Documente Academic
Documente Profesional
Documente Cultură
Preoperative patient evaluation is an essential com- fortunately, most laboratory values are based on a
ponent of any surgical practice. A complete history 95% confidence limit; therefore, it is possible that
and physical, along with appropriate diagnostic tests, 5% of ‘‘normal’’ patients who do have any pathologic
are performed routinely to ensure a safe and predict- condition have an ‘‘abnormal’’ test result [1]. This
able delivery of care. Oral and maxillofacial surgeons may lead to misinterpretation of a pathologic con-
use this principle in everyday practice. Regardless of dition. It is just as important to consider not only if
type of surgery and practice (office-based dentoalveo- a laboratory value is abnormal but also if an abnor-
lar surgery, orthognathic surgery, trauma, elective mal value may affect the perioperative care of pa-
aesthetic surgery), oral and maxillofacial surgeons tients or is able to predict a complication [2]. It is
must formulate a decision-making process and a treat- estimated that only 0.22% of all ‘‘abnormal’’ pre-
ment plan regarding the perioperative management operative tests done before elective surgery could
of patients. The anesthetic plan and the surgical plan influence the perioperative management of the sur-
must be assessed preoperatively. gical patients [3].
Preoperative evaluation of surgical patients and It is estimated that the health care industry spends
the decisions regarding choosing the appropriate and 20 to 30 billion dollars annually on preoperative
specific presurgical laboratory tests can be a daunting laboratory testing in this country [4]. This is an
task at times because often it is riddled with con- enormous expense considering the volume of scien-
fusion and ambiguity. The dilemma facing health- tifically based studies refuting the benefits of routine
care providers is twofold: one, there is the need to preoperative laboratory work. A 1-year study of out-
reduce or eliminate nonindicated preoperative tests; patient surgical patients at a teaching hospital reveals
two, there is a responsibility to continue to order in- the potential of more than $400,000 in cost reduc-
dicated tests to maximize and improve patient care. tion if preoperative laboratory tests had been ordered
There is no doubt that there exist some limitations properly [2].
regarding preoperative testing of surgery patients. A PubMed search for ‘‘preoperative laboratory
One of the first difficulties faced by clinicians is the testing’’ reveals more than 200 articles. A quick
definition of the word, ‘‘abnormal.’’ When ordering a review of these articles demonstrates a paucity of
test, clinicians are attempting to discriminate between scientific evidence to validate the benefits of a ran-
patients who have normal values and those who have dom, preoperative testing paradigm. The American
abnormal ones. This knowledge then is used to de- Society of Anesthesiologists (ASA) Task Force on
termine the possibility for the existence of a patho- Preanesthesia Evaluation released its report in Febru-
logic condition, which ultimately may have an impact ary of 2002 [5]. The task force was unable to issue true
on the proposed surgical and anesthetic plan. Un- practice standards or guidelines based on strict
evidence-based information because of a lack of an
adequate number of controlled scientific studies.
E-mail address: Tirbod.Fattahi@jax.ufl.edu Instead, a practice advisory report was formulated
1042-3699/06/$ – see front matter D 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.coms.2005.09.012 oralmaxsurgery.theclinics.com
2 fattahi
Surgical Patient--
History & Physical
Completed
Specific findings
discovered during
history and physical—
Go to Figure 2 and/or
Table 3
Female Patients
Male Patients
Male Patients Age ≥ 40
< 40 years
Pregnancy Test (Urine
Human Chorionic
Gonadotrophin—HCG--)
indicated only by patient
history
GO TO TABLE 4
GO TO TABLE 4
Surgical Patient
ASA Classification
Determined
Go to Table 3
Category 1 Surgery
Category 2 Surgery
Category 3 or 4 Surgery
NO PRE-OPERATIVE
LABS/TESTS
INDICATED
Fig. 2. Indications for routine preoperative laboratory testing based on patient ASA and surgical classification system
(independent of patient age).
quirements are independent of other patient fac- 10 women between 15 and 19 years of age becomes
tors, such as ASA classification or nature of the pregnant each year in the United States and more than
planned surgical procedure. For example, a healthy 95% of these pregnancies are unplanned [22]. It is
45-year-old patient undergoing an elective outpatient conceivable, therefore, that some of these patients
surgical procedure may not require as many preop- may present for elective surgical procedures.
erative tests as a 45-year-old patient who has a Although there are few data regarding the teratogenic
significant cardiovascular history and is undergoing effects of anesthetics on the developing fetus, there is
the same operation. a significant risk of spontaneous abortion, intrauterine
Preoperative assessment of pediatric patients also growth retardation, and prematurity if a pregnant
has been evaluated. As for adult patients, many female is anesthetized during the first trimester.
practitioners continue the practice of ordering non- Based on these facts, a recent national survey reveals
indicated tests for pediatric patients. Studies show no that 27% of all practitioners routinely order a urine
clinical benefit of routine preoperative laboratory pregnancy test in adolescent patients before surgery
testing in children undergoing outpatient or non- [22]. There are a number of multicenter studies
invasive surgical procedures [20,21]. indicating, however, that the potential for an unrecog-
Preoperative assessment of female patients of nized pregnancy, following a detailed history and
childbearing age also is of interest. One of every physical with specific questions regarding the last
perioperative laboratory and diagnostic testing 5
going an elective, outpatient procedure in an oral and ing postoperative outcomes with efficient preoperative
maxillofacial surgery office do not need any preop- assessment and management. Crit Care Med 2004;
erative testing based on current clinical data and 32(Suppl):S76 – 86.
