Usefulness of routine pre-operative chest radiography for anaesthetic management: a prospective multicentre pilot study

Factors influencing preoperative chest radiography request for elective endoscopic procedures among medical personnel

Background

Chest radiography is not routinely recommended before elective endoscopies. A high incidence of perioperative chest radiography requests was observed at our institution. This study aims to investigate factors influencing preoperative chest radiography request for patients undergoing elective gastrointestinal (GI) endoscopies.

Methods

This cross-sectional clinical study recruited 264 participants from different medical specialties who were responsible for preoperative endoscopic chest x-ray (CXR) ordering including anesthesiologists, surgeons and gastroenterologists. They completed questionnaires exploring their general knowledge and attitudes about preoperative chest radiography. Demographic characteristic of the participants affecting the knowledge on preoperative chest radiography was determined. A Structural Equation Model (SEM) was constructed from validated conceptual framework to find causal relationships between hypothesized factors and intention for preoperative endoscopic chest radiography request. Statistical analyses were performed using the SPSS software version 18.0 and Analysis of Moment Structures (AMOS) version 18.0.

Results

The questionnaire response rate was 53.79%. Baseline general knowledge on preoperative chest radiography of the participants was comparable. The SEM results showed unsupported relationship between hypothesized factors and the intention for preprocedural GI endoscopic CXR request (p < 0.1).

Conclusions

General knowledge of medical personnel on tuberculosis needs improvement. To rectify the unnecessary chest radiography request before elective GI endoscopic procedures, awareness of the patients’ health conditions, adherence to the hospital’s policy and realizing of possible patient-related mishaps are not the determinants for preprocedural endoscopic chest radiography request. Future works are required to explore other alternative factors involved for reducing chest radiography requests which are not indicated.

Perioperative Management of the Rheumatoid Patient

Rheumatoid arthritis is a complex disease state with multiple associated comorbidities. Perioperative evaluation of the rheumatoid patient from a multidisciplinary approach is necessary to achieve favorable outcomes. A complete history and physical, laboratory, cervical, cardiovascular, pulmonary, and medication assessment before surgery should be performed. Educating the patient on potential complications, such as wound dehiscence, infection, and venous thromboembolism, as well as general postoperative expectations, is essential when evaluating the rheumatoid patient for surgery.

Prevalence and predictors of myocardial ischemia by preoperative myocardial perfusion single photon emission computed tomography in patients undergoing noncardiac surgery

BACKGROUND

The prevalence and predictors of myocardial ischemia before noncardiac surgery are unknown. In addition the predictive value of myocardial perfusion single-photon emission computed tomography (SPECT) before noncardiac in individual patients is uncertain.

OBJECTIVE

Evaluate the prevalence and predictors of myocardial ischemia before noncardiac surgery, and determine the postoperative cardiac outcome based on results of myocardial perfusion SPECT.

DESIGN

Retrospective.

SETTING

Single tertiary care center.

PATIENTS AND METHODS

We reviewed the records of adult patients diagnosed with myocardial ischemia by myocardial perfusion SPECT who were undergoing noncardiac surgery. Myocardial perfusion SPECT had been performed within 4 weeks prior to noncardiac surgery requiring general anesthesia.

MAIN OUTCOME MEASURES

Prevalence of abnormal myocardial perfusion SPECT results on preoperative evaluation; abnormal myocardial perfusion SPECT results as a predictor for postoperative cardiac events such as cardiac death, nonfatal myocardial infarction, and unstable angina.

RESULTS

Of 131 patients who underwent noncardiac surgery from February 2015 to April 2016, 84 (64%) patients were female and the mean (SD) age was 64.1 (13.6) years. The prevalence of abnormal myocardial perfusion SPECT was 18% (24 of 131). Normal myocardial perfusion SPECT was highly predictive (up to 100%), but a positive myocardial perfusion SPECT had low positive predictive value (4%). Variables associated with an abnormal myocardial perfusion SPECT included ischemic heart disease, congestive heart failure, ASA score of 3 or more, limited exercise capacity (less than 4 METs), male sex, hypercholesterolemia, hypertension, smoking, and abnormal ECG. In a multivariable analysis, history of ischemic heart disease and history of smoking were significant predictors of abnormal myocardial perfusion SPECT (P=.001, and .029, respectively).

