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Richburg CE, Pesavento CM, Vastardis A, Antunez AG, Gavrila V, Cuttitta A, Nathan H, Byrnes ME, Dossett LA. Targets for De-implementation of Unnecessary Testing Before Low-Risk Surgery: A Qualitative Study. J Surg Res 2024; 293:28-36. [PMID: 37703701 DOI: 10.1016/j.jss.2023.07.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 07/10/2023] [Accepted: 07/25/2023] [Indexed: 09/15/2023]
Abstract
INTRODUCTION Despite multispecialty recommendations to avoid routine preoperative testing before low-risk surgery, the practice remains common and de-implementation has proven difficult. The goal of this study as to elicit determinants of unnecessary testing before low-risk surgery to inform de-implementation efforts. METHODS We conducted focused ethnography at a large academic institution, including semi-structured interviews and direct observations at two preoperative evaluation clinics and one outpatient surgery center. Themes were identified through narrative thematic analysis and mapped to a comprehensive and integrated checklist of determinants of practice, the Tailored Implementation for Chronic Diseases framework (TICD). RESULTS Thirty individuals participated (surgeons, anesthesiologists, primary care physicians, physician assistants, nurses, and medical assistants). Three themes were identified: (1) Shared Values (TICD Social, Political, and Legal Factors), (2) Gaps in Knowledge (TICD Individual Health Professional Factors, Guideline Factors), and (3) Communication Breakdown (TICD Professional Interactions, Incentives and Resources, Capacity for Organizational Change). Shared Values describe core tenets expressed by all groups of clinicians, namely prioritizing patient safety and utilizing evidence-based medicine. Clinicians had Gaps in Knowledge related to existing data and preoperative testing recommendations. Communication Breakdowns within interdisciplinary teams resulted in unnecessary testing ordered to meet perceived expectations of other providers. CONCLUSIONS Clinicians have knowledge gaps related to preoperative testing recommendations and may be amenable to de-implementation efforts and educational interventions. Consensus guidelines may streamline interdisciplinary communication by clarifying interdisciplinary needs and reducing testing ordered to meet perceived expectations of other clinicians.
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Affiliation(s)
- Caroline E Richburg
- University of Michigan Medical School, Ann Arbor, Michigan; National Institute of Health Short-Term Biomedical Research Training Program, Bethesda, Maryland
| | - Cecilia M Pesavento
- University of Michigan Medical School, Ann Arbor, Michigan; National Institute of Health Short-Term Biomedical Research Training Program, Bethesda, Maryland
| | - Andrew Vastardis
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Alexis G Antunez
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Valerie Gavrila
- University of Michigan Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
| | - Anthony Cuttitta
- University of Michigan Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
| | - Hari Nathan
- Department of Surgery, University of Michigan, Ann Arbor, Michigan; University of Michigan Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
| | - Mary E Byrnes
- Department of Surgery, University of Michigan, Ann Arbor, Michigan; University of Michigan Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
| | - Lesly A Dossett
- Department of Surgery, University of Michigan, Ann Arbor, Michigan; University of Michigan Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan.
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Jonker P, van den Heuvel S, Hoeks S, Heijkoop È, Stolker RJ, Korstanje JW. Alternatives to the in-person anaesthetist-led preoperative assessment in adults undergoing low-risk or intermediate-risk surgery: A scoping review. Eur J Anaesthesiol 2023; 40:343-355. [PMID: 36876738 PMCID: PMC10097490 DOI: 10.1097/eja.0000000000001815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
BACKGROUND The design of the optimal preoperative evaluation is a much debated topic, with the anaesthetist-led in-person evaluation being most widely used. This approach is possibly leading to overuse of a valuable resource, especially in low-risk patients. Without compromising patient safety, we hypothesised that not all patients would require this type of elaborate evaluation. OBJECTIVE The current scoping review aims to critically appraise the range and nature of the existing literature investigating alternatives to the anaesthetist-led preoperative evaluation and their impact on outcomes, to inform future knowledge translation and ultimately improve perioperative clinical practice. DESIGN A scoping review of the available literature. DATA SOURCES Embase, Medline, Web-of-Science, Cochrane Library and Google Scholar. No date restriction was used. ELIGIBILITY CRITERIA Studies in patients scheduled for elective low-risk or intermediate-risk surgery, which compared anaesthetist-led in-person preoperative evaluation with non-anaesthetist-led preoperative evaluation or no outpatient evaluation. The focus was on outcomes, including surgical cancellation, perioperative complications, patient satisfaction and costs. RESULTS Twenty-six studies with a total of 361 719 patients were included, reporting on various interventions: telephone evaluation, telemedicine evaluation, evaluation by questionnaire, surgeon-led evaluation, nurse-led evaluation, other types of evaluation and no evaluation up to the day of surgery. Most studies were conducted in the United States and were either pre/post or one group post-test-only studies, with only two randomised controlled trials. Studies differed largely in outcome measures and were of moderate quality overall. CONCLUSIONS A number of alternatives to the anaesthetists-led in-person preoperative evaluation have already been researched: that is telephone evaluation, telemedicine evaluation, evaluation by questionnaire and nurse-led evaluation. However, more high-quality research is needed to assess viability in terms of intraoperative or early postoperative complications, surgical cancellation, costs, and patient satisfaction in the form of Patient-Reported Outcome Measures and Patient-Reported Experience Measures.
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Affiliation(s)
- Philip Jonker
- From the Department of Anaesthesia, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands (PJ, SvdH, SH, EH, RJS, JWK)
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Hanna V, Popovic MM, El-Defrawy S, Schlenker MB, Alaei R, Kertes PJ. Preoperative evaluations for ophthalmic surgery: A systematic review of 48,869 eyes. Surv Ophthalmol 2022; 68:526-538. [PMID: 36572226 DOI: 10.1016/j.survophthal.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 12/17/2022] [Accepted: 12/19/2022] [Indexed: 12/25/2022]
Abstract
Eliminating low-yield testing can reduce the burden on modern health care systems. Our purpose is to determine whether routine preoperative assessment impacts the incidence of perioperative complications in ophthalmic surgery. We conducted a comprehensive search of Ovid MEDLINE, EMBASE, and Cochrane Library databases to identify studies investigating the incidence of perioperative complications following any preoperative assessment for patients undergoing ophthalmic surgery (PROSPERO ID#164008). Four randomized controlled trials (RCTs) and 5 observational studies were selected for inclusion. Risk of bias assessment revealed a lack of masking and insufficient statistical power in RCTs, and confounding in observational studies. Routine preoperative testing-including laboratory tests, electrocardiogram, and imaging studiesdid not decrease the incidence of adverse events or risk of perioperative ocular and systemic complications in most studies. Two cohort studies (1 retrospective, 1 prospective) suggestd that patients with certain preexisting health conditions were at increased risk for adverse events perioperatively. Another retrospective study found a lower risk of complications in high-risk patients who underwent evaluation. While patients with comorbidities may be at increased risk of adverse events, the role of preoperative assessment is not well delineated in this population. Further study is required to determine the comparative safety, effectiveness, and implementation of alternative assessment tools.
