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Table of Contents
REVIEW ARTICLE
Year : 2020  |  Volume : 11  |  Issue : 1  |  Page : 3-9  

“Too much information with little meaning,” relevance of preoperative laboratory testing in elective oral and maxillofacial surgeries: A systematic integrative review


1 Department of Oral and Maxillofacial Surgery, Government Dental College and Hospital, Jamnagar, Gujarat, India
2 Department of Biochemistry, M. P. Shah Government Medical College, Guru Gobind Singh Government Hospital, Jamnagar, Gujarat, India

Date of Submission08-Oct-2019
Date of Acceptance02-Feb-2020
Date of Web Publication18-Jun-2020

Correspondence Address:
Dr. Bijoya P Chatterjee
Department of Biochemistry, M. P. Shah Government Medical College, Guru Gobind Singh Government Hospital, Jamnagar - 361 008, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njms.NJMS_60_19

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   Abstract 


Aim: In the recent times due to accessibility of tools and advent of technology advising battery of laboratory tests prior to any electeve surgical procedure has become a norm. This review aims at investigating relevance of such tests in healthy patients undergoing routine elective oral and maxillofacial surgical procedures.
Methods: Various search engines were thoroughly searched to identify relevant literature. The population of interest was asymptomatic adults above 18 years of age undergoing elective surgery.
Results: The preoperative tests of interest for the current study included complete blood count, coagulation tests, biochemistry, and chest X-rays. An algorithm for preoperative tests has been proposed.
Conclusion: We conclude that advising battery of routine tests in such patients leads to further delays and rise in overall cost of the surgery.

Keywords: Dentoalveolar, elective surgeries, guidelines for preoperative evaluations, maxillofacial surgeries, preanesthetic preparations, preoperative laboratory investigations


How to cite this article:
Kaur TS, Chatterjee BP. “Too much information with little meaning,” relevance of preoperative laboratory testing in elective oral and maxillofacial surgeries: A systematic integrative review. Natl J Maxillofac Surg 2020;11:3-9

How to cite this URL:
Kaur TS, Chatterjee BP. “Too much information with little meaning,” relevance of preoperative laboratory testing in elective oral and maxillofacial surgeries: A systematic integrative review. Natl J Maxillofac Surg [serial online] 2020 [cited 2020 Jul 5];11:3-9. Available from: http://www.njms.in/text.asp?2020/11/1/3/287121




   Introduction Top


Preoperative laboratory investigations are an important part of any surgical checklist. Surgeons, all over, recognize the significance of this step in optimizing their patients before the surgeries. Preanesthetic assessment of patients involves a thorough investigation through the history and clinical assessment along with physical examination.[1],[2],[3],[4],[5],[6] Laboratory investigations supplement this judgment. Advice of routine blood investigations for elective surgical procedures in clinically healthy patients is based on long-term perception that such tests aid in the detection of abnormal findings that are clinically concealed, which place patients at risk during surgery and delay postsurgical recovery, if left undetected. There is a lack of uniformity in the practice of advising preoperative tests. This could be due to poor awareness and implementation of guidelines world over.

A plenty of scientific literature concerning this subject is found in general surgery, yet such is not the case for Oral and Maxillofacial Surgery (OMFs). The conclusions are drawn for elective OMF surgeries from the general surgical guidelines on preoperative evaluation.[7],[8] Therefore, the main objectives of this review are to compile and appraise the available literature to understand the current perspective of the surgeons and anesthetists in preparing their patients for the elective OMF surgeries and suggest an algorithm for the selection of relevant preoperative laboratory tests.


   Methods Top


Literature search

Different search engines were used to compile the studies relevant to the topic under review. The databases MEDLINE, PubMed, ScienceDirect, Cochrane Database of Systematic Reviews, Wiley Online Library, and Google Scholar were thoroughly searched relevant systematic reviews, narrative reviews, guidelines, recommendations, studies, and abstracts. The keywords utilized for search were presurgical, preoperative laboratory investigations, preoperative test, evaluation, guidelines, preanesthetic preparations, elective surgeries, maxillofacial surgeries, and ASA categories. At first, search the keywords and their combinations were used, and then, the process was continued by selecting manually other relevant citations from the initial search. This process continued till sufficient literature was collected. Since this is a review without any participation of human or animal models, no ethical committee approval was required.

