures.

Increased Testing and Health Care Costs for Pediatric Cannabis Exposures

OBJECTIVES

This study aimed to evaluate the process of identifying marijuana exposure in a children's hospital emergency department and compare the cost of diagnostic testing and procedures.

METHODS

A retrospective chart review was performed on patients 31 days to 20 years old with a positive marijuana toxicology screen result between November 2009 and December 2014. Primary outcomes included time to provider recognition of marijuana exposure, number of diagnostic tests and procedures performed, and length of hospital stay. Patients were analyzed based on time of exposure recognition (forthcoming compared with not forthcoming of marijuana exposure) and age (children <12 years compared with adolescents >12 years).

RESULTS

There were 37 children and 38 adolescents included. Mean time to exposure recognition was 2.3 ± 4.3 hours in children compared with 0.4 ± 0.9 hours in adolescents (P = 0.02). Patients who were not forthcoming of marijuana exposure experienced more than twice as many diagnostic tests or procedures compared with children who were forthcoming of marijuana exposure (mean, 8.91 vs 4 tests, P < 0.0001) and more than a 4-fold higher cost of potentially avoidable diagnostic tests/procedures. Length of hospital stay was significantly longer in children (18.34 ± 2.39 hours) compared with adolescents (4.22 ± 0.52 hours; P ≤ 0.0001). Few parents or guardians were able to disclose characteristics of the marijuana product.

CONCLUSION

Delay in recognition of marijuana exposure is associated with high resource utilization, unnecessary medical costs, and prolonged length of stay.

[Operation preparation in trauma surgery]

The success of a surgical procedure is significantly influenced by several critical factors. The safety of the patient is the primary goal. To this end, the term surgical preparation covers a number of procedures aiming to ensure the safety for the patient and a successful surgical intervention: verifying the indications, planning the intervention, identification of potential harmful factors, risks and countermeasures, patient education and documentation. Trauma surgery poses a particular challenge to preoperative preparation, especially due to urgent surgical interventions. Here, a standardized and evidence-based preoperative evaluation ensures a successful treatment of the patient.

Rethinking the routine: Preoperative laboratory testing among American Society of Anesthesiologists class 1 and 2 patients before low-risk ambulatory surgery in the 2017 National Surgical Quality Improvement Program cohort

BACKGROUND

Routine preoperative laboratory testing is not recommended for American Society of Anesthesiologists classification 1 or 2 patients before low-risk ambulatory surgery.

METHODS

The 2017 National Surgical Quality Improvement Program data set was retrospectively queried for American Society of Anesthesiologists class 1 and 2 patients who underwent low-risk, elective outpatient anorectal, breast, endocrine, gynecologic, hernia, otolaryngology, oral-maxillofacial, orthopedic, plastic/reconstructive, urologic, and vascular operations. Preoperative laboratory testing was defined as any chemistry, hematology, coagulation, or liver function studies obtained ≤30 days preoperatively. Demographics, comorbidities, and outcomes were compared between those with and without testing. The numbers needed to test to prevent serious morbidity or any complication were calculated. Laboratory testing costs were estimated using Centers for Medicare and Medicaid Services data.

RESULTS

Of 111,589 patients studied, 57,590 (51.6%) received preoperative laboratory testing; 26,709 (46.4%) had at least 1 abnormal result. Factors associated with receiving preoperative laboratory testing included increasing age, female sex, non-White race/ethnicity, American Society of Anesthesiologists class 2, diabetes, dyspnea, hypertension, obesity, and steroid use. Mortality did not differ between patients with and without testing. The complication rate was 2.5% among tested patients and 1.7% among patients without tests (P < .01). The numbers needed to test was 599 for serious morbidity and 133 for any complication. An estimated $373 million annually is spent on preoperative laboratory testing in this population.

CONCLUSION

Despite American Society of Anesthesiologists guidelines, a majority of American Society of Anesthesiologists class 1 and 2 patients undergo preoperative laboratory testing before elective low-risk outpatient surgery. The differences in the rates of complications between patients with and without testing is low. Preoperative testing should be used more judiciously in this population, which may lead to cost savings.

Re-evaluating the necessity of routine laboratory tests after high tibial osteotomy surgery

BACKGROUND

To assess the utility of routine postoperative laboratory tests for patients undergoing high tibial osteotomy (HTO) surgery.

METHODS

The associations between clinical risk factors and postoperative clinical treatment were analyzed. Additionally, a logistic regression analysis was performed to detect independent risk factors for patients requiring postoperative clinical treatment.

