Elizabeth A. M. Frost MD
Dept of Anesthesiology
Icahn Medical Center at Mount Sinai
“On feeling the pulse of a 21 y/o…I found it to be
small, weak, and intermitting. I told the
patient he had nothing to apprehend. His pulse
improved. He inhaled the chloroform, His teeth
were extracted. He woke up. Now, if the
inhalation had commenced without inquiry,
the syncope would have had the appearance of
being caused by the chloroform” pp 77-8 John
Snow.
And so, physical
examination before
anesthesia was born!
Surgeon at Flower Fifth 1898
 Canvassed patients for surgeons so he could
anesthetize them..his total training in
anesthesia
 Became 1st anesthetist at Flower, 1899
 Later Professor of Anesthesia, NY Medical
College.
(the start of fee splitting ???)
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Huge hospitals…lots of beds…all inpatients.
Surgeons depended on internists for patient
referrals.
Patients sent back to internists for work up.
Many tests recommended
1990’s…Questions…do these tests make any
difference in outcome?
Answer: But we ALWAYS did it that way.
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Cost >$60 billion annually
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>60% not indicated
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0.22% reveal pertinent abnormalities
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Abnormalities mostly ignored
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No adverse consequences
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False positives potentially harmful
(Roizen, Can J Anaesth 1989)
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Chest X-ray=$128
EKG=$216
CBC=$156
Electrolytes=$626
Urinalysis=$85
Stress test=$2300
?? Bundling??
Total= $3511
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Choosing wisely: educational initiative, under
the auspices of Amer Board of Internal
Medicine, Consumer Reports, 9 specialty
boards.
$750b spent on unnecessary tests and
hospitalizations (1/3rd all health costs)
Should perform fewer tests; patients should
question need for tests.
Proceedings of the 4th Annual Perioperative Medicine Summit:
Cleveland Clinic 2009: suppl 4 Vol 76.The role of testing in the
preoperative evaluation
Practice Advisory for Preanesthesia Evaluation: ASA Oct 2011;
Anesthesiology 2012 (with 173 references)
American College of Cardiology/American Heart Association,
European Society of Cardiology. Updated guidelines
(Schiefermueller J et al Angiology 2012: May 3rd)
Preanesthesia Evaluation for ambulatory surgery; Hofer J. Curr
Opin Anaesthesiol 2013; 26(6): 669-76
Emphasis on preoperative clinical risk stratification
EKG: older (age not specified), cardiorespiratory disease
 Stress test :Cardiovascular compromise
 Chest X ray: Recent URI , smoking, COPD, cardiac disease
 PFTs :Reactive disease, COPD, scoliosis
 Hb/Hct :Anemia, bleeding disorders
 Coagulation studies: Bleeding, renal dysfunction, liver disease,
anticoagulants
 Chemistries: Endocrine, renal disease, medications
 Pregnancy: Women of child bearing age
 OSA suspected: Sleep study
(ASA 2013)
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Thailand: Use institution’s preop guidelines: decrease unnecessary testing and
financial burden(1)
UK: No evidence of clinical and cost effectiveness of routine preop tests (2)
Germany: Implementation of guidelines in 2010 to decrease testing allowed
more reasonable approach to preop risk evaluation(3)
Canada: Pregnancy testing indicated (4)
AND THEN THERE IS A SURGICAL OPINION
Texas: Recommendations from the ASA not specific to ambulatory surgery, not
based on strongly designed and adequately powered studies. Unclear. Need
studies involving surgeons and others (5)
1. Siriussawakul A et al Biomed Res Int 2013: 2013:835426, 2. Czoski-Murray C Health Technol
Assess 2012; 16(50): i-xvi, 1-159, 3. Bohmer AB Anaesthetist 2014; 63(3): 198-208, 4. Maher
JL Can J Plast Surg 2012; 20(3): e32-4, 5. Benarroch-Gampel J Adv Surg 2013; 47; 81-98
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My administrator (secretary, wife) orders
them
Patient expects to give blood and be tested
Anesthesia will cancel the case if there are no
tests
There is medicolegal liability without testing
It makes me feel comfortable
I have to support the hospital and labs
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Must follow history and physical
Diabetic and blood sugar day of surgery
Renal failure and potassium
Chest X-ray only if H and P dictates (no age
limit)
EKG? Age limit? Probably not.
Tests; ONLY per H and P
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EKG if older and not minor surgery (EKG valid
for 6 months if no interval change)
Chest X ray not mandatory at any age
Pregnancy urine test on day of surgery
Blood sugar for all diabetics
Potassium in ESRD
CBC and electrolytes as indicated by H and P
only
Let’s (Not) Get Physicals
We cling to the ritual of the annual exam,
despite evidence that it isn’t needed.
Jettison EKG, chest X-ray, blood work for healthy
people.
E Rosenthal
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Preop lab and EKG testing should be driven by
history, physical and surgical risk
Test indicated only if it can correctly identify
abnormalities, change diagnosis, management plan
or outcome (includes radiology)
Needless tests cause expense,delays, complications
Improved standardization needed
One size does not fit all.