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preoperative laboratory testing

Indications: - routine preoperative laboratory testing not indicated for healthy patients undergoing low-risk surgery [7,8] - standard preoperative tests in non-emergency operations (may be outdated or conditional on type of surgery) - patients with < 1% risk for perioperative major cardiovascular event do not need additional testing [7] Contraindications: 1) laboratory testing &/or imaging may be indicated in high-risk patients only [4] 2) only indicated if results will affect management [7] - only if an abnormal result is expected on the basis of known or suspected comorbidities & when the result would affect management [7] 3) urine culture for bacteriuria not indicated [6] 4) bleeding time not useful Laboratory: 1) hemoglobin/hematocrit a) all women b) men > 60 years c) anticipated blood loss d) renal disease [7] e) further studies as indicated to identify cause of anemia [7,9] 2) electrolytes, serum creatinine, basic metabolic panel a) patients > 60 years of age b) renal disease - serum creatinine > 2.0 mg/dL a risk factor per Revised Cardiac Risk Index - > 1.45 mg/dL associated with excess postoperative complications & death [11] - low serum creatinine is associated with sarcopenia & frailty [11] - associated with excess postoperative complications & death [11] c) diabetes mellitus, also obtain Hgb A1c d) medications that predispose to electrolyte imbalance - diuretics, ACE inhibitors, ARBs e) steroids f) bowel preparations g) other risk of hyponatremia [5] 3) PT/PTT & platelet count a) liver disease b) history of bleeding c) malignancy d) anticoagulation e) medical condtions that predispose to coagulopathy or bleeding - liver disease, hemophilia f) not routinely indicated [7] 4) liver function test - cirrhosis - history of abnormal liver function tests - evidence of liver disease 5) urinalysis - suspected urinary tract infection - planned urologic procedure - planned implantation of prosthesis - not necessary prior to joint arthroplasty [7] 6) pregnancy test for all women in whom pregnancy is possible [7] 7) consider arterial blood gas in patients at risk for postoperative respiratory failure 8) preoperative serum NT-ProBNP predicts postoperative cardiovascular (CV) events [10]* - both preoperative serum NT-ProBNP & high-sensitivity serum cardiac troponin T correlated with higher incidence of postoperative adverse CV events [14] - European Society of Cardiology recommends postoperative serum cardiac troponin T [15] 9) stable patients whose laboratory tests were normal within 4 months do not need repeat laboratory testing prior to surgery [7] * American College of Cardiology/American Heart Association guidelines recommend adding functional status (expressed in METs) plus a validated clinical risk score to guide risk stratification [13] - serum NT-proBNP alternative to functional status [13] Special laboratory: 1) electrocardiogram within 1-3 months of surgery a) patients > 50 years of age - functional status better predictor of cardiac complications than ECG in patients > 70 years of age [2] - preoperative electrocardiogram indicated for asymptomatic patients with known cardiovascular disease & good performance status (> 4 METS) [7] - not indicated in patients undergoing low-risk procedures [7] b) cardiovascular disease - coronary artery disease - cerebrovascular disease (TIA, stroke) - peripheral arterial disease - cardiac arrhythmias c) pulmonary disease d) diabetes mellitus 2) pulmonary function testing - patients with unexplained dyspnea or hypoxia [3,7] - lung transplantation [7] 3) echocardiogram in patients with aortic stenosis (known or suspected) 4) myocardial perfusion study would appear indicated if poor functional capacity (< 4 METS) Radiology: - chest X-ray a) patients > 60 years of age b) pulmonary disease - not routine in patients with chronic lung disease [7] - acute pulmonary symptoms c) cardiovascular disease