All the studies evaluating the current topic of investigation, irrespective of type of surgical specialization, were included. The criteria for exclusion were studies published before 1985, studies that did not report primary outcome data relevant to the current review, and studies that included investigations in co-morbidities. The entire search process was restricted to publications in English language. The literature that was included in the current review was recent reviews, guidelines, recommendations, and prospective and retrospective studies published in the time frame mentioned above. The population of interest was asymptomatic adults above 18 years of age undergoing elective surgery. The preoperative studies that were of interest for the current study included chiefly laboratory tests (complete blood count, coagulation tests, and biochemistry) and chest X-rays. Electrocardiogram (ECG) and echo were discussed briefly. Studies on pediatric patients were excluded.


   Results Top


One hundred and fifty research papers were found in the first search. Scientific literature relevant to the study was identified and segregated into following categories:

  1. Guidelines: 4
  2. Reviews on preoperative tests in general elective surgery: 8
  3. Reviews on preoperative tests in OMF elective surgery: 2
  4. Prospective/retrospective studies on preoperative tests in general elective surgery: 34
  5. Prospective/retrospective studies on preoperative tests in OMF elective surgery: 3


Total number of papers included: 51.


   Discussion Top


Preoperative laboratory investigations represent a special class of screening tests. The main purpose of these tests as mentioned earlier is to provide additional diagnostic and prognostic information to supplement the clinical history and assessment of a patient with the following aims:

  • Evaluating the appropriateness of the ongoing course of clinical assessment and management
  • Comprehensive risk evaluation of the patient due to general anesthesia
  • Possibility of delay or cancellation of surgery due to unavailability of test results
  • Establishing a baseline measurement for later reference
  • Predicting intraoperative and postoperative complications
  • Predicting risk due to unknown undiagnosed medically relevant conditions and medicolegal considerations.[9]


Till the mid-nineties, clinicians evaluated patients preoperatively. Based on thorough history and physical examination, only selective laboratory tests were ordered to support or negate the clinical findings.[10],[11],[12] However, with change in times and better patient awareness of their rights along with advent of automation in clinical laboratories, injudicious ordering of scores of tests has gained support among physicians and surgeons.[12],[13],[14] The practice of unscrupulously advising laboratory tests before elective surgical procedures lacks concrete scientific evidence. There is very little scientific literature supporting relevance of these tests in terms of clinical utility in apparently healthy individuals (American Society of Anesthesiologists [ASA] 1 and 2) before the surgical procedure.[13],[14],[15] The Practice Advisory released by Task Force of the ASA in 2002 that updated again in 2012 clearly mentions ordering of preoperative laboratory tests be preceded by complete evaluation of patients medical records, patient interview, and physical examination along with the type and degree of invasiveness of the procedure proposed.[16] In 2003, the National Institute for Health and Care Excellence released guidelines based on systematic review conducted by Munro et al., which were revised and updated again in 2016.[17],[18],[19] The guidelines for preoperative tests were based on specific type of surgery and ASA grade. Preoperative tests such as full blood count, hemostasis, kidney function tests, and ECG are not routinely recommended in minor to intermediate surgeries in ASA 1 and 2 patients. The guidelines provide recommendations on preoperative testing in patients above 16 years of age with the aim of reducing unnecessary test requests offered to patients before minor, intermediate, and major surgeries, keeping in mind cardiovascular, diabetes, obesity, renal, and respiratory comorbidities.[18]

