Presurgical Testing

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Presurgical Testing

Definition
Purpose
Demographics
Description
Diagnosis/Preparation

Definition

Presurgical or preoperative testing refers to the preparation and management of a patient before surgery.

Purpose

Presurgical testing, sometimes called preoperative testing, prepares a patient for surgery psychologically and physically.

Demographics

The U.S. Department of Health and Human Services’ National Center for Health Statistics reported more than 44.9 million inpatient surgical procedures (requiring an overnight hospital stay) performed in the United States in 2005. About 50 million outpatient surgical procedures (in which the patient goes home the same day of surgery) were performed in that year.

Obstetrical, cardiovascular, digestive, musculoskeletal, and neurological surgeries are among the majority of the inpatient surgical procedures performed. The majority of outpatient surgeries were performed on the digestive system, eyes, musculoskeletal system, female reproductive organs, and urinary system.

In recent years there has been a change in attitude toward routine presurgical testing. In the years following World War II, administering routine laboratory tests to patients before surgery became part of normal clinical procedure. It was thought that such testing would help doctors to detect abnormalities before surgery that might lead to complications during or after the operation. Until the 1980s few surgeons evaluated either the clinical or the cost-effectiveness of these tests. In the mid-1980s, however, some researchers began to publish papers showing that preoperative testing was not only expensive but also did not necessarily benefit patients. One study published in the Journal of the American Medical Association in 1985 noted that 60% of a sample group of 2000 patients had had laboratory tests ordered for no apparent reason. Of the abnormal test findings, only 0.22% influenced preoperative management of the patients.

Newer recommendations for presurgical testing of healthy patients undergoing elective surgery are as follows:

  • Consider a complete patient history and thorough physical examination the most important part of preoperative testing.
  • The patient’s hemoglobin level should be tested before for major surgery with significant expected blood loss or CBC count if the cost is not substantially increased.
  • Serum creatinine level (a blood test) should be tested in people older than 40 years.
  • Electrocardiogram (ECG or EKG) for patients over 40.
  • Chest x-ray for patients older than 60.
  • It is not necessary to repeat any laboratory test if the results were normal within 4 months of the scheduled surgery and if there has been no change in the patient’s health.

Patients with heart disease or lung disease, or undergoing emergency surgery, require more complete evaluation.

KEY TERMS

Biopsy— The removal of a small sample of tissue for analysis to determine a diagnosis.

Bone densitometry test— A test that quickly and accurately measures the density of bone.

Catheter— A small, flexible tube used to deliver fluids or medications.

Chest x ray— A diagnostic procedure in which a small amount of radiation is used to produce an image of the structures of the chest (heart, lungs, and bones) on film.

Echocardiogram— An imaging procedure used to create a picture of the heart’s movement, valves and chambers. The test uses high-frequency sound waves that come from a hand wand placed on the chest. Echocardiogram may be used in combination with Doppler ultrasound to evaluate the blood flow across the heart’s valves.

Electrocardiogram (ECG, EKG)— A test that records the electrical activity of the heart using small electrode patches attached to the skin on the chest.

Pulmonary function test— A test that measures the capacity and function of the lungs, as well as the blood’s ability to carry oxygen. During the test, patient breathes into a device called a spirometer.

Description

A planned surgery usually involves a surgical consultation, presurgical testing, the surgery itself, and recovery at home .

During the surgical consultation, the patient meets with the surgeon or a member of the surgeon’s healthcare team to discuss the surgery and other potential treatment options for the patient’s medical condition. A thorough review of the patient’s medical history and a complete physical exam are performed at this time. The medical review includes an evaluation of the patient’s previous and current medical conditions, surgeries and procedures, medications, and any other health conditions, such as allergies, that may impact the surgery.

The surgical team will ensure that the patient understands the potential benefits and risks of the procedure. Patient education may include one-on-one instruction from a health care provider, educational sessions in a group setting, or self-guided learning videos or modules. Informative and instructional handouts are usually provided to explain specific pre-surgical requirements.

After attending the surgical consultation, the patient may desire a second opinion to confirm the first doctor’s treatment recommendations.

Diagnosis/Preparation

Presurgical testing includes a variety of tests, patient education, and meetings with the health care team to inform the patient about what to expect before the procedure and during the recovery. Presurgical testing is generally scheduled within one week before the surgery.