Related

perioperative risk assessment

General

preoperative evaluation & management

References

  1. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 349
  2. Journal Watch 22(17):137, 2002 Liu LL, Dzankic S, Leung JM. Preoperative electrocardiogram abnormalities do not predict postoperative cardiac complications in geriatric surgical patients. J Am Geriatr Soc. 2002 Jul;50(7):1186-91. PMID: 12133011
  3. Qaseem A, Snow V, Fitterman N, Hornbake ER, Lawrence VA, Smetana GW, Weiss K, Owens DK, Aronson M, Barry P, Casey DE Jr, Cross JT Jr, Fitterman N, Sherif KD, Weiss KB; Clinical Efficacy Assessment Subcommittee of the American College of Physicians. Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardio- thoracic surgery: a guideline from the American College of Physicians. Ann Intern Med. 2006 Apr 18;144(8):575-80. PMID: 16618955 http://www.annals.org/content/144/8/575.full - Smetana GW et al, Perioperative pulmonary risk stratification for noncardithoracic surgery: Systematic review for the American College of Physicians. Ann Intern Med 2006; 144:581 PMID: 16618956 http://www.annals.org/content/144/8/581.full - Lawrence VA et al, Stategies to reduce postoperative pulmonary complications after noncardiothoracic surgery: Systematic review for the American College of Physicians Ann Intern Med 2006; 144:596 PMID: 16618957 http://www.annals.org/content/144/8/596.full
  4. Poldermans D et al, Should major vascular surgery be delayed because of preoperative testing in intermediate-risk patients receiving beta-blocker therapy with tight heart rate control? J Am Coll Cardiol 2006, 48:964 PMID: 16949487 - Eagle KA and Lau WC Any need for preoperative cardiac testing in intermediate-risk patients with tight beta-adrenergic blockade? J Am Coll Cardiol 2006, 48:970 PMID: 16949488
  5. Leung AA et al Preoperative Hyponatremia and Perioperative Complications Arch Intern Med. Published online September 10, 2012 PMID: 22965221 http://archinte.jamanetwork.com/article.aspx?articleid=1357514 - Vassalotti JA and DuPree E Preoperative Hyponatremia: An Opportunity for Intervention? Comment on "Preoperative Hyponatremia and Perioperative Complications" Arch Intern Med. Published online September 10, 2012 PMID: 22965069 http://archinte.jamanetwork.com/article.aspx?articleid=1357510
  6. Drekonja DM et al Preoperative Urine Cultures at a Veterans Affairs Medical Center Arch Intern Med. 2012;():1-2 PMID: 23212291 http://archinte.jamanetwork.com/article.aspx?articleid=1470566
  7. Medical Knowledge Self Assessment Program (MKSAP) 16, 17, 18, 19. American College of Physicians, Philadelphia 2012, 2015, 2018, 2022. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - Hepner DL The role of testing in the preoperative evaluation. Cleve Clin J Med. 2009 Nov;76 Suppl 4:S22-7 PMID: 19880831
  8. Martin SK, Cifu, AS Routine Preoperative Laboratory Tests for Elective Surgery. JAMA. 2017;318(6):567-568 PMID: 28787493 http://jamanetwork.com/journals/jama/article-abstract/2647855
  9. Goodnough LT, Maniatis A, Earnshaw P et al Detection, evaluation, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines. Br J Anaesth. 2011 Jan;106(1):13-22. Review. PMID: 21148637 Free PMC Article
  10. Duceppe E, Patel A, Chan MTV et al. Preoperative N-terminal pro-B-type natriuretic peptide and cardiovascular events after noncardiac surgery: A cohort study. Ann Intern Med 2019 Dec 24 PMID: 31869834
  11. Loria A et al. Low preoperative serum creatinine is common and associated with poor outcomes after nonemergent inpatient surgery. Ann Surg 2023 Feb; 277:246. PMID: 36448909 https://journals.lww.com/annalsofsurgery/Abstract/2023/02000/Low_Preoperative_Serum_Creatinine_is_Common_and.12.aspx
  12. Edwards AF, Forest DJ. Preoperative laboratory testing. Anesthesiol Clin. 2018;36:493-507. PMID: 30390774
  13. Wijeysundera DN, Pearse RM, Shulman MA et al Assessment of functional capacity before major non-cardiac surgery: an international, prospective cohort study. Lancet. 2018 Jun 30;391(10140):2631-2640. PMID: 30070222 - Lurati Buse G et al. NT-proBNP or self-reported functional capacity in estimating risk of cardiovascular events after noncardiac surgery. JAMA Netw Open 2023 Nov 8; 6:e2342527. PMID: 37938844 PMCID: PMC10632953 Free PMC article https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2811525
  14. Zhao B-C et al. Preoperative N-terminal pro-B-type natriuretic peptide and high-sensitivity cardiac troponin T and outcomes after major noncardiac surgery: A prospective cohort study. PMID: 38753984 https://pubs.asahq.org/anesthesiology/article/141/3/475/141459/Preoperative-N-terminal-Pro-B-type-Natriuretic
  15. Halvorsen S, Mehilli J, Cassese S et al 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery: Developed by the task force for cardiovascular assessment and management of patients undergoing non-cardiac surgery of the European Society of Cardiology (ESC) Endorsed by the European Society of Anaesthesiology and Intensive Care (ESAIC). Eur Heart J. 2022 Oct 14;43(39):3826-3924 PMID: 36017553 https://academic.oup.com/eurheartj/article/43/39/3826/6675076