CONCLUSIONS

Because of the low positive predictive value of myocardial perfusion SPECT, utilization of the technique in the workup of cardiac patients undergoing noncardiac surgery has been inappropriate. Myocardial perfusion SPECT should be restricted to only clearly defined appropriate use criteria.

LIMITATIONS

Relatively small number of patients and retrospective design.

Pre-operative laboratory testing: A prospective study on comparison and cost analysis

Background and Aims:

Pre-operative investigations are performed before any surgical intervention under anaesthesia. Many are considered as routine. However, there are no clear guidelines regarding these in India. We aim to look at the relevance of the laboratory investigations ordered routinely and their cost implications compared with the National Institute of Clinical Excellence (NICE) guidelines.

Methods:

This prospective study was carried out at a tertiary care hospital. A total of 163 patients scheduled for elective surgical procedures were included in this study. Neither the surgeons nor anaesthesiologists involved in the case were aware of the study. The laboratory investigations of the patients who underwent surgery were noted. All values were categorised as normal or abnormal and they were assessed as indicated or unindicated based on NICE guidelines.

Results:

One hundred and sixty-three patients were subjected to a total of 984 tests. Forty three patients (26%) were subjected to tests as per NICE guidelines. Of the 984 tests, 515 tests were unindicated (52%). Out of the 515 unindicated tests, 7 (1.3%) were abnormal. None of these seven tests required any intervention or change of anaesthetic plan. The most common unindicated tests done were cardiac echocardiography and chest X-ray (92.5% and 93% respectively). The additional cost incurred towards unindicated tests was 63% of the total cost for the tests.

Conclusion:

Pre-operative laboratory investigations add to cost significantly. Patient premorbid conditions and surgical grade should guide the clinician to request for the relevant laboratory tests.

Preoperative tests recommendations in adult patients for ambulatory surgery

Anesthetic assessment traditionally included a series of laboratory tests intended to detect undiagnosed diseases, and to ensure that the patient undergoes surgery following safety criteria. These tests, without a specific clinical indication, are expensive, of questionable diagnostic value and often useless. In the context of outpatient surgery, recent evidence suggests that patients of any age without significant comorbidity, ASA physical status gradei and grade ii, do not need additional preoperative tests routinely. The aim of the present recommendations is to determine the general indications in which these tests should be performed in ASA gradei and grade ii patients undergoing ambulatory surgery.

Perioperative management of patients with rheumatic diseases

This paper aims to explore the assessment of patients with rheumatologic diseases, especially rheumatoid arthritis (RA), before undergoing orthopedic surgery. Perioperative assessment ensures an early diagnosis of the patient's medical condition, overall health, medical co-morbidities, and the assessment of the risk factors associated with the proposed procedures. Perioperative assessment allows for proper postoperative management of complications and of the management of drugs such as disease-modifying anti-rheumatic drugs (DMARD) and anti-platelets, and corticosteroids. The assessment also supports follow up plans, and patient education. Perioperative assessment enables the discussion of the proposed treatment plans and the factors associated with them in each case among the different specialists involved to facilitate an appropriate early decision-making about the assessment and treatment of patients with rheumatologic diseases. It also enables the discussion of both condition and procedure with the patient to ensure a good postoperative care. The article identifies the components of perioperative medical evaluation, discusses perioperative management of co-morbidities and the management of specific clinical problems related to RA, systemic lupus erythematosus, the management of DMARDs, like methotrexate (MTX) and biologic therapies, prophylactic antibiotics, and postoperative follow up, including patient education and rehabilitation.

Role of routine laboratory investigations in preoperative evaluation

Traditionally, routine investigations prior to surgery are considered an important element of preanesthetic evaluation to determine the fitness for anesthesia and surgery. During past few decades this practice has been a subject of close scrutiny due to low yield and high aggregate cost. Performing routine screening tests in patients who are otherwise healthy is invariably of little value in detecting diseases and in changing the anesthetic management or outcome. Thorough history and investigation of positive answers by the clinicians, combined with physical examination of patient represents the best method for screening diseases followed by few selective tests as guided by patient's health condition, invasiveness of planned surgery and potential for blood loss. A large number of investigations which are costly to pursue often detect minor abnormalities of no clinical relevance, may be risky to patients, cause unnecessary delay or cancellation of surgery, and increase medico-legal liability. An approach of selective testing reduces cost without sacrificing safety or quality of surgical care.

