Routine preoperative tests for elective surgery: summary of updated NICE guidance

O’Neill, Frank J.; Carter, Eleanor; Pink, Natalie; Smith, Ian

doi:10.1136/bmj.i3292

Cited by 58 publications

(57 citation statements)

References 5 publications

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“…Interventional studies are required to elucidate whether prevention of new-onset POAF can improve long-term outcomes. [24].…”

Section: Discussionmentioning

confidence: 99%

“…Baseline data included demographic variables (age, sex, body mass index), surgical diagnosis, preoperative comorbidities (chronic heart failure, hypertension, coronary heart disease, diabetes mellitus, chronic obstructive pulmonary disease, asthma, chronic renal failure and non-AF arrhythmia), main results of preoperative examination (including echocardiogram), and American Society of Anesthesiologist (ASA) classification. Perioperative data included type and duration of surgery, complexity [24] and cardiac risk [25] , which might be combined with other diseases. Non-fatal cardiac arrest (I46.9) referred to cardiac arrest (ventricular fibrillation, pulseless ventricular tachycardia, asystole, and pulseless electrical activity) caused by various reasons, followed by return of spontaneous circulation after cardiopulmonary resuscitation (CPR), and patient survived.…”

Section: Collection Of Baseline and Perioperative Datamentioning

confidence: 99%

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New-onset postoperative atrial fibrillation is associated with worse long-term outcome in critically ill patients after non-cardiac surgery: 3-year follow-up of a case-control study

Xie

Pan

et al. 2019

Preprint

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Background The impact of new-onset postoperative atrial fibrillation (POAF) on long-term outcomes of patients after non-cardiac surgery remains controversial. Here we report the 3-year follow-up of a previous case-control study to determine the relationship between new-onset POAF and long-term outcomes in patients after non-cardiac surgery. Methods In a previous case-control study, 213 patients who were admitted to the intensive care unit (ICU) after non-cardiac surgery were included; of them 71 were in the POAF group and 142 the control group. A telephone interview was performed with patients or their family members at 3 years after surgery. The primary endpoint was the incidence of major adverse cardiovascular events (MACEs) within 3 years, including cardiovascular death, non-fatal cardiac arrest, acute myocardial infarction, congestive heart failure, and ischemic stroke. A logistic regression model was established to assess the association between the occurrence of new-onset POAF and the development of 3-year MACEs. Results 202 patients completed the 3-year follow-up and were included in the analysis; of them 68 were in the POAF group and 134 were in the control group. The incidence of 3-year MACEs was higher in the POAF group than in the control group (64.7% [44/68] vs. 23.1% [31/134], p<0.001). After correction for confounding factors, new-onset POAF was independently associated with an increased risk of 3-year MACEs (odds ratio 5.448, 95% confidence interval 2.202-13.481, p<0.001). Conclusions For adult patients admitted to the ICU after non-cardiac surgery, new-onset POAF was an independent risk factor for the development of MACEs within 3 years.

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“…Interventional studies are required to elucidate whether prevention of new-onset POAF can improve long-term outcomes. [24].…”

Section: Discussionmentioning

confidence: 99%

Section: Collection Of Baseline and Perioperative Datamentioning

confidence: 99%

New-onset postoperative atrial fibrillation is associated with worse long-term outcome in critically ill patients after non-cardiac surgery: 3-year follow-up of a case-control study

Xie

Pan

et al. 2019

Preprint

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“…A very recent updated NICE (UK National Institute for Health and Clinical Excellence) guidance regarding routine POTs for elective surgery not only suggests including the results of tests undertaken in primary care when referring people for surgical consultation in order to avoid unnecessary repetition but emphasizes the lack of evidence that routine tests either improve or worsen postoperative outcome. More specifically, a systematic review of the literature has recommended avoiding routine coagulation screening before procedures to predict bleeding risk because unexpected coagulation defects are uncommon ( 3 ). In those cases, it is more preferable to review medical records looking for bleeding abnormalities.…”

Section: Discussionmentioning

confidence: 99%

“…In fact, its usefulness and cost-effectiveness have been questioned, as the probability of finding a significant abnormality is small ( 2 ). Besides, routine POTs rarely change management, involve a sizable cost and may cause harm to patients ( 3 ). We assume that a normal test value is set arbitrarily based on 95% confidence interval; therefore up to 5% of normal individuals may have a value outside of the reference interval.…”

