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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

Debate on:PRE-OPERATIVE ROUTINE LABORATORY EXAMINATION

Cabahug, Martin Joseph

Cruz, Haidee

Gonzales, Roberto

Estonilo, Edwin

Gabrielle, Allan

Malabanan, Jonathan

routine test work up
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 .
slide4
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.
slide5
"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.
slide6
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.
slide7
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
slide9
The cost of inappropriate tests was estimated at $47 to $80 per patient. The authors emphasize the need of changingobsolete practices.
slide10
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.
slide11
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.
slide12
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.
slide13
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.
slide14
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

slide15
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%
slide16
White blood cells test / tests of coagulation/ serum biochemistry - rarely lead to changes in patient treatment
  • Urinalysis - 0.1% to 2.8%
slide17
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%.
slide18
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.
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