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Affiliation(s)
- Verina Hanna
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Marko M Popovic
- Department of Ophthalmology & Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Sherif El-Defrawy
- Department of Ophthalmology & Vision Sciences, University of Toronto, Toronto, Ontario, Canada; Department of Ophthalmology, Kensington Eye Institute, Toronto, Ontario, Canada
| | - Matthew B Schlenker
- Department of Ophthalmology & Vision Sciences, University of Toronto, Toronto, Ontario, Canada; Department of Ophthalmology, Kensington Eye Institute, Toronto, Ontario, Canada
| | - Ravin Alaei
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Peter J Kertes
- Department of Ophthalmology & Vision Sciences, University of Toronto, Toronto, Ontario, Canada; John and Liz Tory Eye Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
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Barriers to reducing preoperative testing for low-risk surgical procedures: A qualitative assessment guided by the Theoretical Domains Framework. PLoS One 2022; 17:e0278549. [PMID: 36480568 PMCID: PMC9731462 DOI: 10.1371/journal.pone.0278549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 11/02/2022] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION While numerous guidelines do not recommend preoperative tests for low risk patients undergoing low risk surgeries, they are often routinely performed. Canadian data suggests preoperative tests (e.g. ECGs and chest x-rays) preceded 17.9%-35.5% of low-risk procedures. Translating guidelines into clinical practice can be challenging and it is important to understand what is driving behaviour when developing interventions to change it. AIM Thus, we completed a theory-based investigation of the perceived barriers and enablers to reducing unnecessary preoperative tests for low-risk surgical procedures in Newfoundland, Canada. METHOD We used snowball sampling to recruit surgeons, anaesthesiologists, or preoperative clinic nurses. Interviews were conducted by two researchers using an interview guide with 31 questions based on the theoretical domains framework. Data was transcribed and coded into the 14 theoretical domains and then themes were identified for each domain. RESULTS We interviewed 17 surgeons, anaesthesiologists, or preoperative clinic nurses with 1 to 34 years' experience. Overall, while respondents agreed with the guidelines they described several factors, across seven relevant theoretical domains, that influence whether tests are ordered. The most common included uncertainty about who is responsible for test ordering, inability to access patient records or to consult/communicate with colleagues about ordering decisions and worry about surgery delays/cancellation if tests are not ordered. Other factors included workplace norms that conflicted with guidelines and concerns about missing something serious or litigation. In terms of enablers, respondents believed that clear institutional guidelines including who is responsible for test ordering and information about the risk of missing something serious, supported by improved communication between those involved in the ordering process and periodic evaluation will reduce any unnecessary preoperative testing. CONCLUSION These findings suggest that both health system and health provider factors need to be addressed in an intervention to reduce pre-operative testing.
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Is there variation in utilization of preoperative tests among patients undergoing total hip and knee replacement in the US, and does it affect outcomes? A population-based analysis. BMC Musculoskelet Disord 2022; 23:972. [PMID: 36357880 PMCID: PMC9647906 DOI: 10.1186/s12891-022-05945-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 11/02/2022] [Indexed: 11/11/2022] Open
Abstract
Study objective To describe recent practice patterns of preoperative tests and to examine their association with 90-day all-cause readmissions and length of stay. Design Retrospective cohort study using the New York Statewide Planning and Research Cooperative System (SPARCS). Setting SPARCS from March 1, 2016, to July 1, 2017. Participants Adults undergoing Total Hip Replacement (THR) or Total Knee Replacement (TKR) had a preoperative screening outpatient visit within two months before their surgery. Interventions Electrocardiogram (EKG), chest X-ray, and seven preoperative laboratory tests (RBCs antibody screen, Prothrombin time (PT) and Thromboplastin time, Metabolic Panel, Complete Blood Count (CBC), Methicillin Resistance Staphylococcus Aureus (MRSA) Nasal DNA probe, Urinalysis, Urine culture) were identified. Primary and secondary outcome measures Regression analyses were utilized to determine the association between each preoperative test and two postoperative outcomes (90-day all-cause readmission and length of stay). Regression models adjusted for hospital-level random effects, patient demographics, insurance, hospital TKR, THR surgical volume, and comorbidities. Sensitivity analysis was conducted using the subset of patients with no comorbidities. Results Fifty-five thousand ninety-nine patients (60% Female, mean age 66.1+/− 9.8 SD) were included. The most common tests were metabolic panel (74.5%), CBC (66.8%), and RBC antibody screen (58.8%). The least common tests were MRSA Nasal DNA probe (13.0%), EKG (11.7%), urine culture (10.7%), and chest X-ray (7.9%). Carrying out MRSA testing, urine culture, and EKG was associated with a lower likelihood of 90-day all-cause readmissions. The length of hospital stay was not associated with carrying out any preoperative tests. Results were similar in the subset with no comorbidities. Conclusions Wide variation exists in preoperative tests before THR and TKR. We identified three preoperative tests that may play a role in reducing readmissions. Further investigation is needed to evaluate these findings using more granular clinical data. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-022-05945-y.
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Affiliation(s)
- Lesly A Dossett
- Department of Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Anthony L Edelman
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | | | - Shannon M Ruzycki
- Department of Medicine, Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Admass BA, Ego BY, Tawye HY, Ahmed SA. Preoperative investigations for elective surgical patients in a resource limited setting: Systematic review. Ann Med Surg (Lond) 2022; 82:104777. [PMID: 36268455 PMCID: PMC9577970 DOI: 10.1016/j.amsu.2022.104777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 09/19/2022] [Accepted: 09/19/2022] [Indexed: 11/27/2022] Open
Abstract
Background Methods Results Conclusion Ordering preoperative investigation is a common practice. Routine laboratory tests has significant burden on health care costs. Preoperative tests should be guided by the patient's clinical history, co-morbidities, and physical examination. Ordering preoperative investigations based on recommendation of guidelines is very essential.
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Rao GSU. Good Preanesthetic Evaluation Is a Prelude to Good Surgical Outcome—But Where Are the Guidelines? JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2022. [DOI: 10.1055/s-0042-1751242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Affiliation(s)
- Ganne S. U. Rao
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
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Shahid R, Chaya M, Lutz I, Taylor B, Xiao L, Groot G. Exploration of a quality improvement process to standardised preoperative tests for a surgical procedure to reduce waste. BMJ Open Qual 2021; 10:bmjoq-2021-001570. [PMID: 34580084 PMCID: PMC8477314 DOI: 10.1136/bmjoq-2021-001570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 09/16/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Preoperative tests are done to determine a patient's fitness for anaesthesia and surgery. LOCAL PROBLEM Although routine tests before surgery in the absence of specific clinical indications are not recommended, we observed high volumes of routine preoperative tests were performed in our institution. We describe a process to implement a standardised preoperative investigational approach to reduce unnecessary testing before surgeries. METHODS A series of six Plan-Do-Study-Act (PDSA) cycles was conducted for root cause analysis and process mapping, development of standardised tool (GRID), collection of baseline data, education and feedback, pilot testing and implementation and uptake of GRID.Root cause analysis revealed a lack of awareness of guidelines and a lack of a standardised tool to guide preoperative testing. We undertook a pilot quality improvement project to reduce unnecessary testing before knee and hip arthroplasty by developing and implementing a standardised tool (GRID) and engaging all stakeholders. INTERVENTIONS A clinical development team (CDT) was formed, including all the stakeholders. Our CDT focused on a continuous rapid cycle improvement strategy. RESULTS After implementation of the tool in a subgroup of patients undergoing elective hip or knee arthroplasty, unnecessary coagulation tests (activated partial thromboplastin time and the international normalised ratio), electrolyte/renal panel tests and electrocardiograms were reduced by 81% (91%-17%), 81% (41%-7%) and 68% (35%-11%), respectively. No surgery was delayed or cancelled due to tests not performed before surgery. CONCLUSIONS A standardised preoperative investigational approach based on patients' medical conditions rather than routine testing can reduce unnecessary tests before surgery. Further, implementing guidelines is more complex than developing guidelines. Hence, continuous PDSA cycles are essential to evaluate the processes in a quality improvement project. It can take time to build teams and have shared goals; however, once this is achieved, the success of a quality improvement project is certain.
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Affiliation(s)
- Rabia Shahid
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Malone Chaya
- Department of Anesthesiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Ian Lutz
- Department of Orthopedic, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Brian Taylor
- Department of Anesthesiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Lily Xiao
- College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Gary Groot
- Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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Galyfos G. Non-cardiac surgery: Evaluating cardiac risk preoperatively and defining proper perioperative treatment. Trends Cardiovasc Med 2021; 32:285-286. [PMID: 34314822 DOI: 10.1016/j.tcm.2021.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 11/30/2022]
Affiliation(s)
- George Galyfos
- First Propaedeutic Department of Surgery, National and Kapodistrian University of Athens, Hippocration Hospital, Athens, Greece.