[Utility of preoperative chest radiography in smokers undergoing transurethral resection of urinary bladder tumors]

OBJECTIVES

To assess the utility of preoperative chest radiographic findings for predicting cardiopulmonary complications in smokers undergoing transurethral resection of urinary bladder tumors under spinal anesthesia. To analyze perioperative changes in attitude in this setting.

MATERIAL AND METHODS

Prospective study of 309 smokers with > or = 20 pack-years of cumulative smoking who were candidates for transurethral resection of urinary bladder tumors. The patients were classified in 2 groups according to radiographic findings. Between groups we compared the incidence of cardiopulmonary complications, perioperative changes in attitude to anesthesia and surgery, delays in completing the preanesthesia workup, and differences in the duration of surgery and hospital stay.

RESULTS

Patients older than 65 years were 1.92 times more likely to have significant findings on the chest radiograph. Radiographic findings were associated with a higher incidence of perioperative complications (P=.02), need for further preoperative consultations (P<.01), longer delay in completing the preanesthesia study (P<.01), longer mean (SD) hospital stay (3.43 [3.17] days vs 2.50 [1.77] days, P<.001), and longer duration of surgery (P<.001). Attitudes did not change in relation to radiographic findings during or after surgery. Chest radiography correctly classified 3.54% of the patients with complications (predictive value).

CONCLUSIONS

The predictive value of chest radiography for cardiopulmonary complications is low and findings do not influence intra- or postoperative attitudes. We therefore find no justification for performing chest x-rays in the population studied.

Evaluating effectiveness of preoperative testing procedure: some notes on modelling strategies in multi-centre surveys

Rationale In technology assessment in health-related fields the construction of a model for interpreting the economic implications of the introduction of a technology is only a part of the problem. The most important part is often the formulation of a model that can be used for selecting patients to submit to the new cost-saving procedure or medical strategy. The model is usually complicated by the fact that data are often non-homogeneous with respect to some uncontrolled variables and are correlated. The most typical example is the so-called hospital effect in multi-centre studies.

AIMS AND OBJECTIVES

We show the implications derived by different choices in modelling strategies when evaluating the usefulness of preoperative chest radiography, an exam performed before surgery, usually with the aim to detect unsuspected abnormalities that could influence the anaesthetic management and/or surgical plan.

METHOD

We analyze the data from a multi-centre study including more than 7000 patients. We use about 6000 patients to fit regression models using both a population averaged and a subject-specific approach. We explore the limitations of these models when used for predictive purposes using a validation set of more than 1000 patients.

RESULTS

We show the importance of taking into account the heterogeneity among observations and the correlation structure of the data and propose an approach for integrating a population-averaged and subject specific approach into a single modeling strategy. We find that the hospital represents an important variable causing heterogeneity that influences the probability of a useful POCR.

CONCLUSIONS

We find that starting with a marginal model, evaluating the shrinkage effect and eventually move to a more detailed model for the heterogeneity is preferable. This kind of flexible approach seems to be more informative at various phases of the model-building strategy.

The value of screening preoperative chest x-rays: a systematic review

PURPOSE

Chest x-ray (CXR) is the most frequently ordered radiological test in Canada. Despite published guidelines, variable policies exist amongst different hospitals for ordering of preoperative CXRs. The purpose of this study was to systematically review the literature on the value of screening CXRs and establish evidence to support guidelines for the use of preoperative screening CXRs.

SOURCE

Medline and Embase were searched under set terms for all English language articles published during 1966-2004. All eligible studies were reviewed and data were extracted individually by two authors. Of the 513 articles identified, 14 studies met both inclusion and exclusion criteria.

PRINCIPAL FINDINGS

The quality of published evidence was modest as only six of the studies were rated as fair and eight as poor. Of the reported studies, diagnostic yield increased with age. However, most of the abnormalities consisted of chronic disorders such as cardiomegaly and chronic obstructive pulmonary disease (up to 65%). The rate of subsequent investigations was highly variable (4-47%). When further investigations were performed, the proportion of patients who had a change in management was low (10% of investigated patients). Postoperative pulmonary complications were also similar between patients who had preoperative CXRs (12.8%) and patients who did not (16%).

