Preoperative Testing

Preoperative Testing

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Medical consultants are generally asked to assess preoperative risk in most patients who are to undergo surgery. The focus of discussion in this article applies to healthy people who are to undergo an elective surgical procedure. [1, 2]

Despite a low risk of perioperative complications, the use of laboratory tests before surgery became ingrained in clinical practice not only across the United States, but also across the world in the latter half of the 20th century. At that time, clinicians thought it logical to order tests to detect abnormalities that might lead to increased morbidity or mortality in the perioperative period. Despite its widespread use, however, systematic evaluations of the clinical effectiveness and cost-effectiveness of routine laboratory testing were often lacking.

In the early and mid 1980s, several investigators published a number of papers demonstrating that routine preoperative testing (preoperative screening) was not cost-effective and did not benefit the patient. For example, in the mid 1980s, Kaplan and colleagues, in a retrospective review of the charts of 2000 patients who underwent elective surgery, demonstrated that 60% of these patients had laboratory tests ordered for no apparent reason, and that only 0.22% of the abnormal results influenced preoperative management. [3]

In another study, Turnbull and colleagues reviewed the charts of 2570 patients undergoing elective surgery, finding that only 104 of 5003 laboratory test results were abnormal and significant, and that only 4 patients would have benefited from “routine” laboratory testing. [4]

To compound the problem, it appears that physicians are poor at evaluating the preoperative tests ordered. For example, in a study in which the records of 3782 elective surgery patients were reviewed, only 10 of 160 patients with abnormal test results were treated for such abnormalities. [5] The lack of treatment of identified abnormalities therefore raises the issue of increased legal liability.

In the last 20 years, a progressive challenge to the use of gratuitous routine laboratory testing has developed, especially within the environment of cost-containment and managed care. What, then, should physicians do? A good history and physical examination followed by a review of a patient’s chart are undoubtedly the most important routine tests needed.

For example, Narr and colleagues reviewed the charts of 1044 healthy patients who did not undergo any preoperative laboratory testing (preoperative laboratory screening) before their elective surgeries. [6] These patients did not experience any significant perioperative morbidity or mortality.

The use of previous laboratory results, performed within 4 months before elective surgery, was supported by a study in which 7549 laboratory results of 1109 patients were reviewed. [7] This study showed that 47% of the laboratory test results duplicated those obtained within 1 year. Of the 3096 normal laboratory test results, only 13 (0.4%) repeated values were abnormal, most of which could have been predicted on the basis of patient history and physical findings.

Furthermore, 5% of healthy people have abnormal test results. This is due to arbitrary cut points that define the range of normal laboratory values to include 2 standard deviations (SD) with a 95% confidence interval (CI). For example, the chance that the results of 1 of 6 tests included in a basic metabolic profile will be abnormal is 26%; hence, the predictive value (PV) of the test will be low, especially if the prevalence of the disease is low. For example, based on the Bayes theorem, the positive predictive value (PPV) of an abnormal hemoglobin test finding is 16.1%, as the prevalence of anemia in healthy individuals is approximately 1%. Accordingly, such abnormal laboratory values, with very low predictive values, may result in further unnecessary workup and delays in surgery.

In a review of studies of routine preoperative testing by Smetana and Macpherson, the positive likelihood ratio was modest (>3) for hemoglobin, electrolytes, and renal dysfunction but had a low impact for change on preoperative management. [8] Normal preoperative test results did not reduce the likelihood of postoperative complications. In a single center study, the incidence of unindicated preoperative screening tests was found to be more than 50%, but it did not add to any benefit to support this persistence of unwarranted testing.

A retrospective analysis examined the long-term national effect of the 2002 professional guidelines from the American College of Cardiology/American Heart Association and the American Society of Anesthesiologists on physicians’ use of routine preoperative testing. The study found that the release of the 2002 guidelines was associated with a reduced incidence of routine electrocardiogram testing but not of plain radiography, hematocrit, urinalysis, or cardiac stress testing. [9, 10]

Advancing age, especially older than 70 years, is associated with increased hospital stay and perioperative morbidity and mortality. However, most people in this age group have comorbid conditions, and it remains unclear if perioperative complications are secondary to comorbid conditions or age itself (see also the article Perioperative Management of the Geriatric Patient).