RESULTS

A total of 482 patients with symptomatic isolated medial compartment osteoarthritis from January 2015 to May 2020 were included in the present study and underwent examination by the full set of postoperative laboratory tests within 3 days after HTO surgery. However, only a small proportion of the patients with anemia (3.9 %), hypoalbuminemia (4.1 %), and abnormal serum potassium levels (3.5 %) required clinical intervention after surgery. Binary logistic regression analysis showed that the body mass index (BMI), preoperative hemoglobin level, estimated blood loss and operative duration were independent risk factors for postoperative blood transfusion in patients who underwent HTO surgery, and factors associated with albumin supplementation were female sex and preoperative albumin level. In addition, these results indicated that preoperative potassium was potential risk factor for patients who required potassium supplementation postoperatively.

CONCLUSIONS

Based on the analysis, we conclude that routinely ordering postoperative laboratory tests after HTO surgery is unnecessary. However, for patients with identified risk factors, routine postoperative laboratory tests are still needed.

Targeted ordering of investigations reduces costs of treatment for surgical inpatients

BACKGROUND

Laboratory testing forms an important part of diagnostic investigation in modern medicine; however, the overuse of 'routine blood tests' can result in significant potential harm and financial cost to the patient and the healthcare system. In 2018, a new protocol targeting the ordering of investigations was implemented within the General Surgical Teams of Wollongong Hospital in New South Wales, an Australian tertiary referral hospital, to reduce the number of 'routine blood tests' as a quality improvement initiative.

OBJECTIVE

To identify whether there was a reduction in the number of 'routine blood tests' and associated costs following implementation of the new protocol.

METHODS

The protocol involved regular review of the laboratory investigations being ordered for the following day with a senior team member. The medical records of all patients admitted under the general surgery service at Wollongong Hospital were retrospectively reviewed over two 10-week periods in 2017 and 2018 (control and study, respectively). The casemix was categorized into Minor, Intermediate, Major or Unscored, depending on case complexity coding.

RESULTS

A total of 838 patients were identified during the control period (2017) and 805 patients were identified during the study period (2018). Ten thousand and thirty tests were included in the control period, compared to 8610 over the study period, resulting in a 16% (or greater) reduction in 'routine blood tests' per patient, per day of admission and a 6% reduction in costs in the study group (P < 0.001).

CONCLUSION

Targeted ordering of investigations with personalized education and feedback to junior staff during review of clinical status of each patient as a part of normal workflow can reduce inappropriate ordering of 'routine blood tests' and associated costs to the patient and the healthcare system.

Factors influencing preoperative chest radiography request for elective endoscopic procedures among medical personnel

Background

Chest radiography is not routinely recommended before elective endoscopies. A high incidence of perioperative chest radiography requests was observed at our institution. This study aims to investigate factors influencing preoperative chest radiography request for patients undergoing elective gastrointestinal (GI) endoscopies.

Methods

This cross-sectional clinical study recruited 264 participants from different medical specialties who were responsible for preoperative endoscopic chest x-ray (CXR) ordering including anesthesiologists, surgeons and gastroenterologists. They completed questionnaires exploring their general knowledge and attitudes about preoperative chest radiography. Demographic characteristic of the participants affecting the knowledge on preoperative chest radiography was determined. A Structural Equation Model (SEM) was constructed from validated conceptual framework to find causal relationships between hypothesized factors and intention for preoperative endoscopic chest radiography request. Statistical analyses were performed using the SPSS software version 18.0 and Analysis of Moment Structures (AMOS) version 18.0.

Results

The questionnaire response rate was 53.79%. Baseline general knowledge on preoperative chest radiography of the participants was comparable. The SEM results showed unsupported relationship between hypothesized factors and the intention for preprocedural GI endoscopic CXR request (p < 0.1).

Conclusions

General knowledge of medical personnel on tuberculosis needs improvement. To rectify the unnecessary chest radiography request before elective GI endoscopic procedures, awareness of the patients’ health conditions, adherence to the hospital’s policy and realizing of possible patient-related mishaps are not the determinants for preprocedural endoscopic chest radiography request. Future works are required to explore other alternative factors involved for reducing chest radiography requests which are not indicated.

Management of Ambulatory Anesthesia in Older Adults

The number of older patients is increasing globally. Combined with the growing number of ambulatory surgeries, many older patients will undergo ambulatory surgery in the future. The ambulatory setting offers many advantages: early mobilization, higher patient satisfaction, lower costs, and a low incidence of several complications such as infections and thromboembolic events. Moreover, cognitive recovery seems to be enhanced compared with in-hospital surgery, and both frail patients and patients with dementia can benefit from ambulatory surgery. This review provides suggestions for managing perioperative anesthesia for older patients in the ambulatory setting. Not all older patients are eligible for ambulatory surgery, and clinicians must be aware of risk factors for complications, especially frailty. Most anesthesia techniques and agents can be used in the ambulatory setting, but short-acting agents are preferred to ensure fast recovery. Both regional and general anesthesia are useful, but clinicians must be familiar with the physiological changes and specific implications in the older population. The older patients are more sensitive to anesthetic agents, meaning that a lower dose is needed to obtain the desired effect. However, they exhibit huge variation in pharmacodynamics and pharmacokinetics. Prolonged onset time may lead to overdosing and extended recovery. After surgery, effective pain management with opioid minimization is essential to ensure rapid recovery.