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The inductor role of cardiac consultation in the pre-anesthetic evaluation of asymptomatic patients submitted to non-cardiac minor and intermediate-risk surgery: a cross-sectional study. Braz J Anesthesiol 2021; 71:530-537. [PMID: 34097944 PMCID: PMC9373626 DOI: 10.1016/j.bjane.2020.10.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 09/27/2020] [Accepted: 10/18/2020] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Asymptomatic patients with moderate functional capacity do not require Coronary Artery Disease (CAD) workup in the preoperative period of non-cardiac surgeries, especially when scheduled for minor and intermediate-risk surgeries. The workup is inappropriate because it promotes over diagnosing and pointless treatments. Moreover, those patients usually undergo cardiology assessment, in addition to pre-anesthetic evaluation. OBJECTIVE Investigate the role of cardiology consultation as mediator in inappropriate assessment of CAD for preoperative of non-cardiac surgeries. METHOD Retrospective study performed in a private anesthesia service using medical charts of asymptomatic patients with a history of controlled systemic disease and moderate functional capacity, submitted to pre-anesthetic consultation for minor and intermediate risk surgeries. Cardiology consultations were identified by the presence of a consultation report by a cardiologist. CAD workup was defined as undergoing cardiac stress tests. RESULTS We included 390 medical charts of patients with mean age of 48.6 ± 15.4 years, 67% women and 69% intermediate risk surgeries. CAD workup was infrequent and performed in 3.9% of patients. Besides, pre-anesthetic evaluation, 93 (24%) patients had a cardiology consultation. Among those patients, 15.1% were submitted to CAD workup, compared to 0.34% of patients without cardiology assessment (p < 0.001; RR = 4.4; 95% CI: 3.5-5.6). CONCLUSIONS Inappropriate testing for CAD investigation is infrequent for asymptomatic individuals submitted to minor and intermediate risk surgeries. However, cardiology consultation increases substantially the likelihood of a patient undergoing CAD workup, suggesting that, unlike the anesthesiologist, the cardiologist is a major mediator of this kind of management.
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Ghosal S, Trivedi J, Barlowe D, Zhao L, Ji X, Slaughter MS, Kong M, Huang J. Preoperative Functional Platelet Number Is Inversely Associated With 30-Day Mortality After Cardiac Surgery: A Retrospective Cohort Study. Semin Cardiothorac Vasc Anesth 2020; 24:313-320. [PMID: 32698733 DOI: 10.1177/1089253220943023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background. We hypothesize that preoperative functional platelet number (platelet count multiplied by platelet aggregation percentage) are associated with 30-day mortality after cardiac surgery. Methods. We linked our preoperative testing database with the STS (Society of Thoracic Surgeon) database to form a study cohort of 1390 patients who had cardiac surgeries between January 2008 and December 2013. Preoperative tests of platelet count and platelet aggregation were routinely performed on all cardiac surgical patients within 24 hours before entering the operating room. Multiple logistic regression models were used to determine whether functional platelet number are associated with 30-day mortality, modified composite major adverse cardiocerebral events, postoperative renal failure or requirement for new renal replacement therapy, and reoperation for bleeding. Log-linear models were used to examine whether functional platelet numbers are associated with hospital length of stay and intensive care unit length of stay. Results. Functional platelet number had an inverse association with 30-day mortality, and each 50 × 109/L increase in functional platelet number resulted in decreased 30-day mortality (odds ratio of 0.767 with 95% confidence interval = 0.591-0.996). For secondary outcomes, functional platelet number was neither associated with major adverse cardiocerebral event nor length of stay. However, we found that each 50 × 109/L increase in functional platelet number was associated with decreased reoperations for bleeding (odds ratio of 0.778 with 95% confidence interval = 0.636-0.951). Conclusions. The preoperative functional platelet number had significant associations with 30-day mortality after cardiac surgery. Functional platelet number could be used to guide timing of cardiac surgery, especially as more and more patients are receiving antiplatelet medications nowadays.
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Affiliation(s)
| | | | | | - Lei Zhao
- Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiaolin Ji
- Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
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Ciapponi A, Tapia-López E, Virgilio S, Bardach A. The quality of clinical practice guidelines for preoperative care using the AGREE II instrument: a systematic review. Syst Rev 2020; 9:159. [PMID: 32660571 PMCID: PMC7359265 DOI: 10.1186/s13643-020-01404-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 06/01/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Our aim was to summarize and compare relevant recommendations from evidence-based CPGs (EB-CPGs). METHODS Systematic review of clinical practice guidelines. DATA SOURCES PubMed, EMBase, Cochrane Library, LILACS, Tripdatabase, and additional sources. In July 2017, we searched CPGs that were published in the last 10 years, without language restrictions, in electronic databases, and also searched specific CPG sources, reference lists, and consulted experts. Pairs of independent reviewers selected EB-CPGs and rated their methodological quality using the AGREE-II instrument. We summarized recommendations, its supporting evidence, and strength of recommendations according to the GRADE methodology. RESULTS We included 16 EB-CPGs out of 2262 references identified. Only nine of them had searches within the last 5 years and seven used GRADE. The median (percentile 25-75) AGREE-II scores for rigor of development was 49% (35-76%) and the domain "applicability" obtained the worst score 16% (9-31%). We summarized 31 risk stratification recommendations, 21.6% of which were supported by high/moderate quality of evidence (41% of them were strong recommendations), and 16 therapeutic/preventive recommendations, 59% of which were supported by high/moderate quality of evidence (75.7% strong). We found inconsistency in ratings of evidence level. "Guidelines' applicability" and "monitoring" were the most deficient domains. Only half of the EB-CPGs were updated in the past 5 years. CONCLUSIONS We present many strong recommendations that are ready to be considered for implementation as well as others to be interrupted, and we reveal opportunities to improve guidelines' quality.
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Affiliation(s)
- Agustín Ciapponi
- Instituto de Efectividad Clínica y Sanitaria (IECS-CONICET), Emilio Ravignani 2024 (C1414CPV), Buenos Aires, Argentina.
| | - Elena Tapia-López
- Instituto de Efectividad Clínica y Sanitaria (IECS-CONICET), Emilio Ravignani 2024 (C1414CPV), Buenos Aires, Argentina
| | - Sacha Virgilio
- Instituto de Efectividad Clínica y Sanitaria (IECS-CONICET), Emilio Ravignani 2024 (C1414CPV), Buenos Aires, Argentina
| | - Ariel Bardach
- Instituto de Efectividad Clínica y Sanitaria (IECS-CONICET), Emilio Ravignani 2024 (C1414CPV), Buenos Aires, Argentina
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Kaur TS, Chatterjee BP. "Too much information with little meaning," relevance of preoperative laboratory testing in elective oral and maxillofacial surgeries: A systematic integrative review. Natl J Maxillofac Surg 2020; 11:3-9. [PMID: 33041569 PMCID: PMC7518500 DOI: 10.4103/njms.njms_60_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 12/12/2019] [Accepted: 02/02/2020] [Indexed: 12/19/2022] Open
Abstract
Aim: In the recent times due to accessibility of tools and advent of technology advising battery of laboratory tests prior to any electeve surgical procedure has become a norm. This review aims at investigating relevance of such tests in healthy patients undergoing routine elective oral and maxillofacial surgical procedures. Methods: Various search engines were thoroughly searched to identify relevant literature. The population of interest was asymptomatic adults above 18 years of age undergoing elective surgery. Results: The preoperative tests of interest for the current study included complete blood count, coagulation tests, biochemistry, and chest X-rays. An algorithm for preoperative tests has been proposed. Conclusion: We conclude that advising battery of routine tests in such patients leads to further delays and rise in overall cost of the surgery.