Contrary to a common belief, obesity does not increase postoperative complications. In a prospective cohort of 6336 patients undergoing general elective surgery, Dindo et al did not find obesity to be a risk factor for the development of postoperative complications. [11]

In one study, body mass index greater than or equal to 30 was found to be one of the independent predictors of cardiac adverse events after general, vascular, and urological surgery. [12]

The type of surgery is important in the risk stratification. For cataract surgery, a systematic review of 3 randomized trials did not show any difference in the adverse events between those who were tested versus Thse who did not have preoperative testing. [13] Rather, preoperative testing resulted in 2.5-fold increase in the cost. Similarly, 30-day events rates were not different in ambulatory surgery patients with or without preoperative testing. [14, 15]

For patient education resources, see the Procedures Center and Imaging Center, as well as Complete Blood Count, Electrocardiogram (ECG), Urinalysis, Understanding X-rays, and Common Health Tests.

Complete blood cell (CBC) count

Several studies have reported a wide range of hemoglobin abnormalities among elective surgery patients, based on different study populations. In healthy individuals undergoing elective surgery, the variation is estimated to be less than 1%. A mild hemoglobin abnormality was not associated with an increased incidence of perioperative morbidity or mortality.

More recent guidelines recommend preoperative hemoglobin testing if the history is suggestive of underlying anemia or if a significant blood loss is anticipated during the operation. In one study, even mild degrees of preoperative anemia or polycythemia were associated with an increased risk of 30-day postoperative mortality and cardiac events in older, mostly male veterans undergoing major noncardiac surgery. [16] It is reasonable to check hemoglobin for all patients aged 65 years or older and for younger patients undergoing surgery with expected major blood loss.

The prevalence of severe leukopenia or leukocytosis is extremely low and rarely leads to a change in patient management. Similarly, thrombocytopenia is found in fewer than 1% of healthy elective surgery patients; thus, a routine preoperative white blood cell (WBC) or platelet count is not recommended unless the cost of a CBC count is not substantially higher than that of a hemoglobin level. The cost of falsely pursuing an abnormal WBC or platelet count may not be substantial, although no studies in that regard are available except that for platelets. [17]

Electrolytes

Unanticipated electrolyte abnormalities (sodium, potassium, bicarbonate, chloride) range from 0.2% to 8.0% among surgery patients. One systemic literature review reported that unsuspected electrolyte abnormality is 1.4% among healthy elective surgery patients.

Although hypokalemia is considered a minor risk factor for perioperative cardiac complications based on the Goldman risk index, no study showed a relation between hypokalemia and perioperative morbidity and mortality.

Postoperative hyponatremia is common in certain types of surgeries, such as transurethral resection of the prostate and neurosurgical procedures; however, it is still unclear how baseline electrolyte abnormality may affect physicians’ decisions in postoperative management. Accordingly, electrolyte determination is not routinely recommended for elective surgery in healthy individuals.

Creatinine

The prevalence of elevated creatinine levels in asymptomatic patients ranges from 0.2% to 2.4% and increases with age. Approximately 9.8% of patients aged 46-60 years have elevated creatinine levels. [18]

Patients with mild to moderate renal insufficiency are usually asymptomatic but have an increased risk of perioperative morbidity and mortality. Accordingly, testing renal function with a serum creatinine level is recommended for all patients older than 50 years, especially if hypotension or the use of nephrotoxic medications is anticipated. Some medications may need dose adjustment based on creatinine clearance.

Blood sugar (blood glucose)

The frequency of abnormal glucose laboratory results in asymptomatic patients ranges from 1.8% to 5.5%. This frequency increases with age, so that nearly 25% of patients older than 60 years have a fasting blood sugar level above 120 mg/dL. [18] However, asymptomatic hyperglycemia is unlikely to contribute to postoperative complications, [19] and routine measurement of glucose is not recommended in all cases.

