BREAK THIS PRACTICE HABIT

Replace routine preoperative testing with individualized risk assessment and indicated testing

OBG Manag. 2020 December;32(12):40-44, E1 | doi: 10.12788/obgm.0054

References

Kachalia A, Berg A, Fagerlin A, et al. Overuse of testing in preoperative evaluation and syncope: a survey of hospitalists. Ann Intern Med. 2015;162:100-108.
Onuoha OC, Hatch M, Miano TA, et al. The incidence of un-indicated preoperative testing in a tertiary academic ambulatory center: a retrospective cohort study. Perioper Med. 2015; 4:14.
Kaplan EB, Sheiner LB, Boeckmann AJ, et al. The usefulness of preoperative laboratory screening. JAMA. 1985;253:3576-3581.
Centers for Disease Control and Prevention National Center for Health Statistics. Table 42: Gross domestic product, national health expenditures, per capita amounts, percent distribution, and average annual percent change: United States, selected years 1960-2017. https://www.cdc.gov/nchs/ data/hus/2018/042.pdf. Accessed July 2020.
Benarroch-Gampel J, Sheffield KM, Duncan CB, et al. Preoperative laboratory testing in patients undergoing elective, low-risk ambulatory surgery. Ann Surg. 2012;256:518-528.
O’Neill F, Carter E, Pink N, et al. Routine preoperative tests for elective surgery: summary of updated NICE guidance. BMJ. 2016;354: i3292.
Committee on Standards and Practice Parameters; Apfelbaum JL, Connis RT, Nickinovich DG, et al. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology. 2012;116:522-538.
American Society of Anesthesiologists. ASA physical status classification system. https://www.asahq.org/standardsand-guidelines/asa-physical-status-classification-system. Accessed July 2020.
Pasternak LR, Johns A. Ambulatory gynaecological surgery: risk and assessment. Best Pract Res Clin Obstet Gynaecol. 2005;19:663-679.
Shields J, Lupo A, Walsh T, et al. Preoperative evaluation for gynecologic surgery: a guide to judicious, evidence-based testing. Curr Opin Obstet Gynecol. 2018;30:252-259.
Sigmund AE, Stevens ER, Blitz JD, et al. Use of preoperative testing and physicians’ response to professional society guidance. JAMA Intern Med. 2015;175:1352-1359.
St Clair CM, Shah M, Diver EJ, et al. Adherence to evidence-based guidelines for preoperative testing in women undergoing gynecologic surgery. Obstet Gynecol. 2010;116:694-700.
De Sousa Soares D, Brandao RR, Mourao MR, et al. Relevance of routine testing in low-risk patients undergoing minor and medium surgical procedures. Braz J Anesthesiol. 2013;63:197-201.
Shields J, Kho KA. Preoperative evaluation for minimally invasive gynecologic surgery: what is the best evidence and recommendations for clinical practice. J Minim Invasive Gynecol. 2019;26:312-320.
Palace MR. Perioperative management of thyroid dysfunction. Health Serv Insights. 2017;10:1178632916689677.
Smetana GW, Macpherson DS. The case against routine preoperative laboratory testing. Med Clin North Am. 2003;87:7-40.
Jehan F, Khan M, Sakran JV, et al. Perioperative glycemic control and postoperative complications in patients undergoing emergency general surgery: what is the role of plasma hemoglobin A1c? J Trauma Acute Care Surg. 2018;84:112-117.
Feely MA, Collins CS, Daniels PR, et al. Preoperative testing before noncardiac surgery: guidelines and recommendations. Am Fam Physician. 2013;87:414-418.
Rusk MH. Avoiding unnecessary preoperative testing. Med Clin North Am. 2016;100:1003-1008.
Dexter F, Ledolter J, Davis E, et al. Systematic criteria for type and screen based on procedure’s probability of erythrocyte transfusion. Anesthesiology. 2012;116:768-778.
Gehrich AP, Lustik MB, Mehr AA, et al. Risk of postoperative urinary tract infections following midurethral sling operations in women undergoing hysterectomy. Int Urogynecol J. 2016;27:483-490.
American College of Obstetricians and Gynecologists. ACOG practice bulletin No. 195 summary: prevention of infection after gynecologic procedures. Obstet Gynecol. 2018;131:1177- 1179.
Noordzij PG, Boersma E, Bax JJ, et al. Prognostic value of routine preoperative electrocardiography in patients undergoing noncardiac surgery. Am J Cardiol, 2006;97: 1103-1106.
Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/ AHA guideline on perioperative cardiovascular examination and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:2215-2245.
Correll DJ, Hepner DL, Chang C, et al. Preoperative electrocardiograms: patient factors predictive of abnormalities. Anesthesiology. 2009;110:1217-1122.
Fritsch G, Flamm M, Hepner DL, et al. Abnormal preoperative tests, pathologic findings of medical history, and their predictive value for perioperative complications. Acta Anaesthesiol Scand. 2012;56:339-350.

