|Year : 2020 | Volume
| 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
Taranjit S Kaur1, Bijoya P Chatterjee2
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 Submission||08-Oct-2019|
|Date of Acceptance||02-Feb-2020|
|Date of Web Publication||18-Jun-2020|
Dr. Bijoya P Chatterjee
Department of Biochemistry, M. P. Shah Government Medical College, Guru Gobind Singh Government Hospital, Jamnagar - 361 008, Gujarat
Source of Support: None, Conflict of Interest: None
| 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 2021 Jan 19];11:3-9. Available from: https://www.njms.in/text.asp?2020/11/1/3/287121
| Introduction|| |
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.,,,,, 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., 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|| |
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|| |
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:
- Guidelines: 4
- Reviews on preoperative tests in general elective surgery: 8
- Reviews on preoperative tests in OMF elective surgery: 2
- Prospective/retrospective studies on preoperative tests in general elective surgery: 34Prospective/retrospective studies on preoperative tests in OMF elective surgery: 3
Total number of papers included: 51.
| Discussion|| |
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.
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.,, 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.,, 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.,, 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. 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.,, 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.
The literature searches highlighted a systematic review by Munro et al. which clearly mentions the counter-productiveness of various tests of hemostasis. 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.,,,,,,, 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].,,,,,,,,,,,,,,,, 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. 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. 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. 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].,,,
|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.
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. Although age remains an independent factor in decision-making process, the other factors are ASA status and type of surgical procedure.,, As observed by Munro et al 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. Similar observations have been reported by other authors in context to OMF surgery.,, 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. 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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| Conclusion|| |
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
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]