[13] Velanovich V. How much routine preoperative labo-
suggestions. It is warranted, however, to restate that
ratory testing is enough. Am J Med Qual 1993;8:
specific laboratory testing is indicated based on key
145 – 51.
findings during a history and physical examination. [14] Smetana GW, Macpherson DS. The case against rou-
The tables cited in this article are guidelines based on tine preoperative laboratory testing. Med Clin North
current literature; variations from the suggesting Am 2003;87:7 – 40.
testing protocol may be warranted based on patients’ [15] Wagner JD, Moore DL. Preoperative laboratory test-
surgical condition or other concomitant diseases. ing for the oral and maxillofacial surgery patient. J
Oral Maxillofac Surg 1991;49:177 – 82.
[16] Fleisher LA. Preoperative cardiac evaluation. Anes-
thesiology Clin North Am 2004;22:59 – 75.
References [17] Haug RH, Reifeis RL. A prospective evaluation of
the value of preoperative laboratory testing for office
[1] Schoen I, Brooks S. Judgment based on 95% con- anesthesia sedation. J Oral Maxillofac Surg 1999;57:
fidence limits: a statistical dilemma involving multitest 16 – 20.
screening and proficiency testing of multiple speci- [18] Narr BJ, Warner ME, Schroeder DR, et al. Outcomes
mens. Am J Clin Pathol 1970;53:190 – 5. of patients with no laboratory assessment before
[2] Wattsman TA, Davies RS. The utility of preoperative anesthesia and a surgical procedure. Mayo Clin Proc
laboratory testing in general surgery patients for 1997;72:505 – 9.
outpatient procedures. Am Surg 1997;63:81 – 90. [19] Dzankic S, Pastor D, Gonzales C, et al. The prevalence
[3] Kaplan EB, Sheiner LB, Boeckman AJ, et al. The and predictive value of abnormal preoperative labo-
usefulness of preoperative laboratory screening. JAMA ratory tests in elderly surgical patients. Anesth Analg
1985;253:3576 – 81. 2001;93:301 – 8.
[4] Pasternak LR. Preoperative assessment: guidelines and [20] O’Connor ME, Drasner K. Preoperative laboratory
challenges. Acta Anaesthesiol Scand Suppl 1997;111: testing of children undergoing elective surgery. Anesth
318 – 20. Analg 1990;70:176 – 80.
[5] American Society of Anesthesiologists Task Force [21] Patel RI, DeWitt L, Hannallah RS. Preoperative
on Preanesthesia Evaluation. Practice advisory for laboratory testing in children undergoing elective
preanesthesia evaluation. Anesthesiology 2002;96: surgery:analysis of current practice. J Clin Anesthesiol
485 – 96. 1997;9:569 – 75.
[6] Maurer WG, Borkowski RG, Parker BM. Quality [22] Malviya S, D’Errico C, Reynolds C, et al. Should
and resource utilization in managing preoperative pregnancy test be routine in adolescent patients prior
evaluation. Anesthesiology Clin North Am 2004;22: to surgery? Anesth Analg 1996;83:854 – 8.
155 – 75. [23] Manley S, de Kelaita G, Joseph N, et al. Preoperative
[7] Pasternak LR. Preoperative laboratory testing: general pregnancy testing in ambulatory surgery: incidence
issues and considerations. Anesthesiology Clin North and impact of positive results. Anesthesiology 1995;
Am 2004;22:13 – 25. 83:690 – 3.
[8] Roizen MF. Routine preoperative evaluation. In: Anes- [24] Pierre N, Moy LK, Redd S, et al. Evaluation of
thesia. Churchill Livingston; 1986. p. 225 – 53. a pregnancy-testing protocol in adolescents under-
[9] Khuri SF, Daley J, Henderson W, et al. The National going surgery. J Pediatr Adolesc Gynecol 1998;11:
Veterans Administration Surgical Risk Study: risk ad- 139 – 41.
justment for the comparative assessment of the qual- [25] Sandler G. Cost of unnecessary tests. Br J Med 1979;
ity of surgical care. J Am Coll Surg 1995;180:519 – 31. 2:21 – 4.
[10] King MS. Preoperative evaluation. Am Fam Physician [26] Bordage G. Where are the history and the physical?
2000;62:387 – 96. CMAJ 1995;1:517 – 8.
[11] Velanovich V. Preoperative laboratory screening based [27] Peterson MC, Holbrook JH, Von Hales D, et al. Con-
on age, gender, and concomitant medical disease. Sur- tributions of the history, physical examination, and
gery 1994;115:56 – 61. laboratory investigation in making medical diagnoses.
[12] Halaszynski TM, Juda R, Silverman DG. Optimiz- West J Med 1992;156:163 – 5.