The literature searches highlighted a systematic review by Munro et al. which clearly mentions the counter-productiveness of various tests of hemostasis.[18] Routine bleeding time (BT), prothrombin time (PT), and partial thromboplastin time (PTT) in clinically healthy patients have shown abnormality in various ranges (3.8% for BT, 4.8% for PT, and 15.6% for PTT). Regardless of abnormal findings, management remained unchanged in most surgical procedures.[20],[21],[22],[23],[24],[25],[26],[27] Similar observations were made with regard to blood electrolytes, renal function tests, and blood glucose (biochemistry) in other significant systematic reviews [Table 1] and studies [Table 2].[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44] Another systematic review by Czoski-Murray et al. deals with some pertinent questions on clinical effectiveness and cost-effectiveness of the routine preoperative laboratory tests in ASA 1 and 2 patients, undergoing minor to intermediate elective surgery.[29] Johansson et al., 2013 in their systematic review, made comparable conclusions from other high-quality studies stating the lack of evidence supporting routine preoperative testing in otherwise healthy adult patients. They also recommend need for large-scale multicenter random clinical trials to explore clinical effectiveness of preoperative testing compared to no testing in patients with low-risk elective surgeries, for more conclusive statements.[31] The authors of the current review are also of the same opinion, as more systematic research would be helpful in better evidence-based policy-making for clinicians and hospitals. In a retrospective study conducted on 2000 patients undergoing elective surgery, Kaplan et al. concluded that 60% of routinely ordered tests could be avoided if the clinician relied on the history and examination, since only 0.22% of these revealed abnormalities that may have led to a change in the perioperative management of the patient.[33] Contrary to this, the study by Correll et al. and others have concluded that preoperative evaluation along with laboratory tests can aid in identification and resolving of underlying unknown medical issues that can have positive effect on the overall patient management, but tests should be requested judiciously as shown in [Table 2].[42],[43],[44],[45]
Table 1: Systematic reviews assessing routine laboratory investigations in preoperative evaluation

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Table 2: Studies assessing routine laboratory investigations in preoperative evaluation

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A detailed evaluation of patients undergoing OMF procedures follows the same principles as for any other surgical procedure elsewhere in the body. Wagner and Moore published a comprehensive review on the relevance of preoperative testing in OMF surgeries. The article discusses the WHO criteria, which emphasizes on the evaluation of overall general condition of the patient before advising the laboratory tests. The advised test should have clear indication in terms of morbidity and mortality and at the same time should have significant impact on the overall management of the patient. The review discusses limitations of laboratory tests in terms of its sensitivity and specificity and their inability to detect the underlying abnormalities (false negative) accurately or raising caution by false-positive results; this contributes to additional cost and discomfort to the patient.[7]

Fattahi in his review on preoperative laboratory and diagnostic testing highlights age of the patient as one of the important criteria for advising preoperative tests.[8] Although age remains an independent factor in decision-making process, the other factors are ASA status and type of surgical procedure.[47],[48],[49] As observed by Munro et al[18] routine preoperative tests are not competent in anticipating postoperative outcomes in asymptomatic patients, except in certain well-defined groups such as patients beyond a certain age.[34] Similar observations have been reported by other authors in context to OMF surgery.[2],[50],[51] As observed by Wagner and Moore, majority of procedures performed by OMF surgeon fall into ASA 1 and 2 categories, most of whom are young.[7] Keeping these observations in mind, authors of the current review suggest a working algorithm (utilizing the classification of surgical procedures in maxillofacial spectrum) proposed by the authors that incorporates the ASA category, type of surgical procedure, and age of the patient as essential criteria for the selection of preoperative laboratory tests [Figure 1] and [Table 3]. The proposed algorithm and table are recommendations in the form of screening tool for choosing appropriate preoperative laboratory tests; the authors suggest further studies to substantiate clinical validity of the same.
Figure 1: Indications for routine preoperative laboratory testing for oral and maxillofacial surgery based on age, American Society of Anesthesiologists, and surgical classification system

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Table 3: Surgical classification system based in maxillofacial spectrum

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   Conclusion Top


By ordering battery of tests before surgeries, anesthetists and clinicians generate ample information about the current status of the patient. This information in authors' view, which is substantiated by present review, has limited influence on the overall management and outcome of elective maxillofacial surgical patients. Guidelines are now in place and emphasize careful selection of preoperative laboratory tests based on personalized case. In authors' observation, excessive data generated through unmindful “one for all, all for one” attitude of clinicians need immediate shift, as this leads to unnecessary procedural delay, lack of overall patient satisfaction and trust.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Roizen MF. Preoperative evaluation: A shared vision for change. J Clin Anesth 1997;9:435-6.  Back to cited text no. 1
    
