When is pre-surg exam needed?

Factual Questions
1

I’ve had a few surgeries - mostly for orthopedic issues - knee meniscus, broken ankle, etc. Each time, I believe I had to undergo a pre-operative exam involving bloodwork and an ECG. I’d assumed that the intent was to identify any potential issues fro the procedure and anesthesia.

I was speaking to someone recently who described a family member’s experience w/ elective plastic surgery, which was performed under anesthesia. No pre-op exam was required. (In fact, they said the facility didn’t even ask for ID on the day of surgery!)

It just struck me as add that no pre-screening was required. Even if it was considered minimally invasive, the patient was under anesthesia, and complications COULD have arisen. Wouldn’t the doctor want to cover his ass for malpractice purposes?

Again, looking back on my experiences, I can’t recall what - if any - clearance was needed before possibly similar procedures such as endoscopies.

2

The only time I’ve had pre-op bloodwork was before a planned C-section and the only time I’ve needed clearance from a cardiologist before having a procedure involving anesthesia was for a colonoscopy after I had a stent placed. The colonoscopy before the stent ( with the same dr) didn’t require cardiac clearance and other minor surgeries did not require bloodwork - even the angiogram that resulted in the stent did not require bloodwork in advance.

3

I had two surgeries in the 90s - a lumpectomy and gallbladder removal. Both were under general anesthesia and before both I had a pre-op workup with chest x-ray, EKG and blood work. A few years ago I fractured my elbow and had to have a piece of bone removed. I wondered why I did not have any pre-op work done but thought at least they would do blood work the day of surgery. Nope, got there and they just started getting me ready for the surgery (under general). I was too nervous to think about it at the time, but later wondered if they forgot. Maybe in the past it was done out of an abundance of caution and it’s not considered (probably by insurance companies) as always necessary these days.

4

At 58, I’ve only had one major procedure. Hip replacement. Blood work, etc. Had to get a sign-off from both a Cardiologist AND my Dentist.

Good thing they did Pre-Op blood work. It caught the early Pneumonia that I’d developed that stopped the train cold. 2 months later I had it done instead. :frowning:

Loooooooong 2 months.

I’m surprised that cosmetic surgery didn’t require a pre-op. Also mighty surprised about the lack of I.D. check on the day of.

I did my work at H.S.S. in NYC. They’re top-drawer. VERY careful on I.D., paperwork, approvals, etc.

For perspective, the surgery was February of 2018.

5

My boss was waiting for a hip replacement. In Canada, that can be a significant wait if the patient does not absolutely need it. So after 6 months, he goes for the pre-op workup. They do X-rays - “Hey, you have two metal screws in your thighbone!” Well, yes, that’s from the snowmobile accident (how Canadian) over 25 years ago. He’d been walking with a slightly shorter leg since then, so the hip was poorly worn. So they take him out of he hip replacement queue, and have him operated on to remove the screws (redundant by now). Then back at the end of the hip queue. Total time, 16 months, since he was only in minor pain. (My grandfather-in-law had his done the same day when he fell and shattered his hip)

But that’s the thing. It would have sucked bigly if they’d opened him up and chopped off the end of his thighbone only to find the insert wouldn’t go in because screws were in the way. Preliminary X-rays were money well spent.

One of my college roommates was doing an internship and told me about following the doctors doing their rounds and looking at an elderly lady who had just had a kidney removed.The doctor remarked she looked like she was pulling through remarkably well, and she replied “Yes! Much better than when I had the other one taken out.” WHAT?? Quick look at her medical records, and yes, they had just removed her only remaining kidney. Maybe if they’d taken note of that previously, they would have tried more options to save it.

6

Here’s the current evidence-based recommendations on who needs pre-surgical examination/clearance, from UpToDate. These recommendations make sense to me, as a primary care doctor who has to do the clearance when needed:

The overall risk of surgery is low in healthy individuals. Preoperative tests usually lead to false-positive results, unnecessary costs, and a potential delay of surgery. Preoperative tests should not be performed unless there is a clear clinical indication.

●A simple screening questionnaire can be helpful in the preoperative evaluation. Important potential risk factors to discuss with the patient include age, exercise capacity, alcohol, smoking, illicit drug use, and medication use. Obesity is not a risk factor for most major adverse postoperative outcomes in patients undergoing noncardiac surgery, with the exception of thromboembolic events. Clinicians should also inquire about personal or family history of complications from anesthesia and screen for symptoms of obstructive sleep apnea (OSA).

●We suggest baseline hemoglobin measurement for all patients 65 years of age or older who are undergoing major surgery and for younger patients undergoing surgery that is expected to result in significant blood loss. Hemoglobin measurement is not necessary for younger patients undergoing minor surgery unless the history suggests anemia. For other healthy patients, we suggest NOT performing routine hemoglobin, white blood count, or platelet measurements

●In the revised cardiac risk index, a serum creatinine >2.0 mg/dL (177 micromol/L) predicted postoperative cardiac complications. We suggest NOT obtaining a serum creatinine concentration, except in the following patients:

•Patients over the age of 50 undergoing intermediate or high risk surgery

•Younger patients suspected of having renal disease, when hypotension is likely during surgery, or when nephrotoxic medications will be used

●We suggest NOT testing for serum electrolytes, blood glucose, liver function, hemostasis, or urinalysis in the healthy preoperative patient We suggest pregnancy testing in all reproductive age women prior to surgery, rather than use of history-taking alone to determine pregnancy

●We suggest NOT ordering an electrocardiogram (ECG) for asymptomatic patients undergoing low-risk surgical procedures.