Several tests are performed before surgery to provide complete information about the patient’s overall health, to prepare the patient for anesthesia (as applicable), and to identify and treat any potential problems ahead of time. Each surgery patient does not have the same presurgery tests. In addition to checking the patient’s vital signs (temperature, blood pressure, and pulse), more common tests include:

  • blood tests
  • urine tests
  • chest x rays
  • pulmonary function tests
  • computed tomography scan (CT or CAT scan)
  • heart function tests that may include an electrocardiogram or echocardiogram

If the patient recently had these tests performed (within the past six months), he or she can request the test results be forwarded to the surgical center.

Before some surgical procedures, such as valve surgery, a complete dental exam is needed to reduce the risk of infection. Other precautions will be taken before the surgery to reduce the patient’s risk of infection.

Informed consent is an educational process between health-care providers and patients. Before any procedure is performed, the patient is asked to sign a consent form. Before signing the form, the patient should understand the nature and purpose of the diagnostic procedure or treatment, the risks and benefits of the procedure, and alternatives, including the option of not proceeding with the test or treatment. During the discussion about the procedure, the health-care providers are available to answer the patient’s questions about the consent form or procedure.

Advance directives are legal documents that increase a patient’s control over medical decisions. A patient may decide medical treatment in advance, in the event that he or she becomes physically or mentally unable to communicate his or her wishes. Advance directives either state what kind of treatment the patient wants to receive (living will ), or authorize another person to make medical decisions for the patient when he or she is unable to do so (durable power of attorney ).

Advance directives are not required and may be changed or canceled at any time. Any change should be written, signed, and dated in accordance with state law, and copies should be given to the physician and to others who received original copies. Advance directives can be revoked either in writing or by destroying the document.

Advance directives are not a do-not-resuscitate (DNR) order, which indicates that a person—usually with a terminal illness or other serious medical condition—has decided not to have cardiopulmonary resuscitation (CPR) performed in the event that his or her heart or breathing stops.

Patients who will undergo any surgical procedure are encouraged to quit smoking and stop using tobacco products at least two weeks before the procedure, and to make a commitment to be a nonsmoker after the procedure. Quitting smoking before surgery helps the patient recover more quickly from surgery. There are several smoking cessation programs available in the community. The patient should ask a health-care provider for more information if he or she needs help quitting smoking.

The presurgical evaluation may include meetings with the anesthesiologist, surgeon, nurse clinicians, and other health-care providers who will manage the patient’s care during and after surgery, such as a dietitian, social worker, or rehabilitation specialist.

The patient’s surgery time may not be determined until the business day before the scheduled surgery. The patient may be instructed to call the surgical center to find out the time of the scheduled surgery.

Patients are told to come to the surgery center far enough in advance (usually about two hours prior to the scheduled surgery time) so they can be properly prepared for surgery. In some cases, the patient’s surgery may need to be rescheduled if another patient requires emergency surgery at the patient’s scheduled time.

Some surgery centers offer services such as guided imagery and relaxation tapes, massage therapy, or other complementary techniques to reduce a patient’s level of stress and anxiety before a surgical procedure.

Guided imagery is a form of focused relaxation that coaches the patient to visualize calm, peaceful images. Several research studies have proven that guided imagery can significantly reduce stress and anxiety before and after surgical and medical procedures and help the patient recover more rapidly. Guided imagery tapes are available at many major bookstores and from some surgery centers. The patient listens to the guided imagery tapes on his or her own CD or tape player before and after the surgery. The patient may even be able to continue listening to the tapes during the procedure, depending on the type of procedure being performed.

Blood transfusions may be necessary during surgery. A blood transfusion is the delivery of whole blood or blood components to replace blood lost through trauma, surgery, or disease. About one in three hospitalized patients will require a blood transfusion. The surgeon can provide an estimate of how much blood the patient’s procedure may require.

To decrease the risk of infection and immunologic complications, some surgery centers offer a preoperative blood donation program. Autologous blood (blood taken from the patient) is the safest blood available for transfusion, since there is no risk of disease transmission. Methods of autologous donation or collection include:

  • Intraoperative blood collection: The blood lost during surgery is processed and the red blood cells are reinfused during or immediately after surgery.
  • Preoperative donation: The patient donates blood once a week for about one to three weeks before surgery. The blood is separated, and the blood components needed are reinfused during surgery.
  • Immediate preoperative hemodilution: The patient donates blood immediately before surgery to decrease the loss of red blood cells during surgery. After donating, the patient receives fluids to compensate for the amount of blood removed. Since the blood is diluted, fewer red blood cells are lost from bleeding during surgery.
  • Postoperative blood collection: Blood lost from the surgical site right after surgery is collected and rein-fused after the surgical site has been closed.