2.
Biery KA, Shamaskin RG, Campbell RL. Analysis of preoperative laboratory values prior to outpatient dental anesthesia. Anesth Prog. 1987;34:58–60.  Back to cited text no. 2
    
3.
Pedersen T, Eliasen K, Henriksen E. A prospective study of mortality associated with anaesthesia and surgery: Risk indicators of mortality in hospital. Acta Anaesthesiol Scand 1990;34:176-82.  Back to cited text no. 3
    
4.
Kitts JB. The preoperative assessment: Who is responsible? Can J Anaesth 1997;44:1232-6.  Back to cited text no. 4
    
5.
Blery C, Charpak Y, Szatan M, Darne B, Fourgeaux B, Chastang C, et al. Evaluation of a protocol for selective ordering of preoperative tests. Lancet 1986;1:139-41.  Back to cited text no. 5
    
6.
Benarroch-Gampel J, Sheffield KM, Duncan CB, Brown KM, Han Y, Townsend CM Jr., et al. Preoperative laboratory testing in patients undergoing elective, low-risk ambulatory surgery. Ann Surg 2012;256:518-28.  Back to cited text no. 6
    
7.
Wagner JD, Moore DL. Preoperative laboratory testing for the oral and maxillofacial surgery patient. J Oral Maxillofac Surg 1991;49:177-82.  Back to cited text no. 7
    
8.
Fattahi T. Perioperative laboratory and diagnostic testing – What is needed and when? Oral Maxillofac Surg Clin North Am 2006;18:1-6, v.  Back to cited text no. 8
    
9.
Barnard NA, Williams RW, Spencer EM. Preoperative patient assessment: A review of the literature and recommendations. Ann R Coll Surg Engl 1994;76:293-7.  Back to cited text no. 9
    
10.
Roizen MF. More preoperative assessment by physicians and less by laboratory tests. N Engl J Med 2000;342:204-5.  Back to cited text no. 10
    
11.
Fischer SP, Bader AM, Sweitzer B. Preoperative evaluation. In: Miller RD, Eriksson LI, Fleisher LA, Wiener-Kronish JP, Young WL, editors. Millers Anesthesia. 7th ed. Churchill Livingstone Elsevier; 2010. p. 1001-66.  Back to cited text no. 11
    
12.
Pasternak LR. Pre- operative laboratory testing: General issues and consideration. Anesthesiol Clin North America 2004;22:13-25.  Back to cited text no. 12
    
13.
MacPherson RD, Reeve SA, Stewart TV, Cunningham AE, Craven ML, Fox G, et al. Effective strategy to guide pathology test ordering in surgical patients. ANZ J Surg 2005;75:138-43.  Back to cited text no. 13
    
14.
Badar AM. Pre-operative testing. Curr Anesth Reports 2001;1:67-9.  Back to cited text no. 14
    
15.
Schein OD, Katz J, Bass EB, Tielsch JM, Lubomski LH, Feldman MA, et al. The value of routine preoperative medical testing before cataract surgery. Study of Medical Testing for Cataract Surgery. N Engl J Med 2000;342:168-75.  Back to cited text no. 15
    
16.
Committee on Standards and Practice Parameters, Apfelbaum JL, Connis RT, Nickinovich DG; American Society of Anesthesiologists Task Force on Preanesthesia Evaluation, Pasternak LR, et al. Practice advisory for preanesthesia evaluation: An updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology 2012;116:522-38.  Back to cited text no. 16
    
17.
CG3 Preoperative Tests-Full Guideline – NICE; 2003. Available from: https://www.nice.org.uk/guidance/./evidence/appendix-o-cg3-full-guideline-pdf-87258. [last accessed on 2018 Oct 25].  Back to cited text no. 17
    
18.
Munro J, Booth A, Nichol J. Routine pre operative testing: A systematic review of the evidence. Health Technol Assess 1997;12:1-62.  Back to cited text no. 18
    