Diagnostic studies

Electrocardiography (ECG). The absolute difference in cardiovascular death is less than 1% among patients with and without ECG abnormalities undergoing a noncardiac procedure with minimal to moderate risk; therefore, routine ECG for low-risk patients should not be performed.²³ Instead, ECG should be performed in patients with known coronary artery disease or structural heart disease and in patients aged 65 years and older, since age older than 65 years is an independent predictor of significant ECG abnormalities.^24,25 We therefore recommend that the following individuals have an ECG within the last 12 months: patients aged 65 years and older, patients in class ASA II or higher with cardiovascular disease, and patients in class ASA III or higher undergoing general anesthesia. If there is a change in cardiovascular health since the most recent ECG—even if it was performed within 12 months—a repeat ECG is warranted.^10,14

Chest x-ray. Despite a high rate of abnormalities seen on routine and indicated chest x-rays, there is no significant difference in perioperative pulmonary complications among patients with a normal or abnormal chest x-ray.¹⁶ Rather than changing surgical management, these abnormal results are more likely to lead to the cancellation or postponement of a surgical procedure.⁷ We therefore recommend against routine preoperative chest x-ray.¹⁴

The bottom line

Preoperative testing serves as an additional component of surgical planning. The fact is, however, that abnormal test results are common and frequently do not correlate with surgical outcomes.²⁶ Instead, they can lead to unnecessary surgical procedure cancellations or postponements, undue anxiety in patients, increased liability among physicians, and rising health care costs.^5-7

Rather than overly relying on routine laboratory or diagnostic studies, the history and physical examination should continue to be the cornerstone for surgeons responsible for assessing surgical risk. With individualized risk assessment, specific, indicated testing rather than routine nonspecific testing can be obtained.^10,14 In short, low-risk patients undergoing noncardiac surgery are unlikely to benefit from preoperative ECG, chest x-ray, or routine laboratory testing without clinical indication. ●