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Affiliation(s)
- Taranjit S Kaur
- Department of Oral and Maxillofacial Surgery, Government Dental College and Hospital, Jamnagar, Gujarat, India
| | - Bijoya P Chatterjee
- Department of Biochemistry, M. P. Shah Government Medical College, Guru Gobind Singh Government Hospital, Jamnagar, Gujarat, India
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Levy BJ, Sperling K, Davila J, Levy IM. A Novel Case of Recurrent Hemarthrosis Following Knee Arthroscopy in a Patient with Undiagnosed Hemophilia. Arthrosc Sports Med Rehabil 2020; 2:e289-e294. [PMID: 32548594 PMCID: PMC7283926 DOI: 10.1016/j.asmr.2020.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 03/12/2020] [Indexed: 12/19/2022] Open
Affiliation(s)
- Benjamin J Levy
- University of Connecticut, Department of Orthopaedic Surgery, UCONN Health, Farmington, Connecticut
| | - Karen Sperling
- Department of Radiology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
| | - Jennifer Davila
- Department of Pediatrics, Division of Hematology, Albert Einstein College of Medicine, Bronx, New York
| | - I Martin Levy
- Department of Orthopaedic Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
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Pike A, Mahoney K, Patey AM, Inwood S, Mortazhejri S, Lawrence R, Hall A. Protocol for assessing the determinants of preoperative test-ordering behaviour for low-risk surgical procedures using a theoretically driven, qualitative design. BMJ Open 2020; 10:e036511. [PMID: 32398338 PMCID: PMC7223279 DOI: 10.1136/bmjopen-2019-036511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Current evidence suggests that preoperative tests such as chest X-rays, electrocardiograms and baseline laboratory studies may not be useful for healthy patients undergoing low-risk surgical procedures. Routine preoperative testing for healthy patients having low-risk surgery is not a scientifically sound practice. In this study, we will interview healthcare providers working at medical facilities where low-risk surgical procedures are carried out. This will allow us to gain insight into the determinants of preoperative testing behaviours for healthy patients undergoing low-risk surgeries and their barriers and enablers to guideline adherence. METHODS AND ANALYSIS We will use semistructured interviews with anaesthesiologists, surgeons and preadmission clinic nurses to assess the determinants of preoperative testing behaviours. The interview guide was designed around the Theoretical Domains Framework (TDF), developed specifically to determine the barriers and enablers to implementing evidence-based guidelines. Interviews will be audio-recorded, transcribed verbatim and coded according to the TDF. Key themes will be generated for each of the identified domains. ETHICS AND DISSEMINATION We have received ethics approval from the Health Research Ethics Board in Newfoundland and Labrador (HREB #2018.190) for this study. The results of this work will be disseminated through a peer-reviewed publication, presentation at a healthcare forum and plain-language infographic summaries. Additionally, deidentified data collected and analysed for this study will be available for review from the corresponding author on reasonable request.
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Affiliation(s)
- Andrea Pike
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Krista Mahoney
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Andrea M Patey
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Samantha Inwood
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Sameh Mortazhejri
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Rebecca Lawrence
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Amanda Hall
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
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Jones SE, Jooste EH, Gottlieb EA, Schwartz J, Goswami D, Gautam NK, Benkwitz C, Downey LA, Guzzetta NA, Zabala L, Latham GJ, Faraoni D, Navaratnam M, Wise-Faberowski L, McDaniel M, Spurrier E, Machovec KA. Preoperative Laboratory Studies for Pediatric Cardiac Surgery Patients: A Multi-Institutional Perspective. Anesth Analg 2020; 128:1051-1054. [PMID: 30896598 DOI: 10.1213/ane.0000000000004114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Stephanie E Jones
- From the Department of Anesthesiology, Division of Pediatric Anesthesia, Duke University Medical Center, Durham, North Carolina
| | - Edmund H Jooste
- From the Department of Anesthesiology, Division of Pediatric Anesthesia, Duke University Medical Center, Durham, North Carolina
| | - Erin A Gottlieb
- Department of Anesthesiology, Perioperative, and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Jamie Schwartz
- Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesia and Critical Care Medicine, Johns Hopkins Children's Center, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Dheeraj Goswami
- Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesia and Critical Care Medicine, Johns Hopkins Children's Center, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Nischal K Gautam
- Department of Anesthesiology, Division of Pediatric Cardiothoracic Anesthesiology, The University of Texas Medical Center at Houston, Houston, Texas
| | - Claudia Benkwitz
- Department of Anesthesia and Perioperative Care, Division of Congenital Cardiac Anesthesia, University of California at San Francisco School of Medicine, San Francisco, California
| | - Laura A Downey
- Department of Anesthesiology, Division of Pediatric Cardiac Anesthesiology, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Nina A Guzzetta
- Department of Anesthesiology, Division of Pediatric Cardiac Anesthesiology, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Luis Zabala
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Gregory J Latham
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
| | - David Faraoni
- The Hospital for Sick Children, Department of Anesthesia and Pain Medicine, Division of Cardiac Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Manchula Navaratnam
- Lucile Packard Children's Hospital, Department of Anesthesiology, Perioperative and Pain Management, Division of Pediatric Anesthesia, Stanford University, Stanford, California
| | - Lisa Wise-Faberowski
- Lucile Packard Children's Hospital, Department of Anesthesiology, Perioperative and Pain Management, Division of Pediatric Anesthesia, Stanford University, Stanford, California
| | - Matthew McDaniel
- Department of Anesthesiology, Division of Pediatric Anesthesia, University of North Carolina, Chapel Hill, North Carolina
| | - Ellen Spurrier
- Department of Anesthesiology and Critical Care, Nemours/Alfred I duPont Hospital for Children, Wilmington, Delaware
| | - Kelly A Machovec
- From the Department of Anesthesiology, Division of Pediatric Anesthesia, Duke University Medical Center, Durham, North Carolina
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Chen CL, Clay TH, McLeod S, Chang HYP, Gelb AW, Dudley RA. A Revised Estimate of Costs Associated With Routine Preoperative Testing in Medicare Cataract Patients With a Procedure-Specific Indicator. JAMA Ophthalmol 2019; 136:231-238. [PMID: 29346472 DOI: 10.1001/jamaophthalmol.2017.6372] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance Routine preoperative medical testing is not recommended for patients undergoing low-risk surgery, but testing is common before surgery. A 30-day preoperative testing window is conventionally used for study purposes; however, the extent of routine testing that occurs prior to that point is unknown. Objective To improve on existing cost estimates by identifying all routine preoperative testing that takes place after the decision is made to perform cataract surgery. Design, Setting, and Participants This cross-sectional study assessed preoperative care in a 50% sample of Medicare beneficiaries older than 66 years who underwent ambulatory cataract surgery in 2011. Data analysis was completed from March 2016 to October 2017. Main Outcomes and Measures Using ocular biometry as a procedure-specific indicator to mark the start of the routine preoperative testing window, we measured testing rates in the interval between ocular biometry and cataract surgery and compared this with testing rates in the 6 months preceding biometry. We estimated the total cost of testing that occurred between biometry and cataract surgery. Results A total of 440 857 patients underwent cataract surgery. A total of 423 710 (96.1%) had an ocular biometry claim before index surgery, of whom 264 514 (60.0%) were female; the mean (SD) age of the cohort was 76.1 (6.2) years. A total of 111 998 (25.4%) underwent surgery more than 30 days after biometry. Among patients with a biometry claim, the mean number of tests/patient/month increased from 1.1 in the baseline period to 1.7 in the interval between biometry and cataract surgery. Although preoperative testing peaked in all patients in the 30 days preceding surgery (1.8 tests/patient/month), the subset of patients with no overlap between postbiometry and presurgery periods experienced increased testing rates to 1.8 tests per patient per month in the 30 days after biometry, regardless of the elapsed time between biometry and surgery. The total estimated cost of routine preoperative testing in the full cohort was $22.7 million; we estimate that routine preoperative testing costs Medicare up to $45.4 million annually. Conclusions and Relevance In this study of Medicare beneficiaries, routine preoperative medical testing occurs more often and is costlier than has been reported previously. Extra costs are attributable to testing that occurs prior to the 30-day window preceding surgery. As a cost-cutting measure, routine preoperative medical testing should be avoided in patients with cataracts throughout the interval between ocular biometry and cataract surgery.