Only in certain operations, such as vascular surgery and coronary artery bypass grafting (CABG), diabetes was associated with higher perioperative risks; hence, routine blood sugar determination is recommended in such cases. [20, 21]

Liver enzymes

The frequency of a hepatic aminotransferase enzyme (aspartate aminotransferase [AST], alanine aminotransferase [ALT]) abnormalities is estimated to be approximately 0.3%. Although Powell-Jackson and colleagues showed that severe liver test abnormalities may lead to an increase in surgical morbidity and mortality risk, [22] no evidence confirms that mild elevation in liver enzymes is associated with such an increased risk.

Because most patients with severe aminotransferase enzyme elevation are likely to be symptomatic, and jaundice may be detected by physical examination, routine preoperative testing (preoperative screening) is not recommended for healthy individuals.

Hemostasis

In the absence of a history of bleeding diathesis in elective surgery patients, abnormal bleeding time, prothrombin time (PT), and activated partial thromboplastin time (aPTT) results are estimated to be less than 1%. Bleeding time may not be a useful predictor of bleeding risk, and a normal bleeding time does not exclude the possibility of excessive bleeding. [23]

Suchman and Mushlin showed that in low-risk patients, per history and physical examination, aPTT does not predict the risk of perioperative bleeding. [24] Similarly, the bleeding time has no predictive value on the incidence of perioperative bleeding in healthy elective surgery patients. Rather, pursuit of abnormal coagulation tests may increase preoperative costs. [25] Accordingly, PT, aPTT, and bleeding time are not recommended for routine preoperative testing (preoperative screening).

Urinalysis (UA)

The primary rationale for ordering a UA preoperatively is to detect either asymptomatic renal disease or an underlying urinary tract infection (UTI). To detect unsuspected renal insufficiency, serum creatinine measurement is recommended for any elective surgery patient older than 40 years, although it is unclear if any correlation exists between asymptomatic UTI and surgical wound infection.

One study that included 200 patients undergoing orthopedic procedures showed that physicians addressed only 5 of 27 abnormal urine test results. [26] A further economic analysis showed that in order to prevent a single wound infection, approximately $1.5 million must be spent on UAs. [27] Therefore, urine analysis should not be routinely done for asymptomatic patients.

Fecal occult blood

The prevalence of positive fecal occult blood findings among healthy individuals undergoing elective surgery is unknown. In addition, the benefits of routine screening are unclear.

A decision-analysis study showed no benefit of routine screening [28] ; therefore, insufficient evidence exists to support routine screening for fecal occult blood.

Pregnancy testing

Pregnancy has an important bearing in the perioperative care of a woman. The American Society of Anesthesiologists recommends pregnancy testing for all women of child bearing age. [29] History alone may not be completely reliable to exclude pregnancy.

Electrocardiography (ECG)

The prevalence of abnormal ECG findings among healthy elective surgery patients ranges from 14% to 53% and increases with age in a continuous fashion.

The rationale for obtaining an ECG preoperatively is to identify high-risk patients with previous myocardial infarction or arrhythmia. Detecting a silent myocardial infarction is of main clinical benefit, because numerous investigations have shown an association between preoperative myocardial infarction and surgical mortality. One study showed that 25% of 708 myocardial infarctions in the Framingham study were detected by ECG. In addition, any rhythm other than sinus, including frequent premature ventricular contractions (PVCs), is associated with an increase in surgical risk. Accordingly, routine ECG is recommended for all patients older than 40 years undergoing elective surgery. [30, 31]

In a retrospective study of 23,036 patients who underwent 28,457 surgical procedures, Noordzij et al used multivariate logistic regression was to evaluate the relationship between ECG abnormalities and cardiovascular death. [31] A total of 199 in-hospital cardiovascular deaths (0.7%) occurred. A higher incidence of cardiovascular death was observed in patients with an abnormal ECG (1.8%) than in those with normal ECG results (0.3%); adjusted odds ratio [OR] 4.5, 95% CI 3.3-6.0). [31] However, there was no significant difference (0.5%) in the incidence of cardiovascular death in patients, with or without ECG abnormality, who underwent low-risk or low- to intermediate-risk surgery.

