Preoperative evaluation: a shared vision for change

"Too much information with little meaning," relevance of preoperative laboratory testing in elective oral and maxillofacial surgeries: A systematic integrative review

Aim:

In the recent times due to accessibility of tools and advent of technology advising battery of laboratory tests prior to any electeve surgical procedure has become a norm. This review aims at investigating relevance of such tests in healthy patients undergoing routine elective oral and maxillofacial surgical procedures.

Methods:

Various search engines were thoroughly searched to identify relevant literature. The population of interest was asymptomatic adults above 18 years of age undergoing elective surgery.

Results:

The preoperative tests of interest for the current study included complete blood count, coagulation tests, biochemistry, and chest X-rays. An algorithm for preoperative tests has been proposed.

Conclusion:

We conclude that advising battery of routine tests in such patients leads to further delays and rise in overall cost of the surgery.

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

BACKGROUND

Despite 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.

METHODS

We 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.

RESULTS

During 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.

CONCLUSIONS

The 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.

Optimizing postoperative outcomes with efficient preoperative assessment and management

OBJECTIVE

To review the essential features of preoperative assessment, management, and planning, with special emphasis on high-risk patients who are likely to have manifestations related to their co-existing disease and disease treatment(s) in the postoperative setting.

DATA SOURCE

Review of recent studies and reviews as reprinted in Index Medicus.

CONCLUSIONS

The major shift in preoperative assessment and management from within the hospital to outside the hospital has prompted new efforts to coordinate preoperative care. Much of this can be accomplished with the introduction of a preadmission testing center. Under the direction of a physician (typically an anesthesiologist), the Pre-Admission Testing Center staff performs necessary assessments and coordinates necessary information about the presurgical patient. This assessment should include features essential to the general history and physical examination, as well as the specific issues related to anesthesia and surgery. The preoperative visit is also an opportunity to perform directed laboratory testing (as opposed to across the board batteries of tests) and to carefully plan out the continuance, discontinuance, or initiation of medications in the perioperative period. It also may be beneficial to stabilize disorders such as hypertension and, when indicated, initiate preoperative optimization of patients with advanced disease. The ultimate goal is to provide safe and "efficient" care, without exhausting highly valued intensive care resources.

Validation of a pre-anaesthetic screening questionnaire

We developed a screening questionnaire to be used by nurses to decide which patients should see an anaesthetist for further evaluation before the day of surgery. Our objective was to measure the accuracy of responses to the questionnaire. Agreement between questionnaire responses and the anaesthetist's assessment was assessed. For questions with a prevalence of 5 to 95%, the Kappa coefficient was used; percentage agreement was used for all other questions. Criterion validity was excellent/good for all questions with a prevalence between 5 and 95%, except for the question 'Do you have kidney disease?' For questions with prevalence < 5%, all demonstrated adequate criterion validity except the questions 'Has anyone in your family had a problem following an anaesthetic?' and 'If you have been put to sleep for an operation were there any anaesthetic problems?' Therefore, it is reasonable for nurses to use this questionnaire to determine which patients an anaesthetist should see before the day of surgery.