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Affiliation(s)
- Catherine L Chen
- Philip R. Lee Institute for Health Policy Studies, School of Medicine, University of California, San Francisco.,Center for Healthcare Value, University of California, San Francisco.,Department of Anesthesiology and Perioperative Care, University of California, San Francisco
| | | | - Stephen McLeod
- Department of Ophthalmology, University of California, San Francisco
| | - Han-Ying Peggy Chang
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston
| | - Adrian W Gelb
- Department of Anesthesiology and Perioperative Care, University of California, San Francisco
| | - R Adams Dudley
- Philip R. Lee Institute for Health Policy Studies, School of Medicine, University of California, San Francisco.,Center for Healthcare Value, University of California, San Francisco.,Department of Medicine, University of California, San Francisco
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Karim HMR. Healthcare delivery cost and anesthesiologists: Time to have a greater role and responsibility. World J Anesthesiol 2019; 8:19-24. [DOI: 10.5313/wja.v8.i3.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 06/06/2019] [Accepted: 06/18/2019] [Indexed: 02/06/2023] Open
Abstract
With the advancement of technology and health sciences, health care delivery costs are steadily increasing. This affects both households and governments. Unfortunately, the present truth is that health has become an essential but unaffordable commodity. This is very concerning. Quality, up-to-date, cost-effective health care delivery is one of the prime objectives, and focuses on administration and health care authority. As the per capita spent on health from public/government funds is very poor in developing countries, the responsibility of cost-effective health care delivery falls primarily on the shoulder of the treating physicians. Anesthesiologists are becoming an indispensable part of health care delivery, having a diverse role in the emergency, critical care, pain, and perioperative care of patients. As the population ages, the need for surgical care is also increasing. Therefore, the anesthesiologist can also play a more significant role in delivering cost-effective health care, and minimize the cost without affecting the quality. This brief narrative review analyzes the current practice of anesthesiologists in two prime areas in the context of cost-savings: Preoperative investigation and low/minimal flow anesthesia.
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Affiliation(s)
- Habib Md Reazaul Karim
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Raipur 492099, India
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20
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Nieto-Benito L, Vilas-Boas P, Zaballos M, Llorente-Parrado C, Avilés-Izquierdo J. Recommendations on Testing Before Outpatient Dermatologic Surgery. ACTAS DERMO-SIFILIOGRAFICAS 2019. [DOI: 10.1016/j.adengl.2019.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Abstract
In the future an increasing number of older patients with significant comorbidities will have to undergo major surgical procedures. Perioperative cardiovascular events account for many major complications and even fatalities. While perioperative myocardial infarction (PMI) is a generally well-known and recognized complication, the less severe myocardial injury after non-cardiac surgery (MINS) has not gained widespread scientific attention until recently; however, two large observational trials (VISION 1 and VISION 2) have shown a significantly increased mortality after MINS with even subtle increases in troponin T being associated with an increased risk of death. This review summarizes the current knowledge pertaining to PMI and MINS and proposes a diagnostic and therapeutic framework for optimally guiding patients at risk through the perioperative period.
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Nieto-Benito LM, Vilas-Boas P, Zaballos M, Llorente-Parrado C, Avilés-Izquierdo JA. Recommendations on Testing Before Outpatient Dermatologic Surgery. ACTAS DERMO-SIFILIOGRAFICAS 2019; 110:469-473. [PMID: 31023483 DOI: 10.1016/j.ad.2019.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 02/27/2019] [Accepted: 02/28/2019] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Short-duration ambulatory surgery for the removal of skin tumors under local anesthesia is increasingly common in dermatology. Preoperative assessment has traditionally targeted the identification of any unknown diseases or other health conditions that might lead to changes in plans for anesthesia or surgery. Hospitals and specialists differ greatly in the tests they order in patients about to undergo outpatient dermatologic surgery given that hardly any finding would be likely to contraindicate or lead to changes in the procedure. This study aimed to provide guidance for those ordering tests before outpatient dermatologic surgery. METHODS In 2017 our hospital developed a protocol to standardize preoperative testing for outpatient dermatologic surgery. We designed an observational, descriptive, retrospective analysis of tests ordered for patients scheduled for such surgery before and after the protocol was applied. RESULTS Fewer tests were ordered after the protocol was introduced. We detected no statistically significant differences in relation to type of surgery planned or postoperative complications. CONCLUSIONS Patients about to undergo outpatient dermatologic surgery under local anesthesia who have no unusual health risks may not require preoperative testing.
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Affiliation(s)
- L M Nieto-Benito
- Servicio de Dermatología, Hospital General Universitario Gregorio Marañón, Madrid, España.
| | - P Vilas-Boas
- Servicio de Dermatología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - M Zaballos
- Servicio de Anestesiología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - C Llorente-Parrado
- Servicio de Medicina Preventiva, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - J A Avilés-Izquierdo
- Servicio de Dermatología, Hospital General Universitario Gregorio Marañón, Madrid, España
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Nickel C, Segarra D, Padhya T, Mifsud M. The evidence-based preoperative assessment for the otolaryngologist. Laryngoscope 2019; 130:38-44. [PMID: 30702154 DOI: 10.1002/lary.27845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2019] [Indexed: 11/05/2022]
Abstract
There is a narrow window of opportunity between surgical scheduling and the operative date to optimize patients for an elective surgical procedure. Traditionally, preoperative care has involved extended routine testing batteries with intermittent referrals for medical clearance. These traditions are costly, inefficient, and yield no clear reduction in perioperative morbidity and mortality. Evidence, which has evolved over the past decade, suggests that optimal preoperative care requires a patient-centric, personalized, and often multidisciplinary approach. We present an up-to-date overview of this literature with a focus on the otolaryngologic surgical population. An algorithmic approach to preoperative patient assessment is also proposed in hopes of both optimizing patient outcome and streamlining routine clinical workflow. Laryngoscope, 130:38-44, 2020.
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Affiliation(s)
- Christopher Nickel
- Department of Otolaryngology-Head and Neck Surgery, University of South Florida, Tampa, Florida, U.S.A
| | - Daniel Segarra
- Morsani College of Medicine, University of South Florida, Tampa, Florida, U.S.A
| | - Tapan Padhya
- Department of Otolaryngology-Head and Neck Surgery, University of South Florida, Tampa, Florida, U.S.A
| | - Matthew Mifsud
- Department of Otolaryngology-Head and Neck Surgery, University of South Florida, Tampa, Florida, U.S.A
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Abstract
Obtaining routine preoperative laboratory tests increases health care costs and has been listed, by the Choosing Wisely Campaign, as one of the top 5 practices anesthesiologists should avoid. Routine testing without clinical indication is not cost-effective and could cause harm and unnecessary delays. Abnormal findings are more likely to be false positive and costly to pursue, introduce new risks, and increase anxiety for the patient. Preoperative testing need to be performed only following a targeted history and physical examination, factoring severity of surgery, and comorbidities such that the benefit of the test outweighs risk.