19.
Routine Preoperative Tests for Elective Surgery – NICE; 2012 NG45https://www.nice.org.uk/guidance/ng45. [last accessed on 2018 Dec 01].  Back to cited text no. 19
    
20.
Charpak Y, Blery C, Chastang C, Ben Kemmoun R, Pham J, Brage D, et al. Usefulness of selectively ordered preoperative tests. Med Care 1988;26:95-104.  Back to cited text no. 20
    
21.
Aghajanian A, Grimes DA. Routine prothrombin time determination before elective gynecologic operations. Obstet Gynecol 1991;78:837-9.  Back to cited text no. 21
    
22.
Burk CD, Miller L, Handler SD, Cohen AR. Preoperative history and coagulation screening in children undergoing tonsillectomy comments. Pediatrics 1992;89:691-5.  Back to cited text no. 22
    
23.
Adams JG Jr., Weigelt JA, Poulos E. Usefulness of preoperative laboratory assessment of patients undergoing elective herniorrhaphy. Arch Surg 1992;127:801-4.  Back to cited text no. 23
    
24.
Narr BJ, Hansen TR, Warner MA. Preoperative laboratory screening in healthy Mayo patients: Cost-effective elimination of tests and unchanged outcomes. Mayo Clin Proc 1991;66:155-9.  Back to cited text no. 24
    
25.
MacDonald JB, Dutton MJ, Stott DJ, Hamblen DL. Evaluation of pre-admission screening of elderly patients accepted for major joint replacement. Health Bull (Edinb) 1992;50:54-60.  Back to cited text no. 25
    
26.
Sommerville TE, Murray WB. Information yield from routine pre-operative chest radiography and electrocardiography. S Afr Med J 1992;81:190-6.  Back to cited text no. 26
    
27.
Roizen MF, Kaplan EB, Schreider BD, Lichtor JL, Orkin FK. The relative roles of the history and physical examination and laboratory testing in preoperative evaluation for outpatient surgery: The “Starling Curve” of preoperative laboratory testing. Anesthesiol Clin North Am 1987;5:15-34.  Back to cited text no. 27
    
28.
Kumar A, Srivastava U. Role of routine laboratory investigations in preoperative evaluation. J Anaesthesiol Clin Pharmacol 2011;27:174-9.  Back to cited text no. 28
[PUBMED]  [Full text]  
29.
Czoski-Murray C, Lloyd Jones M, McCabe C, Claxton K, Oluboyede Y, Roberts J, et al. What is the value of routinely testing full blood count, electrolytes and urea, and pulmonary function tests before elective surgery in patients with no apparent clinical indication and in subgroups of patients with common comorbidities: A systematic review of the clinical and cost-effective literature. Health Technol Assess 2012;16:i-xvi, 1-159.  Back to cited text no. 29
    
30.
Keay L, Lindsley K, Tielsch J, Katz J, Schein O. Routine preoperative medical testing for cataract surgery. Cochrane Database Syst Rev. 2009:CD007293. pub2.  Back to cited text no. 30
    
31.
Johansson T, Fritsch G, Flamm M, Hansbauer B, Bachofner N, Mann E, et al. Effectiveness of non-cardiac preoperative testing in non-cardiac elective surgery: A systematic review. Br J Anaesth 2013;110:926-39.  Back to cited text no. 31
    
32.
Balk EM, Earley A, Hadar N, Shah N, Trikalinos TA. Benefits and harms of routine preoperative testing: comparative effectiveness. In: Comparative Effectiveness Review No. 130. Rockville: Agency for Healthcare Research and Quality; 2014.  Back to cited text no. 32
    
33.
Kaplan EB, Sheiner LB, Boeckmann AJ. The usefulness of pre-operative laboratory screening. Journal of the American Medical Association 1985;253:3576-81.  Back to cited text no. 33
    
34.
Turnbull JM, Buck C. The value of preoperative screening investigations in otherwise healthy individuals. Arch Intern Med 1987;147:1101-5.  Back to cited text no. 34
    