According to the 2014 American College of Cardiology/American Heart Association (ACC/AHA) guidelines, a resting 12-lead ECG should be part of the evaluation in patients with known coronary artery disease, significant arrhythmia, peripheral arterial disease, cerebrovascular disease, or other significant structural heart disease, except for those undergoing low-risk surgery.

A preoperative resting ECG can be considered for asymptomatic patients undergoing surgery with elevated risk (risk of major adverse cardiac event ≥1 percent). This is discussed in detail elsewhere.
●We suggest that clinicians NOT order routine preoperative chest radiographs or pulmonary function tests in the healthy patient. We suggest obtaining a preoperative chest radiograph in patients with cardiopulmonary disease and those older than 50 years of age who are undergoing abdominal aortic aneurysm surgery or upper abdominal/thoracic surgery

7

Thaks, Q. Has this advice changed recently? Or should I assume that when such tests were performed on me previously - to repair meniscus via scope or to chisel out hallux rigidus - when I was younger and healthier than now, they were unnecessary and my drs overly cautious?

8

What was the cosmetic procedure? I know someone who had a scar removal done with a local and the nitrous gas that dentists use. There was also some kind of use of a paralytic, but that was local too. I don’t think you’d need extensive bloodwork done for that, as you don’t for a root canal.

But I did have a semi-elective surgery-- ie, it wasn’t life-saving, or prolonging, but it wasn’t cosmetic; it was to improve function in an ankle that apparently had been fractured when I was a teen, and not set, because no one knew it had been fractured. I’d lived with it unrepaired for 30 years, including running on it through Army basic training in my 20s, but the doctor still thought I should have it repaired, because it might delay my developing arthritis in it, and fix my tendency to get mild sprains in that ankle that mostly involved taking ibuprofen for a couple of days. Insurance paid for it, but it was still more elective than not.

Anyway, I needed to get bloodwork before that surgery.

However, before I had a baby, no one made me get any bloodwork specific to having surgery, and I ended up with an unplanned c-section.

I think that the amount of time you are going to spend under matters. I had the c-section under GA, since it was unplanned, but I was under for just a short time. The ankle repair took over an hour, and I was under all that time.

9

I’d say they were overly cautious along with the possibility that they discovered your insurance would cover pre-op eval.

Or, if you answered yes to the questions below, they were most likely being reasonably cautious in deciding to take a closer look at you:

Questions

  1. Do you usually get chest pain or breathlessness when you climb up two flights of stairs at normal speed?
  2. Do you have kidney disease?
  3. Has anyone in your family (blood relatives) had a problem following an anaesthetic?
  4. Have you ever had a heart attack?
  5. Have you ever been diagnosed with an irregular heartbeat?
  6. Have you ever had a stroke?
  7. If you have been put to sleep for an operation were there any anaesthetic problems?
  8. Do you suffer from epilepsy or seizures?
  9. Do you have any problems with pain, stiffness or arthritis in your neck or jaw?
  10. Do you have thyroid disease?
  11. Do you suffer from angina?
  12. Do you have liver disease?
  13. Have you ever been diagnosed with heart failure?
  14. Do you suffer from asthma?
  15. Do you have diabetes that requires insulin?
  16. Do you have diabetes that requires tablets only?
  17. Do you suffer from bronchitis?
10

Asthma is the only one. But I suspect the insurance more likely! :wink:

11

I think sometimes they extend that to “pre” conditions, where there are strong family histories. I have had reactive hypoglycemia my whole adult life, and have a strong family history of autoimmune, adult onset Type 1 diabetes. The pancreas shuts down entirely between about age 55 and 60, resulting in insulin dependence.

I also take a seizure drug for insomnia. Never had a seizure, but the fact that I take it makes some doctors concerned about “withdrawal seizures” if I take it off-schedule a little because of the surgery fasting schedule.

12

It seems to be random, and different practices have different preferences. From my vaguely-remembered details:
1989, septoplasty. I think I needed a chest x-ray, I know i had an EKG, I had bloodwork done - and they even did a clotting time test where they made a slight scratch on my arm then put a piece of blotting paper next to it to see how long / how much it bled. Never had that one again. I wound up spending half a day at the hospital getting it all done. No pregnancy test required which was surprising as I was right in that age group - I actually insisted they do one.

1993: D&C: had blood work (including an HIV test) but nothing else. They probably did a pregnancy test at the same time as the other bloodwork.

2010: gallbladder: bloodwork and I think an EKG - done by my primary care doc. I think they did a pregnancy test at some point there though I was pretty much beyond the age of it being a problem.

Those 3 were all at different hospitals.

2018: wrist surgery. No bloodwork. Needed an EKG because I have type 2 diabetes, otherwise would not have needed anything. No other medical clearance requested. I actually had to find an urgent care clinic to have the EKG done, as my primary care office was closed due to a power outage and I’d run out of time. Possibly they’d have done the EKG at the surgical center if need be.

2018: cataract surgery. Some bloodwork including an updated EKG, done by my primary care doc, who had to send an “OK to operate” form to the surgeon… and never sent it until 3 days before the surgery when I called the surgeon and found they never received it. This was at the same facility as the wrist surgery, but obviously a different surgeon. I don’t think the bloodwork included a pregnancy test - but it would have been rather a surprise given my age at the time!

I’ve never had anything done before my numerous colonoscopies.

A friend has had several D&Cs - and was rather startled that one place required an EKG beforehand. She’d never needed an EKG before surgery - possibly not even before spinal fusion surgery which required several days in the hospital.