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Because more than 80% of patients receiving anesthesia are either outpatients or "come-and-stay" patients (i.e., patients admitted to the hospital after surgery), patients cannot be evaluated preoperatively as they were during the 1970s. A new system had to be devised. The resulting set of questions is extensive, consisting of more than 100 items.
I believe that use of a written or automated questionnaire to ask the screening questions, if coupled with a personal interview to pursue positive answers, does not decrease the accuracy or perceived personalization of the care given (see later) (Trigg DJ et al, unpublished data),[71] [88] [99] [100] [101] [102] Therefore, I began using this combination for inpatients as well (this process is described later in the chapter), especially for "come-and-stay" patients. My task is to explore in depth any positive results from the history-taking and to spend the rest of the time discussing issues that the patient is concerned about, as well as educating the patient about postoperative recovery pain and other plans and motivating him or her to adopt medications or lifestyle changes that have been shown to beneficially affect perioperative outcome.
Furthermore, storing the history and physical information electronically and securely (described later in this chapter) allows the anesthesiologist who is providing care to assess the patient's data the day or night before surgery. Most anesthesiologists have developed ways of putting the classic pattern (chart review; history-taking; physical examination; and discussion of risks, alternative anesthetic plans, and postoperative pain therapies) together so that all of these questions are part of a compassionate flow of thought that helps the patient recall information. A rigid, specific order for questioning is usually unnecessary.
The anesthesiologist must remember that older male patients tend to deny symptoms, often seeing disease as a sign of frailty. Some patients believe that their symptoms indicate a life-threatening disease and therefore resist seeking medical help (and answering questions) until help is imperative. Seeing a physician who has adopted beneficial lifestyle changes motivates the patient to do so.[103] [104] Despite such obstacles to obtaining pertinent information, seeing the patient before surgery does give the anesthesiologist one strong advantage: patients are usually willing and eager to share information. Surgery is usually a major event for both men and women; no patient really views any surgery as "minor." Thus, the preoperative interview can elicit vital information and is a powerful time to motivate patients to choose healthy options such as adhering to blood pressure normalization therapy, stopping smoking, and initiating a program of regular walking ands strength training. The trick is to work with the surgeons to have appointments scheduled far enough in advance to make the lifestyle and drug programs meaningful in perioperative as well as long term outcomes.
Some investigators have suggested that anesthesiologists forget the history and just use laboratory tests to screen for disease. A review of the literature strongly suggests otherwise: the history (whether obtained personally, by questionnaire, or by telephone interview by person or computer screening device), and the investigation of positive answers in an in-person interview is many times more effective in screening for disease than the use of laboratory tests alone. Also, the combination of history and personal interview can be a much less expensive process and avoids the medicolegal problems and inefficiency associated with excessive laboratory testing. Furthermore, testing is not a great personal motivator; even using abnormal test results to motivate compliance is only a small fraction as effective as is human-to-human interaction.[105]
The data presented below lead us to believe that the combination of history-taking (from personal interview or questionnaire supplemented by personal interview) and physical examination is the best tool for optimal evaluation of patients and optimal selection of laboratory tests (i.e., selection of only those tests that have a greater chance of benefiting rather than harming the patient).
The primary problem with ordering batteries of laboratory tests for all patients is that laboratory tests are not very good screening devices for disease. In addition, the subsequent "extra" tests that physicians order as a follow-up of supposedly abnormal results are costly. More important is the fact that nonindicated tests often represent additional risk for the patient, increase medicolegal risk for the physician, and render ORs in outpatient centers and hospitals inefficient.
In general, results of preoperative laboratory testing have been regarded as supplements to the patient's health history and physical examination. Collectively, this information has been the primary source of patient data available to the anesthesiologist. In the perioperative management of the patient, the anesthesiologist may alter the care of the patient based on preoperative laboratory test results. If a preoperative test suggests a change in the care of an individual such that the health of the patient is improved or a potential problem is avoided, then that test has been beneficial to the patient. Other preoperative tests, the results of which are normal and merely borderline, may only distract the physician; the results of these tests create no benefit but rather inconvenience, or worse, harm, through distraction. Furthermore, if a preoperative test suggests a change in the care of an individual so that the health of the patient suffers or a problem arises, that test decreases the overall quality of medical care and is harmful to the patient. One common example is a situation in which abnormal results on a chest radiograph obtained for a 40-year-old man solely because he is scheduled for surgery leads to a computed tomographic needle biopsy that produces normal results but also a pneumothorax. This sequence shows how a "benign" test can result in harm. Thus, testing can incur a risk-benefit ratio that is higher than 1.
On the whole, not much benefit appears to result from unindicated routine laboratory testing. Leonard and co-workers[106] reported that biochemical screening tests had no significant value in the preoperative screening of pediatric patients expected to be hospitalized for less than one week. When Korvin and associates[107] reviewed biochemical tests given routinely to 1,000 patients on hospital admission, none of the tests produced a new diagnosis that was unequivocally beneficial to the patient. In an ambitious, controlled trial of multiphasic screening of 1,500 patients, Olsen and co-workers[108] found no difference in morbidity between control groups and groups subjected to screening tests. Durbridge and colleagues [109] compared 1,500 patients randomly assigned to undergo or not undergo screening tests on admission. With respect to length of hospital stay or patient outcome, no benefit resulted from the 8,363 extra tests performed for the group undergoing screening tests. Narr et al.[23] [110] found that more than 3,000 patients classified as American Society of Anesthesiologists (ASA) I or II failed to benefit from laboratory testing, and that absence of tests in over 1,000 ASA I patients (average age, 21.4 years) did not adversely affect medical care.
Many studies have compared the yield from indicated (warranted based on history or risk group) versus unindicated (unwarranted) preoperative testing [111] [112] [113] [114] [115] [116] [117] [118] [119] [120] [121] [122] [123] [124] [125] [126] [127] [128] [129] [130] [131] ( Table 25-5 ) (Apfelbaum JL et al, unpublished data). Few unindicated tests have yielded beneficial changes in perioperative care: at most, only 16 of more than 16,000 patients who had unindicated preoperative tests benefited from such testing. Furthermore, this figure represents the most optimistic interpretation, because four patients in the study conducted by Kaplan et colleagues.[111] received no benefit, and in another study,[116] the benefit of treating asymptomatic anemia in seven patients prior to non-blood-loss surgery was not clear.
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