Importance of Routine Laboratory Investigations Before Elective Surgery

BACKGROUND AND AIMS

 Certain routine pre-operative laboratory investigations are performed in all patients before elective surgeries. We conducted this study to assess the value of routine pre-operative tests in the ASA (American Society of Anesthesiologists) Grade I and II adults undergoing elective surgery and their influence in the conduct of anaesthesia together with the costs incurred on unwarranted tests.

METHODS

A total of 1271 patients posted for elective surgery under anaesthesia were recruited. Each patient attended the Pre-Anaesthetic Checkup Clinic and underwent clinical evaluation and investigations according to institutional policy. Demographic data and other characteristics were recorded, along with the results of laboratory test, any peri-operative intervention done as a result of abnormality and the cost incurred on tests.

RESULTS

Majority of the patients belonged to ASA status I (74%) and underwent moderately invasive surgery (78%). The total number of routine investigations performed was 8015. Of these, 351 (4.37%) tests had abnormal results. Amongst these 333 (4.15%) abnormalities were suspected clinically and peri-operative intervention was only performed in 0.43% of patients. Anemia was the most common abnormal finding. Abnormal blood glucose was detected in 6 patients who were not clinically suspected. Abnormal electrocardiograph (ECG) was found in 54 patients. However, the intervention was required only in 13 patients. No intervention was required because of abnormal findings of the chest X-Ray. In total cost of investigations, only 6.9% was contributed by abnormal investigations and the rest was spent on the normal tests.

CONCLUSION

The incidence of tests with abnormal results was very low in our study, and less than 1% of the patients with abnormal tests required changes in their peri-anaesthetic management. No major complications were seen in any patient with normal or abnormal test results. Most of the expenses (93%) were related to the normal test, which did not contribute to the perioperative management, safety and outcome of the patient. Thus, pre-operative investigations should be judiciously advised to avoid inconvenience, surgical delays and escalation of the costs of surgical care.

Low Utility of Screening Hematologic Testing for Image-Guided Biopsies in Patients Without Bleeding Risks

OBJECTIVE. This study evaluates the prevalence of an abnormal international normalized ratio (INR) and platelet count before image-guided percutaneous needle biopsies over a 10-year period, comparing data from patients with and those without known conditions predisposing to coagulopathy. MATERIALS AND METHODS. A review of electronic medical records identified patients who were scheduled for a biopsy in a single institution's radiology department for the period of 2007-2016. The following information was recorded: demographic data, patient history of conditions that predispose to bleeding (e.g., liver disease, anticoagulant therapy, history of coagulopathy), and INR and platelet values within 30 days before biopsy. Data were stratified by biopsies that were performed versus those that were cancelled. RESULTS. Over 10 years, 3864 percutaneous biopsies were performed, and 6371 were cancelled. Approximately half of the biopsies (48.2%) were performed in patients without a predisposing condition; of those patients, 0.8% and 0.1% had an INR greater than 1.5 and greater than 1.8, respectively, and 0.4% had a platelet count of 50,000/μL or less (≤ 50 × 10⁹/L). In patients with no known predisposing condition, 0.6% and 0.0% of biopsies cancelled were in patients who had an INR greater than 1.5 and greater than 1.8, respectively, and 0.1% of biopsies cancelled were in patients who had a platelet count of 50,000/μL or less. Ordering prebiopsy testing of patients with no predisposing conditions for the 1864 percutaneous biopsies performed over the 10-year study period resulted in more than $850,000 in laboratory-related health care costs. Our results suggest that the cost of identifying one abnormal INR is nearly $700,000. CONCLUSION. For patients without any known bleeding risks who are scheduled to undergo image-guided percutaneous biopsies, identifying an abnormal INR or abnormal platelet count is rare. Eliminating this testing in patients without predisposing conditions has the potential to create savings in costs and time for both physicians and patients.

High, As Well As Low, Preoperative Platelet Counts Correlate With Adverse Outcomes After Elective Posterior Lumbar Surgery

STUDY DESIGN

Retrospective cohort study of prospectively collected data.

OBJECTIVE

Assess correlation between preoperative platelet counts and postoperative adverse events after elective posterior lumbar surgery procedures.

SUMMARY OF BACKGROUND DATA

Preoperative low platelet counts have been correlated with adverse outcomes after posterior lumbar surgery. Nonetheless, the effect of varying platelet counts has not been studied in detail for a large patient population, especially on the high end of the platelet spectrum.

METHODS

Patients who underwent elective posterior lumbar surgery were identified in the 2011 to 2016 National Surgical Quality Improvement Program database. Preoperative platelet counts were considered relative to 30-day perioperative adverse outcomes. Patients were classified into platelet categories based on determining upper and lower bounds on when the adverse outcomes crossed a relative risk of 1.5. Univariate and multivariate analyses compared 30-day postoperative complications, readmissions, operative time, and hospital length of stay between those with low, normal, and high platelet counts.

