BREAK THIS PRACTICE HABIT

Replace routine preoperative testing with individualized risk assessment and indicated testing

OBG Manag. 2020 December;32(12):40-44, E1 | doi: 10.12788/obgm.0054

References

Kachalia A, Berg A, Fagerlin A, et al. Overuse of testing in preoperative evaluation and syncope: a survey of hospitalists. Ann Intern Med. 2015;162:100-108.
Onuoha OC, Hatch M, Miano TA, et al. The incidence of un-indicated preoperative testing in a tertiary academic ambulatory center: a retrospective cohort study. Perioper Med. 2015; 4:14.
Kaplan EB, Sheiner LB, Boeckmann AJ, et al. The usefulness of preoperative laboratory screening. JAMA. 1985;253:3576-3581.
Centers for Disease Control and Prevention National Center for Health Statistics. Table 42: Gross domestic product, national health expenditures, per capita amounts, percent distribution, and average annual percent change: United States, selected years 1960-2017. https://www.cdc.gov/nchs/ data/hus/2018/042.pdf. Accessed July 2020.
Benarroch-Gampel J, Sheffield KM, Duncan CB, et al. Preoperative laboratory testing in patients undergoing elective, low-risk ambulatory surgery. Ann Surg. 2012;256:518-528.
O’Neill F, Carter E, Pink N, et al. Routine preoperative tests for elective surgery: summary of updated NICE guidance. BMJ. 2016;354: i3292.
Committee on Standards and Practice Parameters; Apfelbaum JL, Connis RT, Nickinovich DG, et al. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology. 2012;116:522-538.
American Society of Anesthesiologists. ASA physical status classification system. https://www.asahq.org/standardsand-guidelines/asa-physical-status-classification-system. Accessed July 2020.
Pasternak LR, Johns A. Ambulatory gynaecological surgery: risk and assessment. Best Pract Res Clin Obstet Gynaecol. 2005;19:663-679.
Shields J, Lupo A, Walsh T, et al. Preoperative evaluation for gynecologic surgery: a guide to judicious, evidence-based testing. Curr Opin Obstet Gynecol. 2018;30:252-259.
Sigmund AE, Stevens ER, Blitz JD, et al. Use of preoperative testing and physicians’ response to professional society guidance. JAMA Intern Med. 2015;175:1352-1359.
St Clair CM, Shah M, Diver EJ, et al. Adherence to evidence-based guidelines for preoperative testing in women undergoing gynecologic surgery. Obstet Gynecol. 2010;116:694-700.
De Sousa Soares D, Brandao RR, Mourao MR, et al. Relevance of routine testing in low-risk patients undergoing minor and medium surgical procedures. Braz J Anesthesiol. 2013;63:197-201.
Shields J, Kho KA. Preoperative evaluation for minimally invasive gynecologic surgery: what is the best evidence and recommendations for clinical practice. J Minim Invasive Gynecol. 2019;26:312-320.
Palace MR. Perioperative management of thyroid dysfunction. Health Serv Insights. 2017;10:1178632916689677.
Smetana GW, Macpherson DS. The case against routine preoperative laboratory testing. Med Clin North Am. 2003;87:7-40.
Jehan F, Khan M, Sakran JV, et al. Perioperative glycemic control and postoperative complications in patients undergoing emergency general surgery: what is the role of plasma hemoglobin A1c? J Trauma Acute Care Surg. 2018;84:112-117.
Feely MA, Collins CS, Daniels PR, et al. Preoperative testing before noncardiac surgery: guidelines and recommendations. Am Fam Physician. 2013;87:414-418.
Rusk MH. Avoiding unnecessary preoperative testing. Med Clin North Am. 2016;100:1003-1008.
Dexter F, Ledolter J, Davis E, et al. Systematic criteria for type and screen based on procedure’s probability of erythrocyte transfusion. Anesthesiology. 2012;116:768-778.
Gehrich AP, Lustik MB, Mehr AA, et al. Risk of postoperative urinary tract infections following midurethral sling operations in women undergoing hysterectomy. Int Urogynecol J. 2016;27:483-490.
American College of Obstetricians and Gynecologists. ACOG practice bulletin No. 195 summary: prevention of infection after gynecologic procedures. Obstet Gynecol. 2018;131:1177- 1179.
Noordzij PG, Boersma E, Bax JJ, et al. Prognostic value of routine preoperative electrocardiography in patients undergoing noncardiac surgery. Am J Cardiol, 2006;97: 1103-1106.
Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/ AHA guideline on perioperative cardiovascular examination and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:2215-2245.
Correll DJ, Hepner DL, Chang C, et al. Preoperative electrocardiograms: patient factors predictive of abnormalities. Anesthesiology. 2009;110:1217-1122.
Fritsch G, Flamm M, Hepner DL, et al. Abnormal preoperative tests, pathologic findings of medical history, and their predictive value for perioperative complications. Acta Anaesthesiol Scand. 2012;56:339-350.

