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Debate on: PRE-OPERATIVE ROUTINE LABORATORY EXAMINATION. Cabahug , Martin Joseph Cruz, Haidee Gonzales, Roberto Estonilo , Edwin Gabrielle, Allan Malabanan , Jonathan. ROUTINE TEST/WORK-UP.

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debate on pre operative routine laboratory examination


Cabahug, Martin Joseph

Cruz, Haidee

Gonzales, Roberto

Estonilo, Edwin

Gabrielle, Allan

Malabanan, Jonathan

routine test work up
  • Those that are performed in apparently healthy individuals without indications from patient's clinical history and examination.
practice point
Practice Point
  • Routine preoperative screening of healthy patients undergoing elective surgery is ineffective, costly and may harm patients .
  • Assessments provide an opportunity to reduce perioperative morbidity .
  • Investigations can only be complimentary to and cannot replace a good clinical history and physical examination .
  • Although screening patients to uncover occult disease appears logical, in reality it has resulted in excessive expenditure with limited benefit.
  • Especially in a developing country like ours where the majority of the population is not covered by medical insurance  cost factors to the patient should be of major consideration .
Shortcomings of doing routine laboratory test on healthy individuals without co-morbidities prior to an elective operation:
  • They can detect abnormalities which may not necessarily improve patient care or outcome.
  • Can be inefficient in screening asymptomatic diseases e.g.: normal ECG does not preclude IHD.
  • Unnecessary testing  may lead physician to pursue and treat borderline and false positive lab abnormalities .
  • Unnecessary tests can increase cost to the patient.
  • Medico-legal liability.
"Routine" preoperative studies. Which studies in which patients?Marcello PW, Roberts PL. SurgClin North Am 1996 Feb;76(1):11-23
  • 60% of routine tests conducted on patients in preparation of their surgery are unnecessary and add an extra $18 billion to the annual health care bill.
In addition, unnecessary tests cause harm resulting from complications associated with the testing procedure, or with the unnecessary treatment of patients who receive a false positive test result.
Unnecessary preoperative investigations: evaluation and cost analysis.Allison JG, Bromley HR. Am Surg 1996 Aug;62(8):686-9
  • Results of this study indicate that two-thirds of the tests patients undergo in preparation of their surgery are UNNECESSARY
The cost of inappropriate tests was estimated at $47 to $80 per patient. The authors emphasize the need of changingobsolete practices.
Value of routine preoperative chest x-rays: a meta-analysis.Archer C, Levy AR, McGregor M. Can J Anaesth 1993 Nov;40(11):1022-7
  • The results of this meta-analysis indicate that only 0.1% of pre-operative chest x-rays that are routinely performed on European and North American patients provide information that affects patient treatment.
On average, routine pre-operative chest x-rays detected abnormalities in 10% of patients. Only in 1.3% of films, though, the abnormality was unexpected, but its finding resulted in a change of treatment in only 0.1 of patients.
The authors concluded that the costs of routine chest x-rays are so high, and the likely benefits so small, that its use is no longer justified in patients who have received a careful anamnesis and clinical evaluation.
Routine preoperative testing: a systematic review of the evidenceMunro J, Booth A, Nicholl J. Health Technol Assess 1997;1(12):i-iv; 1-62

Value of different routine pre-operative tests:

  • Chest x-ray - the results of performing routine pre-operative tests lead to a change in clinical patient management in 0% to 2.1% of patients.
The following are Royal College Of Radiologists Recommendations For Use Of Preoperative Chest Radiograms:

1. Patients  with  acute respiratory infections. 2. Patients  with possible  metastasis. 3. Patients with suspected or established cardio-respiratory disease  who have not had a chest radiograph in the last twelve  months. 4. Recent immigration from countries with T.B. who have not had  chest  X RAY in previous twelve months.

5. Trauma

Electrocardiography - 0% to 2.2% . Routine preoperative ECG'S are unnecessary in children unless there are clinical symptoms of heart diseases or heart disease is suspected.
  • Complete blood count - 0.1% to 2.7%
White blood cells test / tests of coagulation/ serum biochemistry - rarely lead to changes in patient treatment
  • Urinalysis - 0.1% to 2.8%
Preoperative laboratory testing: should any tests be "routine" before surgery?Macpherson DS. Med Clin North Am 1993 Mar;77(2):289-308
  • Any routine test performed in patients admitted for elective surgery is unjustified, since the percentage of patients who will have abnormal test results is about 0.1-2%.
There is little evidence indicating that the abnormality detected by the test will have an adverse impact on the surgery.
  • Unnecessary testing may lead physicians to pursue and treatborderline and false-positive laboratory abnormalities.