RESULTS

In total, 137,709 posterior lumbar surgery patients were identified. Using the relative risk threshold of 1.5 for the occurrence of any adverse event, patients were divided into abnormally low (≤140,000/mL) and abnormally high (≥447,000/mL) platelet cohorts. The abnormally low and high platelet groups were associated with higher rates of any, major, minor adverse events, transfusion, and longer hospital length of stay. Furthermore, the abnormally low platelet counts were associated with a higher risk of readmissions.

CONCLUSION

The data-based cut-offs for abnormally high and low platelet counts closely mirrored those found in literature. Based on these definitions, abnormally high and low preoperative platelet counts were associated with adverse outcomes after elective posterior lumbar surgery. These findings facilitate risk stratification and suggest targeted consideration for patients with high, as well as low, preoperative platelet counts.

LEVEL OF EVIDENCE

3.

Do we need elastography for EUS?

We recently introduced a series of papers “What should be known prior to performing EUS exams.” In Part I, the authors discussed which clinical information and whether other imaging modalities are needed before embarking EUS examinations. In Part II, technical controversies on how EUS is performed were discussed from different points of view. In this article, important practical issues regarding EUS elastography will be raised and controversially discussed from very different points of view.

Perioperative Guidelines in Anesthesia

Agreement between surgical and anesthesia teams regarding appropriate perioperative management strategies is vital to delivering safe and effective patient care. Perioperative guidelines serve as a valuable reference in optimizing patients for surgery. The article provides a broad set of guidelines related to cardiovascular evaluation, medication reconciliation, and preoperative fasting and includes a framework for the care of patients with comorbidities, such as coronary artery disease and obstructive sleep apnea.

Are Routine Postoperative Laboratory Tests Really Necessary After Lumbar Spinal Surgery?

BACKGROUND

For patients undergoing lumbar spinal surgery, many surgeons routinely perform laboratory tests within 3 days after surgery. However, few studies have reported the necessity for routine laboratory tests for patients with uncomplicated cases within 3 days after surgery.

METHODS

We performed a retrospective study of patients with lumbar degenerative disease who had undergone lumbar spinal surgery from May 2014 to May 2017. The perioperative patient information was recorded. The abnormal postoperative laboratory tests were recorded. Finally, the incidence and risk factors for patients requiring postoperative clinical treatment were analyzed.

RESULTS

A total of 1915 patients were included in the present study. Postoperative laboratory tests had been ordered for 870 patients (45.43%). Of these patients, only a small proportion had required postoperative clinical intervention to treat abnormal serum hemoglobin (2.53%), albumin (1.95%), serum potassium (0.92%), or serum calcium (6.55%) levels. Multivariate logistic regression analysis showed that female gender and operative time were risk factors for the need for blood transfusion after lumbar spinal surgery. Age and operative time were risk factors for patients requiring albumin supplementation after lumbar spinal surgery. Finally, intraoperative blood loss and operative time were independent risk factors for patients requiring calcium supplementation after surgery.

CONCLUSIONS

Owing to the small number of postoperative clinical interventions for abnormal laboratory test results, we believe that the use of routine laboratory tests within 3 days after lumbar spinal surgery for patients with uncomplicated cases are unnecessary. Our results showed that operative time is a potential risk factor for the necessity for clinical treatment after lumbar spinal surgery.

Routine preoperative medical testing for cataract surgery

BACKGROUND

Cataract surgery is practiced widely, and substantial resources are committed to an increasing cataract surgical rate in low- and middle-income countries. With the current volume of cataract surgery and future increases, it is critical to optimize the safety and cost-effectiveness of this procedure. Most cataracts are performed on older individuals with correspondingly high systemic and ocular comorbidities. It is likely that routine preoperative medical testing will detect medical conditions, but it is questionable whether these conditions should preclude individuals from cataract surgery or change their perioperative management.

OBJECTIVES

1. To investigate the evidence for reductions in adverse events through preoperative medical testing2. To estimate the average cost of performing routine medical testing SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2018, Issue 6); Ovid MEDLINE; Embase.com; PubMed; LILACS BIREME, the metaRegister of Controlled Trials (mRCT) (last searched 5 January 2012); ClinicalTrials.gov and the WHO ICTRP. The date of the search was 29 June 2018, with the exception of mRCT which is no longer in service. We searched the references of reports from included studies for additional relevant studies without restrictions regarding language or date of publication.

SELECTION CRITERIA

We included randomized clinical trials in which routine preoperative medical testing was compared to no preoperative or selective preoperative testing prior to age-related cataract surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed abstracts to identify possible trials for inclusion. For each included study, two review authors independently documented study characteristics, extracted data, and assessed risk of bias.