The surgeon determines what type of blood collection process, if any, is appropriate.

Depending on the type of surgery scheduled, certain medications may be prescribed or restricted before the surgery. The health-care team will provide specific guidelines. If certain medications need to be restricted before surgery, the patient will receive a complete list of the medications (including prescription, over-the-counter, and herbal medications) to avoid taking before the scheduled surgery.

Prescribed medications that need to be taken within 12 hours before surgery should be swallowed with small sips of water.

Before most surgeries, the patient is advised not to eat or drink anything after midnight the evening before the surgery. This fast includes no smoking and no gum chewing. The patient should not drink any alcoholic beverages for at least 24 hours before surgery, unless instructed otherwise.

Most patients are admitted to the surgery center or hospital the same day as the scheduled surgery. The patient should bring a list of current medications, allergies, and appropriate medical records upon admission to the surgery center.

The patient should arrange for transportation home, since the effects of anesthesia and other medications given before surgery make it unsafe to drive.

Resources

BOOKS

[No authors listed.] Diagnostic Tests. Philadelphia: Lippincott Williams and Wilkins, 2007.

Kee, Joyce LeFever. Handbook of Laboratory and Diagnostic Tests: with Nursing Implications. Upper Saddle River, NJ: Pearson/Prentice Hall, 2008.

Newman, Mark, Lee Fleisher, and Mitchell Fink, eds. Perioperative Medicine: Managing for Outcome. Philadelphia: Saunders Elsevier, 2008.

“Preoperative Care.” In Mosby’s Nursing and Allied Health Dictionary, 5th ed. Edited by Kenneth Anderson, Lois E. Anderson, and Walter D. Glanze. B.C. Decker, 1998.

PERIODICALS

Fattahi, T. “Perioperative Laboratory and Diagnostic Testing: What Is Needed and When?” Oral and Maxillofacial Surgery Clinics of North America 18 (February 2006): 1–6.

Froehlich, J. B., D. Karavite, P. L. Russman, et al. “American College of Cardiology/American Heart Association Preoperative Assessment Guidelines Reduce Resource Utilization before Aortic Surgery.” Journal of Vascular Surgery 36 (October 2002): 758–763.

Hoeks, S. C., et al. “Preoperative Cardiac Testing before Major Vascular Surgery.” Journal of Nuclear Cardiology 14 (November-December 2007): 885–891.

Kaplan, E. B., L. B. Sheiner, and A. J. Boeckmann. “The Usefulness of Preoperative Laboratory Screening.” Journal of the American Medical Association 253 (June 28, 1985): 3576–3581.

Meding, J. B., M. Klay, A. Healy, et al. “The Prescreening History and Physical in Elective Total Joint Arthroplasty.” Journal of Arthroplasty 22 (September 2007): 21–23.

“Recommended Practices for Managing the Patient Receiving Anesthesia.” AORN Journal 75, no. 4 (April 2002): 849.

ORGANIZATIONS

American Board of Surgery. 1617 John F. Kennedy Boulevard, Suite 860, Philadelphia, PA 19103. (215) 568-4000. http://www.absurgery.org/.

American College of Surgeons. 633 N. Saint Clair Street, Chicago, IL 60611-3211. (312) 202-5000. http://www.facs.org/.

American Hospital Association (AHA). One North Franklin, Chicago, IL 60606-3421. (312) 422-3000. http://www.aha.org/aha_app/index.jsp.

National Heart, Lung and Blood Institute. Information Center. P.O. Box 30105, Bethesda, MD 20824-0105. (301) 592-8573. http://www.nhlbi.nih.gov.

OTHER

Reports of the Surgeon General. National Library of Medicine. http://sgreports.nlm.nih.gov/NN/.

Sharma, Gyanendra. “Preoperative Testing.” eMedicine, March 15, 2007. http://www.emedicine.com/med/ topic3172.htm [cited January 11, 2008].

Surgery Linx. MDLinx, Inc. 1025 Vermont Avenue, NW, Suite 810, Washington, DC 20005. (202) 543-6544. http://sgreports.nlm.nih.gov/NN/.

Surgical Procedures, Operative. http://www.mic.ki.se/Diseases/e4.html.

Angela M. Costello

Rebecca Frey, Ph.D.

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Presurgical Testing

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