Title: Preoperative Investigations in ASA I and II Patients – Do We Really Follow Recommendations?
Authors: Sapna Annaji Nikhar, Kavitha Jayaram
DOI: https://dx.doi.org/10.18535/jmscr/v4i11.80
Abstract
Background: Pre-anaesthetic check up (PAC) is to assess the clinical condition of patient and advice necessary investigations. This ultimately helps in risk stratification of patients. Though there are recommendations for evaluating patients, it is not getting followed and investigative modalities are increasing and clinical touch is lacking. We aimed to show that the preoperative investigations needed to optimize patients for surgery are exceeding the recommendations.
Methods: We carried a prospective, observational study in 200 ASA I and II patients, of either sex or any age group. The record of the investigations was done which was already advised and any advice further given by senior anaesthesiologist.
Results: Though ASA I and II patients do not need most of the investigations, CBP, SE, RFT, coagulation profile, ECG and CXR were advised already by surgeons, in almost 100 % patients. TFT was already done in 15 (25%) patients of ASA II group posted for thyroid surgery, only in 5 (8.3%) patients it was needed to demand. ECHO also same way was already done in 63 (45%) patients of ASA I group and 46(76.7%) patients of ASA II group. Out of cardiology referrals, 14 (10%) was done by surgeons themselves and clearance for surgery was taken though belong to ASA class I.
Keywords: Surgery, investigations, recommendations.
References
1. Fleisher LA. Risk of anesthesia. In Anesthesia. 5th Edition. Miller RD (ed) Philadelphia, Churchill-Livingstone, 2000, p.795-823.
2. Cohen MM, Duncan PG, Tate RB. Does anesthesia contribute to operative mortality? JAMA 1988; 260:2859
3. Duke JC, Chandler M. Preoperative evaluation. In: Duke JC, Keech BM, editors. Anesthesia Secrets. 5th ed. Philadelphia: Elsevier Saunders; 2016. p.113.
4. Chung F, Yuan H, Yin L, Vairavanathan S, Wong DT. Elimination of preoperative testing in ambulatory surgery. Anesthesia and Analgesia 2009; 108: 467-75.
5. Feely MA, Collins CS, Daniels PR, Kebede EB, Jatoi A, Mauck KF. Preoperative testing before noncardiac surgery: Guidelines and recommendations. Am Fam Physician 2013; 87:414‑8.
6. Asua J, López‑Argumedo M. Preoperative evaluation in elective surgery. INAHTA synthesis report. Int J Technol Assess Health Care 2000; 16:673‑83.
7. Criteria Committee of the New York Heart Association: Nomenclature and Criteria for Diagnosis of Disease of the Heart and Great Vessels. 9th ed. Boston, Little, Brown, 1994.
8. Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 Guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. Journal of the American College of Cardiology 2007; 50: 1707-32.
9. Practice Advisory for Preanesthesia Evaluation. An Updated Report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology 2012; 116:1–1
10. Fleisher LA, Fleischmann K E et al. Evaluation and Management of Patients Undergoing Noncardiac Surgery. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:e278-e333.
11. Eagle KA, Coley CM, Newell JB, Brewster DC, Darling RC, Strauss HW, et al. Combining clinical and thallium data optimizes preoperative assessment of cardiac risk before major vascular surgery. Ann Intern Med. 1989 Jun 1. 110(11):859-66.
12. Higgins TL, Estafanous FG, Loop FD, Beck GJ, Blum JM, Paranandi L. Stratification of morbidity and mortality outcome by preoperative risk factors in coronary artery bypass patients. A clinical severity score. JAMA. 1992 May 6. 267(17):2344-8.
13. Goldberger AL, O'Konski M. Utility of the routine electrocardiogram before surgery and on general hospital admission. Critical review and new guidelines. Ann Intern Med. 1986 Oct. 105(4):552-7.
14. Noordzij PG, Boersma E, Bax JJ, et al. Prognostic value of routine preoperative electrocardiography in patients undergoing noncardiac surgery. Am J Cardiol. 2006 Apr 1. 97(7):1103-6.
15. Poirier P, Alpert MA, Fleisher LA, Thompson PD, Sugerman HJ, Burke LE, et al. Cardiovascular evaluation and management of severely obese patients undergoing surgery: a science advisory from the American Heart Association. Circulation. 2009 Jul 7. 120(1):86-95.
16. Tornebrandt K, Fletcher R. Pre-operative chest x-rays in elderly patients. Anaesthesia. 1982 Sep. 37(9):901-2.
17. Nze PU, Njike C. Is routine preoperative chest X-ray indicated in elderly patients undergoing elective surgery?. Niger J Med. 2008 Apr-Jun. 17(2):150-2.
18. Kaplan EB, Sheiner LB, Boeckmann AJ, et al. The usefulness of preoperative laboratory screening. JAMA. 1985 Jun 28. 253(24):3576-81.
19. Turnbull JM, Buck C. The value of preoperative screening investigations in otherwise healthy individuals. Arch Intern Med. 1987 Jun. 147(6):1101-5.
20. Karim HM, Yunus M, Bhattacharyya P. An observational cohort study on pre-operative investigations and referrals: How far are we following recommendations? Indian JAnaesth 2016; 60:552-9.