MAIN RESULTS

We identified three randomized clinical trials that compared routine preoperative medical testing versus selective or no preoperative testing for 21,531 cataract surgeries. The largest trial, in which 19,557 surgeries were randomized, was conducted in Canada and the USA. Another study was conducted in Brazil and the third in Italy. Although the studies had some issues with respect to performance and detection bias due to lack of masking (high risk for one study, unclear for two studies), we assessed the studies as at overall low risk of bias.The three randomized clinical trials included in this review reported results for 21,531 total cataract surgeries with 707 total surgery-associated medical adverse events, including 61 hospitalizations and three deaths. Of the 707 medical adverse events reported, 353 occurred in the pre-testing group and 354 occurred in the no-testing group (odds ratio (OR) 1.00, 95% confidence interval (CI) 0.86 to 1.16; high-certainty evidence). Most events were cardiovascular and occurred during the intraoperative period. Routine preoperative medical testing did not reduce the risk of intraoperative (OR 0.99, 95% CI 0.71 to 1.38) or postoperative ocular adverse events (OR 1.11, 95% CI 0.74 to 1.67) when compared to selective or no testing (2 studies; 2281 cataract surgeries; moderate-certainty evidence). One study evaluated cost savings, estimating the costs to be 2.55 times higher in those with preoperative medical testing compared to those without preoperative medical testing (1 study; 1005 cataract surgeries; moderate-certainty evidence). There was no difference in cancellation of surgery between those with preoperative medical testing and those with selective or no preoperative testing, reported by two studies with 20,582 cataract surgeries (OR 0.97, 95% CI 0.78 to 1.21; high-certainty evidence). No study reported outcomes related to clinical management changes (other than cancellation) or quality of life scores.

AUTHORS' CONCLUSIONS

This review has shown that routine preoperative testing does not increase the safety of cataract surgery. Alternatives to routine preoperative medical testing have been proposed, including self administered health questionnaires, which could substitute for health provider histories and physical examinations. Such avenues may lead to cost-effective means of identifying those at increased risk of medical adverse events due to cataract surgery. However, despite the rare occurrence, adverse medical events precipitated by cataract surgery remain a concern because of the large number of elderly patients with multiple medical comorbidities who have cataract surgery in various settings. The studies summarized in this review should assist recommendations for the standard of care of cataract surgery, at least in low- and middle-income settings. Unfortunately, in these settings, medical history questionnaires may be useless to screen for risk because few people have ever been to a physician, let alone been diagnosed with any chronic disease.

What should be known prior to performing EUS?

Direct referral of patients for EUS – instead of preprocedural consultation with the endosonographer – has become standard practice (like for other endoscopic procedures) as it is time- and cost-effective. To ensure appropriate indications and safe examinations, the endosonographer should carefully consider what information is needed before accepting the referral. This includes important clinical data regarding relevant comorbidities, the fitness of the patient to consent and undergo the procedure, and the anticoagulation status. In addition, relevant findings from other imaging methods to clarify the clinical question may be necessary. Appropriate knowledge and management of the patients’ anticoagulation and antiplatelet therapy, antibiotic prophylaxis, and sedation issues can avoid unnecessary delays and unsafe procedures. Insisting on optimal preparation, appropriate indications, and clear clinical referral questions will increase the quality of the outcomes of EUS. In this paper, important practical issues regarding EUS preparations are raised and discussed from different points of view.

Impact of Preoperative Testing on Ophthalmologic and Systemic Outcomes in Cataract Surgery

Purpose

To evaluate the incidence of ophthalmologic and systemic complications in patients who undergo cataract surgery without preoperative tests compared to subjects undergoing cataract surgery preceded by preoperative tests.

Methods

The randomized controlled study included 1276 consecutive patients admitted to the Institute of Ophthalmology of the University of Modena and Reggio Emilia for cataract surgery. The patients were randomly divided into two groups: 638 were assigned not to undergo preoperative evaluation based on routine medical tests and electrocardiograms; the other 638 underwent preoperative evaluation based on said tests. Ophthalmologic and systemic complications were assessed intraoperatively and 1 month after surgery.

Results

Eleven intraoperative complications occurred in the group without preoperative tests and eight in the group with preoperative tests; at 1 month six complications were recorded in the group without tests and five in the group with tests. Systemic adverse events occurred intraoperatively in four patients, whereas no systemic adverse event was recorded at 1 month in either group. No statistically significant differences were observed between the two groups.

Conclusions

The findings of this study have broad applicability, because the sample is representative of the population existing in numerous social and healthcare settings; they are of value for administrative purposes, because they may be taken as reference in resource allocation plans; and they have medicolegal implications, as the resulting conduct of healthcare providers is supported by a rigorous scientific study.