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Affiliation(s)
- Angela F Edwards
- Department of Anesthesiology, Wake Forest University School of Medicine, Medical Center Boulevard, 9 CSB Janeway Tower, Winston-Salem, NC 27157, USA.
| | - Daniel J Forest
- Preoperative Assessment Clinic, Department of Anesthesiology, Wake Forest University School of Medicine, Medical Center Boulevard, 9 CSB Janeway Tower, Winston-Salem, NC 27157, USA
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26
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Ramos LWF, Souza CF, Dias IWH, Oliveira RG, Cristina B, Calil M, Góes JCS. Validity time of normal results of preoperative tests for surgical reintervention and the impact on postoperative outcomes. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2018. [PMID: 29137873 PMCID: PMC9391796 DOI: 10.1016/j.bjane.2017.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background and objective There are few data defining the period of time in which preoperative tests can be considered valid. The purpose of this study was to determine the likelihood of changes in the results of preoperative tests previously normal in relation to time, and the impact of these changes on postoperative outcomes. Methods A total of 970 patients with normal preoperative tests before the first surgery and who required a new intervention were included. The preoperative tests performed for the first procedure were compared with those performed for the second procedure. The following variables were assessed regarding their potential to induce changes in test results: sex, age, surgical risk, previous chemotherapy or radiotherapy, and presence of comorbidities. In-hospital outcomes were analyzed. Results The median time between procedures was 27 months (6–84). The probability of change in at least one of the preoperative exams was 1.7% (95% CI: 0.5–2.9), 3.6% (95% CI: 1.8–5.4), and 6.4% (95% CI: 3.9–8.9) during the 12, 24, and 36-month intervals, respectively, for patients aged <50 years and 2.1% (95% CI: 0.7–3.5), 9.2% (95% CI: 5.9–12.5), and 13.4% (95% CI: 9.3–17.5), respectively, for patients ≥50 years of age. Age (p = 0.009), surgical risk (p < 0.001), chemotherapy (p = 0.001), radiotherapy (p = 0.012), and comorbidities (p < 0.001) were associated with the likelihood of changes in test results. Test changes were not significantly associated with in-hospital adverse outcomes (p = 0.426). Conclusion For patients undergoing a second surgical procedure, the probability of change in previously normal preoperative tests is low during the first years after the first surgical intervention, and when changes occurred, they did not adversely affect the in-hospital postoperative outcomes.
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Affiliation(s)
| | | | | | | | - Bárbara Cristina
- Pontifícia Universidade Católica de São Paulo, Sorocaba, SP, Brasil
| | - Marcelo Calil
- Instituto Brasileiro de Controle do Câncer, São Paulo, SP, Brasil
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The Utility of Preoperative Laboratory Testing Before Urogynecologic Surgery. Female Pelvic Med Reconstr Surg 2018; 24:105-108. [PMID: 29474281 DOI: 10.1097/spv.0000000000000551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES National guidelines for preoperative laboratory testing are based on limited, low-quality evidence. The role of age as a risk factor for testing is unclear. We sought to compare the prevalence of abnormal preoperative laboratory results in older vs younger urogynecologic surgical patients. METHODS In this retrospective cohort study of women undergoing urogynecologic surgery, we compared older (age, ≥65 years) with younger (age, 50-64 years) women. Our primary outcome was the prevalence of an abnormal preoperative laboratory result. RESULTS We included 317 women, with 167 (52.7%) in the older cohort (ages, 65-91 years; mean, 73.3 ± 5.6 years) and 150 (47.3%) in the younger cohort (ages, 50-64 years; mean, 57.3 ± 4.1 years). Overall, 18.3% of participants had at least one abnormal preoperative laboratory, with older women more likely to have an abnormal result (28.7% vs 10.7%, P < 0.001). Compared with the younger cohort, older women had higher rates of abnormal hemoglobin (13.8% vs 6.0%, P = 0.02) and creatinine values (10.8% vs 2.7%, P = 0.005), with no significant differences for platelets (3.0% vs 1.3%, P = 0.53), sodium (3.0% vs 0.7%, P = 0.22), or potassium (6.0% vs 3.3%, P = 0.27). After adjusting for potential confounders, older age remained associated with an abnormal preoperative result (odds ratio, 3.6; 95% confidence interval, 1.9-7.1). CONCLUSIONS In our sample, women 65 years or older had a greater than 25% chance of having an abnormal preoperative laboratory result and were at higher risk compared with younger women. Age 65 years or greater should be considered as a criterion for preoperative laboratory testing in urogynecologic patients.
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Affiliation(s)
- Erika L Brinson
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, California
| | - Kevin C Thornton
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, California
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Ramos LWF, Souza CF, Dias IWH, Oliveira RG, Cristina B, Calil M, Góes JCS. [Validity time of normal results of preoperative tests for surgical reintervention and the impact on postoperative outcomes]. Rev Bras Anestesiol 2017; 68:154-161. [PMID: 29137873 DOI: 10.1016/j.bjan.2017.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 10/06/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND OBJECTIVE There are few data defining the period of time in which preoperative tests can be considered valid. The purpose of this study was to determine the likelihood of changes in the results of preoperative tests previously normal in relation to time, and the impact of these changes on postoperative outcomes. METHODS A total of 970 patients with normal preoperative tests before the first surgery and who required a new intervention were included. The preoperative tests performed for the first procedure were compared with those performed for the second procedure. The following variables were assessed regarding their potential to induce changes in test results: sex, age, surgical risk, previous chemotherapy or radiotherapy, and presence of comorbidities. In-hospital outcomes were analyzed. RESULTS The median time between procedures was 27 months (6-84). The probability of change in at least one of the preoperative exams was 1.7% (95% CI: 0.5-2.9), 3.6% (95% CI: 1.8-5.4), and 6.4% (95% CI: 3.9-8.9) during the 12, 24, and 36-month intervals, respectively, for patients aged <50 years and 2.1% (95% CI: 0.7-3.5), 9.2% (95% CI: 5.9-12.5), and 13.4% (95% CI: 9.3-17.5), respectively, for patients ≥ 50 years of age. Age (p=0.009), surgical risk (p <0.001), chemotherapy (p=0.001), radiotherapy (p=0.012), and comorbidities (p <0.001) were associated with the likelihood of changes in test results. Test changes were not significantly associated with in-hospital adverse outcomes (p=0.426). CONCLUSION For patients undergoing a second surgical procedure, the probability of change in previously normal preoperative tests is low during the first years after the first surgical intervention, and when changes occurred, they did not adversely affect the in-hospital postoperative outcomes.
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Affiliation(s)
| | | | | | | | - Bárbara Cristina
- Pontifícia Universidade Católica de São Paulo, Sorocaba, SP, Brasil
| | - Marcelo Calil
- Instituto Brasileiro de Controle do Câncer, São Paulo, SP, Brasil
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Kunze S. EVALUACIÓN PREOPERATORIA EN EL SIGLO XXI. REVISTA MÉDICA CLÍNICA LAS CONDES 2017. [DOI: 10.1016/j.rmclc.2017.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Santos ML, Iglesias AC. Impact of using a local protocol in preoperative testing: blind randomized clinical trial. Rev Col Bras Cir 2017; 44:54-63. [PMID: 28489212 DOI: 10.1590/0100-69912017001015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 12/05/2016] [Indexed: 12/19/2022] Open
Abstract
Objective to evaluate the impact of the use of a local protocol of preoperative test requests in reducing the number of exams requested and in the occurrence of changes in surgical anesthetic management and perioperative complications. Methods we conducted a randomized, blinded clinical trial at the Gaffrée and Guinle University Hospital with 405 patients candidates for elective surgery randomly divided into two groups, according to the practice of requesting preoperative exams: a group with non-selectively requested exams and a protocol group with exams requested according to the study protocol. Studied exams: complete blood count, coagulogram, glycemia, electrolytes, urea and creatinine, ECG and chest X-ray. Primary outcomes: changes in surgical anesthetic management caused by abnormal exams, reduction of the number of exams requested after the use of the protocol and perioperative complications. Results there was a significant difference (p<0.001) in the number of exams with altered results between the two groups (14.9% vs. 29.1%) and a reduction of 57.3% in the number of exams requested between the two groups (p<0.001), which was more pronounced in patients of lower age groups, ASA I, without associated diseases and submitted to smaller procedures. There was no significant difference in the frequency of conduct changes motivated by the results of exams or complications between the two groups. In the multivariate analysis, complete blood count and coagulogram were the only exams capable of modifying the anesthetic-surgical management. Conclusion the proposed protocol was effective in eliminating a significant number of complementary exams without clinical indication, without an increase in perioperative morbidity and mortality.
