Does more testing in routine preoperative evaluation benefit the orthopedic patient? Case control study from a resource-constrained setting

Abstract

Background Routine preoperative tests in healthy patients not only cause extra anxiety, but may delay treatment without influencing surgical plan. This has worse impact in resource-constrained settings where fee for service rather than health insurance is the usual norm. Investigators aim to determine if “routine” pre-operative tests are justified in healthy orthopedic patients. Methods We conducted a non-commercialized, non-funded matched case control study in tertiary care university hospital and a level-1 trauma centre for healthy patients (ASA-1&2) admitted from January 2014–December 2016 for elective orthopedic intermediate and major procedures. Cases (patient who had a change in his/her surgical plan after admission) and controls were selected independently of the exposure of interest then matched randomly to cases on age, gender and procedure type. Primary exposure was the routine preoperative lab tests, as defined by the American Society of Anesthesiologist, which included 13 blood tests. Analysis was done using Principle Component Analysis and Conditional logistic regression at univariate and multivariable levels reporting matched adjusted Odds Ratios. The data was reported in line with STROCSS criteria. Results Overall, 7610 preoperative tests were done for 670 patients with 62% men among cases and 53% men among controls with mean age of 49.9 22.5 years and 41.1 23.0 years, respectively. There were 1076 (14%) abnormal result that influenced surgical plan in 0.96% cases only. Matched adjusted OR with 95% confidence interval of primary exposure was insignificant. Conclusion Routine preoperative tests were superfluous and did not influence the surgical plan when adjusted for other variables in the model as well as after matching on potential confounders. This study would be amongst first steps to move towards an evidence based surgical practice for preoperative evaluation.

Preoperative Investigations: Practice Guidelines from the Indian Society of Anaesthesiologists

“…Literature review regarding complete blood count (CBC) revealed that some of the available studies had tested individual components of CBC, that is, haemoglobin or haematocrit, total and differential leukocyte count and platelet count, while others had tested CBC as a whole. [ 3 11 12 13 19 20 21 22 23 24 ]…”

“…Anaemia is a global health issue with a prevalence rate of approximately 14% in ASA PS 1 and 2 preoperative patients. [ 3 11 12 13 19 20 21 22 23 24 25 26 27 ] This can contribute to adverse events such as tachycardia, arrhythmias, increased risk of infection, heart failure in the perioperative period. It can also contribute to increased duration of hospital stay, rates of intensive care admission and blood transfusion, which carry their own associated risks.…”

“…Nine studies (n = 27697) tested the effects of preoperative haemoglobin/haematocrit on immediate perioperative outcomes [ Table 4 ]. [ 3 11 12 13 19 20 21 22 23 ] Most studies included combinations of minor, intermediate and major surgeries. Review of evidence indicates the need for haemoglobin testing preoperatively in patients scheduled for intermediate to major surgeries.…”

“…Out of the 11 available studies [ Table 4 ],[ 3 11 12 13 20 21 23 24 29 30 31 ] 9 studies estimated serum creatinine. [ 3 11 12 13 20 21 24 30 31 ] Two studies involving intermediate surgeries (n = 21165) and one study (n = 670) involving intermediate and major surgeries showed abnormal creatinine to have no influence on outcomes.…”

“…Out of the 11 available studies [ Table 4 ],[ 3 11 12 13 20 21 23 24 29 30 31 ] 9 studies estimated serum creatinine. [ 3 11 12 13 20 21 24 30 31 ] Two studies involving intermediate surgeries (n = 21165) and one study (n = 670) involving intermediate and major surgeries showed abnormal creatinine to have no influence on outcomes. [ 11 20 23 ] Six studies (n = 3547) involving all three surgery categories, showed adverse outcomes in 18 patients having high preoperative serum creatinine levels.…”