Role of preoperative investigations in elderly patients undergoing oncosurgical procedures - A retrospective review audit

Background and Aims:

The aim of the study was to evaluate the efficacy and usefulness of the current practice of various investigations and consultations being done during preanesthetic evaluation in patients undergoing oncosurgical procedures in our hospital. We also evaluated the delay caused due to these and its value in predicting postoperative complications.

Material and Methods:

The preanesthetic charts of 300 elderly patients >65 years of age were reviewed, and the incidence of abnormal investigations and number of consultations advised were noted. The incidence and predictive values of these were assessed.

Results:

More than half the number of patients had more than one comorbidity and were advised various consultations based on history, National Institute of Clinical and Health Excellence (NICE) guidelines, and institutional protocol. Multiple visits to preanesthetic clinic were required in patients who had abnormal thyroid tests or respiratory complaints which was the main reason for delay in scheduling surgery. However, despite multiple comorbidities not more than 12.7% of the blood tests ordered were found to be abnormal. Abnormal blood tests were not significantly associated with higher incidence of postoperative complications.

Conclusion:

Blood investigations do not predict postoperative complication rate and do not influence anesthetic management of elderly patients undergoing oncosurgical procedures but are rather influenced by surgical procedure and presence of comorbidities. Hence, preanesthetic clinic should assess patients based on other predictive tests rather than relying on blood investigations alone.

The role of preoperative blood parameters to predict the risk of surgical site infection

BACKGROUND

Routine preoperative blood work is not recommended but selected biochemical markers may predict the risk of surgical site infection (SSI). This study examines the association between preoperative biochemical markers and the risk of SSI.

METHODS

This observational cohort study, nested in a randomized controlled trial, was conducted at two tertiary referral centers in Switzerland.

RESULTS

122 (5.8%) of 2093 patients experienced SSI. Preoperative increasing levels of albumin (OR 0.93), CRP (OR 1.34), hemoglobin (OR 0.87) and eGFR (OR 0.90) were significantly associated with the odds of SSI. The same accounts for categorized parameters. The highest area under the curve from ROC curves was 0.62 for albumin. Positive predictive values ranged from 6.4% to 9.5% and negative predictive values from 94.8% to 95.7%. The association of CRP, mildly and moderately decreased eGFR and hemoglobin with the odds of SSI remained significant on multivariate analysis.

CONCLUSIONS

Our results do not support generally delaying elective surgery based on preoperative blood results. However, it may be considered in situations with potentially severe sequelae of SSI.

Preoperative Assessment for Ambulatory Surgery

PURPOSE OF REVIEW

Ambulatory surgery has grown in recent decades in volume and represents a significant number of anesthetics delivered throughout the USA. Preoperative anesthetic assessment in the ambulatory setting has become important because patients with numerous complex comorbidities are now commonplace in this arena. Disease states involving the lungs, the heart, the kidneys, and subpopulations including those who are obese and the elderly commonly receive anesthetics in an ambulatory setting.

RECENT FINDINGS

This review presents key aspects of current thinking with regard to preoperative assessment and considerations for different critical disease states and subpopulations that are now being managed under ambulatory surgery. Same day surgery centers require patient safety, and expectations are high for patient satisfaction. Advancements in surgical and anesthetic technique have allowed for more complex patients to partake in ambulatory surgery. Anesthesiologists must be familiar with guidelines, state-of-the-art pain management, and standards of preoperative patient evaluation to accurately stratify patient risk and to advocate for patient safety.

A model to predict risk of blood transfusion after gynecologic surgery

BACKGROUND

A model that predicts a patient's risk of receiving a blood transfusion may facilitate selective preoperative testing and more efficient perioperative blood management utilization.

OBJECTIVE

We sought to construct and validate a model that predicts a patient's risk of receiving a blood transfusion after gynecologic surgery.

STUDY DESIGN

In all, 18,319 women who underwent gynecologic surgery at 10 institutions in a single health system by 116 surgeons from January 2010 through June 2014 were analyzed. The data set was split into a model training cohort of 12,219 surgeries performed from January 2010 through December 2012 and a separate validation cohort of 6100 surgeries performed from January 2013 through June 2014. In all, 47 candidate risk factors for transfusion were collected. Multiple logistic models were fit onto the training cohort to predict transfusion within 30 days of surgery. Variables were removed using stepwise backward reduction to find the best parsimonious model. Model discrimination was measured using the concordance index. The model was internally validated using 1000 bootstrapped samples and temporally validated by testing the model's performance in the validation cohort. Calibration and decision curves were plotted to inform clinicians about the accuracy of predicted probabilities and whether the model adds clinical benefit when making decisions.

RESULTS

The transfusion rate in the training cohort was 2% (95% confidence interval, 1.72-2.22). The model had excellent discrimination and calibration during internal validation (bias-corrected concordance index, 0.906; 95% confidence interval, 0.890-0.928) and maintained accuracy during temporal validation using the separate validation cohort (concordance index, 0.915; 95% confidence interval, 0.872-0.954). Calibration curves demonstrated the model was accurate up to 40% then it began to overpredict risk. The model provides superior net benefit when clinical decision thresholds are between 0-50% predicted risk.