Hematologic studies

Complete blood count (CBC). Many patients undergoing gynecologic procedures may have unreported or undiagnosed anemia secondary to abnormal uterine bleeding, which also may encompass heavy menstrual bleeding. With an abnormal CBC likely to affect preoperative management, assessment of preoperative hemoglobin levels is critical so that hemoglobin levels can be appropriately corrected before surgery. We therefore recommend obtaining a CBC for patients in class ASA II or higher who are undergoing intermediate-risk or major surgery.^10,14

Coagulation studies. Preoperative coagulation studies are unlikely to uncover previously undiagnosed inherited coagulopathies, which are generally uncommon in the general population, and they do not predict operative bleeding when ordered unnecessarily.^18,19 Therefore, we recommend preoperative coagulation studies only in patients 1) currently on anticoagulation therapy undergoing intermediate-risk or major surgery or 2) in class ASA III or higher with bleeding disorders or cirrhosis undergoing intermediate-risk or major surgery.¹⁴

Type and screen (T&S). Complicated algorithms have been proposed to determine when a preoperative T&S is necessary, but these may be impractical for busy gynecologists.²⁰ We recommend a T&S within 72 hours, or on the day, of surgery for all patients undergoing major surgery, including hysterectomy, or with an anticipated blood loss of more than 500 mL; routine crossmatching of blood is not recommended.^10,14

Urologic studies

Urine pregnancy test. Although the probability of a positive pregnancy test is likely very low, its occurrence frequently leads to the cancellation of surgery. We therefore recommend a preoperative urine pregnancy test, particularly in reproductive-aged patients with unknown pregnancy status or unreliable contraceptive habits.¹⁴ Preoperative urine pregnancy testing, even in patients who report sexual inactivity, ideally should be individualized and based on risk of fetal harm during or subsequent to surgery. Surgeries involving the uterus, or those involving possible teratogens like radiation, also should be considered when making recommendations for testing.

Urinalysis and urine culture. In asymptomatic patients undergoing general gynecologic procedures, a routine preoperative urinalysis and urine culture are of little value.¹⁸ However, among patients undergoing a urogynecologic surgical procedure, the risk of a postoperative urinary tract infection is higher than among patients undergoing a nonurogynecologic procedure.^21,22 Therefore, we typically do not recommend routine preoperative urinalysis or urine culture, but a preoperative urine culture may be beneficial in patients undergoing urogynecologic surgery.¹⁴

Continue to: Diagnostic studies...