CONCLUSION

An association between preoperative screening CXRs and decrease in morbidity or mortality could not be established. As the prevalence of CXR abnormalities is low in patients under the age of 70, there is fair evidence that routine CXRs should not be performed for patients in this age group without risk factors. For patients over 70, there is insufficient evidence for or against performance of routine CXRs. The current recommendation from the Guidelines Association Committee that routine CXRs should not be performed for patients over 70 without risk factors is supported by this study.

Extensive preoperative testing is not necessary in morbidly obese patients undergoing gastric bypass

Morbidly obese patients are considered at high risk for perioperative complications and often undergo extensive testing for preoperative clearance. We analyzed prospectively collected data from 193 patients undergoing weight loss surgery between November 2000 and November 2002. Preoperative chest x-ray examination, pulmonary function tests, noninvasive cardiac testing, and blood work were performed routinely. Preoperative testing identified abnormalities on eight chest x-ray films (4%) and 29 electrocardiograms (15%), none of which required preoperative intervention. Spirometry was abnormal in 41 patients (21%); logistic regression identified preexisting asthma as predictive of obstructive physiology (odds ratio [OR] 3.3; 95% confidence interval [CI] 1.2 to 8.9), and body mass index as predictive of restrictive physiology (OR 1.1; 95% CI 1.01 to 1.2). Arterial blood gases identified only one case of severe hypoxemia requiring intervention. Mild hypoxemia was associated with increasing age (OR 14.5; 95% CI 1.8 to 114). Echocardiography demonstrated four abnormalities (2%); previous history of cardiac disease was the only risk factor (OR 14.5; 95% CI 1.8 to 114). Complete blood count did not identify 84% and 50% of the patients with iron (n=31) and vitamin B(12) (n=12) deficiencies, respectively. Age, body mass index, and history of asthma were associated with abnormal pulmonary function tests and previous cardiac disease with abnormal cardiac testing. These tests are not mandatory as a routine preoperative evaluation and can be used selectively on the basis of medical history.

Preoperative assessment

Although anaesthetic and surgical procedures should be individualised for every patient, in practice many preoperative protocols and routines are used generally. In this article, we aim to emphasise: why preoperative assessment is important; how it should be done, and by whom; what can be expected; and the importance of test selection based on patients' needs and on scientific evidence of effectiveness. We outline the roles of preoperative medical assessment in otherwise healthy patients. Clinical history, preoperative questionnaires, physical examination, routine tests, individual risk-assessment, and fasting policies are investigated by review of published work. Cost of routine preoperative assessment, the anaesthetist's legal responsibility, and patients'views in the preoperative process are also considered. A thorough clinical preoperative assessment of the patient is more important than routine preoperative tests, which should be requested only when justified by clinical indications. Moreover, this practice eliminates unnecessary cost without compromising the safety and quality of care. Education and training of medical doctors should be more scientifically guided, emphasising the relevance of effectiveness, and cost-effectiveness in clinical decision-making and complemented by audit.

The case against routine preoperative laboratory testing

In this article, we have shown that almost all "routine" laboratory tests before surgery have limited clinical value. Clinicians should order only a small number of routine tests based on age as noted in Table 13. Selective use of other preoperative tests should be based on history and physical examination findings that identify subgroups of patients who are more likely to have abnormal results. In general, clinicians should order tests only if the outcome of an abnormal test will influence management. When an abnormal test results from such testing, it is critical that physicians document their thinking about the result. Most routine preoperative tests are neither expensive nor risky. For this reason, clinicians can have a low threshold for ordering these tests in patients for whom the frequency of abnormalities is increased compared with a healthy population. We believe that physicians should not be criticized for selective test ordering before surgery. Physicians and institutions recommending routine preoperative testing for all patients provide no clinical value to their patients at considerable cost.

Economics of preoperative evaluation clinics

Studies continue to support that a process for screening patients prior to their planned anesthesia and surgery can optimize both the status of the patient, decreasing delays and cancellations, and optimize the use of resources, ensuring that needed testing is completed and unneeded testing is avoided.