CONCLUSION

This model accurately predicts a patient's risk of transfusion after gynecologic surgery facilitating selective preoperative testing and more efficient perioperative blood management utilization.

[Incidental findings in chest X‑rays]

Conventional projection radiography (chest x‑ray) is one of the most frequently requested procedures in radiology. Even though chest x‑ray imaging is frequently performed in asymptomatic patients for preoperative assessment, clinically relevant incidental findings are relatively scarce. This is due to the relatively low sensitivity of chest x‑rays where few clinically relevant incidental findings are to be expected, as any detectable pathologies will as a rule already be clinically symptomatic. Recommendations from relevant societies for the management of incidental findings, apart from the clarification of incidental nodules, do not exist. This review article therefore describes the most frequent and typical incidental findings of lung parenchyma (apart from pulmonary nodules), mediastinal structures including the hilum of the lungs, pleura, chest wall and major vessels. Also described are those findings which can be diagnosed with sufficient certainty from chest x‑rays so that further clarification is not necessary and those which must be further clarified by multislice imaging procedures or other techniques.

ACR Appropriateness Criteria® Routine Chest Radiography

Chest radiographs are sometimes taken before surgeries and interventional procedures on hospital admissions and outpatients. This manuscript summarizes the American College of Radiology review of the literature and recommendations on routinely performed chest radiographies in these settings. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Routine preoperative laboratory testing in elective pediatric cardiothoracic surgery is largely unnecessary

OBJECTIVE

Routine preoperative laboratory testing (RLT) is common practice in pediatric cardiothoracic surgery and is associated with significant cost burden to patients and families. We sought to examine the value of RLT in patients undergoing elective pediatric cardiothoracic surgery.

METHODS

We conducted a retrospective study of all scheduled elective pediatric cardiothoracic surgery at our institution from 2012 to 2014. Inpatients were excluded. Patient charts were reviewed to obtain preoperative laboratory values and determine relationship to case cancellation. RLT includes complete blood count, prothrombin time, partial thromboplastin time, urinalysis, 7 chemistry metabolic panel, electrocardiogram, and 2-view chest radiograph.

RESULTS

RLT was completed for 1106 scheduled elective cases. Six (0.5%) cancellations were related to abnormal preoperative laboratory test results: 5 complete blood counts and 1 urinalysis. Hospital charge for RLT averaged $2064 per patient. Based on this incidence, we estimated that 184 routine preoperative laboratory tests, which generated a total hospital charge of $379,776, were required to capture 1 abnormal test significant enough to cancel surgery. An estimated charge of $2,169,552 was generated on prothrombin time, partial thromboplastin time, 7 chemistry metabolic panel, electrocardiogram, and 2-view chest radiograph, and none of these tests resulted in a cancellation.

CONCLUSIONS

RLT does not significantly impact decision-making in elective pediatric cardiothoracic surgery. The decision to order a specific screening test should be clinically driven. Selective preoperative laboratory testing may have a positive impact on healthcare costs without affecting outcomes.

Perioperative Evaluation of Patients with Pulmonary Conditions Undergoing Non-Cardiothoracic Surgery

This review describes the perioperative management of patients with suspected or established pulmonary conditions undergoing non-cardiothoracic surgery, with a focus on common pulmonary conditions such as obstructive airway disease, pulmonary hypertension, obstructive sleep apnea, and chronic hypoxic respiratory conditions. Considering that postoperative pulmonary complications are common and given the increasing number of surgical procedures and the size of the aging population, familiarity with current guidelines for preoperative risk assessment and intra- and postoperative patient management is recommended to decrease the morbidity and mortality. In particular, smoking cessation and pulmonary rehabilitation are perioperative strategies for improving patients’ short- and long-term outcomes. Understanding the potential risk for pulmonary complications allows the medical team to appropriately plan the intra- and postoperative care of each patient.

Preoperative Laboratory Investigations: Rates and Variability Prior to Low-risk Surgical Procedures

BACKGROUND

Increasing attention has been focused on low-value healthcare services. Through Choosing Wisely campaigns, routine laboratory testing before low-risk surgery has been discouraged in the absence of clinical indications. The authors investigated rates, determinants, and institutional variation in laboratory testing before low-risk procedures.

METHODS

Patients who underwent ophthalmologic surgeries or predefined low-risk surgeries in Ontario, Canada, between April 1, 2008, and March 31, 2013, were identified from population-based administrative databases. Preoperative blood work was defined as a complete blood count, prothrombin time, partial thromboplastin, or basic metabolic panel within 60 days before an index procedure. Adjusted associations between patient and institutional factors and preoperative testing were assessed with hierarchical multivariable logistic regression. Institutional variation was characterized using the median odds ratio.