References

Kachalia A, Berg A, Fagerlin A, et al. Overuse of testing in preoperative evaluation and syncope: a survey of hospitalists. Ann Intern Med. 2015;162:100-108.
Onuoha OC, Hatch M, Miano TA, et al. The incidence of un-indicated preoperative testing in a tertiary academic ambulatory center: a retrospective cohort study. Perioper Med. 2015; 4:14.
Kaplan EB, Sheiner LB, Boeckmann AJ, et al. The usefulness of preoperative laboratory screening. JAMA. 1985;253:3576-3581.
Centers for Disease Control and Prevention National Center for Health Statistics. Table 42: Gross domestic product, national health expenditures, per capita amounts, percent distribution, and average annual percent change: United States, selected years 1960-2017. https://www.cdc.gov/nchs/ data/hus/2018/042.pdf. Accessed July 2020.
Benarroch-Gampel J, Sheffield KM, Duncan CB, et al. Preoperative laboratory testing in patients undergoing elective, low-risk ambulatory surgery. Ann Surg. 2012;256:518-528.
O’Neill F, Carter E, Pink N, et al. Routine preoperative tests for elective surgery: summary of updated NICE guidance. BMJ. 2016;354: i3292.
Committee on Standards and Practice Parameters; Apfelbaum JL, Connis RT, Nickinovich DG, et al. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology. 2012;116:522-538.
American Society of Anesthesiologists. ASA physical status classification system. https://www.asahq.org/standardsand-guidelines/asa-physical-status-classification-system. Accessed July 2020.
Pasternak LR, Johns A. Ambulatory gynaecological surgery: risk and assessment. Best Pract Res Clin Obstet Gynaecol. 2005;19:663-679.
Shields J, Lupo A, Walsh T, et al. Preoperative evaluation for gynecologic surgery: a guide to judicious, evidence-based testing. Curr Opin Obstet Gynecol. 2018;30:252-259.
Sigmund AE, Stevens ER, Blitz JD, et al. Use of preoperative testing and physicians’ response to professional society guidance. JAMA Intern Med. 2015;175:1352-1359.
St Clair CM, Shah M, Diver EJ, et al. Adherence to evidence-based guidelines for preoperative testing in women undergoing gynecologic surgery. Obstet Gynecol. 2010;116:694-700.
De Sousa Soares D, Brandao RR, Mourao MR, et al. Relevance of routine testing in low-risk patients undergoing minor and medium surgical procedures. Braz J Anesthesiol. 2013;63:197-201.
Shields J, Kho KA. Preoperative evaluation for minimally invasive gynecologic surgery: what is the best evidence and recommendations for clinical practice. J Minim Invasive Gynecol. 2019;26:312-320.
Palace MR. Perioperative management of thyroid dysfunction. Health Serv Insights. 2017;10:1178632916689677.
Smetana GW, Macpherson DS. The case against routine preoperative laboratory testing. Med Clin North Am. 2003;87:7-40.
Jehan F, Khan M, Sakran JV, et al. Perioperative glycemic control and postoperative complications in patients undergoing emergency general surgery: what is the role of plasma hemoglobin A1c? J Trauma Acute Care Surg. 2018;84:112-117.
Feely MA, Collins CS, Daniels PR, et al. Preoperative testing before noncardiac surgery: guidelines and recommendations. Am Fam Physician. 2013;87:414-418.
Rusk MH. Avoiding unnecessary preoperative testing. Med Clin North Am. 2016;100:1003-1008.
Dexter F, Ledolter J, Davis E, et al. Systematic criteria for type and screen based on procedure’s probability of erythrocyte transfusion. Anesthesiology. 2012;116:768-778.
Gehrich AP, Lustik MB, Mehr AA, et al. Risk of postoperative urinary tract infections following midurethral sling operations in women undergoing hysterectomy. Int Urogynecol J. 2016;27:483-490.
American College of Obstetricians and Gynecologists. ACOG practice bulletin No. 195 summary: prevention of infection after gynecologic procedures. Obstet Gynecol. 2018;131:1177- 1179.
Noordzij PG, Boersma E, Bax JJ, et al. Prognostic value of routine preoperative electrocardiography in patients undergoing noncardiac surgery. Am J Cardiol, 2006;97: 1103-1106.
Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/ AHA guideline on perioperative cardiovascular examination and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:2215-2245.
Correll DJ, Hepner DL, Chang C, et al. Preoperative electrocardiograms: patient factors predictive of abnormalities. Anesthesiology. 2009;110:1217-1122.
Fritsch G, Flamm M, Hepner DL, et al. Abnormal preoperative tests, pathologic findings of medical history, and their predictive value for perioperative complications. Acta Anaesthesiol Scand. 2012;56:339-350.

Prophylactic antibiotics for myomectomy?

Replace routine preoperative testing with individualized risk assessment and indicated testing

References

Hematologic studies

Urologic studies

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