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Affiliation(s)
- Mônica Loureiro Santos
- - Gaffree and Guinle University Hospital, Federal University of the State of Rio de Janeiro, Service of Anesthesiology, Rio de Janeiro, Rio de Janeiro State, Brazil
| | - Antônio Carlos Iglesias
- - Gaffree and Guinle University Hospital, Federal University of the State of Rio de Janeiro, Service of Anesthesiology, Rio de Janeiro, Rio de Janeiro State, Brazil.,- School of Medicine and Surgery, Federal University of the State of Rio de Janeiro, Service of General and Specialized Surgery, Rio de Janeiro, Rio de Janeiro State, Brazil
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Abstract
PURPOSE OF REVIEW This review aims to familiarize with the most current findings regarding preoperative evaluation and preparation of morbidly obese patients prior to elective, noncardiac surgery. In the light of the increasing number of surgical patients being morbidly obese, the knowledge of evidence-based preoperative evaluation strategies is profound for a rational approach. RECENT FINDINGS Preoperative evaluation should be carried out with sufficient time before the day of surgery to allow modification of the perioperative management. Medical history-taking and physical examination ought to be performed following a standardized scheme especially focussing on the presence of obstructive sleep apnea. Routine testing for fasting glucose and lipoprotein levels should be performed in order to diagnose a metabolic syndrome. ECG recording should be limited to those patients having one or more additional cardiac risk factors or presenting clinical signs of cardiovascular disease or were planned for intermediate or high-risk surgery. Spirometry should be limited to those patients with obstructive sleep apnea or other respiratory findings. SUMMARY Synthesis of proper medical history-taking and physical examination as well as detailed search for obstructive sleep apnea and metabolic syndrome are key components of preoperative evaluation. Further testing should be based on the findings of these steps and comprise the cardiac risk of the surgical procedure.
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Renner J, Grünewald M, Bein B. Monitoring high-risk patients: minimally invasive and non-invasive possibilities. Best Pract Res Clin Anaesthesiol 2016; 30:201-16. [PMID: 27396807 DOI: 10.1016/j.bpa.2016.04.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 04/21/2016] [Accepted: 04/27/2016] [Indexed: 12/19/2022]
Abstract
Over the past decades, there has been considerable progress in the field of less invasive haemodynamic monitoring technologies. Substantial evidence has accumulated, which supports the continuous measurement and optimization of flow-based variables such as stroke volume, that is, cardiac output, in order to prevent occult hypoperfusion and consequently to improve patients' outcome in the perioperative setting. However, there is a striking gap between the developments in haemodynamic monitoring and the increasing evidence to implement defined treatment protocols based on the measured variables, and daily clinical routine. Recent trials have shown that perioperative morbidity and mortality is higher than anticipated. This emphasizes the need for the anaesthesia community to address this issue and promotes the implementation of proven concepts into clinical practice in order to improve patients' outcome, especially in high-risk patients. The advances in minimally invasive and non-invasive monitoring techniques can be seen as a driving force in this respect, as the degree of invasiveness of any monitoring tool determines the frequency of its application, especially in the operating room (OR). From this point of view, we are very confident that some of these minimally invasive and non-invasive haemodynamic monitoring technologies will become an inherent part of our monitoring armamentarium in the OR and in the intensive care unit (ICU).
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Affiliation(s)
- Jochen Renner
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Germany.
| | - Matthias Grünewald
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Germany.
| | - Berthold Bein
- Department of Anaesthesiology and Intensive Care Medicine, Asklepios Klinik St. Georg, Hamburg, Germany.
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Abstract
Routine preoperative testing is not cost-effective, because it is unlikely to identify significant abnormalities. Abnormal findings from routine testing are more likely to be false positive, are costly to pursue, introduce a new risk, increase the patient's anxiety, and are inconvenient to the patient. Abnormal findings rarely alter the surgical or anesthetic plan, and there is usually no association between perioperative complications and abnormal laboratory results. Incidental findings and false positive results may lead to increased hospital visits and admissions. Preoperative testing needs to be done based on a targeted history and physical examination and the type of surgery.
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Affiliation(s)
- Matthias Bock
- Department of Anesthesia and Intensive Care Medicine, Central Hospital, Via Lorenz Boehler 5, Bolzano 39100, Italy; Department of Anesthesiology, Perioperative Medicine and Intensive Care, Paracelsus Medical University, Muellner Hauptrstrasse 48, Salzburg 5020, Austria
| | - Gerhard Fritsch
- Department of Anesthesiology, Perioperative Medicine and Intensive Care, Paracelsus Medical University, Muellner Hauptrstrasse 48, Salzburg 5020, Austria; Department of Anesthesiology and Intensive Care, UKH Lorenz Boehler, Donaueschingerstrasse 3, Vienna 1220, Austria
| | - David L Hepner
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02459, USA.
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Suria S, Harkouk H, Eghiaian A, Weil G. How to rationalize preoperative tests? A method to implement local guidelines successfully. Anaesth Crit Care Pain Med 2015; 35:103-7. [PMID: 26711017 DOI: 10.1016/j.accpm.2015.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 06/19/2015] [Accepted: 10/06/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Preoperative screening includes clinical examination and tests. Systematic prescription leads to excessive tests. We conducted an observational retrospective study to assess the success of implementing a protocol-guided prescription procedure for preoperative tests (PTs). We compared the number of PTs prescribed for scheduled surgery before and after the implementation of local guidelines with a specific method. METHODS Local guidelines for prescribing PTs based on the French Society of Anaesthesia's recommendations were developed, validated by the anaesthesia team and actively implemented. The implementation procedure was complex and based on the application of sociologic concepts to facilitate PT prescriptions in accordance with the protocol. All PTs (except for children and emergency surgeries) prescribed over a one-week observation period were analysed before and after protocol implementation, respectively in 2011 and 2013. RESULTS Two hundred and ninety-two patient files were analysed: 157 in 2011 and 135 in 2013. Ninety-one percent of the prescriptions were in accordance with the recommendations in 2013. Excessive prescribing decreased significantly after the implementation of recommendations (7.1% versus 20.7%, P<0.0001), enabling us to reduce excess costs. CONCLUSION We observed excellent adherence to the prescription protocol for PTs. The method used to implement the protocol was successful. A future evaluation should be undertaken to confirm these results over the long-term.
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Affiliation(s)
- Stéphanie Suria
- Service d'anesthésie, Gustave-Roussy Cancer Campus, 94805 Villejuif, France.
| | - Hakim Harkouk
- Service d'anesthésie, Gustave-Roussy Cancer Campus, 94805 Villejuif, France.
| | - Alexandre Eghiaian
- Service d'anesthésie, Gustave-Roussy Cancer Campus, 94805 Villejuif, France.
| | - Grégoire Weil
- Service d'anesthésie, Gustave-Roussy Cancer Campus, 94805 Villejuif, France.