Noordzij et al concluded that preoperative ECG provides prognostic information in addition to clinical characteristics and the type of surgery. However, the usefulness of routine ECG testing in lower risk surgery is questionable. [31]

According to 2007 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines, routine ECG is not recommended in asymptomatic patients without any clinical risk factors who are to undergo a low-risk surgery. However, ECG is reasonable in patients undergoing a vascular surgery or intermediate-risk surgery with at least one risk factor.

The AHA recommends ECG in all severely obese patients (body mass index ≥40kg/m2) with at least one other risk factor. [32]

Chest radiography

The frequency of abnormal chest radiographic (CXR) findings increases with age. One study showed that 0.3% of patients younger than 60 years had unsuspected abnormal CXR results or clinical findings suggestive of underlying cardiac or pulmonary disease as compared with 22% of patients older than 60 years. [33] In addition, one report demonstrated that CXRs in patients with congestive heart failure (CHF) does not independently add to the risk of perioperative mortality and morbidity. The AHA recommends CXR to assess for heart failure and chamber enlargement in severely obese patients (body mass index ≥ 40kg/m2). [32]

A meta-analysis of 21 studies that included 14,390 routine CXR showed that only 140 of 1444 abnormal results were not clinically expected and that only 14 affected physicians’ decisions in managing their patients. [34] Accordingly, routine CXR is recommended only for patients older than 60-70 years unless underlying heart or lung disease is a possibility. [35, 36]

Routine preoperative testing (preoperative screening) of healthy people undergoing elective surgery is not recommended. Instead, a selective strategy, as outlined above, is safe and cost-effective as long as a complete history and physical examination are obtained. Based on the available evidence, the authors recommend the following preoperative tests:

Hemoglobin level for major surgery with significant expected blood loss or in patients 65 years or older

Serum creatinine level for people older than 50 years

Pregnancy testing in all reproductive-age group women.

ECG in patients undergoing high-risk surgery (eg, vascular surgery) or intermediate-risk surgery and with at least one risk factor

CXR in patients older than 60 years

No laboratory test must be repeated if results were normal within 4 months of the surgery and no change in the patient’s clinical status occurred.

Finally, this strategy applies only to healthy, asymptomatic patients undergoing elective surgery. Patients with suspected pulmonary or cardiac disease or those undergoing urgent operation require additional evaluation that is beyond the scope of this article. 

In general, routine preoperative testing does not provide significant incremental value in healthy adults. More studies are needed in this area to evaluate physician behavior and improve adherence to guidelines and reduce cost of unnecessary workup. 

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Gyanendra K Sharma, MD, FACC, FASE Professor of Medicine and Radiology, Director, Adult Echocardiography Laboratory, Section of Cardiology, Medical College of Georgia at Augusta University

Gyanendra K Sharma, MD, FACC, FASE is a member of the following medical societies: American Association of Cardiologists of Indian Origin, American Association of Physicians of Indian Origin, American College of Cardiology, American Society of Echocardiography, Society for Cardiovascular Magnetic Resonance, Society of Cardiovascular Computed Tomography

Disclosure: Nothing to disclose.

Saroj Bala Sharma, MD Assistant Professor of Medicine, Department of Internal Medicine, Medical College of Georgia

Saroj Bala Sharma, MD is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Donna Leco Mercado, MD, MD 

Donna Leco Mercado, MD, MD is a member of the following medical societies: Sigma Xi

Disclosure: Nothing to disclose.

William A Schwer, MD Professor, Department of Family Medicine, Rush Medical College; Chairman, Department of Family Medicine, Rush-Presbyterian-St Luke’s Medical Center

William A Schwer, MD is a member of the following medical societies: American Academy of Family Physicians

Disclosure: Nothing to disclose.

Juan B Ochoa, MD Assistant Professor, Department of Surgery, University of Pittsburgh School of Medicine; Medical and Scientific Director, HCN, Nestle Healthcare Nutrition

Disclosure: Nothing to disclose.

Wassim H Shaheen, MD Staff Physician, Department of Internal Medicine, Wesley Medical Center

Wassim H Shaheen, MD is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

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