Section: Introductionmentioning

confidence: 99%

Utility of routine laboratory preoperative tests based on previous results: Time to give up

et al. 2017

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IntroductionThe usefulness and cost-effectiveness of routine laboratory preoperative tests (POTs) have been challenged recently. In fact, the American Society of Anesthesiologists (ASA) Task Force has stated that test results obtained from the medical record within 6 months of surgery generally are mostly acceptable. The aim of our study was to evaluate the degree of utility of POTs and their clinical benefit based on this recommendation.Material and methodsWe studied retrospectively every routine POT request from 8 randomly selected weeks in 2016. Every POT contained glucose, creatinine, haemoglobin and coagulation tests (PT-INR). Each pathological result for these tests was registered and classified as “expected” (if previous pathological result within 6 months existed for that test) or “unexpected” (if previous pathological result within 6 months did not exist for that test). Results of ASA physical status classification (a system for assessing the fitness of patients before surgery) and changes in patient management after POTs were retrieved from medical history as well.ResultsA total of 4516 tests (from 1129 patients) were analysed and 498 results were found pathological (11%). Of these, 403 were expected (8.9%) and 95 unexpected (2.1%). There was not any change in anaesthetic management for any patient due to these findings.ConclusionsRoutine POTs are an inefficient and low-value service. POTs have to be always ordered selectively after a previous consideration of specific information obtained from several sources (medical records, interviews, examinations, type of surgery) and only if the information obtained will result in changes in the management of the patient.

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“…Investigations were classified as 'indicated' or 'unindicated' on the basis of the NICE guidelines. 5 The NICE guidelines are based on an algorithm which uses the ASA physical status classification along with the complexity of the surgery. Any investigations not indicated by NICE guidelines with documentation of a specific indication (e.g.…”

Section: Data Collectionmentioning

confidence: 99%

Over‐ordering of ultrasound and pre‐operative investigations for inguinal hernia repair at Northern Health: a Choosing Wisely audit

Chmiel

Pearson

Mori

2019

ANZ Journal of Surgery

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Background Choosing Wisely Australia is an initiative aimed at reducing the incidence of unnecessary investigations. This study is an audit of Northern Health's adherence to two Choosing Wisely recommendations in the context of inguinal hernia repair. Recommendation 1: Avoid routinely performing pre‐operative investigations in patients, but instead order in response to patient factors, signs and symptoms, disease or planned surgery. Recommendation 2: Do not order ultrasound for clinically apparent inguinal hernias. Methods Records of 264 patients who underwent elective inguinal hernia repair at Northern Health in 2016 were reviewed. Results Recommendation 1: Results demonstrated over‐ordering of coagulation studies. Thirty‐four percent of patients received coagulation studies, 86% of which were unindicated. There was better adherence to Choosing Wisely guidelines for other investigations: 38% of patients received a full blood examination (42% unindicated), 38% received a urea, electrolytes and creatinine (14% unindicated), 7% received a glycated haemaglobin (0% unindicated) and 38% received an electrocardiogram (11% unindicated). Recommendation 2: Seventy percent (n = 186) of patients received an ultrasound of which 25% (n = 46) had a documented indication. Correlation with surgical findings showed a positive predictive value of 95.6% and sensitivity of 97.8% for ultrasound. Conclusion Recommendation 1: Most pre‐operative coagulation studies were unindicated, while adherence to Choosing Wisely guidelines was better for pre‐operative full blood examination, urea, electrolytes and creatinine, glycated haemaglobin and electrocardiogram. Recommendation 2: The majority of patients received an inguinal hernia ultrasound, most of which had no documented indication.

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Routine preoperative tests for elective surgery: summary of updated NICE guidance

Cited by 58 publications

References 5 publications

New-onset postoperative atrial fibrillation is associated with worse long-term outcome in critically ill patients after non-cardiac surgery: 3-year follow-up of a case-control study

New-onset postoperative atrial fibrillation is associated with worse long-term outcome in critically ill patients after non-cardiac surgery: 3-year follow-up of a case-control study

Utility of routine laboratory preoperative tests based on previous results: Time to give up

Over‐ordering of ultrasound and pre‐operative investigations for inguinal hernia repair at Northern Health: a Choosing Wisely audit

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