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Routine Preanaesthetic Testing: General Topics Tutorial456
Routine Preanaesthetic Testing: General Topics Tutorial456
Edited by: Alex Konstantatos, MD, Senior Lecturer, Monash University, Melbourne,
Australia
†
Corresponding author e-mail: pibarrawfsa@gmail.com
KEY POINTS
Preanaesthetic testing is a universal practice with little current scientific support.
In the United States alone, more than 20 billion US dollars are spent on preanaesthetic testing with questionable
indications.
Preanaesthetic testing should be ordered only if a clinical decision will be influenced by results.
Several recommendations for routine testing are described, all of which have low levels of evidence of support, which
are mainly through expert opinion and retrospective observational studies.
Every institution should endorse or develop a protocol that highlights judicious use of preanaesthetic testing.
INTRODUCTION
Preanaesthetic testing has been routinely performed in most countries around the world for the majority of patients scheduled
for surgical procedures. This approach was proposed in the mid-1940s after Adams and Lundy1 speculated that these tests
could help decrease the risk of perioperative anaesthetic complications. The implications of ordering routine testing are
tremendous with unclear benefits and spiralling costs ranging close to 20 billion US dollars per year in the United States alone.
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COST IMPLICATIONS
In the past decade, all health care stakeholders have endorsed the concept of value in health care. The concept of value is
simple: achieve the best possible outcome at the least cost possible. In this scenario, all medical interventions are subject to
economic scrutiny to determine their impact of achieving best outcomes.
At more than 20 billion US dollars per year, preanaesthetic testing costs are staggering, in a setting where evidence supporting
the impact of this expenditure does not currently exist. At Clinica Reina Sofia, we calculated the impact of streamlining
preanaesthetic testing and showed that even when taking into account the cost one anaesthesiology consult per patient, the
savings over 10 years in a middle-income country exceeded 151 000 USD.14
After an analysis of Medicare-funded cataract surgery, Chen calculated an expense of ~107 USD per patient, adding to an
existing estimate of 45.4 million USD, which did not demonstrate impact on outcomes.15 There is also the ‘‘cascading’’ effect of
ordering a test that is not indicated, such as an electrocardiogram (ECG). Ganguli et al16 showed that patients scheduled for
cataracts having an ECG ordered had 5 to 10 additional interventions per 100 patients with no impact on outcomes at the
expense of 35 million USD additional cost.16
GUIDELINES
There are many guidelines on this topic, among them the ASA Practice Advisory for Preanesthesia Evaluation (Table 1),17 the
National Institute for Health and Care Excellence (NICE) routine preoperative tests for elective surgery (Table 2)18 and from a
website sponsored by most of the medical specialty societies of the United States, ChoosingWisely.org (Table 3). It is interesting to
note that these recommendations are based mainly on expert opinions, as there is a great void of supportive evidence in the field.
The NICE guideline is stratified according to surgery magnitude and comorbidities and is useful to consider for its details.
A concept highlighted in the ASA Advisory is, ‘‘Practice Advisories are not supported by scientific literature to the same degree
as standards or guidelines because of the lack of sufficient numbers of adequately controlled studies.’’
Figure 1. Clinica Reina Sofia routine preoperative testing protocol based on .163;000 patients.19 (One specific exception: in our practice,
neurosurgical patients are not considered major surgery although admitted to a high-dependency unit; this is done mainly for neurological
observation.)
Table 2. Summary of National Institute for Health and Care Excellence Recommendations.18 ASA indicates American Society
of Anesthesiologists; ECG, electrocardiogram
Table 3. Summary of Choosing Wisely Preanaesthetic Testing. ASA indicates American Society of Anesthesiologists
SUMMARY
Preanaesthetic testing is a complex area currently not supported strongly by research. Each institution should
approach preanaesthetic testing by adopting existing validated guidelines or produce guidelines of their own that are
influenced by current research and seek strong compliance from stakeholders. The goal should be to achieve the ideal
balance to minimise testing that is not warranted to save money and avoid unnecessary cancellations of surgery while
assuring patient safety.
REFERENCES
1. Adam R, Lundy J. Anesthesia in cases of poor risk: Some suggestions for decreasing the risk. Surg Gynecol Obstet.
1942;74(3):1011-1101.
2. Narr BJ, Warner ME, Schroeder DR, Warner MA. Outcomes of patients with no laboratory assessment before anesthesia
and a surgical procedure. Mayo Clin Proc. 1997;72:505-509.
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