35.
Mancuso CA. Impact of new guidelines on physicians' ordering of preoperative tests. J Gen Intern Med 1999;14:166-72.  Back to cited text no. 35
    
36.
Johnson RK, Mortimer AJ. Routine pre-operative blood testing: Is it necessary? Anaesthesia 2002;57:914-7.  Back to cited text no. 36
    
37.
Bryson GL, Wyand A, Bragg PR. Preoperative testing is inconsistent with published guidelines and rarely changes management. Can J Anaesth 2006;53:236-41.  Back to cited text no. 37
    
38.
Ranasinghe P, Perera YS, Abayadeera A. Preoperative investigations in elective surgery: Practices and costs at the national hospital of Sri Lanka. Sri Lankan J Anaesthesiol 2010;18:29-35.  Back to cited text no. 38
    
39.
Garcia AP, Pastorio KA, Nunes RL, Locks GF, Almeida MC. Indication of preoperative tests according to clinical criteria: Need for supervision. Braz J Anesthesiol 2014;64:54-61.  Back to cited text no. 39
    
40.
Keshavan VH, Swamy CM. Pre-operative laboratory testing: A prospective study on comparison and cost analysis. Indian J Anaesth 2016;60:838-42.  Back to cited text no. 40
[PUBMED]  [Full text]  
41.
Akwasi AK, Obasuyi BI, Addison W. Preoperative laboratory testing in patients undergoing elective surgery: An analysis of practice at Komofo Anokye teaching hospital. Journal of Anaesthesiology 2017;5:5-10.  Back to cited text no. 41
    
42.
Perez A, Planell J, Bacardaz C, Hounie A, Franci J, Brotons C, et al. Value of routine preoperative tests: A multicentre study in four general hospitals. Br J Anaesth 1995;74:250-6.  Back to cited text no. 42
    
43.
van Klei WA, Moons KG, Rutten CL, Schuurhuis A, Knape JT, Kalkman CJ, et al. The effect of outpatient preoperative evaluation of hospital inpatients on cancellation of surgery and length of hospital stay. Anesth Analg 2002;94:644-9.  Back to cited text no. 43
    
44.
Correll DJ, Bader AM, Hull MW, Hsu C, Tsen LC, Hepner DL. Value of preoperative clinic visits in identifying issues with potential impact on operating room efficiency. Anesthesiology 2006;105:1254-9.  Back to cited text no. 44
    
45.
Shah SA, Sajid T, Asif M, Khan F, Ghani R. Significance and cost effectiveness of preoperative routine laboratory investigation in young healthy patients undergoing elective ear nose and throat surgery. J Ayub Med Coll Abbotabad 2007;19:3-6.  Back to cited text no. 45
    
46.
Antwi-Kusi A, Addison W, Obasuyi BI, Domoyeri P. Preoperative Laboratory Testing by Surgeons: Implication on Anaesthetic Management. International Journal of Clinical Medicine 2019;10:345-52.  Back to cited text no. 46
    
47.
Khuri SF, Daley J, Henderson W, Barbour G, Lowry P, Irvin G, et al. The National Veterans Administration Surgical Risk Study: Risk adjustment for the comparative assessment of the quality of surgical care. J Am Coll Surg 1995;180:519-31.  Back to cited text no. 47
    
48.
King MS. Preoperative evaluation. Am Fam Physician 2000;62:387-96.  Back to cited text no. 48
    
49.
Dzankic S, Pastor D, Gonzalez C, Leung JM. The prevalence and predictive value of abnormal preoperative laboratory tests in elderly surgical patients. Anesth Analg 2001;93:301-8.  Back to cited text no. 49
    
50.
Haug RH, Reifeis RL. A prospective evaluation of the value of preoperative laboratory testing for office anesthesia and sedation. J Oral Maxillofac Surg 1999;57:16-20.  Back to cited text no. 50
    
51.
da Silva LC, Oliveira AC, dos Santos JA, Santos Tde S. Criteria for the request of preoperative tests among oral and maxillofacial surgeons. J Craniomaxillofac Surg 2012;40:604-7.  Back to cited text no. 51
    


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