References

Kachalia A, Berg A, Fagerlin A, et al. Overuse of testing in preoperative evaluation and syncope: a survey of hospitalists. Ann Intern Med. 2015;162:100-108.
Onuoha OC, Hatch M, Miano TA, et al. The incidence of un-indicated preoperative testing in a tertiary academic ambulatory center: a retrospective cohort study. Perioper Med. 2015; 4:14.
Kaplan EB, Sheiner LB, Boeckmann AJ, et al. The usefulness of preoperative laboratory screening. JAMA. 1985;253:3576-3581.
Centers for Disease Control and Prevention National Center for Health Statistics. Table 42: Gross domestic product, national health expenditures, per capita amounts, percent distribution, and average annual percent change: United States, selected years 1960-2017. https://www.cdc.gov/nchs/ data/hus/2018/042.pdf. Accessed July 2020.
Benarroch-Gampel J, Sheffield KM, Duncan CB, et al. Preoperative laboratory testing in patients undergoing elective, low-risk ambulatory surgery. Ann Surg. 2012;256:518-528.
O’Neill F, Carter E, Pink N, et al. Routine preoperative tests for elective surgery: summary of updated NICE guidance. BMJ. 2016;354: i3292.
Committee on Standards and Practice Parameters; Apfelbaum JL, Connis RT, Nickinovich DG, et al. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology. 2012;116:522-538.
American Society of Anesthesiologists. ASA physical status classification system. https://www.asahq.org/standardsand-guidelines/asa-physical-status-classification-system. Accessed July 2020.
Pasternak LR, Johns A. Ambulatory gynaecological surgery: risk and assessment. Best Pract Res Clin Obstet Gynaecol. 2005;19:663-679.
Shields J, Lupo A, Walsh T, et al. Preoperative evaluation for gynecologic surgery: a guide to judicious, evidence-based testing. Curr Opin Obstet Gynecol. 2018;30:252-259.
Sigmund AE, Stevens ER, Blitz JD, et al. Use of preoperative testing and physicians’ response to professional society guidance. JAMA Intern Med. 2015;175:1352-1359.
St Clair CM, Shah M, Diver EJ, et al. Adherence to evidence-based guidelines for preoperative testing in women undergoing gynecologic surgery. Obstet Gynecol. 2010;116:694-700.
De Sousa Soares D, Brandao RR, Mourao MR, et al. Relevance of routine testing in low-risk patients undergoing minor and medium surgical procedures. Braz J Anesthesiol. 2013;63:197-201.
Shields J, Kho KA. Preoperative evaluation for minimally invasive gynecologic surgery: what is the best evidence and recommendations for clinical practice. J Minim Invasive Gynecol. 2019;26:312-320.
Palace MR. Perioperative management of thyroid dysfunction. Health Serv Insights. 2017;10:1178632916689677.
Smetana GW, Macpherson DS. The case against routine preoperative laboratory testing. Med Clin North Am. 2003;87:7-40.
Jehan F, Khan M, Sakran JV, et al. Perioperative glycemic control and postoperative complications in patients undergoing emergency general surgery: what is the role of plasma hemoglobin A1c? J Trauma Acute Care Surg. 2018;84:112-117.
Feely MA, Collins CS, Daniels PR, et al. Preoperative testing before noncardiac surgery: guidelines and recommendations. Am Fam Physician. 2013;87:414-418.
Rusk MH. Avoiding unnecessary preoperative testing. Med Clin North Am. 2016;100:1003-1008.
Dexter F, Ledolter J, Davis E, et al. Systematic criteria for type and screen based on procedure’s probability of erythrocyte transfusion. Anesthesiology. 2012;116:768-778.
Gehrich AP, Lustik MB, Mehr AA, et al. Risk of postoperative urinary tract infections following midurethral sling operations in women undergoing hysterectomy. Int Urogynecol J. 2016;27:483-490.
American College of Obstetricians and Gynecologists. ACOG practice bulletin No. 195 summary: prevention of infection after gynecologic procedures. Obstet Gynecol. 2018;131:1177- 1179.
Noordzij PG, Boersma E, Bax JJ, et al. Prognostic value of routine preoperative electrocardiography in patients undergoing noncardiac surgery. Am J Cardiol, 2006;97: 1103-1106.
Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/ AHA guideline on perioperative cardiovascular examination and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:2215-2245.
Correll DJ, Hepner DL, Chang C, et al. Preoperative electrocardiograms: patient factors predictive of abnormalities. Anesthesiology. 2009;110:1217-1122.
Fritsch G, Flamm M, Hepner DL, et al. Abnormal preoperative tests, pathologic findings of medical history, and their predictive value for perioperative complications. Acta Anaesthesiol Scand. 2012;56:339-350.

Replace routine preoperative testing with individualized risk assessment and indicated testing

References

Diagnostic studies

<img class="media-element file-medstat-image-full-text" data-delta="3" typeof="foaf:Image" src="https://cdn.mdedge.com/files/s3fs-public/obgm0321240_kho_t3.jpg" width="778" height="784" alt="" title="" />

The bottom line

Pages

Recommended Reading