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The impact of preoperative testing for blood glucose concentration and haemoglobin A1c on mortality, changes in management and complications in noncardiac elective surgery: a systematic review. Eur J Anaesthesiol 2015; 32:152-9. [PMID: 25046561 DOI: 10.1097/eja.0000000000000117] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The risks associated with surgery are elevated in patients with diabetes mellitus. For this reason, preoperative diagnostics frequently include the measurement of blood glucose and haemoglobin A1c (HbA1c), but it is unclear whether these tests contribute to improved perioperative or postoperative outcomes. OBJECTIVES This systematic review aimed to evaluate the evidence that preoperative testing for blood glucose and HbA1c might influence the following outcome parameters: changes in clinical management; mortality; and the incidence of perioperative and postoperative complications in patients undergoing elective, noncardiac surgery. DESIGN We performed a systematic search of the literature from January 2001 to March 2013, thus updating a review carried out by the National Institute for Health and Clinical Excellence (NICE) up to the year 2001. ELIGIBILITY CRITERIA Controlled studies including cohort and case-control studies with a population of at least 60 patients were eligible. RESULTS The search retrieved 1346 records (including hand-search). Twenty-two studies met all inclusion criteria and were included in the review. Fifteen cohort and two case-control studies evaluated the effectiveness of preoperative blood glucose testing and nine studies the effectiveness of testing HbA1c. Four of the included studies evaluated both tests. There were no data derived from high-quality studies supporting routine preoperative testing for blood glucose or HbA1c in otherwise healthy adult patients undergoing elective noncardiac surgery. Only in vascular and orthopaedic surgery may screening identify patients at an increased risk. CONCLUSION Preoperative blood glucose testing and testing for HbA1c is not required in nondiabetic patients unless there are clinical sings arousing suspicion. Patients scheduled for vascular and orthopaedic surgery carry an elevated risk justifying preoperative testing for blood glucose or HbA1c as a screening tool.
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Tong NM, Zwingenberger AL, Blair WH, Taylor SL, Chen RX, Sturges BK. Effect of screening abdominal ultrasound examination on the decision to pursue advanced diagnostic tests and treatment in dogs with neurologic disease. J Vet Intern Med 2015; 29:893-9. [PMID: 25900766 PMCID: PMC4895405 DOI: 10.1111/jvim.12602] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 02/03/2015] [Accepted: 03/24/2015] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Abdominal ultrasound examinations (AUS) are commonly performed before advanced neurodiagnostics to screen for diseases that might affect diagnostic plans and prognosis. OBJECTIVES Describe the type and frequency of abnormalities found by AUS in dogs presenting with a neurological condition, identify risk factors associated with abnormalities, and evaluate treatment decisions based on findings. ANIMALS Seven hundred and fifty-nine hospitalized dogs. METHODS Retrospective study. Medical records of dogs presented from 2007 to 2009 for neurologic disease were searched for signalment, neuroanatomic localization, and AUS findings. Whether dogs had advanced neurodiagnostics and treatment was analyzed. RESULTS Fifty-eight percent of dogs had abnormal findings on AUS. Probability of abnormalities increased with age (P < 0.001). Nondachshund breeds had higher probability of abnormal AUS than dachshunds (odds ratio [OR] = 1.87). Eleven percent of dogs did not have advanced neurodiagnostics and in 1.3%, this was because of abnormal AUS. Dogs with ultrasonographic abnormalities were less likely than dogs without to have advanced neurodiagnostics (OR = 0.3 [95% confidence interval [CI]: 0.17, 0.52]), however, the probability of performing advanced diagnostics was high regardless of normal (OR = 0.95 [95% CI: 0.92, 0.97]) or abnormal (OR = 0.85 [95% CI: 0.81, 0.88]) AUS. Treatment was more often pursued in small dogs and less often in dogs with brain disease. CONCLUSIONS AND CLINICAL IMPORTANCE Findings from screening AUS had a small negative effect on the likelihood of pursuing advanced neurodiagnostics. Although it should be included in the extracranial diagnostic workup in dogs with significant history or physical examination abnormalities, AUS is considered a low-yield diagnostic test in young dogs and dachshunds.
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Affiliation(s)
- N M Tong
- William R. Pritchard Veterinary Medical Teaching Hospital, University of California School of Veterinary Medicine, Davis, CA
| | - A L Zwingenberger
- Department of Surgical and Radiological Sciences, University of California School of Veterinary Medicine, Davis, CA
| | - W H Blair
- William R. Pritchard Veterinary Medical Teaching Hospital, University of California School of Veterinary Medicine, Davis, CA
| | - S L Taylor
- Clinical and Translational Science Center, School of Medicine, University of California, Sacramento, CA
| | - R X Chen
- Clinical and Translational Science Center, School of Medicine, University of California, Sacramento, CA
| | - B K Sturges
- Department of Surgical and Radiological Sciences, University of California School of Veterinary Medicine, Davis, CA
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Evidence-based clinical practice manual: Patient preparation for surgery and transfer to the operating room☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1097/01819236-201543010-00006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Manual de práctica clínica basado en la evidencia: preparación del paciente para el acto quirúrgico y traslado al quirófano. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1016/j.rca.2014.10.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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Rincón-Valenzuela DA, Escobar B. Evidence-based clinical practice manual: Patient preparation for surgery and transfer to the operating room. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1016/j.rcae.2014.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Scandrett KG, Zuckerbraun BS, Peitzman AB. Operative risk stratification in the older adult. Surg Clin North Am 2014; 95:149-72. [PMID: 25459549 DOI: 10.1016/j.suc.2014.09.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
As the population ages, the health care system must to adapt to the needs of the older population. Hospitalization risks are particularly significant in the frail geriatric patients, with costly and morbid consequences. Appropriate preoperative assessment can identify sources of increased risk and enable the surgical team to manage this risk, through "prehabilitation," intraoperative modification, and postoperative care. Geriatric preoperative assessment expands usual risk stratification and careful medication review to include screening for functional disability, cognitive impairment, nutritional deficiency, and frailty. The information gathered can also equip the surgeon to develop a patient-centered and realistic treatment plan.
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Affiliation(s)
- Karen G Scandrett
- Department of Geriatric Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Brian S Zuckerbraun
- VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Andrew B Peitzman
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
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Fong R, Sweitzer BJ. Preoperative Optimization of Patients Undergoing Ambulatory Surgery. CURRENT ANESTHESIOLOGY REPORTS 2014. [DOI: 10.1007/s40140-014-0082-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Böhmer AB, Wappler F, Zwissler B. Preoperative risk assessment--from routine tests to individualized investigation. DEUTSCHES ARZTEBLATT INTERNATIONAL 2014; 111:437-45; quiz 446. [PMID: 25008311 PMCID: PMC4095591 DOI: 10.3238/arztebl.2014.0437] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 04/14/2014] [Accepted: 04/14/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Risk assessment in adults who are about to undergo elective surgery (other than cardiac and thoracic procedures) involves history-taking, physical examination, and ancillary studies performed for individual indications. Further testing beyond the history and physical examination is often of low predictive value for perioperative complications. METHOD This review is based on pertinent articles that were retrieved by a selective search in the Medline and Cochrane Library databases and on the consensus-derived recommendations of the German specialty societies. RESULTS The history and physical examination remain the central components of preoperative risk assessment. Advanced age is not, in itself, a reason for ancillary testing. Laboratory testing should be performed only if relevant organ disease is known or suspected, or to assess the potential side effects of pharmacotherapy. Electrocardiography as a screening test seems to add little relevant information, even in patients with stable heart disease. A chest X-ray should be obtained only if a disease is suspected whose detection would have clinical consequences in the perioperative period. CONCLUSION In preoperative risk assessment, the history and physical examination are the strongest predictors of perioperative complications. Ancillary tests are indicated on an individual basis if the history and physical examination reveal that significant disease may be present.
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Affiliation(s)
- Andreas B Böhmer
- University Hospital Witten/Herdecke—Cologne, Department of Anesthesiology and Intensive Care Medicine at the Hospital Cologne-Merheim
| | - Frank Wappler
- University Hospital Witten/Herdecke—Cologne, Department of Anesthesiology and Intensive Care Medicine at the Hospital Cologne-Merheim
| | - Bernd Zwissler
- Department of Anesthesiology, Ludwig-Maximilian-Universität, Munich
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Böhmer A, Defosse J, Geldner G, Mertens E, Zwissler B, Wappler F. Präoperative Risikoevaluation erwachsener Patienten vor elektiven, nichtkardiochirurgischen Eingriffen. Anaesthesist 2014; 63:198-208. [DOI: 10.1007/s00101-014-2288-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 12/19/2013] [Accepted: 12/30/2013] [Indexed: 12/18/2022]
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