RESULTS

The cohort included 906,902 patients who underwent 1,330,466 procedures (57.1% ophthalmologic and 42.9% low-risk surgery) at 119 institutions. Preoperative blood work preceded 400,058 (30.1%) procedures. The unadjusted institutional rate of preoperative blood work varied widely (0.0 to 98.1%). In regression modeling, significant predictors of preoperative testing included atrial fibrillation (adjusted odds ratio [AOR], 2.58; 95% CI, 2.51 to 2.66), preoperative medical consultation (AOR, 1.68; 95% CI, 1.65 to 1.71), previous mitral valve replacement (AOR, 2.33; 95% CI, 2.10 to 2.58), and liver disease (AOR, 1.69; 95% CI, 1.55 to 1.84). The median odds ratio for interinstitutional variation was 2.43.

CONCLUSIONS

Results of this study suggest that testing is associated with a range of clinical covariates. However, an association was similarly identified with preoperative consultation, and significant variation between institutions exists across the jurisdiction.

Pre-operative labs: Wasted dollars or predictors of post-operative cardiac and septic events in orthopaedic trauma patients?

PURPOSE

As US healthcare expenditures continue to rise, there is significant pressure to reduce the cost of inpatient medical services. Studies have estimated that over 70% of routine labs may not yield clinical benefits while adding over $300 in costs per day for every inpatient. Although orthopaedic trauma patients tend to have longer inpatient stays and hip fractures have been associated with significant morbidity, there is a dearth of data examining pre-operative labs in predicting post-operative adverse events in these populations. The purpose of this study was to assess whether pre-operative labs significantly predict post-operative cardiac and septic complications in orthopaedic trauma and hip fracture patients.

METHODS

Between 2006 and 2013, 56,336 (15.6%) orthopaedic trauma patients were identified and 27,441 patients (7.6%) were diagnosed with hip fractures. Pre-operative labs included sodium, BUN, creatinine, albumin, bilirubin, SGOT, alkaline phosphatase, white count, hematocrit, platelet count, prothrombin time, INR, and partial thromboplastin time. For each of these labs, patients were deemed to have normal or abnormal values. Patients were noted to have developed cardiac or septic complications if they sustained (1) myocardial infarction (MI), (2) cardiac arrest, or (3) septic shock within 30 days after surgery. Separate regressions incorporating over 40 patient characteristics including age, gender, pre-operative comorbidities, and labs were performed for orthopaedic trauma patients in order to determine whether pre-operative labs predicted adverse cardiac or septic outcomes.

RESULTS

749 (1.3%) orthopaedic trauma patients developed cardiac complications and 311 (0.6%) developed septic shock. Multivariate regression demonstrated that abnormal pre-operative platelet values were significantly predictive of post-operative cardiac arrest (OR: 11.107, p=0.036), and abnormal bilirubin levels were predictive (OR: 8.487, p=0.008) of the development of septic shock in trauma patients. In the hip fracture cohort, abnormal partial thromboplastin time was significantly associated with post-operative myocardial infarction (OR: 15.083, p=0.046), and abnormal bilirubin (OR: 58.674, p=0.002) significantly predicted the onset of septic shock.

CONCLUSIONS

This is the first study to demonstrate the utility of pre-operative labs in predicting perioperative cardiac and septic adverse events in orthopaedic trauma and hip fracture patients. Particular attention should be paid to haematologic/coagulation labs (platelets, PTT) and bilirubin values.

LEVEL OF EVIDENCE

Prognostic Level II.

How to rationalize preoperative tests? A method to implement local guidelines successfully

BACKGROUND

Preoperative screening includes clinical examination and tests. Systematic prescription leads to excessive tests. We conducted an observational retrospective study to assess the success of implementing a protocol-guided prescription procedure for preoperative tests (PTs). We compared the number of PTs prescribed for scheduled surgery before and after the implementation of local guidelines with a specific method.

METHODS

Local guidelines for prescribing PTs based on the French Society of Anaesthesia's recommendations were developed, validated by the anaesthesia team and actively implemented. The implementation procedure was complex and based on the application of sociologic concepts to facilitate PT prescriptions in accordance with the protocol. All PTs (except for children and emergency surgeries) prescribed over a one-week observation period were analysed before and after protocol implementation, respectively in 2011 and 2013.

RESULTS

Two hundred and ninety-two patient files were analysed: 157 in 2011 and 135 in 2013. Ninety-one percent of the prescriptions were in accordance with the recommendations in 2013. Excessive prescribing decreased significantly after the implementation of recommendations (7.1% versus 20.7%, P<0.0001), enabling us to reduce excess costs.

CONCLUSION

We observed excellent adherence to the prescription protocol for PTs. The method used to implement the protocol was successful. A future evaluation should be undertaken to confirm these results over the long-term.