Preoperative screening

Surgery and hemostasis

PURPOSE OF REVIEW

Blood coagulation exists to halt excessive blood loss. It is paradoxical that surgery and trauma simultaneously represent major risk factors for both hemorrhagic and thrombotic complications. A summary of the available evidence used to guide contemporary approaches to perioperative care will be reviewed.

RECENT FINDINGS

Although the advent of factor-specific products has safely allowed for intervention on patients with congenital hemostatic defects, the presence of an increasingly complex surgical population (chronic liver disease, traumatic injuries, and requirements for chronic anticoagulation) has renewed concerns about hemorrhagic risks. However, the past three decades of clinical sciences have supported a re-emphasis on the prevention of venous thromboembolism (VTE), a major cause of morbidity and mortality in hospitalized surgical patients. There is now an abundance of data confirming the robust risk:benefit ratio of antithrombotic prophylaxis in the vast majority of surgical patients, regardless of their medical comorbidities.

SUMMARY

Perioperative hemorrhage is a natural risk of any surgical intervention and deserves careful evaluation and prompt intervention. However, in order to support ongoing efforts in the prevention of medical errors, the application of evidence-based guidelines for the prophylaxis of VTE in surgical patients must become a standard part of daily practice.

Frailty is associated with postoperative complications in older adults with medical problems

We sought to test whether frailty may be predictive of operative risk in older adults with medical problems. One hundred and twenty-five patients at least 70 years of age had a previously developed frailty screen, the Edmonton Frail Scale (EFS), administered at a pre-surgical clinic, prior to elective non-cardiac surgery. A blinded chart audit assessed for postoperative medical complications, length of stay and inability to be discharged home. The mean age of patients was 77 (range 70-92) and most (82%) underwent orthopedic procedures. Increasing frailty was associated with postoperative complications (p=0.02), increased length of hospitalization (p=0.004) and inability to be discharged home (p=0.01), independent of age. EFS scores of 3 or less were associated with a lower risk of having a complication (age-adjusted OR 0.27, 95% CI 0.09-0.80, likelihood ratio of 0.33) and a higher chance (80%) of being discharged home (p<0.02). EFS scores exceeding 7 were associated with increased complications (OR 5.02, 95% CI 1.55-16.25, likelihood ratio of 3.9) and a lower chance of being discharged home (40%, p<0.02). This study suggests that a frailty screen can refine risk estimates of postoperative complications in older adults undergoing elective non-cardiac surgery.

To bleed or not to bleed? Is that the question for the PTT?

The activated partial thromboplastin time (PTT) is the grandchild of the Lee-White whole blood clot time (WBCT). Both tests were developed to assist the diagnostic process for patients who exhibited features consistent with hemophilia, i.e., the pretest probability was extremely high. Probably <0.1%-1.0% of PTTs ordered in current medical practice fit that indication with the most common indication now being routine admission order; i.e., a pretest probability that is extremely low. The question asked of the PTT has evolved from 'why does this patient bleed?' to 'will this patient bleed?' As the PTT was never intended to answer that question, one must be careful regarding interpretation of results of that test. As many situations not related to hemorrhage are associated with perturbations of the PTT, a prolonged PTT is not strongly predictive of hemorrhage nor does a normal PTT provide shelter against hemorrhagic risk.

The Management of Postoperative Bleeding

This article addresses the management of postoperative bleeding. The problem is called postoperative bleeding rather than postoperative hemorrhage to emphasize the fact that perfect postoperative hemostasis rather than acceptable postoperative blood loss is the ideal. Postoperative bleeding is a risk of all surgical procedures. The best way to reduce the risk of hemorrhage is to identify and correct potential causes of coagulopathy both pre- and post-operatively.

The Prevalence and Significance of Low Preoperative Hemoglobin in ASA 1 or 2 Outpatient Surgery Candidates

Asymptomatic anemia in healthy patients undergoing low risk surgery is rare. In this retrospective study, we examined the records of 9584 ASA class I-II patients scheduled for elective low risk surgery who had a preoperative hemoglobin (hgb) test for the presence of anemia. Hgb <9 g/dL was detected in 75 patients (0.8%). Perioperative management of anemia occurred in no cases of elective surgery in this group. Transfusion of red cells occurred in four other patients, all of whom had hgb >9 g/dL. In all cases, management decisions were based on clinical factors rather than the preoperative hemoglobin test. In healthy patients undergoing low risk elective surgery, routine preoperative hgb testing is not indicated.

Efecto de la adscripción de internistas a un servicio quirúrgico

BACKGROUND AND OBJECTIVE

Although surgical units commonly request the collaboration of internists via medical consultation, the efficiency of this system is low and expensive. We studied the effect of the integration of full-time internists in a surgical department.

PATIENTS AND METHOD

The study group consisted of the patients admitted during intervention in the Orthopedic Surgery and Traumatology Department. Those patients admitted during the same period of the previous year made up the control group. We analyzed pre-surgical stay, post-surgical stay and total stay. We also studied in-hospital mortality, re-admissions and those patients who were not submitted to surgery (NSS). Control variables were age, sex, type of admission (programmed/emergency) and main diagnosis.

RESULTS

1,216 patients were included, 599 in the control group and 617 in the study group, 48.0% were emergency admissions and 11.7% NSS patients. Study of programmed patients did not suggest any differences between both groups in any of the analyzed variables. In emergency patients, the total stay was decreased in 18.2%, and it was reduced in 40.2% of the NSS. The distribution of the re-admissions was similar in both study and control groups. We observed a decrease in the NSS and a 50% decrease in the deaths of the study group. The obtained saving was 329,170 Euros.

CONCLUSIONS

The adscription of full-time internists to a surgical service clearly improves the quality of the service it provides, with important hospital savings.

Implementation and evaluation of guidelines for preoperative testing in a tertiary hospital

The aim of this study was to determine the extent of unnecessary investigation performed as part of the preoperative preparation of elective surgical patients in a teaching hospital and to audit the effect of guidelines and education designed to reduce unnecessary investigation. Guidelines were developed for preoperative anaesthetic investigation for elective surgical procedures in patients over one year of age according to internationally accepted criteria, with some adjustment for local differences in patient morbidity. Forrms outlining these criteria were placed in all operating theatres and anaesthetists were asked to determine whether tests performed were indicated or not, according to these criteria, over a two-week period, in each patient undergoing elective surgery. Tests indicated for surgical reasons were excluded. These same guidelines were then issued to all surgical departments along with explanatory lectures. The audit was repeated six months later and results compared. The incidence of over-investigation decreased from 13.8% to 11.6% (P = 0.03) without a significant increase in under-investigation (0.7 v 1.0%; P = 0.2). This study highlights the incidence of unwarranted screening tests in patients presenting for elective surgery and the role of protocols and ongoing education in reducing this incidence.